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Ophthalmology Times - Ophthalmology news, articles, and events

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Spotlight

Presbyopia: A part of Aging and Challenges

Clinical

1rem

Articles

Emerging technology may facilitate individualized care, disease management.

The value of new diagnostics and personalized medicine

Higher levels of 3 macular pigments minimize risk of age-related disease. 

Dietary supplement can improve measurable visual outcomes

Imaging ciliary muscle details mechanism of accommodation, effects of aging .

Evaluating scleral biomechanics to pinpoint root of accommodation

Process eliminates need for expensive in-person examination of patients without DR.


Teleretinal screening: Effective, less costly option for DR

Study finds imaging-based formulas are less accurate in post-myopic LASIK eyes.

Investigators challenge IOL power calculations

Dilation may be an important step to reduce the rate of ungradable images

AI algorithms: a work in progress

High-quality images can be useful for early diagnosis, prognosis, monitoring

Retinal pathologies challenging to image with current technologies 

Study designed to identify patterns in abnormalities and differences characteristic of disease.


FAF shedding light on patterns related to disease chronicity in CSC

Investigators find value in screening for macular disease in preoperative evaluation


Macular OCT imaging is vital in work-up of cataract surgery patients

This subtype of artificial intelligence technology may have long-range implications for clinical trials.

How deep learning may play a role in predicting retinitis pigmentosa visual impairment

A team of researchers have found that STOC tomography enables unprecedented views of eye structure.

Unmasking secrets of the retina and choroid 

The ocular biomarkers studied showed poor to moderate accuracy for detecting the 2 disorders.

Ocular biomarkers for cognitive impairment

The procedures may result in temporary pressure spikes later than expected. 

Getting a better handle on IOP control

Lawrence Whittle, Chief Commercial Officer for Verana Health, explains what the significance of imaging data linked with electronic health record data means for patient outcomes.



Verana Health + AAO IRIS Registry joint initiative yields 3.5 million ophthalmic images

Hello and welcome to another edition of the neuron guru. I'm here with my good friend Dr. Elizabeth Fortin.

And today we're going to be talking about comparing the 1.5 Tesla magnet and the 3.0 Tesla magnet for MRI of acute demyelinating optic neuritis. So Elizabeth, maybe you could just tell us the difference between a 1.5 and a 3.0. Tesla. And of course, we're not talking about the car here, we're talking about magnets.

Exactly. So the Tesla is a unit of measurement of the strength of your magnetic field in your MRI. The higher the Tesla number is the highest the signal-to-ratio will be which translates into better image quality and definition. So that's basically what the Tesla is.

And what were the results here that we have on this little slide here?

Yeah, so that's actually showing the results of this study, which was a retrospective review of patients diagnosed with the optic neuritis in 2020 in one university academic center. And this slide specifically shows that you have an increased sensitivity of diagnosis, radiographically, diagnosing optic neuritis, with a 3 Tesla as opposed to a 1 Tesla. So if you look at the three columns, the first one is globally the overall radiologic diagnosis of optic neuritis and you see that the difference is statistically significant. If you look at the P up top, there's a higher proportion of patients who had gadolinium enhancement of their optic nerve and also hyper T to a hyperintensity of the optic nerve, which are two signs on MRI of optic neuritis. And so that slide basically shows basically the main results of this study, which shows that you have a higher performance if you use the 3 Tesla, MRI.

So what's the downside here? Why not just do the 3 Tesla on everybody?

So that's a good question. Well, first, I think the main issue is access to the 3 Tesla MRI. So I think not all the centers have access to them. Personally, it's harder to get access here to the 3 Tesla. So 1.5 Tesla's are normally what we have around. So I don't know about you what you've been using recently. But it's normally easier for us to get the 1.5.

Yeah, so for us, we get what they give us. So whichever machine comes open, first, I don't really get to choose the 1.5 or 3 Tesla magnet. However, I have a patient who had an MRI already, and I know it was a 1 Tesla or a 1.5 Tesla, and it didn't show enhancement, and for some reason I'm repeating it because they didn't do the orbit or they didn't do that suppression, then I will try and do a better magnet 3 Tesla magnet. We actually have a 7 Tesla magnet here at Methodist as well. But we haven't been using it for routine care. Although I think in the future bigger magnets are going to become the standard. Right now. It's just for research purposes.

