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Browning SD, Costello JM, Dunn HP, Fraser CL. The Use Of Fundus Photography In The Emergency Room-A Review. Curr Neurol Neurosci Rep 2025; 25:30. [PMID: 40214922 PMCID: PMC11991934 DOI: 10.1007/s11910-025-01417-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2025] [Indexed: 04/14/2025]
Abstract
PURPOSE OF REVIEW The ocular fundus reveals a wealth of pathophysiological findings which should change patient management in the emergency room (ER). Traditional fundoscopy has been technically challenging and diagnostically inaccurate, but technological advances in non-mydriatic fundus photography (NMFP) have facilitated clinically meaningful fundoscopy. This review presents an update on the literature regarding NMFP and its application to the ER, illustrating pivotal publications and recent advances within this field. RECENT FINDINGS NMFP's application in the ER is demonstrably feasible and seamlessly integrates into emergency physicians' (EP) diagnostic workflows in a clinically meaningful and time efficient manner. The images of the ocular fundus (OF) generated by NMFP are consistently high quality, allowing a greater diagnostic accuracy to EP and ophthalmology interpreters alike. Digital NMFP images facilitate effective ophthalmology input via telemedicine to review the images in the ER. NMFP has been shown to change management decisions in the ER, improving patient and departmental outcomes. Interpretation of fundus images remains a medical education challenge, and early research highlights the potential for artificial intelligence (AI) image systems of NMFP to augment image interpretation in the ER. NMFP can change the ER approach to OF assessment, however the factors limiting its routine implementation need further consideration. There is potential for AI to contribute to NMFP image screening systems to augment EPs diagnostic accuracy.
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Affiliation(s)
- Samuel D Browning
- Faculty of Medicine, The University of New South Wales, New South Wales, Australia
| | - Julia M Costello
- Port Macquarie Eye Centre, Port Macquarie, New South Wales, Australia
- Port Macquarie Base Hospital, Port Macquarie, New South Wales, Australia
| | - Hamish P Dunn
- Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
- Faculty of Medicine, The University of New South Wales, New South Wales, Australia
- Port Macquarie Eye Centre, Port Macquarie, New South Wales, Australia
| | - Clare L Fraser
- Save Sight Institute, The University of Sydney, New South Wales, Australia.
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Cai CX, Hribar M, Baxter S, Goetz K, Swaminathan SS, Flowers A, Brown EN, Toy B, Xu B, Chen J, Chen A, Wang S, Lee C, Leng T, Ehrlich JR, Barkmeier A, Armbrust KR, Boland MV, Dorr D, Boyce D, Alshammari T, Swerdel J, Suchard MA, Schuemie M, Bu F, Sena AG, Hripcsak G, Nishimura A, Nagy P, Falconer T, DuVall SL, Matheny M, Viernes B, O’Brien W, Zhang L, Martin B, Westlund E, Mathioudakis N, Fan R, Wilcox A, Lai A, Stocking JC, Takkouche S, Lee LH, Xie Y, Humes I, McCoy DB, Adibuzzaman M, Areaux RG, Rojas-Carabali W, Brash J, Lee DA, Weiskopf NG, Mawn L, Agrawal R, Morgan-Cooper H, Desai P, Ryan PB. Semaglutide and Nonarteritic Anterior Ischemic Optic Neuropathy. JAMA Ophthalmol 2025; 143:304-314. [PMID: 39976940 PMCID: PMC11843465 DOI: 10.1001/jamaophthalmol.2024.6555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Accepted: 12/08/2024] [Indexed: 02/23/2025]
Abstract
Importance Semaglutide, a glucagonlike peptide-1 receptor agonist (GLP-1RA), has recently been implicated in cases of nonarteritic anterior ischemic optic neuropathy (NAION), raising safety concerns in the treatment of type 2 diabetes (T2D). Objective To investigate the potential association between semaglutide and NAION in the Observational Health Data Sciences and Informatics (OHDSI) network. Design, Setting, and Participants This was a retrospective study across 14 databases (6 administrative claims and 8 electronic health records). Included were adults with T2D taking semaglutide, other GLP-1RA (dulaglutide, exenatide), or non-GLP-1RA medications (empagliflozin, sitagliptin, glipizide) from December 1, 2017, to December 31, 2023. The incidence proportion and rate of NAION were calculated. Association between semaglutide and NAION was assessed using 2 approaches: an active-comparator cohort design comparing new users of semaglutide with those taking other GLP-1RAs and non-GLP-1RA drugs, and a self-controlled case-series (SCCS) analysis to compare individuals' risks during exposure and nonexposure periods for each drug. The cohort design used propensity score-adjusted Cox proportional hazards models to estimate hazard ratios (HRs). The SCCS used conditional Poisson regression models to estimate incidence rate ratios (IRRs). Network-wide HR and IRR estimates were generated using a random-effects meta-analysis model. Exposures GLP-1RA and non-GLP-1RAs. Main Outcomes and Measures NAION under 2 alternative definitions based on diagnosis codes: one more inclusive and sensitive, the other more restrictive and specific. Results The study included 37.1 million individuals with T2D, including 810 390 new semaglutide users. Of the 43 620 new users of semaglutide in the Optum's deidentified Clinformatics Data Mart Database, 24 473 (56%) were aged 50 to 69 years, and 26 699 (61%) were female. The incidence rate of NAION was 14.5 per 100 000 person-years among semaglutide users. The HR for NAION among new users of semaglutide was not different compared with that of the non-GLP-1RAs using the sensitive NAION definition-empagliflozin (HR, 1.44; 95% CI, 0.78-2.68; P = .12), sitagliptin (HR, 1.30; 95% CI, 0.56-3.01; P = .27), and glipizide (HR, 1.23; 95% CI, 0.66-2.28; P = .25). The risk was higher only compared with patients taking empagliflozin (HR, 2.27; 95% CI, 1.16-4.46; P = .02) using the specific definition. SCCS analysis of semaglutide exposure showed an increased risk of NAION (meta-analysis IRR, 1.32; 95% CI, 1.14-1.54; P < .001). Conclusions and Relevance Results of this study suggest a modest increase in the risk of NAION among individuals with T2D associated with semaglutide use, smaller than that previously reported, and warranting further investigation into the clinical implications of this association.
