Deep Learning for Localized Detection of Optic Disc Hemorrhages

PURPOSE

To develop an automated deep learning system for detecting the presence and location of disc hemorrhages in optic disc photographs.

DESIGN

Development and testing of a deep learning algorithm.

METHODS

Optic disc photos (597 images with at least 1 disc hemorrhage and 1075 images without any disc hemorrhage from 1562 eyes) from 5 institutions were classified by expert graders based on the presence or absence of disc hemorrhage. The images were split into training (n = 1340), validation (n = 167), and test (n = 165) datasets. Two state-of-the-art deep learning algorithms based on either object-level detection or image-level classification were trained on the dataset. These models were compared to one another and against 2 independent glaucoma specialists. We evaluated model performance by the area under the receiver operating characteristic curve (AUC). AUCs were compared with the Hanley-McNeil method.

RESULTS

The object detection model achieved an AUC of 0.936 (95% CI = 0.857-0.964) across all held-out images (n = 165 photographs), which was significantly superior to the image classification model (AUC = 0.845, 95% CI = 0.740-0.912; P = .006). At an operating point selected for high specificity, the model achieved a specificity of 94.3% and a sensitivity of 70.0%, which was statistically indistinguishable from an expert clinician (P = .7). At an operating point selected for high sensitivity, the model achieves a sensitivity of 96.7% and a specificity of 73.3%.

CONCLUSIONS

An autonomous object detection model is superior to an image classification model for detecting disc hemorrhages, and performed comparably to 2 clinicians.

Misleading Presentation of Unilateral Phthiriasis Palpebrarum in a 2-Year-Old Boy

A 2-year-old boy with recently treated head lice presented with worsening right eyelid pruritus, irritation, and bleeding that was presumed to be a reinfection of head lice. Clinical examination revealed ectoparasites along the superior eyelid margin that were later identified as Phthirus pubis, or pubic lice. Treatment and management strategies are discussed. [J Pediatr Ophthalmol Strabismus. 2023;60(5):e55-e58.].

ACUTE MYOCARDITIS WITH CARDIOGENIC SHOCK AND MULTIPLE ORGAN FAILURE, FOLLOWED BY BILATERAL PANUVEITIS MASQUERADING AS ENDOGENOUS ENDOPHTHALMITIS, DUE TO TOXOPLASMA GONDII IN AN IMMUNOCOMPETENT PATIENT

PURPOSE

To report a case of systemic and ocular toxoplasmosis in an immunocompetent patient, who developed myocarditis with resulting cardiogenic shock and multiple organ failure, followed by bilateral panuveitis masquerading as endogenous endophthalmitis.

METHODS

Single case report with images.

RESULTS

A 59-year-old man with a history of monoclonal gammopathy of undetermined significance and associated scleromyxedema but otherwise immunocompetent was admitted to the intensive care unit for cardiogenic shock and multiple organ failure due to presumed viral myocarditis. After hospital discharge, ophthalmic examination revealed what seemed to be endogenous fungal endophthalmitis in both eyes. The ocular inflammation failed to improve on local and systemic antifungal therapies. After repeated testing and vitrectomy, the causative organism responsible for his intraocular inflammation remained elusive. The patient was then found to have significantly elevated serum titers of anti-Toxoplasma gondii IgG and IgM, followed by an appearance of a focal retinochoroidal lesion more typical of ocular toxoplasmosis. Systemic anti-Toxoplasma therapy led to resolution of intraocular inflammation, and the patient had since fully recovered from the myocarditis and its multiple comorbidities. Of note, myocardial biopsy and polymerase chain reaction testing of aqueous and vitreous fluids were all negative for Toxoplasma.

CONCLUSION

Even in an immunocompetent patient, Toxoplasma can result in myocarditis with significant morbidities and even death, and its ocular manifestation may be quite different from the classic focal retinochoroiditis. In addition, polymerase chain reaction analysis of ocular fluids can be unreliable in an immunocompetent host, and thus treatment decision should be guided by clinical history and examination findings.

Treatment of Noninfectious Retinal Vasculitis Using Subcutaneous Repository Corticotropin Injection

Purpose

To show whether subcutaneous repository corticotropin injection (RCI, Acthar® Gel, a repository corticotropin injection, can be an effective potential therapeutic agent for noninfectious retinal vasculitis.

Methods

Patients with active retinal vasculitis were followed with serial ultra-wide-field fluorescein angiograms and treated with 80 units of subcutaneous repository corticotropin injection twice weekly.