No, exactly. And I think one other finding that was interesting in that study is that if you do your MRI very early after the onset of clinical symptoms, you might miss the enhancement or the findings on MRI and they showed in there that up to four days new so if you do it within four days, as opposed to after four days, you might miss radiologically your findings. And so sometimes like you're saying it might be worth repeating even just for the time, purpose, the MRI later to see if there's enhancement that appears on your optic nerve.

What difference does it make? Who cares if it's clinically acute demyelinating optic neuritis? Would it matter to you if it was a short segment or a long segment of enhancement?

Yeah, well, we've been using it a lot more recently for diagnosing idiopathic versus antibody associated optic neuritis. So I think that's a very good point, that you want to look at how it looks on MRI to base your decision on early treatment of your optic neuritis. So if you have a long segment enhancement, or if you have bilateral involvement or hierarchize involvement, then you might be more aggressive because that these are signs that points toward an antibody associated optic neuritis. So you might want to treat those patients more aggressively. And definitely want to start them on steroids as opposed to if you have just a sort of short segment then this points towards an idiopathic optic neuritis and then you might want to be more conservative. So yes, there's a very you know, it's very important to look at the radiologic appearance of your optic neuritis because this might guide management in the early phases.

And what would you think about having a negative No, no enhancement in terms of changing your differential diagnosis, for example, in a young male with a central scotoma. If I don't see the enhancement, I start getting worried about labor. But how much weight are you going to put to it's not optic neuritis if you don't see the enhancement?

So it really depends on how high your clinical suspicion is. First, I rely on clinics more than, you know, radiology. But as this the sensitivity of the MRI is increasing over time like we're seeing that study, almost 98% of optic neuritis were caused by the 3 Tesla machine as opposed to 76 with the 1.5 Tesla. So, it used to be true that you will miss some of your optic neuritis. So there will be no enhancement on your MRI because the imaging has some limitations. But I think over time, this will become less and less true, and you can rely more and more on your MRIs as they get more performance. But you always have to keep in mind your clinic because I think optic neuritis from the get go is a clinical diagnosis and you use the imaging to help you with management.

What do you think about this T-2 hyperintensity? Without enhancement? How do you use that? Or do you think that nonspecific?

Well, T-2 hyperintensity you can find in any type of optic neuropathy, I think so if you have even you know, at any one you might find in any type of you know, in the chronic phase of your optic neuropathy is with a lot of different causes of optic neuropathy, you might find T-2 hyperintensity. So I don't use it a lot without enhancement. I always keep my cards up. And I want to consider all the differential diagnosis. What about you?

So we have gotten a lot more reports lately with this T two hyperintensity. And now that we have the 3 Tesla, the 3 Tesla is detecting a lot more T-2 hyperintensity from people who don't have anything that's neurotic they had old NAI when a million years ago or they even had glaucoma or some other optic neuropathy. So I don't think it's specific at all, but they certainly are finding it more.

Yeah, absolutely. And I think if you do your MRI later after you know the onset of symptoms, and you might be stuck with only hyperintensity. And then you have to decide if you know the clinic's was really consistent with optic neuritis or not.

So Elizabeth, what do you think the take home message is for our audience in terms of 1.5 versus the 3 Tesla?

Well, I think this study demonstrates that there's a higher sensitivity of the 3 Tesla, which isn't surprising at all, but then you need to be lucky enough to have access to it if you want to use it. So I think you still need to rely on your clinical, you know, impression and if you have a negative 1.5. Then like you were saying I think it's a good idea to see if you can have access to a 3 Tesla to confirm your diagnosis.

Well, I want to thank you again and thank our audience for joining us for another edition of the NeuroOp Guru.

Videos

On this week's episode of the NeuroOp Guru, Andy Lee, MD, and Elizabeth Fortin, MD, compare the 1.5 Tesla magnet and the 3.0 Tesla magnet for MRI. 

Video Series

Vlog: When it comes to MRI magnets, bigger may be better

Gareth Lema, MD, PhD, explains the importance of recognizing the signs and symptoms of eye stroke and timely treatment for patients. He also discusses the role of optical coherence tomography (OCT) and a novel eye stroke program at Mount Sinai Health System that involves collaboration among ophthalmologists, the stroke service, and emergency department physicians. Lema is Site Director of Quality, Safety, and Experience for the Ophthalmology Department at The Mount Sinai Hospital and a retina specialist at the New York Eye and Ear Infirmary of Mount Sinai.

Gareth Lema, MD, PhD, discusses an innovative eye stroke program at Mount Sinai Health System that involves collaboration among ophthalmologists, the stroke service, and emergency department physicians.