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Affiliation(s)
- Cindy X. Cai
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
- Biomedical Informatics and Data Science, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michelle Hribar
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
- Casey Eye Institute, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Sally Baxter
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla
| | - Kerry Goetz
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Swarup S. Swaminathan
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Alexis Flowers
- Vanderbilt Eye Institute, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Eye Institute, Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric N. Brown
- Vanderbilt Eye Institute, Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian Toy
- Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Benjamin Xu
- Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - John Chen
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Aiyin Chen
- Casey Eye Institute, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Sophia Wang
- Byers Eye Institute, Department of Ophthalmology, Stanford University, Palo Alto, California
| | - Cecilia Lee
- Department of Ophthalmology, University of Washington, Seattle
- Karalis Johnson Retina Center, Seattle, Washington
| | - Theodore Leng
- Byers Eye Institute at Stanford, Stanford University School of Medicine, Palo Alto, California
| | - Joshua R. Ehrlich
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor
| | | | - Karen R. Armbrust
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota
| | - Michael V. Boland
- Department of Ophthalmology, Mass Eye and Ear and Harvard Medical School, Boston, Massachusetts
| | - David Dorr
- Department of Medical Informatics & Clinical Epidemiology, Portland, Oregon
| | - Danielle Boyce
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Tufts University School of Medicine, Boston, Massachusetts
| | - Thamir Alshammari
- Department of Clinical Practice, Faculty of Pharmacy, Jazan University, Jazan, Saudi Arabia
- Pharmacy Practice Research Unit, Faculty of Pharmacy, Jazan University, Jazan, Saudi Arabia
| | - Joel Swerdel
- Janssen Research and Development, Titusville, New Jersey
| | - Marc A. Suchard
- Department of Biostatistics, UCLA School of Public Health, University of California, Los Angeles, Los Angeles
- VA Informatics and Computing Infrastructure, US Department of Veterans Affairs, Salt Lake City, Utah
| | - Martijn Schuemie
- Janssen Research and Development, Titusville, New Jersey
- Department of Biostatistics, UCLA School of Public Health, University of California, Los Angeles, Los Angeles
| | - Fan Bu
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Anthony G. Sena
- Janssen Research and Development, Titusville, New Jersey
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - Akihiko Nishimura
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Paul Nagy
- Department of Biomedical Informatics and Data Science, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Thomas Falconer
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - Scott L. DuVall
- VA Informatics and Computing Infrastructure, US Department of Veterans Affairs, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Michael Matheny
- VA Informatics and Computing Infrastructure, US Department of Veterans Affairs, Nashville, Tennessee
| | - Benjamin Viernes
- VA Informatics and Computing Infrastructure, US Department of Veterans Affairs, Salt Lake City, Utah
| | - William O’Brien
- VA Informatics and Computing Infrastructure, US Department of Veterans Affairs, Salt Lake City, Utah
| | - Linying Zhang
- Institute for Informatics, Data Science and Biostatistics, Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Benjamin Martin
- Biomedical Informatics and Data Science, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Erik Westlund
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nestoras Mathioudakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ruochong Fan
- Institute for Informatics, Data Science and Biostatistics, Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Adam Wilcox
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Albert Lai
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | - Sahar Takkouche
- Department of Medicine, Division of Diabetes and Endocrinology, Vanderbilt University, Nashville, Tennessee
| | - Lok Hin Lee
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Yangyiran Xie
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Izabelle Humes
- Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland
| | - David B. McCoy
- Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland
| | - Mohammad Adibuzzaman
- Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland
| | - Raymond G. Areaux
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota
| | | | - James Brash
- IQVIA, Real World Solutions, Brighton, United Kingdom
| | - David A. Lee
- Ruiz Department of Ophthalmology and Visual Science, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Nicole G. Weiskopf
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Louise Mawn
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Priya Desai
- Stanford School of Medicine and Stanford Health Care, Palo Alto, California
| | - Patrick B. Ryan
- Columbia University Irving Medical Center, New York, New York
- Johnson & Johnson, Horsham, Pennsylvania
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Davidson S, de Souza WR, Eggleton K. Use of a smartphone-based, non-mydriatic fundus camera for patients with red flag ophthalmic presentations in a rural general practice. J Prim Health Care 2025; 17:4-9. [PMID: 40152959 DOI: 10.1071/hc24040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 05/07/2024] [Indexed: 03/30/2025] Open
Abstract
Introduction Fundus examination by direct ophthalmoscopy is widely used in general practice; however, it offers limited field of view, requires close approximation to the patient, has a steep learning curve and is a difficult skill to master and maintain. Non-mydriatic fundus photography (NMFP) offers an alternative with a wider field of view, ability for image analysis and transmission, and is able to be conducted by allied healthcare staff. Aim This study aimed to compare the use of direct ophthalmoscopy with smart-phone NMFP in a large rural general practice. It also aimed to analyse the number of adequate views and positive findings achieved with each instrument and the impact of NMFP on ophthalmology referral decisions. Methods Patients aged ≥16 years presenting to Dargaville Medical Centre (Dargaville, New Zealand) with visual disturbance, headache, hypertensive urgency (systolic blood pressure (BP) >200 mmHg or diastolic BP >120 mmHg), transient ischemic attack (TIA) or stroke were enrolled prospectively into an observational study of visualisation, diagnosis and management impact for a 1-year period (n = 152, 304 eyes). Direct ophthalmoscopy findings and management plans were documented by the attending general practitioner (GP), and then again following assessment of the NMFP. Results NMFP significantly improved visualisation of the fundal structures with an increase in adequate views achieved of both the optic disc and the retina. Inter-rater agreement between the referring GP and ophthalmologist was good. Discussion The use of NMFP in general practice might result in greater accuracy in diagnosing retina and optic disc disease. Routine transmission of NMFP images to specialist eye clinics as part of the referral might improve management and result in health system efficiencies.
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Affiliation(s)
- Scott Davidson
- Dargaville Medical Centre, Dargaville, Northland, New Zealand
| | - Waldir Rodrigues de Souza
- Dunedin Hospital, Te Whatu Ora Southern, New Zealand; and Ophthalmology Section, Department of Medicine, University of Otago, New Zealand
| | - Kyle Eggleton
- Rural Health Unit, Department of General Practice and Primary Health Care, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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4
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Berman G, Pendley AM, Wright DW, Silverman R, Kelley C, Duran MR, Soto MT, Shanmugam N, Keadey M, Newman NJ, Biousse V. Breaking the barriers: Methodology of implementation of a non-mydriatic ocular fundus camera in an emergency department. Surv Ophthalmol 2025; 70:153-161. [PMID: 39357747 DOI: 10.1016/j.survophthal.2024.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 09/23/2024] [Accepted: 09/24/2024] [Indexed: 10/04/2024]
Abstract
Despite evidence that non-mydriatic fundus cameras are beneficial in non-ophthalmic settings, they are only available in a minority of hospitals in the US. The lag from research-based evidence to change in clinical practice highlights the complexities of implementation of new technology and practice. We describe the steps used to implement successfully a non-mydriatic ocular fundus camera combined with optical coherence tomography (OCT) in a general emergency department (ED) using Kotter's 8-Step Change Model. We prospectively collected the number of trained personnel in the ED, the number of imaging studies obtained each week during the first year following implementation, and we documented major achievements each month, as well as outcome measures, barriers to implementation and possible solutions. Between 12 and 42 patients were imaged per week, resulting in a total of 1274 patients imaged demonstrating sustained usage of non-mydriatic fundus camera/OCT in the ED one year after implementation. The implementation process was contingent upon multidisciplinary collaboration, extensive communication, coordinated training of staff, and continuous motivation. The future will likely include the use of artificial intelligence deep learning systems for automated interpretation of ocular imaging as an immediate diagnostic aid for ED or other non-eye care providers.
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Affiliation(s)
- Gabriele Berman
- Department of Ophthalmology, Emory Eye Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrew M Pendley
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Chris Kelley
- Department of Ophthalmology, Emory Eye Center, Emory University School of Medicine, Atlanta, GA, USA; Information Technology, Department of Ophthalmology, Emory Healthcare, Atlanta, GA, USA
| | - Mariana Rodriguez Duran
- Department of Ophthalmology, Emory Eye Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Mariam Torres Soto
- Department of Ophthalmology, Emory Eye Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Nithya Shanmugam
- Department of Ophthalmology, Emory Eye Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew Keadey
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Nancy J Newman
- Department of Ophthalmology, Emory Eye Center, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Valérie Biousse
- Department of Ophthalmology, Emory Eye Center, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
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Margolis TP, Galor A, Novack GD. Implications of Diagnostic Error in Ocular Surface Disease: The Role of Anchoring and Ambiguous Diagnostic Terminology. JAMA Ophthalmol 2025; 143:5-6. [PMID: 39541097 DOI: 10.1001/jamaophthalmol.2024.4867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
This Viewpoint addresses the high rate of incorrect ophthalmological diagnoses and harm experienced by patients and examines causes.
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Affiliation(s)
- Todd P Margolis
- John F. Hardesty, MD, Department of Ophthalmology and Visual Science, Washington University in St Louis, St Louis, Missouri
| | - Anat Galor
- Surgical Services, University of Miami, Miami, Florida
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | - Gary D Novack
- PharmaLogic Development, Inc, San Rafael, California
- Department of Ophthalmology and Vision Science, University of California, Davis School of Medicine, Sacramento
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Warner JEA, Krikova I. Physician Assistants in Neuro-Ophthalmology. Neuroophthalmology 2024; 49:123-126. [PMID: 40051717 PMCID: PMC11881863 DOI: 10.1080/01658107.2024.2435311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Revised: 11/01/2024] [Accepted: 11/22/2024] [Indexed: 03/09/2025] Open
Affiliation(s)
- Judith E. A. Warner
- Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah, USA
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Irina Krikova
- Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah, USA
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Ray HJ, Okrent Smolar AL, Dattilo M, Bouthour W, Berman G, Peragallo JH, Kedar S, Pendley AM, Greene JG, Keadey MT, Wright DW, Bruce BB, Newman NJ, Biousse V. The Increasing Burden of Emergency Department and Inpatient Consultations for "Papilledema". J Neuroophthalmol 2024; 44:571-577. [PMID: 38502219 DOI: 10.1097/wno.0000000000002120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Increasing incidence of idiopathic intracranial hypertension (IIH), overreported radiologic signs of intracranial hypertension, difficult access to outpatient neuro-ophthalmology services, poor insurance coverage, and medicolegal concerns have lowered the threshold for emergency department (ED) visits for "papilledema." Our objective was to examine referral patterns and outcomes of neuro-ophthalmology ED and inpatient consultations for concern for papilledema. METHODS At one university-based quaternary care center, all adults referred for "papilledema" over one year underwent a standardized ED "papilledema protocol." We collected patient demographics, final diagnoses, and referral patterns. RESULTS Over 1 year, 153 consecutive patients were referred for concern for papilledema. After papilledema protocol, 89 of 153 patients (58%) had bilateral optic disc edema, among whom 89% (79/89) had papilledema (intracranial hypertension). Of the 38 of 153 (25%) consultations for suspected disorder of intracranial pressure without previous fundus examination (Group 1), 74% (28/38) did not have optic disc edema, 21% (8/38) had papilledema, and 5% (2/38) had other causes of bilateral disc edema. Of the 89 of 153 (58%) consultations for presumed papilledema seen on fundus examination (Group 2), 58% (66/89) had confirmed papilledema, 17% (15/89) had pseudopapilledema, and 9% (8/89) had other causes of bilateral optic disc edema. Of the 26 of 153 (17%) patients with known IIH (Group 3), 5 had papilledema and 4 required urgent intervention. The most common diagnosis was IIH (58/79). Compared with IIH, patients with secondary causes of intracranial hypertension were older ( P = 0.002), men ( P < 0.001), not obese ( P < 0.001), and more likely to have neurologic symptoms ( P = 0.002). CONCLUSIONS Inpatient and ED consultations for "papilledema" are increasing. Of the 153 ED and inpatient neuro-ophthalmology consultations seen for "papilledema" over 1 year, one-third of patients with optic disc edema of unknown cause before presentation to our ED had new vision- or life-threatening disease, supporting the need for prompt identification and evaluation of optic disc edema in the ED. In the face of limited access to neuro-ophthalmologists, this study supports the need for emergency department access to expert eye-care evaluation or ocular fundus camera for prompt identification of optic disc edema and standardized evaluation for neurologic emergencies.
