Assessment of a Large Language Model's Responses to Questions and Cases About Glaucoma and Retina Management.

Importance: Large language models (LLMs) are revolutionizing medical diagnosis and treatment, offering unprecedented accuracy and ease surpassing conventional search engines. Their integration into medical assistance programs will become pivotal for ophthalmologists as an adjunct for practicing evidence-based medicine. Therefore, the diagnostic and treatment accuracy of LLM-generated responses compared with fellowship-trained ophthalmologists can help assess their accuracy and validate their potential utility in ophthalmic subspecialties. Objective: To compare the diagnostic accuracy and comprehensiveness of responses from an LLM chatbot with those of fellowship-trained glaucoma and retina specialists on ophthalmological questions and real patient case management. Design, Setting, and Participants: This comparative cross-sectional study recruited 15 participants aged 31 to 67 years, including 12 attending physicians and 3 senior trainees, from eye clinics affiliated with the Department of Ophthalmology at Icahn School of Medicine at Mount Sinai, New York, New York. Glaucoma and retina questions (10 of each type) were randomly selected from the American Academy of Ophthalmology's commonly asked questions Ask an Ophthalmologist. Deidentified glaucoma and retinal cases (10 of each type) were randomly selected from ophthalmology patients seen at Icahn School of Medicine at Mount Sinai-affiliated clinics. The LLM used was GPT-4 (version dated May 12, 2023). Data were collected from June to August 2023. Main Outcomes and Measures: Responses were assessed via a Likert scale for medical accuracy and completeness. Statistical analysis involved the Mann-Whitney U test and the Kruskal-Wallis test, followed by pairwise comparison. Results: The combined question-case mean rank for accuracy was 506.2 for the LLM chatbot and 403.4 for glaucoma specialists (n = 831; Mann-Whitney U = 27976.5; P < .001), and the mean rank for completeness was 528.3 and 398.7, respectively (n = 828; Mann-Whitney U = 25218.5; P < .001). The mean rank for accuracy was 235.3 for the LLM chatbot and 216.1 for retina specialists (n = 440; Mann-Whitney U = 15518.0; P = .17), and the mean rank for completeness was 258.3 and 208.7, respectively (n = 439; Mann-Whitney U = 13123.5; P = .005). The Dunn test revealed a significant difference between all pairwise comparisons, except specialist vs trainee in rating chatbot completeness. The overall pairwise comparisons showed that both trainees and specialists rated the chatbot's accuracy and completeness more favorably than those of their specialist counterparts, with specialists noting a significant difference in the chatbot's accuracy (z = 3.23; P = .007) and completeness (z = 5.86; P < .001). Conclusions and Relevance: This study accentuates the comparative proficiency of LLM chatbots in diagnostic accuracy and completeness compared with fellowship-trained ophthalmologists in various clinical scenarios. The LLM chatbot outperformed glaucoma specialists and matched retina specialists in diagnostic and treatment accuracy, substantiating its role as a promising diagnostic adjunct in ophthalmology.

Unilateral acute posterior multifocal placoid pigment epitheliopathy (APMPPE) with delayed contralateral eye involvement.

BACKGROUND: Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a rare presumed inflammatory chorioretinopathy characterized by creamy, yellow-white placoid lesions at the level of the retinal pigment epithelium (RPE). Unilateral cases often have fellow eye involvement within days to a few weeks. This report details a rare case of delayed contralateral APMPPE, in which unilateral lesion resolution was followed by contralateral eye involvement 31 months later. CASE PRESENTATION: A 38-year-old woman presented with three days of blurry vision and photopsias in the right eye (OD). She endorsed a viral GI illness one month prior. Visual acuity was 20/25 -2 OD and 20/20 -1 in the left eye (OS). Examination revealed creamy, yellow-white placoid lesions in the posterior pole. Fluorescein angiography (FA) was notable for early hypofluorescence and late hyperfluorescence of the lesions, consistent with APMPPE. MRI and MRA brain were negative for cerebral vasculitis. She was treated with oral prednisone with complete resolution of her symptoms, vision, and lesion regression. She then presented 31 months later, with blurry vision OS and similar new creamy, yellow-white placoid lesions in the posterior pole OS. She endorsed receiving an influenza vaccine one month prior. FA again was notable for early hypofluorescence. She was diagnosed with APMPPE, this time involving the left eye, and was once again started on oral steroids with complete resolution. She denied any neurologic symptoms. CONCLUSIONS: APMPPE is an inflammatory vasculitis of the choroid, leading to hypoperfusion and ischemic injury of the RPE with subsequent lesion formation. APMPPE may be preceded by a viral prodrome or vaccination, both of which were seen in this case. Choroidal inflammation seen in APMPPE is therefore thought to stem from immune-mediated processes. Unilateral cases often have fellow eye involvement within days to a few weeks. Single eye involvement with delayed contralateral presentation, as seen in our patient, is rare. This case demonstrates that lesion resolution in one eye can be followed by contralateral eye involvement up to 31 months later, highlighting the importance of routine ophthalmic monitoring for patients with unilateral APMPPE.