Results

Primary outcome of ≥50% improvement in response level (RL) for retinal vasculitis and percent improvement in retinal vasculitis severity scoring (RVSS) by more than one quartile (≥25%) at week 12 was met in 15 and 16 of the 30 total eyes, respectively, including 1 eye with severe retinal vasculitis in each group. Complete resolution of retinal vasculitis was seen in seven eyes with a mean time of 17.1 weeks. Intraocular pressure elevation requiring therapy and cataract progression were noted in two and three eyes, respectively. One patient stopped medication due to side effects (injection site reaction).

Conclusion

Repository corticotropin injection was well-tolerated overall. Repository corticotropin injection may be an effective therapeutic agent in the treatment of noninfectious retinal vasculitis.

Widefield Fundus Fluorescein Angiography Features of Uveitis Associated with Juvenile Idiopathic Arthritis

PURPOSE

To evaluate the wide-field fundus fluorescein angiography (WFA) characteristics of uveitis associated with juvenile idiopathic arthritis (JIA-uveitis).

METHODS

Retrospective review of records. WFA with Spectralis (Heidelberg) of JIA-uveitis patients were analyzed using the scoring system by Angiography Scoring for Uveitis Nomenclature.

RESULTS

Thirty-seven eyes of 20 patients were studied. A total score of at least 1 was noted in 27 eyes (72.97%). WFA features included optic disc hyperfluorescence (51.35%), macular leakage (27.03%), retinal vascular staining/leakage at posterior pole (27.03%) and peripheral retina (64.86%), capillary leakage at the posterior pole (37.84%), and peripheral retina (59.46%). A decision to change the management plan was made in 8 of 9 patients with bilateral quiet anterior chambers after WFA results.

CONCLUSION

More than 70% of JIA-uveitis eyes showed some WFA-evidence of posterior segment inflammation, which changed the course of therapy for a major proportion of patients with no clinically active anterior chamber inflammation.

Uveitis in Patients Treated with CTLA-4 and PD-1 Checkpoint Blockade Inhibition

Purpose: To investigate the link between treatment with CTLA-4 and PD-1 checkpoint blockade inhibitors and the development of noninfectious uveitis.Methods: A survey was distributed to uveitis specialists to identify patients who developed uveitis while receiving either PD-1 inhibitors pembrolizumab and nivolumab; PD-L1 inhibitors atezolizumab, avelumab, and durvalumab; or the CTLA-4 inhibitor ipilimumab.Results: Fifteen patients from seven institutions were identified. The most common cancer diagnosis (13/15) was malignant melanoma. Fourteen patients had a new uveitis diagnosis following checkpoint blockade administration (six anterior uveitis, six panuveitis, one posterior uveitis, one anterior/intermediate combined); one patient developed optic neuritis. Uveitis was diagnosed within 6 months after drug initiation for 11/12 patients (median 63 days). Corticosteroid treatment was effective for most patients, although two patients had permanent loss of vision.Conclusions: Patients on checkpoint inhibitor therapy should be educated to seek care if they develop ocular symptoms, and prompt referral to specialists should be incorporated into oncology protocols.

Paracentesis following intravitreal drug injections in maintaining physiologic ocular perfusion pressure

A retrospective analysis was performed of patients who received a paracentesis immediately following an intravitreal injection of bevacizumab or triamcinolone acetonide. These patients were previously diagnosed as having glaucoma, ocular hypertension, or had responded previously with sustained elevated intraocular pressure. Of 1661 procedures were performed. Totally 219 (13%) of the injections were on phakic patients. A median (SD) of 210 µL (40 µL) of aqueous was removed during each paracentesis. There were no reported incidences of any complications. We propose performing a paracentesis immediately following intravitreal injections for patients at risk for ocular hypertension, glaucoma, and retinal vein or artery occlusion.

Bioconjugates of PAMAM dendrimers with trans-retinal, pyridoxal, and pyridoxal phosphate

Background

Bioconjugates of a polyamidoamine (PAMAM) G3 dendrimer and an aldehyde were synthesized as carriers for vitamins A and B₆, and the bioavailability of these vitamins for skin nutrition was investigated.

Methods

Nuclear magnetic resonance (NMR) and ultraviolet-visible methods were used to characterize the structure of the bioconjugates and for monitoring release of pyridoxal (Pyr) and pyridoxal phosphate (PLP) from these bioconjugates in vitro. A skin model permeation of bioconjugates was also studied in a Franz chamber.