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Affiliation(s)
- Hetal J Ray
- Department of Ophthalmology (HJR, ALOS, MD, WB, GB, JHP, SK, BBB, NJN, VB), Neurology (SK, JGG, NJN, VB), and Emergency Medicine (AMP, MTK, DWW), Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology (BBB), Rollins School of Public Health, Emory University, Atlanta, Georgia; and Department of Neurological Surgery (NJN), Emory University School of Medicine, Atlanta, Georgia
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Madadi Y, Delsoz M, Lao PA, Fong JW, Hollingsworth TJ, Kahook MY, Yousefi S. ChatGPT Assisting Diagnosis of Neuro-Ophthalmology Diseases Based on Case Reports. J Neuroophthalmol 2024:00041327-990000000-00723. [PMID: 39787495 DOI: 10.1097/wno.0000000000002274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2025]
Abstract
BACKGROUND To evaluate the accuracy of Chat Generative Pre-Trained Transformer (ChatGPT), a large language model (LLM), to assist in diagnosing neuro-ophthalmic diseases based on case reports. METHODS We selected 22 different case reports of neuro-ophthalmic diseases from a publicly available online database. These cases included a wide range of chronic and acute diseases commonly seen by neuro-ophthalmic subspecialists. We inserted each case as a new prompt into ChatGPTs (GPT-3.5 and GPT-4) and asked for the most probable diagnosis. We then presented the exact information to 2 neuro-ophthalmologists and recorded their diagnoses, followed by comparing responses from both versions of ChatGPT. RESULTS GPT-3.5 and GPT-4 and the 2 neuro-ophthalmologists were correct in 13 (59%), 18 (82%), 19 (86%), and 19 (86%) out of 22 cases, respectively. The agreements between the various diagnostic sources were as follows: GPT-3.5 and GPT-4, 13 (59%); GPT-3.5 and the first neuro-ophthalmologist, 12 (55%); GPT-3.5 and the second neuro-ophthalmologist, 12 (55%); GPT-4 and the first neuro-ophthalmologist, 17 (77%); GPT-4 and the second neuro-ophthalmologist, 16 (73%); and first and second neuro-ophthalmologists 17 (77%). CONCLUSIONS The accuracy of GPT-3.5 and GPT-4 in diagnosing patients with neuro-ophthalmic diseases was 59% and 82%, respectively. With further development, GPT-4 may have the potential to be used in clinical care settings to assist clinicians in providing quick, accurate diagnoses of patients in neuro-ophthalmology. The applicability of using LLMs like ChatGPT in clinical settings that lack access to subspeciality trained neuro-ophthalmologists deserves further research.
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Affiliation(s)
- Yeganeh Madadi
- Department of Ophthalmology (YM, MD, PAL, JWF, TJH, SY), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Ophthalmology (MYK), University of Colorado School of Medicine, Aurora, Colorado; and Department of Genetics, Genomics, and Informatics (SY), University of Tennessee Health Science Center, Memphis, Tennessee
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9
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Vosoughi AR, Donaldson L, Micieli JA, Margolin EA. Maculopathies Referred to Neuro-Ophthalmology Clinic as Optic Neuropathies: A Case Series. J Neuroophthalmol 2024; 44:355-359. [PMID: 37477986 DOI: 10.1097/wno.0000000000001950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
BACKGROUND The clinical features of maculopathies and optic neuropathies often overlap: Both present with decreased visual acuity and variable loss of color vision; thus, maculopathy can be misdiagnosed as optic neuropathy, leading to patient harm. We aimed to determine what findings and/or tests were most helpful in differentiating between optic neuropathy and maculopathy. METHODS A retrospective chart review of consecutive patients over 4.5 years who were referred to neuro-ophthalmology clinics with the diagnosis of optic neuropathy but whose final diagnosis was maculopathy. Patient demographics, mode of presentation, clinical profile, complete ophthalmological examination, results of all ancillary testing, and final diagnosis were recorded. RESULTS A total of 47 patients (27 women) were included. The median age was 55 years (range, 18-85). Most referrals were by ophthalmologists (72.3%) and optometrists (12.8%). The diagnosis of maculopathy was made in 51.1% of patients at the time of first neuro-ophthalmic consultation. Only 6.4% patients (3) had relative afferent pupillary defect. Benign disc anomalies (tilted, myopic, small, or anomalous discs) were present in 34.0%, and 21.3% had pathologic disc changes unrelated or secondary to maculopathy. Macular ocular coherence tomography (OCT) was abnormal in 84.4% (with outer retinal pathology in 42.2% and inner retina pathology in 17.8%). Retinal nerve fiber layer (RNFL) thickness was normal in 82.6% of patients. CONCLUSIONS Macular OCT is a high-yield test in differentiating between optic neuropathy and maculopathy and should be obtained in patients with suspected optic neuropathies who have normal RNFL thickness. Macular dystrophies, particularly cone dystrophies, unspecified retinal disorders, and macular degeneration were the most common mimics of optic neuropathy. The diagnosis was often present on OCT of the macula. The presence of coexistent benign and pathological disc anomalies may lead to maculopathy being misdiagnosed as optic neuropathy.
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Affiliation(s)
- Amir R Vosoughi
- Max Rady College of Medicine (ARV), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Division of Ophthalmology (LD), Department of Surgery, McMaster University, Hamilton, Canada; Department of Ophthalmology and Vision Sciences (JAM, EAM), Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada; and Division of Neurology (JAM, EAM), Department of Medicine, University of Toronto, Toronto, Canada
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Mollan SP, Menon V, Cunningham A, Plant GT, Bennetto L, Wong SH, Dayan M. Neuro-ophthalmology in the United Kingdom: providing a sustainable, safe and high-quality service for the future. Eye (Lond) 2024; 38:2235-2237. [PMID: 38778141 PMCID: PMC11306774 DOI: 10.1038/s41433-024-03141-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/29/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, B15 2GW, Birmingham, UK.
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Vaishnavi Menon
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, B15 2GW, Birmingham, UK
| | - Alan Cunningham
- Newcastle Eye Centre, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | | | - Luke Bennetto
- Department of Neurology, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
- Moorfields Eye Hospital NHS Foundation Trust, City Road, London, UK
| | - Sui H Wong
- Guys & St Thomas' NHS Foundation Trust, London, UK
| | - Margaret Dayan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, B15 2GW, Birmingham, UK
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11
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Laviers H, Petzold A, Braithwaite T. How far should I manage acute optic neuritis as an ophthalmologist? A United Kingdom perspective. Eye (Lond) 2024; 38:2238-2245. [PMID: 38867071 PMCID: PMC11306244 DOI: 10.1038/s41433-024-03164-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 05/07/2024] [Accepted: 06/04/2024] [Indexed: 06/14/2024] Open
Abstract
Optic neuritis (ON) is an inflammation of or around the optic nerve, frequently caused by infectious or immune-mediated inflammatory disorders. In the UK, its strongest association is with Multiple Sclerosis (MS), though the combined prevalence of other associated infectious and immune-mediated inflammatory diseases (I-IMID) is similar to that of MS-ON. Prompt identification and understanding of ON's underlying cause informs tailored management and prognosis. Several IMIDs linked to ON, such as aquaporin-4 antibody-associated optic neuritis (AQP4-ON), myelin oligodendrocyte glycoprotein antibody-associated optic neuritis (MOG-ON), and neuro-sarcoidosis, show remarkable response to corticosteroid treatment. Therefore, urgent investigation and treatment are crucial in cases 'atypical' for MS-ON. Following the 1992 Optic Neuritis Treatment Trial, clinical practice has evolved, with short-course high-dose corticosteroids considered safe and effective for most people. Timely recognition of patients who could benefit is critical to avoid irreversible vision loss. This review provides a practical guide and a summary of evidence on the investigation and management of acute optic neuritis. It reflects the knowledge and limitations of current evidence, framed through the neuro-ophthalmic perspective of clinical practice at multiple UK academic centres.
