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Tan R, Teo KYC, Husain R, Tan NC, Lee QX, Hamzah H, Wong T, Aung T, Cheng CY, Lamoureux EL, Tan CS, Wong HT, Wong TY, Tan GSW. Evaluating the outcome of screening for glaucoma using colour fundus photography-based referral criteria in a teleophthalmology screening programme for diabetic retinopathy. Br J Ophthalmol 2023:bjo-2023-323339. [PMID: 37852739 DOI: 10.1136/bjo-2023-323339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/17/2023] [Indexed: 10/20/2023]
Abstract
AIMS To evaluate the effectiveness of glaucoma screening using glaucoma suspect (GS) referral criteria assessed on colour fundus photographs in Singapore's Integrated Diabetic Retinopathy Programme (SiDRP). METHODS A case-control study. This study included diabetic subjects who were referred from SiDRP with and without GS between January 2017 and December 2018 and reviewed at Singapore National Eye Centre. The GS referral criteria were based on the presence of a vertical cup-to-disc ratio (VCDR) of ≥0.65 and other GS features. The final glaucoma diagnosis confirmed from electronic medical records was retrospectively matched with GS status. The sensitivity, specificity and positive predictive value (PPV) of the test were evaluated. RESULTS Of 5023 patients (2625 with GS and 2398 without GS) reviewed for glaucoma, 451 (9.0%, 95% CI 8.2% to 9.8%) were confirmed as glaucoma. The average follow-up time was 21.5±10.2 months. Using our current GS referral criteria, the sensitivity, specificity and PPV were 81.6% (95% CI 77.7% to 85.1%), 50.6% (95% CI 49.2% to 52.1%) and 14.0% (95% CI 13.4% to 14.7%), respectively, resulting in 2257 false positive cases. Increasing the VCDR cut-off for referral to ≥0.80, the specificity increased to 93.9% (95% CI 93.1% to 94.5%) but the sensitivity decreased to 11.3% (95% CI 8.5% to 14.6%), with a PPV of 15.4% (95% CI 12.0% to 19.4%). CONCLUSIONS Opportunistic screening for glaucoma in a lower VCDR group could result in a high number of unnecessary referrals. If healthcare infrastructures are limited, targeting case findings on a larger VCDR group with high specificity will still be beneficial.
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Affiliation(s)
- Rose Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Kelvin Yi Chong Teo
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Save Sight Institute, Sydney, New South Wales, Australia
- Duke-NUS Medical School, National University of Singapore, Ophthalmology and Visual Sciences Academic Clinical Program, Singapore
- SNEC Ocular Reading Centre, Singapore National Eye Centre, Singapore
| | - Rahat Husain
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Duke-NUS Medical School, National University of Singapore, Ophthalmology and Visual Sciences Academic Clinical Program, Singapore
| | | | - Qian Xin Lee
- SNEC Ocular Reading Centre, Singapore National Eye Centre, Singapore
| | - Haslina Hamzah
- SNEC Ocular Reading Centre, Singapore National Eye Centre, Singapore
| | - Tina Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Duke-NUS Medical School, National University of Singapore, Ophthalmology and Visual Sciences Academic Clinical Program, Singapore
| | - Tin Aung
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Duke-NUS Medical School, National University of Singapore, Ophthalmology and Visual Sciences Academic Clinical Program, Singapore
| | - Ching Yu Cheng
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Duke-NUS Medical School, National University of Singapore, Ophthalmology and Visual Sciences Academic Clinical Program, Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ecosse Luc Lamoureux
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Duke-NUS Medical School, National University of Singapore, Ophthalmology and Visual Sciences Academic Clinical Program, Singapore
| | - Colin S Tan
- Duke-NUS Medical School, National University of Singapore, Ophthalmology and Visual Sciences Academic Clinical Program, Singapore
- Ophthalmology, Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapore
| | - Hon-Tym Wong
- Ophthalmology, Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapore
| | - Tien Y Wong