Eye stroke: Mount Sinai program stresses awareness and emergent care for sudden vision loss

Mary Durbin, PhD, Chief Scientific Officer at Heru, discusses the benefits and capabilities of the various testing modalities available in 1 wearable platform with Sheryl Stevenson, 

Mary Durbin, PhD, Chief Scientific Officer at Heru, discusses the benefits and capabilities of the various testing modalities available in 1 wearable platform.

What the re:Vive 2.0 platform may mean for the future of vision diagnostics

Dr. Anat Loewenstein discusses her presentation at the Angiogenesis, Exudation and Degeneration meeting. Her talk, “Detection of Diabetic Retinopathy from Ultra-Wide Field Scanning Laser Ophthalmoscope Images: A Multi-Center Deep-Learning Analysis,” delves into how artificial intelligence can aid in patient screening. In testing, the deep learning model scored well in sensitivity, specificity and accuracy.

I'm David Hutton of Ophthalmology Times. The Bascom Palmer Eye Institute at the University of Miami is hosting its Angiogenesis, Exudation and Degeneration 2022 virtual edition. Joining me today is Anat Lowenstein, MD, who is presenting “Detection of Diabetic Retinopathy from Ultra-Wide Field Scanning Laser Ophthalmoscope Images: A Multi-Center Deep-Learning Analysis.” Thank you for joining us today. Tell us about your presentation.

 Thank you, David. I'm very happy to tell you about my presentation on diabetic retinopathy detection from ultra-wide field scanning laser ophthalmoscope images.

So we all know that usually diabetic retinopathy screening uses a limited field of view, 45 to 50 degrees. And theoretically, ultra-wide field imaging can be an alternative to the existing model. But interpretation of these images does require expertise of human graders that are very knowledgeable in diabetic eyes.

We're suggesting models of deep learning to detect variability and assess the referral and vision-threatening diabetic retinopathy, which are important parameters that we want to use.

So in order to do that, we develop models to assess both ability to evaluate a referral diabetic retinopathy and vision-threatening one. And we use the transfer learning procedure for each such a model.

Basically, we looked at almost 10,000 images from almost 2,000 eyes with diabetes. And we had sets for training and validation, the primary set and external testing the external data sets. And when we looked at the sensitivity, specificity and accuracy, we could see that they're pretty high for the primary dataset, 86.5% 82.1% and 83.1%, respectively. So pretty high sensitivity, specificity and accuracy, which were shown by our model.

Also, we were able to show on the receiver operating curves that the performance of the deep learning is on referable diabetic retinopathy were pretty high. So pretty good results on that front as well.

And also for vision-threatening diabetic retinopathy. Again, the area under the receiver operating curve, it was able to show us the rate of accuracy pretty high with our model.

Basically, we were able to show that the diagnosis performance of the deep learning system for detecting referrable diabetic retinopathy and vision-threatening diabetic retinopathy in both primary and external validation sets were pretty high with the ratio of sensitivity, specificity and positive predictive value for both was around 90%. So pretty high and good performance.

And we will show some examples of AI with diabetic retinopathy with referral that the current neuropathy and so forth. So basically, we are able to show high performance in both variability and severity of diabetic retinopathy. And we suggested as a model to facilitate screening of patients with diabetes, for referrable and vision-threatening diabetic retinopathy.

We believe that such readability is crucial for the screening of this disease, it can identify hidden lesions and allows for objective identification of diabetic retinopathy severity.

Of course, our study has advantages and limitations. One of the advantages is that we have multiple ethnicities and geographical location.

But of course, there are also limitations such as the fact that some lesions cannot be captured by the system, maybe artifacts that do affect the prediction. And in the proliferative diabetic retinopathy primary data set, we had a limited number of images.

Of course, the fact that OCT imaging was not used to evaluate the ground truth of diabetic macular edema is a major limitation of our trial. But I think I can conclude that the deep learning system did demonstrate their high rate of identifiable referable diabetic retinopathy cases and that the model has the potential to be implemented in clinical settings, and therefore reduce the burden of both patients and clinicians. Thank you very much, David.

This transcript has been lightly edited for clarity.

During her talk at Angiogenesis, Dr. Loewenstein outlines how artificial intelligence could revolutionize diabetic retinopathy screening.