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Affiliation(s)
- Heidi Laviers
- The Medical Eye Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Ophthalmology, King's College Hospital, London, UK
| | - Axel Petzold
- Neuro-ophthalmology Service, Moorfields Eye Hospital, London, UK
- Neuro-ophthalmology Service, The National Hospital for Neurology and Neurosurgery, London, UK
- Amsterdam University Medical Center (AUMC), Amsterdam, Netherlands
| | - Tasanee Braithwaite
- The Medical Eye Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.
- The School of Immunology and Microbial Science and The School of Life Course and Population Sciences, King's College London, London, UK.
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12
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Gyabaah F, Petersen C, Bateman E, Deoker A. Acute-Onset Blindness in a Patient Diagnosed With Myelin Oligodendrocyte Glycoprotein Antibody Disease (MOG-AD): A Case Report. Cureus 2024; 16:e61767. [PMID: 38975430 PMCID: PMC11227435 DOI: 10.7759/cureus.61767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2024] [Indexed: 07/09/2024] Open
Abstract
Myelin oligodendrocyte glycoprotein antibody disease (MOG-AD) poses a diagnostic challenge, often masquerading as other neurological disorders such as multiple sclerosis and aquaporin-4-positive neuromyelitis optica spectrum disorder. The deceptive clinical similarities demand a nuanced approach to differentiate these conditions effectively. This entails an extensive evaluation encompassing a meticulous medical history, advanced magnetic resonance imaging (MRI), cerebrospinal fluid analysis, and serum studies. In this context, we present a compelling case involving a 28-year-old Hispanic female with a history of migraine headache. She sought medical attention due to acute peripheral vision loss, ultimately diagnosed as MOG-AD through a comprehensive clinical assessment coupled with specific diagnostic tests. This case underscores the critical importance of precision in diagnostic procedures to ensure accurate identification and subsequent tailored treatment for MOG-AD, avoiding potential pitfalls associated with its resemblance to other neurological disorders.
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Affiliation(s)
- Frederick Gyabaah
- Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Cyrena Petersen
- Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Emily Bateman
- Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Abhizith Deoker
- Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
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13
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Biousse V, Najjar RP, Tang Z, Lin MY, Wright DW, Keadey MT, Wong TY, Bruce BB, Milea D, Newman NJ. Application of a Deep Learning System to Detect Papilledema on Nonmydriatic Ocular Fundus Photographs in an Emergency Department. Am J Ophthalmol 2024; 261:199-207. [PMID: 37926337 DOI: 10.1016/j.ajo.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE The Fundus photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) studies showed that ED providers poorly recognized funduscopic findings in patients in the ED. We tested a modified version of the Brain and Optic Nerve Study Artificial Intelligence (BONSAI) deep learning system on nonmydriatic fundus photographs from the FOTO-ED studies to determine if the deep learning system could have improved the detection of papilledema had it been available to ED providers as a real-time diagnostic aid. DESIGN Retrospective secondary analysis of a cohort of patients included in the FOTO-ED studies. METHODS The testing data set included 1608 photographs obtained from 828 patients in the FOTO-ED studies. Photographs were reclassified according to the optic disc classification system used by the deep learning system ("normal optic discs," "papilledema," and "other optic disc abnormalities"). The system's performance was evaluated by calculating the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity using a 1-vs-rest strategy, with reference to expert neuro-ophthalmologists. RESULTS The BONSAI deep learning system successfully distinguished normal from abnormal optic discs (AUC 0.92 [95% confidence interval {CI} 0.90-0.93]; sensitivity 75.6% [73.7%-77.5%] and specificity 89.6% [86.3%-92.8%]), and papilledema from normal and others (AUC 0.97 [0.95-0.99]; sensitivity 84.0% [75.0%-92.6%] and specificity 98.9% [98.5%-99.4%]). Six patients with missed papilledema in 1 eye were correctly identified by the deep learning system as having papilledema in the other eye. CONCLUSIONS The BONSAI deep learning system was able to reliably identify papilledema and normal optic discs on nonmydriatic photographs obtained in the FOTO-ED studies. Our deep learning system has excellent potential as a diagnostic aid in EDs and non-ophthalmology clinics equipped with nonmydriatic fundus cameras. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
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Affiliation(s)
- Valérie Biousse
- From the Department of Ophthalmology (V.B., M.Y.L., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA; Department of Neurology (V.B., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Raymond P Najjar
- Singapore Eye Research Institute and Singapore National Eye Centre (R.P.N., Z.T., T.Y.W., D.M.), Singapore; Duke-NUS Medical School (R.P.N., T.Y.W., D.M.), National University of Singapore, Singapore; Eye N' Brain Research Group (R.P.N.), Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Center for Innovation and Precision Eye Health (R.P.N.), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Zhiqun Tang
- Singapore Eye Research Institute and Singapore National Eye Centre (R.P.N., Z.T., T.Y.W., D.M.), Singapore
| | - Mung Yan Lin
- From the Department of Ophthalmology (V.B., M.Y.L., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA
| | - David W Wright
- Department of Emergency Medicine (D.W.W., M.T.K.), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Matthew T Keadey
- Department of Emergency Medicine (D.W.W., M.T.K.), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tien Y Wong
- Singapore Eye Research Institute and Singapore National Eye Centre (R.P.N., Z.T., T.Y.W., D.M.), Singapore; Duke-NUS Medical School (R.P.N., T.Y.W., D.M.), National University of Singapore, Singapore; Tsinghua Medicine (T.Y.W.), Tsinghua University, China
| | - Beau B Bruce
- From the Department of Ophthalmology (V.B., M.Y.L., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA; Department of Neurology (V.B., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA; Rollins School of Public Health (B.B.B.), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dan Milea
- Singapore Eye Research Institute and Singapore National Eye Centre (R.P.N., Z.T., T.Y.W., D.M.), Singapore; Duke-NUS Medical School (R.P.N., T.Y.W., D.M.), National University of Singapore, Singapore
| | - Nancy J Newman
- From the Department of Ophthalmology (V.B., M.Y.L., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA; Department of Neurology (V.B., B.B.B., N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA; Department of Neurological Surgery (N.J.N.), Emory University School of Medicine, Atlanta, Georgia, USA
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14
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Waisberg E, Ong J, Zaman N, Kamran SA, Tavakkoli A, Lee AG. Impact of COVID-19 on Neuro-Ophthalmology in the United States: A National Survey. Can J Neurol Sci 2024; 51:233-237. [PMID: 36971367 DOI: 10.1017/cjn.2023.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
PURPOSE To evaluate the impacts of the COVID-19 on neuro-ophthalmology practice in the United States. DESIGN Cross-sectional study. METHODS The North American Neuro-ophthalmology Society distributed a survey on the impact of COVID-19 on neuro-ophthalmic practice to its members. The survey consisted of 15 questions regarding the impact of the pandemic on neuro-ophthalmic practice and perspectives. RESULTS Twenty-eight neuro-ophthalmologists practicing in the United States responded to our survey. In this survey, 64% of survey respondents were male (n = 18), while 36% were female (n = 10). The average age of a respondent was 55 years old. According to 77% of survey respondents, various neuro-ophthalmic diseases were reported to have worsened during the pandemic including idiopathic intracranial hypertension, compressive optic neuropathy, optic neuritis, and giant cell arteritis. CONCLUSIONS This survey represents one of the largest studies to describe the impact of the COVID-19 pandemic of neuro-ophthalmology. Given the underrepresentation of neuro-ophthalmology in the United States as described in the literature, this study strengthens the need for more neuro-ophthalmologists to provide timely care, particularly during the pandemic. Further interventions to incentivize the pursuit of neuro-ophthalmology training may help combat the effects of COVID-19 on neuro-ophthalmic conditions.