- Duke-NUS Medical School, National University of Singapore, Ophthalmology and Visual Sciences Academic Clinical Program, Singapore
- Singapore National Eye Centre & Singapore Eye Research Institute, Singapore
- Tsinghua Medicine, Tsinghua University, Beijing, People's Republic of China
- School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Beijing, People's Republic of China
| | - Gavin Siew Wei Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Duke-NUS Medical School, National University of Singapore, Ophthalmology and Visual Sciences Academic Clinical Program, Singapore
- SNEC Ocular Reading Centre, Singapore National Eye Centre, Singapore
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Choe S, Kim YK, Park KH, Choi HJ, Jeoung JW. Natural History of Optic Disc With Physiologic Large Cup: Incidence, Predictors of Glaucoma Conversion After Minimum 10-Year Follow-up. Am J Ophthalmol 2023; 254:150-160. [PMID: 37406843 DOI: 10.1016/j.ajo.2023.05.023] [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: 12/20/2022] [Revised: 05/16/2023] [Accepted: 05/29/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE To investigate the natural history of optic disc with physiologic large cup (PLC) (ie, vertical cup/disc ratio [VCDR] ≥0.6 without retinal nerve fiber layer defect) and the risk factors for glaucoma conversion. DESIGN Observational retrospective cohort study. METHODS Subjects who underwent a health screening examination at Seoul National University Hospital Healthcare System Gangnam Center from 2003 to 2010 (n = 76,030) were involved. The prevalence of PLC in the cohort was analyzed. The incidence rate of glaucoma conversion was estimated per 100 person-years among cases with a follow-up period longer than 10 years. Multivariate Cox proportional hazards regression was used to identify ocular and systemic factors associated with glaucoma conversion. RESULTS Among 74,617 eligible subjects, 3569 subjects (4.8%) had PLC. Of those with a follow-up period longer than 10 years (n = 859), the incidence rate of glaucoma conversion was 0.95 per 100 person-years. A total of 12.1% of PLC eyes progressed to glaucoma after 8.7 ± 3.9 years (range, 2.0-16.5 years). Higher VCDR (adjusted hazard ratio [aHR] = 4.36; 95% CI = 2.675-7.103), violation of the inferior superior nasal temporal neuroretinal rim thickness rule (aHR = 1.86; 95% CI = 1.057-3.258), presence of retinal arterial sclerosis (aHR = 1.63; 95% CI = 1.040-2.550), and lower total bilirubin level (aHR = 0.58; 95% CI = 0.340-0.991) were associated with glaucoma development. CONCLUSION This study identified the prevalence of PLC as well as the incidence rate of glaucoma conversion and the risk factors for glaucoma development in PLC eyes. The natural history of PLC may help clinicians to better understand its risk factors and the specific management needs of their patients.
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Affiliation(s)
- Sooyeon Choe
- Department of Ophthalmology (S.C.), Chungnam National University Hospital, Daejeon, Republic of Korea; Department of Ophthalmology (S.C.), Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Young Kook Kim
- Department of Ophthalmology (Y.K.K., K.H.P., H.J.C., J.W.J.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Ophthalmology (Y.K.K., K.H.P., H.J.C., J.W.J.), Seoul National University Hospital, Seoul, Republic of Korea
| | - Ki Ho Park
- Department of Ophthalmology (Y.K.K., K.H.P., H.J.C., J.W.J.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Ophthalmology (Y.K.K., K.H.P., H.J.C., J.W.J.), Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyuk Jin Choi
- Department of Ophthalmology (Y.K.K., K.H.P., H.J.C., J.W.J.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Ophthalmology (Y.K.K., K.H.P., H.J.C., J.W.J.), Seoul National University Hospital, Seoul, Republic of Korea; Department of Ophthalmology (H.J.C.), Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea.
| | - Jin Wook Jeoung
- Department of Ophthalmology (Y.K.K., K.H.P., H.J.C., J.W.J.), Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Ophthalmology (Y.K.K., K.H.P., H.J.C., J.W.J.), Seoul National University Hospital, Seoul, Republic of Korea.