Results

A transdermal G3 PAMAM dendrimer was used to synthesize bioconjugates with trans-retinal (Ret), pyridoxal (Pyr), or PLP. These nanomolecules, containing up to four covalently linked Ret, Pyr, or PLP (G3^4Ret, G3^4Pyr, and G3^4PLP), were able to permeate the skin, as demonstrated in vitro using a model skin membrane. PLP and Pyr bound to a macromolecular vehicle were active cofactors for glutamic pyruvic transaminase, as shown by ¹H NMR spectral monitoring of the progress of the L-alanine + α-ketoglutarate → glutamic acid + pyruvic acid reaction.

Conclusion

PAMAM-PLP, PAMAM-Pyr, and PAMAM-Ret bioconjugates are able to permeate the skin. PLP and Pyr are available as cofactors for glutamic pyruvic transaminase.

Laboratory investigations of the effects of predator sex and size on prey selection by the Asian crab, Hemigrapsus sanguineus

Laboratory studies have shown that the nonindigenous Asian shore crab, Hemigrapsus sanguineus, readily consumes three species of commercial bivalves: blue mussels, Mytilus edulis, soft-shell clams, Mya arenaria, and oysters, Crassostrea virginica. Although crabs can eat bivalves of a wide size range, they preferred the smaller prey (</=10 mm SL). Prey critical size limits exist for M. edulis and C. virginica, but not M. arenaria, possibly because of differences in shell characteristics among the three species. Crabs preferred M. arenaria over both M. edulis and C. virginica, and M. edulis was strongly preferred over C. virginica in pairwise comparison tests. Experiments to determine feeding rates on mussels showed that H. sanguineus can consume large numbers of mussels daily (12.7+/-11.6 mussels day(-1); sexes pooled; N=59). Mussel consumption rates increased with size of the predator and male crabs consumed more mussels than did similarly sized female crabs. The high densities of Hemigrapsus that occur in the wild, their effectiveness as predators of juvenile bivalves and their large appetites suggest an important role for these predators in restructuring the prey communities in habitats into which they have been introduced.

Allogeneic peripheral blood precursor cell transplants in rabbits

This report summarizes a series of experiments undertaken to evaluate the role of mobilized peripheral blood precursor cells (PBPC) for transplantation across a major histocompatibility barrier. Adult outbred red Burgundy rabbits were used as donors, New Zealand white rabbits of the opposite sex as recipients. Conditioning consisted of single dose total body irradiation (TBI) of 10 Gy supported by a short course of cyclosporine to enhance engraftment. Human recombinant G-CSF at a dose of 10 micrograms/kg was used for mobilization of precursor cells. Three methods of PBPC transplants were tested initially in 5 animals each. PBPC were collected and infused at once on day 0; collected initially, cryopreserved for one month, infused on day 0 and followed by 3 additional fresh donations or collected and infused on 6 occasions between days 0 and + 11. 13 animals engrafted, 2 became complete, longterm chimeras. Survival was best in the group given repetitive infusions (39 days median, 12 days to > 180 days, range). 10 additional animals were transplanted as in the last group and the number of transplanted nucleated cells (10.5 x 10(8)/kg median, 7.3 - 15.7 x 10(8)/kg range) and colony forming units CFU-GM (42 x 10(4)/kg median, 12.3 - 176.8 x 10(4)/kg range), were compared with outcome. Median survival of the 10 animals was 29 days (12 - 55 days range; 1 autologous reconstitution). Survival did not correlate with total nucleated cells per kg (r = 0.10; p = 0.79), but there was a trend to prolong survival with higher numbers of CFU-GM per kg (r = 0.47; p = 0.19). These data show that allogeneic PBPCT can engraft across a major histocompatibility barrier, that the high number of CFU-GM per kg might be advantageous, but also that additional methods are warranted to reduce acute GvHD.

Peripheral blood pressure cells transplants across a major histocompatibility barrier in rabbits: positive effects of a higher number of precursor cells?