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Affiliation(s)
- Ethan Waisberg
- University College, Dublin School of Medicine, Belfield, Dublin, Ireland
| | - Joshua Ong
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nasif Zaman
- Human-Machine Perception Laboratory, Department of Computer Science and Engineering, University of Nevada, Reno, Nevada, USA
| | - Sharif Amit Kamran
- Human-Machine Perception Laboratory, Department of Computer Science and Engineering, University of Nevada, Reno, Nevada, USA
| | - Alireza Tavakkoli
- Human-Machine Perception Laboratory, Department of Computer Science and Engineering, University of Nevada, Reno, Nevada, USA
| | - Andrew G Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
- Center for Space Medicine, Baylor College of Medicine, Houston, Texas, USA
- The Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York, USA
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, Texas, USA
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Texas A&M College of Medicine, Texas, USA
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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15
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Song A, Lusk JB, Roh KM, Hsu ST, Valikodath NG, Lad EM, Muir KW, Engelhard MM, Limkakeng AT, Izatt JA, McNabb RP, Kuo AN. RobOCTNet: Robotics and Deep Learning for Referable Posterior Segment Pathology Detection in an Emergency Department Population. Transl Vis Sci Technol 2024; 13:12. [PMID: 38488431 PMCID: PMC10946693 DOI: 10.1167/tvst.13.3.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/31/2024] [Indexed: 03/19/2024] Open
Abstract
Purpose To evaluate the diagnostic performance of a robotically aligned optical coherence tomography (RAOCT) system coupled with a deep learning model in detecting referable posterior segment pathology in OCT images of emergency department patients. Methods A deep learning model, RobOCTNet, was trained and internally tested to classify OCT images as referable versus non-referable for ophthalmology consultation. For external testing, emergency department patients with signs or symptoms warranting evaluation of the posterior segment were imaged with RAOCT. RobOCTNet was used to classify the images. Model performance was evaluated against a reference standard based on clinical diagnosis and retina specialist OCT review. Results We included 90,250 OCT images for training and 1489 images for internal testing. RobOCTNet achieved an area under the curve (AUC) of 1.00 (95% confidence interval [CI], 0.99-1.00) for detection of referable posterior segment pathology in the internal test set. For external testing, RAOCT was used to image 72 eyes of 38 emergency department patients. In this set, RobOCTNet had an AUC of 0.91 (95% CI, 0.82-0.97), a sensitivity of 95% (95% CI, 87%-100%), and a specificity of 76% (95% CI, 62%-91%). The model's performance was comparable to two human experts' performance. Conclusions A robotically aligned OCT coupled with a deep learning model demonstrated high diagnostic performance in detecting referable posterior segment pathology in a cohort of emergency department patients. Translational Relevance Robotically aligned OCT coupled with a deep learning model may have the potential to improve emergency department patient triage for ophthalmology referral.
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Affiliation(s)
- Ailin Song
- Duke University School of Medicine, Durham, NC, USA
- Department of Ophthalmology, Duke University, Durham, NC, USA
| | - Jay B. Lusk
- Duke University School of Medicine, Durham, NC, USA
| | - Kyung-Min Roh
- Department of Ophthalmology, Duke University, Durham, NC, USA
| | - S. Tammy Hsu
- Department of Ophthalmology, Duke University, Durham, NC, USA
| | | | - Eleonora M. Lad
- Department of Ophthalmology, Duke University, Durham, NC, USA
| | - Kelly W. Muir
- Department of Ophthalmology, Duke University, Durham, NC, USA
| | - Matthew M. Engelhard
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | | | - Joseph A. Izatt
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Ryan P. McNabb
- Department of Ophthalmology, Duke University, Durham, NC, USA
| | - Anthony N. Kuo
- Department of Ophthalmology, Duke University, Durham, NC, USA
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
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16
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Margolis TP, Galor A. Controllable Errors in the Management of Infectious Keratitis. Cornea 2024; 43:137-140. [PMID: 38155400 PMCID: PMC11349038 DOI: 10.1097/ico.0000000000003417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Affiliation(s)
- Todd P Margolis
- John F. Hardesty Department of Ophthalmology and Visual Sciences, Washington University, St. Louis, MO
| | - Anat Galor
- Miami Veterans Administration Medical Center, Miami, FL; and
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
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17
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Lin MY, Najjar RP, Tang Z, Cioplean D, Dragomir M, Chia A, Patil A, Vasseneix C, Peragallo JH, Newman NJ, Biousse V, Milea D. The BONSAI (Brain and Optic Nerve Study with Artificial Intelligence) deep learning system can accurately identify pediatric papilledema on standard ocular fundus photographs. J AAPOS 2024; 28:103803. [PMID: 38216117 DOI: 10.1016/j.jaapos.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/26/2023] [Accepted: 10/15/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Pediatric papilledema often reflects an underlying severe neurologic disorder and may be difficult to appreciate, especially in young children. Ocular fundus photographs are easy to obtain even in young children and in nonophthalmology settings. The aim of our study was to ascertain whether an improved deep-learning system (DLS), previously validated in adults, can accurately identify papilledema and other optic disk abnormalities in children. METHODS The DLS was tested on mydriatic fundus photographs obtained in a multiethnic pediatric population (<17 years) from three centers (Atlanta-USA; Bucharest-Romania; Singapore). The DLS's multiclass classification accuracy (ie, normal optic disk, papilledema, disks with other abnormality) was calculated, and the DLS's performance to specifically detect papilledema and normal disks was evaluated in a one-vs-rest strategy using the AUC, sensitivity and specificity, with reference to expert neuro-ophthalmologists. RESULTS External testing was performed on 898 fundus photographs: 447 patients; mean age, 10.33 (231 patients ≤10 years of age; 216, 11-16 years); 558 normal disks, 254 papilledema, 86 other disk abnormalities. Overall multiclass accuracy of the DLS was 89.6% (range, 87.8%-91.6%). The DLS successfully distinguished "normal" from "abnormal" optic disks (AUC 0.99 [0.98-0.99]; sensitivity, 87.3% [84.9%-89.8%]; specificity, 98.5% [97.6%-99.6%]), and "papilledema" from "normal and other" (AUC 0.99 [0.98-1.0]; sensitivity, 98.0% [96.8%-99.4%]; specificity, 94.1% (92.4%-95.9%)]. CONCLUSIONS Our DLS reliably distinguished papilledema from normal optic disks and other disk abnormalities in children, suggesting it could be utilized as a diagnostic aid for the assessment of optic nerve head appearance in the pediatric age group.
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Affiliation(s)
- Mung Yan Lin
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Raymond P Najjar
- Visual Neuroscience Research Group, Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Duke-NUS Medical School, Singapore; Center for Innovation & Precision Eye Health, Department of Ophthalmology and Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
| | - Zhiqun Tang
- Visual Neuroscience Research Group, Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | | | | | - Audrey Chia
- Duke-NUS Medical School, Singapore; Center for Innovation & Precision Eye Health, Department of Ophthalmology and Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Paediatric and Strabismus Service, Singapore National Eye Centre, Singapore; Myopia Research Group, Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Ajay Patil
- Department of Ophthalmology, University Hospitals Birmingham, Birmingham, England, United Kingdom
| | - Caroline Vasseneix
- Visual Neuroscience Research Group, Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Jason H Peragallo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Dan Milea
- Visual Neuroscience Research Group, Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Duke-NUS Medical School, Singapore; Angers University Hospital, Angers, France; University of Copenhagen, Denmark; Rothschild Foundation Hospital, Paris, France; Neuro-Ophthalmology Department, Singapore National Eye Centre, Singapore.
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18
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Tao BK, Vosoughi AR, Pandya BU, Ishaq J, Margolin EA, Micieli JA. Inappropriate Indexing of Case Reports to the "Papilledema" Subject Heading: A Systematic Review. J Neuroophthalmol 2023; 43:525-530. [PMID: 37307081 DOI: 10.1097/wno.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Papilledema must be managed distinctly from other causes of optic disc edema (ODE) due to its basis in raised intracranial pressure (ICP). However, evidence indicates that the term "papilledema" is widely misused across specialties to describe ODE without raised ICP. Sources of this misconception remain undiscerned. Because all physicians consult medical databases, our objective was to evaluate whether nonspecific "papilledema" subject heading definitions misleadingly associate articles on other conditions with papilledema proper. METHODS Systematic review of case reports, prospectively registered on PROSPERO (CRD42022363651). MEDLINE and Embase were searched to July 2022 for any full-length case report indexed to the "papilledema" subject heading. Studies were graded for incorrect indexing, defined as cases lacking evidence for raised ICP. Nonpapilledema diagnoses were assigned to a predefined set of diseases and pathophysiological mechanisms for subsequent comparison. RESULTS Incorrect indexing occurred in 40.67% of 949 included reports. Embase-derived studies were misindexed significantly less than MEDLINE-derived studies ( P < 0.01). There was also significant heterogeneity in incorrect indexing among specific diseases ( P = 0.0015) and mechanisms ( P = 0.0003). The most commonly misindexed diseases were uveitis (21.24% of errors), optic neuritis (13.47%), and instances with no mention of ODE (13.99%). The most commonly misindexed mechanisms were inflammation (34.97%), other mechanism (e.g., genetic; 25.91%), and ischemia (20.47%). CONCLUSIONS Database subject headings, especially from MEDLINE, do not adequately distinguish between true papilledema and other causes of ODE. Inflammatory diseases were most often incorrectly indexed among other diseases and mechanisms. Current "papilledema" subject headings should be revised to reduce the probability of misinformation.