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Haider A, Arsalan M, Park C, Sultan H, Park KR. Exploring deep feature-blending capabilities to assist glaucoma screening. Appl Soft Comput 2022. [DOI: 10.1016/j.asoc.2022.109918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Panda SK, Cheong H, Tun TA, Chuangsuwanich T, Kadziauskiene A, Senthil V, Krishnadas R, Buist ML, Perera S, Cheng CY, Aung T, Thiery AH, Girard MJ. The three-dimensional structural configuration of the central retinal vessel trunk and branches as a glaucoma biomarker. Am J Ophthalmol 2022; 240:205-216. [PMID: 35247336 DOI: 10.1016/j.ajo.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE To assess whether the 3-dimensional (3D) structural configuration of the central retinal vessel trunk and its branches (CRVT&B) could be used as a diagnostic marker for glaucoma. DESIGN Retrospective, deep-learning approach diagnosis study. METHODS We trained a deep learning network to automatically segment the CRVT&B from the B-scans of the optical coherence tomography (OCT) volume of the optic nerve head. Subsequently, 2 different approaches were used for glaucoma diagnosis using the structural configuration of the CRVT&B as extracted from the OCT volumes. In the first approach, we aimed to provide a diagnosis using only 3D convolutional neural networks and the 3D structure of the CRVT&B. For the second approach, we projected the 3D structure of the CRVT&B orthographically onto sagittal, frontal, and transverse planes to obtain 3 two-dimensional (2D) images, and then a 2D convolutional neural network was used for diagnosis. The segmentation accuracy was evaluated using the Dice coefficient, whereas the diagnostic accuracy was assessed using the area under the receiver operating characteristic curves (AUCs). The diagnostic performance of the CRVT&B was also compared with that of retinal nerve fiber layer (RNFL) thickness (calculated in the same cohorts). RESULTS Our segmentation network was able to efficiently segment retinal blood vessels from OCT scans. On a test set, we achieved a Dice coefficient of 0.81 ± 0.07. The 3D and 2D diagnostic networks were able to differentiate glaucoma from nonglaucoma subjects with accuracies of 82.7% and 83.3%, respectively. The corresponding AUCs for the CRVT&B were 0.89 and 0.90, higher than those obtained with RNFL thickness alone (AUCs ranging from 0.74 to 0.80). CONCLUSIONS Our work demonstrated that the diagnostic power of the CRVT&B is superior to that of a gold-standard glaucoma parameter, that is, RNFL thickness. Our work also suggested that the major retinal blood vessels form a "skeleton"-the configuration of which may be representative of major optic nerve head structural changes as typically observed with the development and progression of glaucoma.
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Teo ZL, Da Soh Z, Tham YC, Yu M, Chee ML, Thakur S, Nongpiur ME, Koh V, Wong TY, Aung T, Cheng CY. Six-year incidence and risk factors for primary angle closure disease: The Singapore Epidemiology of Eye Diseases Study. Ophthalmology 2022; 129:792-802. [DOI: 10.1016/j.ophtha.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/08/2022] [Accepted: 03/09/2022] [Indexed: 10/18/2022] Open
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Kumar RS, Ramgopal B, Rackenchath MV, A V SD, Mannil SS, Nagaraj S, Moe CA, Wittberg DM, O'Brien KS, Stamper RL, Keenan JD. Comparison of Structural, Functional, Tonometric, and Visual Acuity Testing for Glaucoma: A Prospective Diagnostic Accuracy Study. Ophthalmol Glaucoma 2021; 5:345-352. [PMID: 34547504 DOI: 10.1016/j.ogla.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE To determine the diagnostic accuracy of potential screening tests for moderate to advanced glaucoma. DESIGN Prospective diagnostic test accuracy study. PARTICIPANTS The study enrolled a consecutive series of patients aged ≥50 years who presented to a glaucoma clinic in South India without ever having received automated visual field testing. METHODS All participants underwent 8 index tests: OCT of the peripapillary retinal nerve fiber layer, optic disc photography, Moorfield's Motion Displacement Test (MDT), frequency doubling technique perimetry, noncontact tonometry, pneumatonometry, presenting visual acuity, and best-corrected visual acuity. Participants also underwent stereoscopic photographs and Humphrey visual