Peripheral blood precursor cells (PBPCs) are used with increasing frequency for hematopoietic transplants and have more or less replaced autologous bone marrow transplants. First clinical and experimental reports document the feasibility of PBPCs as a source for allogeneic transplants. Few data exist on the optimal procedure and the ideal number of cells for the transplant. We have previously shown in rabbits that PBPCs can be used for transplants even across a major histocompatibility barrier. We used this model to test whether the number of transplanted precursor cells would influence graft outcome. Adult outbred Red Burgundy rabbits were used as donors, New Zealand White rabbits of the opposite sex as recipients. One individual donor was taken for one individual recipient. Conditioning consisted of single-dose total body irradiation of 10 Gy followed by a short course of cyclosporine to enhance engraftment. Donor animals were treated with recombinant human granulocyte-colony-stimulating factor, 10 micrograms/kg subcutaneously daily from day -2 until day +9. PBPCs were obtained from the artery of the donor animal by repetitive centrifugation of 2 x 40 ml heparinized blood on each day of donation, i.e. days 0, +2, +3, +6, +8, and +10 and infused without further manipulation. Eight animals underwent transplantation. Seven took the grafts, six died of graft-versus-host disease and pneumonia between days 12 and 55 (median survival of all animals: 34 days). One animal was still alive after 120 days. Transplanted nucleated cells varied from 7.3 to 15.4 x 10(8)/ kg (median 9.2 x 10(8)/kg) and CFU-GM from 12.3 to 176.8 x 10(4)/kg (median 42 x 10(4)/kg). Survival tended to increase with more CFU-GM) r = 0.716, p = 0.0704). These data confirm that allogeneic PBPCs can engraft across a major histocompatibility barrier and suggest that a higher number of CFU-GM might be advantageous.

Transplantation of G-CSF mobilized allogeneic peripheral blood stem cells in rabbits

Mobilized peripheral blood precursor cells (PBPC) are used with increasing frequency to restore autologous hematopoiesis following high-dose radio-chemotherapy. The success of this method has aroused interest in the use of mobilized PBPC for allogeneic transplants. This approach would eliminate the need for marrow aspiration and general anesthesia. In this project we tested the feasibility of allogeneic histoincompatible PBPC transplants in rabbits. Adult outbred Red Burgundy rabbits were used as donors, histoincompatible New Zealand White rabbits of the opposite sex as recipients. One individual donor was used for one individual recipient. Conditioning consisted of 10 Gy total body irradiation (TBI). Donor animals were pre-treated with recombinant human granulocyte colony-stimulating factor (rh G-CSF) given s.c. at 10 micrograms/kg daily. Three schedules of PBPC collection and reinfusion were tested in 3 groups of animals, each consisting of 5 donor recipient pairs: (A) PBPC were collected either on days -2, -1 and 0, and infused at once after TBI on day 0; (B) collected and infused on days 0, +2, +4, +7, +9, and +11; (C) collected on 3 consecutive days, cryopreserved for 1 month and infused on day 0 followed by 3 fresh donations on days +4, +8 and +11. The median amount of blood processed from donor animals was 470 ml (312-602) containing about 10 x 10(8) (5-71 x 10(8)) nucleated cells. Recipient animals received a median of 2.7 x 10(8) cells/kg equivalent to 9.6 x 10(4) colony-forming units granulocyte-macrophages (CFU-GM)/kg (data derived from Group C of the animals).(ABSTRACT TRUNCATED AT 250 WORDS)

[Contribution to the clinical polymorphism in Huntington's disease]

A family is described in which closely consanguineous parents had Huntington chorea and in their son a severe hypertonic-hypokinetic syndrome with pellagra-like cutaneous changes was present. In two generations of the family in 6 subjects involuntary movements and gait disorders were reported.

[Coexistence of idiopathic spontaneous nocturnal enuresis and migraine in children]

In a 7-year prospective follow-up of 104 children with enuresis in 32 cases (19 boys and 13 girls) coexistence of common migraine was found. Twenty-two children had various other seizure-like disorders, particularly tics, febrile convulsions, pavor nocturnus and fainting, and three had absence attacks. In 20 cases vasomotor disturbances and in 17 abnormal Schellong's test were found. The IQ was normal or high in all cases. Emotional disorders were observed in nearly half the cases. The water-salt test of Decourt was done in 9 cases and it was abnormal in 8 cases. At least two abnormal EEG records were obtained in 26 cases, and in 24 of them seizure activity was demonstrated in the EEG. In the period of follow-up disappearance or very marked improvement of enuresis occurred in all cases and migrainous attacks became less frequent and intense in 27 cases, while in 5 the severity of migraine increased. The author discusses the pathological mechanism of these disturbances calling attention to less good efficiency of the regulatory functions of the centrencephalic activating system and hypothalamus connected with biochemical and bioelectric immaturity.