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Affiliation(s)
- Brendan K Tao
- Faculty of Medicine (BKT), The University of British Columbia, Vancouver, Canada; Max Rady College of Medicine (ARV), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Temerty Faculty of Medicine (BUP), University of Toronto, Toronto, Canada; Michael G. DeGroote School of Medicine (JI, EAM, JAM), Faculty of Health Sciences, McMaster University, Hamilton, Canada; Department of Ophthalmology and Vision Sciences (EAM, JAM), Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada; Division of Neurology (EAM, JAM), Department of Medicine, University of Toronto, Toronto, Canada; Kensington Vision and Research Center (EAM, JAM), Toronto, Canada; St. Michael's Hospital (EAM, JAM), Toronto, Canada; Toronto Western Hospital (EAM, JAM), Toronto, Canada; and University Health Network (EAM, JAM), Toronto, Canada
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19
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Okrent Smolar AL, Ray HJ, Dattilo M, Bouthour W, Berman G, Peragallo JH, Kedar S, Pendley AM, Greene JG, Keadey MT, Wright DW, Bruce BB, Newman NJ, Biousse V. Neuro-ophthalmology Emergency Department and Inpatient Consultations at a Large Academic Referral Center. Ophthalmology 2023; 130:1304-1312. [PMID: 37544433 DOI: 10.1016/j.ophtha.2023.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/17/2023] [Accepted: 07/31/2023] [Indexed: 08/08/2023] Open
Abstract
PURPOSE Prompt neuro-ophthalmology consultation prevents diagnostic errors and improves patient outcomes. The scarcity of neuro-ophthalmologists means that the increasing outpatient demand cannot be met, prompting many emergency department (ED) referrals by non-neuro-ophthalmologists. We describe our quaternary care institution's ED and inpatient neuro-ophthalmology consultation patterns and patient outcomes. DESIGN Prospective observational study. PARTICIPANTS Consecutive neuro-ophthalmology ED and inpatient consultation requests over 1 year. METHODS We collected patient demographics, distance traveled, insurance status, referring provider details, consultation question, final diagnosis, complexity of consultation, time of consultation, and need for outpatient follow-up. MAIN OUTCOME MEASURES Consultation patterns and diagnoses, complexity, and follow-up. RESULTS Of 494 consecutive adult ED and inpatient neuro-ophthalmology consultations requested over 1 year, 241 of 494 consultations (49%) occurred at night or during weekends. Of ED consultations (322 of 494 [65%]), 127 of 322 consultations (39%) occurred during weekdays, 126 of 322 consultations (39%) occurred on weeknights, and 69 of 322 consultations (22%) occurred on weekends or holidays. Of 322 ED consultations, 225 of 322 consultations (70%) were patients who initially sought treatment in the ED with a neuro-ophthalmic chief symptom. Of the 196 patients sent to the ED by a health care professional, 148 patients (148/196 [76%]) were referred by eye care specialists (74 optometrists and 74 ophthalmologists). The most common ED referral questions were for papilledema (75 of 322 [23%]) and vision loss (72 of 322 [22%]). A total of 219 of 322 patients (68%) received a final active neuro-ophthalmic diagnosis, 222 of 322 patients (69%) were cases of high or very high complexity, and 143 of 322 patients (44%) required admission. Inpatient consultations (n = 172) were requested most frequently by hospitalists, including neurologists (71 of 172 [41%]) and oncologists (20 of 172 [12%]) for vision loss (43 of 172 [25%]) and eye movement disorders (36 of 172 [21%]) and by neurosurgeons (58 of 172 [33%]) for examination for mass or a preoperative evaluation (19 of 172 [11%]). An active neuro-ophthalmic diagnosis was confirmed in 67% of patients (116 of 172). Outpatient neuro-ophthalmology follow-up was required for 291 of 494 patients (59%). CONCLUSIONS Neuro-ophthalmology consultations are critical to the diagnosis and management in the hospital setting. In the face of a critical shortage of neuro-ophthalmologists, this study highlights the need for technological and diagnostic aids for greater outpatient access. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
| | - Hetal J Ray
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Dattilo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Walid Bouthour
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Gabriele Berman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Jason H Peragallo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Sachin Kedar
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew M Pendley
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - James G Greene
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew T Keadey
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Beau B Bruce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.
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Harada Y, Watari T, Nagano H, Suzuki T, Kunitomo K, Miyagami T, Aita T, Ishizuka K, Maebashi M, Harada T, Sakamoto T, Tomiyama S, Shimizu T. Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors. Diagnosis (Berl) 2023; 10:329-336. [PMID: 37561056 DOI: 10.1515/dx-2023-0030] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/21/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVES To assess the usefulness of case reports as sources for research on diagnostic errors in uncommon diseases and atypical presentations. CONTENT We reviewed 563 case reports of diagnostic error. The commonality of the final diagnoses was classified based on the description in the articles, Orphanet, or epidemiological data on available references; the typicality of presentation was classified based on the description in the articles and the judgment of the physician researchers. Diagnosis Error Evaluation and Research (DEER), Reliable Diagnosis Challenges (RDC), and Generic Diagnostic Pitfalls (GDP) taxonomies were used to assess the factors contributing to diagnostic errors. SUMMARY AND OUTLOOK Excluding three cases in that commonality could not be classified, 560 cases were classified into four categories: typical presentations of common diseases (60, 10.7 %), atypical presentations of common diseases (35, 6.2 %), typical presentations of uncommon diseases (276, 49.3 %), and atypical presentations of uncommon diseases (189, 33.8 %). The most important DEER taxonomy was "Failure/delay in considering the diagnosis" among the four categories, whereas the most important RDC and GDP taxonomies varied with the categories. Case reports can be a useful data source for research on the diagnostic errors of uncommon diseases with or without atypical presentations.
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Affiliation(s)
- Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Shimotsuga-Gun, Japan
| | - Takashi Watari
- General Medicine Center, Shimane University Hospital, Izumo, Japan
| | - Hiroyuki Nagano
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Kotaro Kunitomo
- National Hospital Organisation Kumamoto Medical Center, Kumamoto, Japan
| | | | - Tetsuro Aita
- Department of General Internal Medicine, Fukushima Medical University, Fukushima, Japan
| | - Kosuke Ishizuka
- Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Japan
| | | | - Taku Harada
- Division of General Medicine, Nerima Hikarigaoka Hospital, Nerima-Ku, Tokyo
| | - Tetsu Sakamoto
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Shimotsuga-Gun, Japan
| | - Shusaku Tomiyama
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Shimotsuga-Gun, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Shimotsuga-Gun, Japan
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Madadi Y, Delsoz M, Lao PA, Fong JW, Hollingsworth TJ, Kahook MY, Yousefi S. ChatGPT Assisting Diagnosis of Neuro-ophthalmology Diseases Based on Case Reports. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.13.23295508. [PMID: 37781591 PMCID: PMC10540811 DOI: 10.1101/2023.09.13.23295508] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Purpose To evaluate the efficiency of large language models (LLMs) including ChatGPT to assist in diagnosing neuro-ophthalmic diseases based on case reports. Design Prospective study. Subjects or Participants We selected 22 different case reports of neuro-ophthalmic diseases from a publicly available online database. These cases included a wide range of chronic and acute diseases that are commonly seen by neuro-ophthalmic sub-specialists. Methods We inserted the text from each case as a new prompt into both ChatGPT v3.5 and ChatGPT Plus v4.0 and asked for the most probable diagnosis. We then presented the exact information to two neuro-ophthalmologists and recorded their diagnoses followed by comparison to responses from both versions of ChatGPT. Main Outcome Measures Diagnostic accuracy in terms of number of correctly diagnosed cases among diagnoses. Results ChatGPT v3.5, ChatGPT Plus v4.0, and the two neuro-ophthalmologists were correct in 13 (59%), 18 (82%), 19 (86%), and 19 (86%) out of 22 cases, respectively. The agreement between the various diagnostic sources were as follows: ChatGPT v3.5 and ChatGPT Plus v4.0, 13 (59%); ChatGPT v3.5 and the first neuro-ophthalmologist, 12 (55%); ChatGPT v3.5 and the second neuro-ophthalmologist, 12 (55%); ChatGPT Plus v4.0 and the first neuro-ophthalmologist, 17 (77%); ChatGPT Plus v4.0 and the second neuro-ophthalmologist, 16 (73%); and first and second neuro-ophthalmologists 17 (17%). Conclusions The accuracy of ChatGPT v3.5 and ChatGPT Plus v4.0 in diagnosing patients with neuro-ophthalmic diseases was 59% and 82%, respectively. With further development, ChatGPT Plus v4.0 may have potential to be used in clinical care settings to assist clinicians in providing quick, accurate diagnoses of patients in neuro-ophthalmology. The applicability of using LLMs like ChatGPT in clinical settings that lack access to subspeciality trained neuro-ophthalmologists deserves further research.