fields, which were used by 2 ophthalmologists to arrive at the reference standard diagnosis of moderate to advanced glaucoma. MAIN OUTCOME MEASURES Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. RESULTS A total of 217 people were enrolled; 321 eyes from 180 participants had all tests performed. Of these, 127 eyes (40%) were classified as having moderate to advanced glaucoma. Among the 8 tests, OCT best optimized sensitivity (84%, 95% confidence interval [CI], 76-90) and specificity (75%, 95% CI, 68-81). Moorfield's Motion Displacement Test was the best perimetric test, with a sensitivity of 91% (95% CI, 85-96) and specificity of 53% (95% CI, 44-61). Pressure and vision tests were not sensitive (e.g., sensitivity of 16%, 95% CI, 9-23 for noncontact tonometry and 23%, 95% CI, 15-31 for best-corrected visual acuity). Moorfield's Motion Displacement Test identified 16 of 127 eyes (13%) with glaucoma that were not captured by OCT, but also had false-positive results in 65 of 194 eyes (34%) without glaucoma that OCT correctly classified as negative. CONCLUSIONS OCT had moderate sensitivity and fair specificity for diagnosing moderate to advanced glaucoma and should be prioritized during an initial assessment for glaucoma.
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Affiliation(s)
- Rajesh S Kumar
- Narayana Nethralaya Eye Hospital, Bangalore, India; Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - B Ramgopal
- Narayana Nethralaya Eye Hospital, Bangalore, India
| | | | | | - Suria S Mannil
- Narayana Nethralaya Eye Hospital, Bangalore, India; Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Byers Eye Institute, Stanford University School of Medicine, Stanford, California
| | | | - Caitlin A Moe
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Dionna M Wittberg
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Kieran S O'Brien
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Robert L Stamper
- Department of Ophthalmology, University of California, San Francisco, California
| | - Jeremy D Keenan
- Francis I Proctor Foundation, University of California, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, California.
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Han X, Steven K, Qassim A, Marshall HN, Bean C, Tremeer M, An J, Siggs OM, Gharahkhani P, Craig JE, Hewitt AW, Trzaskowski M, MacGregor S. Automated AI labeling of optic nerve head enables insights into cross-ancestry glaucoma risk and genetic discovery in >280,000 images from UKB and CLSA. Am J Hum Genet 2021; 108:1204-1216. [PMID: 34077762 DOI: 10.1016/j.ajhg.2021.05.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
Cupping of the optic nerve head, a highly heritable trait, is a hallmark of glaucomatous optic neuropathy. Two key parameters are vertical cup-to-disc ratio (VCDR) and vertical disc diameter (VDD). However, manual assessment often suffers from poor accuracy and is time intensive. Here, we show convolutional neural network models can accurately estimate VCDR and VDD for 282,100 images from both UK Biobank and an independent study (Canadian Longitudinal Study on Aging), enabling cross-ancestry epidemiological studies and new genetic discovery for these optic nerve head parameters. Using the AI approach, we perform a systematic comparison of the distribution of VCDR and VDD and compare these with intraocular pressure and glaucoma diagnoses across various genetically determined ancestries, which provides an explanation for the high rates of normal tension glaucoma in East Asia. We then used the large number of AI gradings to conduct a more powerful genome-wide association study (GWAS) of optic nerve head parameters. Using the AI-based gradings increased estimates of heritability by ∼50% for VCDR and VDD. Our GWAS identified more than 200 loci associated with both VCDR and VDD (double the number of loci from previous studies) and uncovered dozens of biological pathways; many of the loci we discovered also confer risk for glaucoma.
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Gertig D, Smith JR. Screening and avoidance of blindness: One cannot exist without the other. Clin Exp Ophthalmol 2020; 48:1133-1135. [PMID: 33191539 DOI: 10.1111/ceo.13881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Demi Gertig
- Flinders University, Adelaide, South Australia, Australia
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