Deep learning analysis detects diabetic retinopathy on ultra-widefield scanning laser ophthalmoscope images

Robert L. Stamper, MD, speak with Ophthalmology Times®' David Hutton to discuss his presentation at the Glaucoma 360 event in San Francisco, where he presented an update on OCT-Angiography and its role in detecting the density of the capillaries in the macula. 

Glaucoma 360: Angiography 

At the 2021 American Academy of Ophthalmology annual meeting, Ted Leng, MD, presented his talk entitled “Variations in Vitreoretinal Physician Utilization of Ancillary Testing: An IRIS Registry Analysis” during Retina Specialty Day. The IRIS Registry Analysis considered how many ancillary tests were ordered on a per patient basis, accounting for a variety of factors to identify patterns.

 This is a really exciting study that we conducted using the American Academy of Ophthalmology’s IRIS registry, given just a large amount of data that's in there. And as a retinal physician, we are super reliant on ancillary testing in our everyday practices to see, you know, which patients have retinal disease and how we're managing them.

So what we wanted to do in this study was to look at the utilization of ancillary tests by retinal physicians in the United States on retinal patients.

To go into some more detail, this was a three-year study, where we looked at retinal physicians from January 2018 to December 2020. And look at the amount of OCTs, fundus photographs and fluorescein angiograms they were performing. And then we normalized that data and looked at how physicians in different regions throughout the United States were using these tests, whether certain payers like Medicare or non-Medicare were utilizing these tests, and then also different practice settings, such as academic medical centers versus nonacademic medical centers.

What we found was actually quite interesting. Once we did normalize the data, we did see that physicians in the Midwest region—and we use the four regions of the US Census Bureau—so the Midwestern states actually were performing more OCTs on a per patient basis than physicians in other regions. Medicare patients were getting more OCTS on a per patient basis per year than non-Medicare patients. And lastly, patients cared for in a nonacademic medical center, were getting more OCTs on a per patient basis than that not.

So I think, while those results in and of themselves are interesting, we then delve deeper into trying to ask why we saw these differences in practice patterns amongst retinal physicians. And one of the things that we looked into was the volume of wet macular degeneration patients as a kind of benchmark to see if that affected the use of OCT-A, for example.

So what we did was we asked, does a physician who sees more wet AMD patients per year use more OCT or less OCT than someone who doesn't do as many wet macular degeneration patients.

And what we did find was that retinal doctors who saw more wet AMD patients also ordered more OCTs in general.

And what we did with that information, is we went back and did a reanalysis of the data, our findings, and saw that yes, indeed, Midwestern physicians also see more wet AMD patients than non-Midwestern physicians. And that could help to explain why more OCTs are being performed in the Midwest on a per patient basis.

And similarly, in the Medicare population, there are more new wet AMD patients. And in the nonacademic medical center setting, there are more wet AMD patients that are new. So that's why it could help to explain why we are performing as a specialty more OCTs and other ancillary tests in those regions. And in those pair types in this practice settings.

What are the implications for the larger community? I just think it's really good to know, you know, how we're practicing medicine, what the patterns of utilization of our ancillary testing is, so that we can then better inform how to make our practices more efficient, how to better deliver care to the patients, and maybe even identify underserved populations.

You know, one thing we did see was that in the Medicaid population, there was less OCT-A utilization. And so we do need to delve deeper into maybe an explanation as to why that is, but they could be an indication that that populations being under cared for and underserved. And maybe, you know, we need to be ordering more tests to, to better manage those patients. So I think that's one of the potential takeaways from this presentation.

The American Academy of Ophthalmology (AAO) annual meeting was held November 12 to 15 at the Ernest N. Morial Convention Center in New Orleans, Louisiana. The event included Subspecialty Days and a virtual component for remote participation.

Ted Leng, MD, discusses his IRIS Registry analysis presentation regarding variations in vitreoretinal physician utilization of ancillary testing.

Exploring ancillary testing orders by retinal specialists according to the IRIS registry

Michael Mbagwu, MD, of the VA Palo Alto Health Care System; Byers Ophthalmic Innovations Fellow, Byers Eye Institute, Stanford University Medical School, speaks on the highlights of his virtual 2021 ARVO presentation regarding the development of an algorithm tool that links patient imaging to their clinical data, specifically within the American Academy of Ophthalmology's (AAO) IRIS Registry. 

Michael Mbagwu, MD, speaks on the highlights of his virtual 2021 ARVO presentation regarding the development of an algorithm tool that links patient imaging to their clinical data, specifically within the AAO IRIS Registry.  

Imaging

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