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Affiliation(s)
- Yeganeh Madadi
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mohammad Delsoz
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Priscilla A. Lao
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joseph W. Fong
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - TJ Hollingsworth
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Malik Y. Kahook
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Siamak Yousefi
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Genetics, Genomics, and Informatics, University of Tennessee Health Science Center, Memphis, TN, USA
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22
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Liu K, Liu S, Tan X, Li W, Wang L, Li X, Xu X, Fu Y, Liu X, Hong J, Lin H, Yang H. Deep learning system for distinguishing optic neuritis from non-arteritic anterior ischemic optic neuropathy at acute phase based on fundus photographs. Front Med (Lausanne) 2023; 10:1188542. [PMID: 37457581 PMCID: PMC10339343 DOI: 10.3389/fmed.2023.1188542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose To develop a deep learning system to differentiate demyelinating optic neuritis (ON) and non-arteritic anterior ischemic optic neuropathy (NAION) with overlapping clinical profiles at the acute phase. Methods We developed a deep learning system (ONION) to distinguish ON from NAION at the acute phase. Color fundus photographs (CFPs) from 871 eyes of 547 patients were included, including 396 ON from 232 patients and 475 NAION from 315 patients. Efficientnet-B0 was used to train the model, and the performance was measured by calculating the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). Also, Cohen's kappa coefficients were obtained to compare the system's performance to that of different ophthalmologists. Results In the validation data set, the ONION system distinguished between acute ON and NAION achieved the following mean performance: time-consuming (23 s), AUC 0.903 (95% CI 0.827-0.947), sensitivity 0.796 (95% CI 0.704-0.864), and specificity 0.865 (95% CI 0.783-0.920). Testing data set: time-consuming (17 s), AUC 0.902 (95% CI 0.832-0.944), sensitivity 0.814 (95% CI 0.732-0.875), and specificity 0.841 (95% CI 0.762-0.897). The performance (κ = 0.805) was comparable to that of a retinal expert (κ = 0.749) and was better than the other four ophthalmologists (κ = 0.309-0.609). Conclusion The ONION system performed satisfactorily distinguishing ON from NAION at the acute phase. It might greatly benefit the challenging differentiation between ON and NAION.
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Affiliation(s)
- Kaiqun Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Shaopeng Liu
- School of Computer Science, Guangdong Polytechnic Normal University, Guangzhou, China
| | - Xiao Tan
- Department of Ophthalmology, Shenzhen Aier Eye Hospital Affiliated to Jinan University, Shenzhen, Guangdong, China
| | - Wangting Li
- Department of Ophthalmology, Shenzhen Eye Hospital, Shenzhen, Guangdong, China
| | - Ling Wang
- Department of Ophthalmology, the First Hospital of Nanchang, The Third Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xinnan Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiaoyu Xu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yue Fu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiaoning Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Jiaming Hong
- School of Medical Information Engineering, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Haotian Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Hui Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
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23
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Presumptive Idiopathic Intracranial Hypertension Based on Neuroimaging Findings: A Referral Pattern Study. J Neuroophthalmol 2023; 43:55-62. [PMID: 36166790 DOI: 10.1097/wno.0000000000001660] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Radiologic findings of intracranial hypertension (RAD-IH) are common in idiopathic intracranial hypertension (IIH) patients. Paralleling the increasing rates of obesity, the burden of IIH is growing. Urgent neuro-ophthalmology consultations for possible IIH in patients with incidentally detected RAD-IH are increasing, with many patients receiving unnecessary lumbar punctures (LPs) and treatments. This retrospective observational study aimed to determine the prevalence of neuro-ophthalmology consultations for RAD-IH, rate of funduscopic examination by referring providers, prevalence of papilledema, outcomes after neuro-ophthalmic evaluation, and rates of misdiagnosis. METHODS Records of 1,262 consecutive new patients seen in one neuro-ophthalmology clinic from January 2019 to January 2020 were reviewed. We identified patients who were: 1) referred with concern for IIH because of findings of RAD-IH; 2) referred for "papilledema"; 3) referred with a diagnosis of IIH; and 4) referred for spontaneous cranial cerebrospinal fluid (CSF) leaks. In addition to basic demographic profiles for all groups, detailed information was collected for patients referred solely for RAD-IH, including referral patterns, prior history of IIH, previous LPs, prior medical or surgical treatment(s), risk factors for increased intracranial pressure (ICP), presenting symptoms, radiologic features observed on neuroimaging, and final disposition. When available, the neuroimaging was reviewed by an expert neuroradiologist. RESULTS Of 1,262 consecutive new patients, 66 (5%) were referred specifically for RAD-IH; most referrals came from neurologists (58%); 8/66 (12%) patients had papilledema; 16/66 (24%) patients had prior LP and 13/66 (20%) were already treated based on MRI findings; and 22/66 (33%) patients had ≤2 RAD-IH. Only 34/66 (52%) of patients referred for RAD-IH had prior funduscopic examinations. We confirmed papilledema in 26/82 (32%) patients referred for "papilledema." Only 29/83 (35%) patients referred with a diagnosis of IIH had active papilledema, and 3/16 (19%) patients with spontaneous CSF leaks had papilledema. In total, 247/1,262 (20%) new patients were referred to our clinic over 1 year with concern for IIH, among whom only 66 (27%) were confirmed to have active IIH with papilledema. CONCLUSIONS One in 5 new patient referrals seen in our neuro-ophthalmology clinic were referred because of concern for increased ICP, but only 1/4 had active papilledema. Most patients referred for isolated RAD-IH do not have papilledema, many having undergone unnecessary LPs and treatments. The burden of these "rule-out IIH" consultations is overwhelming and will only continue to increase with the concurrent rise of obesity and IIH, straining the already limited neuro-ophthalmologic resources available in the US.
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Xu TT, Kung FF, Lai KE, Ko MW, Brodsky MC, Bhatti MT, Chen JJ. Interprofessional Electronic Consultations for the Diagnosis and Management of Neuro-Ophthalmic Conditions. J Neuroophthalmol 2023; 43:34-39. [PMID: 36166791 DOI: 10.1097/wno.0000000000001643] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Interprofessional electronic consultation (eConsult) is a telemedicine modality in which consulting providers review outside records and provide recommendations without in-person consultation. The purpose of this study was to describe the utilization of eConsults in the management of neuro-ophthalmic conditions. METHODS Retrospective cohort study of all patients who received an eConsult for a neuro-ophthalmic condition at a single quaternary referral center from 2018 to 2020. Main outcome measures included proportion of eConsults in which sufficient data were provided to the neuro-ophthalmologist to generate a definitive management decision, proportion of patients for whom an in-person neuro-ophthalmology evaluation was recommended, and the eConsult's impact on patient care. RESULTS Eighty eConsults were conducted on 78 patients during the 3-year study period. Forty-eight (60.0%) subjects were female, mean age was 54 years, and 65 (81.3%) were White. The median time from eConsult request to completion was 4 days (range: 0-34 days). The most frequent eConsult questions were vision/visual field disturbances in 28 (35.0%) cases, optic neuropathies in 22 (27.5%), and optic disc edema in 17 (21.3%). At the time of eConsult, sufficient prior information was provided in 35 (43.8%) cases for the neuro-ophthalmologist to provide a definitive management decision. In 45 (56.3%) eConsults, further diagnostic testing was recommended. In-person neuro-ophthalmology consultation was recommended in 24 (30.0%) cases. Sixty-one (76.3%) eConsults provided diagnostic and/or treatment direction, and 12 (15.0%) provided reassurance. CONCLUSION eConsults increase access to timely neuro-ophthalmic care and provide diagnostic and treatment direction to non-neuro-ophthalmology providers when sufficient information is provided at the time of eConsult.