[Evaluation of the results of treatment of SSPE (subacute sclerosing panencephalitis) with isoprinosine]

The period of survival in the group of 36 boys and 18 girls with SSPE, as well as the condition of 13 living persons were examined. 30 children were treated with isoprinosine. A 3 years-long period of survival was significantly more frequent in the group of 18 children with long-term therapy by isoprinosine in comparison to 24 children without isoprinosine administration. The best results were observed in children with subacute course of the illness and many epileptic seizures. The 13 living persons are strongly damaged. One girl is decerebrated and 5 patients are completely helpless. The indications to isoprinosine therapy in SSPE are discussed.

[Basilar migraine in children]

The authors describe 3 children aged 12-15 years with severe basilar artery migraine. The follow-up was 2-3 years. In all cases attacks of throbbing headache occurred which showed varying intensity and lateralization in 2 cases. Only one child had always very strong right-sided headaches. The accompanying symptoms and signs were mostly from the area of vascularization of the basilar artery. In one child attacks of unconsciousness occurred additionally. The authors suggest that the symptoms and signs from brain-stem structures associated with attacks of headache may be due not only to construction of the basilar artery but may be due to a steal effect from certain regions of the brain stem in the phase of vasodilation, although the primary haemodynamic disturbance may not necessarily develop within the basilar artery system.

[Humoral immunological reactivity in subacute sclerosing panencephalitis]

In a group of 37 children with SSPE serum protein and cerebrospinal fluid electrophoresis was done (in 34 and 25 cases respectively) determining immunoglobulins in the serum and cerebrospinal fluid in all 37 cases. The obtained results demonstrated a lack of correlation between the changes observed in the serum and cerebrospinal fluid. The most frequent change in the serum was a rise in alpha 2 globulin level (85%) and reduced IgA level (58%), while in the cerebrospinal fluid a rise in gamma globulins (92% of cases) and IgG (100%) was observed most frequently. A comparison of these results with past history of measles, with the clinical course of SSPE and with the survival time of the children showed no correlations. Measles antibodies were determined in the serum and cerebrospinal fluid in 37 children, and the determinations, were repeated several times in the serum of all children and in the cerebrospinal fluid of 9 children. Measles antibodies were found in the serum in all children and in the cerebrospinal fluid in 21 children (57%). The highest titres of antibodies above 1:32 in the cerebrospinal fluid were demonstrated in children with measles at the age up to 2 years. The prognosis was worst in children with acute onset of the disease preceded frequently by cranial injury or infection, with a high serum antibody level and absence of antibody in the cerebrospinal fluid.

Clinical symptoms and signs useful in the early diagnosis of ankylosing spondylitis

Seventy patients between the ages of 18 to 30 with early spondylitis (eAS), with bilateral grade II-III sacroiliitis without syndesmophytes were examined. The control group comprised 32 patients of the same age range with lumbar disc disease (LDD) confirmed by radiculography, without changes in the sacroiliac joints. In both groups the same clinical parameters were evaluated, calculating for each the specificity, sensitivity and Youden index. Statistical analysis was done using Student's t-test and/or the chi-square test. A complex of simple clinical features was isolated suggesting presence of eAS in young subjects with persistent low back pain but without a clear-cut radiological appearance of the sacroiliac joints. The complex included: a history of morning back stiffness, swelling of knee joints, thoracic pain, clinical evidence of limited chest expansion below 5 cm, swelling of joints of lower extremities, positive Mennell's sign, and in laboratory investigations presence of raised ESR and HLA B27-antigen.

[Case of a particularly severe migraine in a boy]

An unusually severe and uncommon clinical syndrome of migraine with complications in a boy treated during 9 years is described. Severe attacks of migraine were associated with changing cerebral function defects, prolonged disturbances of consciousness, and significant symptoms of intracranial hypertension. Vertebral angiography demonstrated disturbances in cerebral circulation.

[Effect of infections on the course and effectiveness of epilepsy treatment in children]

The analysis was carried out in a group of 32 children with coexistent chronic urinary tract or respiratory infections. In 20 children an unfavourable effect of infection on the course of epilepsy was observed. Worsening of epilepsy during infection was observed mainly in children without evidence of nervous system damage with primarily generalized seizures, and in cases when the first attacks developed after protective vaccinations. The effect of urinary tract infections was particularly unfavourable. The authors put forward the hypothesis of immunological basis of exacerbation of epileptic seizures during chronic infections.