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Affiliation(s)
- Timothy T Xu
- Department of Ophthalmology (TTX, FFK, MCB, MTB, JJC), Mayo Clinic, Rochester, Minnesota; Department of Neurology (MCB, MTB, JJC), Mayo Clinic, Rochester, Minnesota; Circle City Neuro-Ophthalmology (KEL), Carmel, Indiana; Neuro-Ophthalmology Section (KEL), Midwest Eye Institute, Carmel, Indiana; Ophthalmology Service (KEL), Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana; Department of Ophthalmology (KEL, MWK), Indiana University School of Medicine, Indianapolis, Indiana; and Department of Neurology and Neurosurgery (MWK), Indiana University School of Medicine, Indianapolis, Indiana
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Tao B, Vosoughi A, Margolin E, Micieli JA. Inappropriate Use of the Term "Papilledema" in the Medical Literature: A Systematic Review of Case Reports across Specialties. Ophthalmology 2023; 130:129-136. [PMID: 36195254 DOI: 10.1016/j.ophtha.2022.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/07/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022] Open
Abstract
TOPIC The term "papilledema" is often misused in different ways when describing nonintracranial pressure-related optic disc edema (ODE) or on fundoscopic examination. However, the extent of these errors is unknown among case reports. CLINICAL RELEVANCE "Papilledema" refers to ODE secondary to raised intracranial pressure (ICP). Papilledema is a leading reason for referral to neuro-ophthalmologists. In any specialty setting, papilledema must be distinguished from other causes of ODE because it implies a unique pathophysiology and management strategy. If managed inappropriately, papilledema may cause permanent vision loss. METHODS Cross-sectional evidence-based study with protocol registered on Open Science Framework (digital object identifier: 10.17605/OSF.IO/BUQS3). From Ovid MEDLINE and EMBASE, we included case reports with "papilledema" in their title, abstract, or article keywords between January 2011 and March 2022. Studies were graded for the following errors: type 1 (using "papilledema" without evidence of elevated ICP), type 2 (declaring "papilledema" on examination before finding evidence of elevated ICP), type 3 (both errors type 1 and 2), or no error. RESULTS Among 722 case reports, there was a total of 482 errors (66.8%). There were 12 type 1 errors, 360 type 2 errors, 110 type 3 errors, and 240 studies with no errors. Ophthalmology, neurology, and neurosurgery were the most represented fields, yet only ophthalmology had a low prevalence of errors among all specialties. Regardless, all specialties with at least 10 included reports had a high error prevalence (>30%). Reduced error prevalence was significantly associated with higher impact factor journals, non-open-access publication models, and origin countries with an English official language. Error prevalence was not significantly associated with publication year. Also, the relationship between article citation counts and the prevalence of any type of error did not reach significance. Risk of bias analysis indicated that error occurrence was unrelated to the quality of case report study design. CONCLUSION "Papilledema" is widely misused even among ophthalmology case reports. When allowed to propagate, this error can mislead care delivery to patients with ODE. Our results, although limited to case reports, indicate a need for more thorough peer-review standards and neuro-ophthalmology exposure in medical education.
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Affiliation(s)
- Brendan Tao
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Amir Vosoughi
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Edward Margolin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jonathan A Micieli
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Kensington Vision and Research Centre, Toronto, Ontario, Canada; Department of Ophthalmology, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada; Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
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Biousse V, Danesh-Meyer HV, Saindane AM, Lamirel C, Newman NJ. Imaging of the optic nerve: technological advances and future prospects. Lancet Neurol 2022; 21:1135-1150. [DOI: 10.1016/s1474-4422(22)00173-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 04/06/2022] [Accepted: 04/13/2022] [Indexed: 01/02/2023]
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Muro-Fuentes EA, Stunkel L. Diagnostic Error in Neuro-ophthalmology: Avenues to Improve. Curr Neurol Neurosci Rep 2022; 22:243-256. [PMID: 35320466 PMCID: PMC8940596 DOI: 10.1007/s11910-022-01189-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/06/2022]
Abstract
Purpose of Review To highlight potential avenues to reduce preventable diagnostic error of neuro-ophthalmic conditions and avoid patient harm. Recent Findings Recent prospective studies and studies of patient harm have advanced our understanding. Additionally, recent studies of fundus photography, telemedicine, and artificial intelligence highlight potential avenues for diagnostic improvement. Summary Diagnostic error of neuro-ophthalmic conditions can often be traced to failure to gather an adequate history, perform a complete physical exam, obtain adequate/appropriate neuroimaging, and generate a complete, appropriate differential diagnosis. Improving triage and identification of neuro-ophthalmic conditions by other providers and increasing access to subspecialty neuro-ophthalmology evaluation are essential avenues to reduce diagnostic error. Further research should evaluate the relationship between misdiagnosis and patient harm, and help identify the most impactful potential targets for improvement.
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Affiliation(s)
| | - Leanne Stunkel
- John F. Hardesty, MD Department of Ophthalmology and Visual Sciences and Department of Neurology, Washington University in St. Louis, 660 S. Euclid Ave, Campus Box 8096, St. Louis, MO, 63110, USA
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Moss HE, Margolin EA, Lee AG, Van Stavern GP. Should Lumbar Puncture Be Required to Diagnose Every Patient With Idiopathic Intracranial Hypertension? J Neuroophthalmol 2021; 41:379-384. [PMID: 34415272 PMCID: PMC9159906 DOI: 10.1097/wno.0000000000001373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Heather E Moss
- Departments of Ophthalmology and Neurology & Neurological Sciences (HEM), Stanford University, Stanford, California; Department of Ophthalmology and Visual Sciences (EM), University of Toronto, Toronto, Ontario; Blanton Eye Institute (AGL), Houston Methodist Hospital, Houston, Texas; and Department of Ophthalmology and Visual Sciences (GPVS), Washington University in St. Louis School of Medicine, St. Louis, Missouri
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Moss HE, Ko MW, Mackay DD, Chauhan D, Gutierrez KG, Villegas NC, Lai KE. The Impact of COVID-19 on Neuro-Ophthalmology Office Visits and Adoption of Telemedicine Services. J Neuroophthalmol 2021; 41:362-367. [PMID: 34415270 PMCID: PMC9159905 DOI: 10.1097/wno.0000000000001356] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The COVID-19 public health emergency (PHE) has significantly changed medical practice in the United States, including an increase in the utilization of telemedicine. Here, we characterize change in neuro-ophthalmic care delivery during the early COVID-19 PHE, including a comparison of care delivered via telemedicine and in office. METHODS Neuro-ophthalmology outpatient encounters from 3 practices in the United States (4 providers) were studied during the early COVID-19 PHE (March 15, 2020-June 15, 2020) and during the same dates 1 year prior. For unique patient visits, patient demographics, visit types, visit format, and diagnosis were compared between years and between synchronous telehealth and in-office formats for 2020. RESULTS There were 1,276 encounters for 1,167 patients. There were 30% fewer unique patient visits in 2020 vs 2019 (477 vs 670) and 55% fewer in-office visits (299 vs 670). Compared with 2019, encounters in 2020 were more likely to be established, to occur via telemedicine and to relate to an efferent diagnosis. In 2020, synchronous telehealth visits were more likely to be established compared with in-office encounters. CONCLUSIONS In the practices studied, a lower volume of neuro-ophthalmic care was delivered during the early COVID-19 public health emergency than in the same period in 2019. The type of care shifted toward established patients with efferent diagnoses and the modality of care shifted toward telemedicine.
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Affiliation(s)
- Heather E. Moss
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
- Department of Neurology & Neurological Sciences, Stanford University, Palo Alto, CA, USA
| | - Melissa W. Ko
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Devin D. Mackay
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Divya Chauhan
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | - Kevin E. Lai
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
- Ophthalmology Service, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
- Neuro-Ophthalmology Section, Midwest Eye Institute, Carmel, IN, USA
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Subramanian PS. Protecting Patients from the Harm We Can Cause. Ophthalmology 2021; 128:1363-1364. [PMID: 34420596 DOI: 10.1016/j.ophtha.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/30/2022] Open
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Re: Stunkel et al.: Patient harm due to diagnostic error of neuro-ophthalmologic conditions (Ophthalmology. 2021;128:1356-1362). Ophthalmology 2021; 128:e42. [PMID: 34103188 DOI: 10.1016/j.ophtha.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/07/2021] [Indexed: 11/22/2022] Open
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Maher ME, Kingston W. Retinal Migraine: Evaluation and Management. Curr Neurol Neurosci Rep 2021; 21:35. [PMID: 33973068 DOI: 10.1007/s11910-021-01122-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize the last 15 years of literature and case reports detailing retinal migraine-an uncommon and somewhat poorly understood migraine variant. RECENT FINDINGS In the last 15 years, only 12 cases of retinal migraine have been outlined. Similar to other migraine statistics, retinal migraine appears to affect women more so than men and presents with unilateral headache which tends to be ipsilateral to the side of vision loss. The pathophysiology may relate to vasoconstriction of retinal vessels, as evidenced by ictal fundus photography in the past few years. Retinal migraine is a rare entity, with a paucity of described cases in the literature. Retinal migraine is a diagnosis of exclusion, as monocular vision loss might be ascribed to several concerning disorders requiring urgent diagnosis and treatment, and any patient presenting as such should be thoroughly investigated. Patients suffering from retinal migraine appear to respond to typical migraine abortive therapies including NSAIDs and migraine prophylactic medications.
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Affiliation(s)
- Monica E Maher
- Division of Neurology, University of Toronto, Toronto, Canada
| | - William Kingston
- Division of Neurology, University of Toronto, Toronto, Canada. .,Sunnybrook Health Sciences Centre, A 455 - 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada. .,Centre for Headache, Women's College Hospital, Toronto, Canada.
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