Polychromatic Aqueous and Vitreous Crystals Due to Phacolytic Glaucoma in a Patient With Marfan Syndrome and Lens Dislocation.

Purpose: To describe a patient with Marfan syndrome and crystalline lens luxation who developed phacolytic glaucoma with polychromatic crystals in the anterior chamber and vitreous. Methods: We present a retrospective case report. Results: A 58-year-old man with Marfan syndrome and crystalline lens luxation since childhood presented with 2 days of pain in the left eye. The visual acuity was 20/30 OS with an aphakic contact lens, and the intraocular pressure (IOP) was 31 mm Hg. Polychromatic crystals were evident in the anterior chamber and vitreous. The retina was attached. Despite medical treatment, the IOP remained elevated; therefore, a pars plana vitrectomy and lensectomy were performed. At the last follow-up, the IOP was normal and the retina remained attached. Conclusions: Phacolytic glaucoma can be seen in eyes with a subluxated or luxated mature or hypermature lens. In these rare cases, iridescent crystals can be observed in the aqueous and vitreous. Vitrectomy with lensectomy is the definitive treatment.

Dose-Dependent and Reversible Serous Retinal Detachments in Fibroblast Growth Factor Receptor Inhibitor-Associated Retinopathy.

We report two cases of fibroblast growth factor receptor (FGFR) inhibitor-associated retinopathy, including the first case of Debio 1347 associated retinopathy manifesting with bilateral serous retinal detachments along the superotemporal arcades and a case of erdafitinib associated retinopathy manifesting with classic foveal serous retinal detachments. Both cases demonstrate a clear dose-dependent and reversible class effect likely secondary to downstream effects of FGFR inhibition on the MEK pathway, resulting in retinal pigment epithelial cell dysfunction, and may also involve additional mechanisms of cellular injury through inhibition of the PI3K/AKT/mTOR pathway. FGFR inhibitor-associated retinopathy appears to manifest differently among patients. [Ophthalmic Surg Lasers Imaging Retina 2023;54:368-370.].

Multimodal Imaging and Macular Hyalocyte Count in a Patient with Acute Macular Neuroretinopathy.

Though rare, acute macular neuroretinopathy is a well-described clinical entity. We report for the first time a detailed analysis of macular hyalocyte count and morphology during the acute phase of acute macular neuroretinopathy. We present a case of a 19-year-old man with bilateral acute onset paracentral scotomas in the setting of an antecedent viral infection. Multimodal imaging demonstrated classic features of acute macular neuroretinopathy. Further analysis revealed increased macular hyalocyte count and an activated hyalocyte morphology during the acute phase of the disease course. Multimodal imaging not only allows for greater confidence in a diagnosis and prognosis but also helps to shed light on underlying pathophysiology. The new clinical capability of monitoring cellular behavior, such as hyalocyte count and morphology, in physiological and pathological conditions may prove useful as biomarkers of early disease activity or response to therapy.

A United States expert consensus to standardise definitions, follow-up, and treatment targets for extra-intestinal manifestations in inflammatory bowel disease.

BACKGROUND AND AIMS: Extra-intestinal manifestations (EIMs) are a common complication of inflammatory bowel diseases (IBD), affecting up to half of the patients. Despite their high prevalence, information on standardised definitions, diagnostic strategies, and treatment targets is limited. METHODS: As a starting point for a national EIM study network, an interdisciplinary expert panel of 12 gastroenterologists, 4 rheumatologists, 3 ophthalmologists, 6 dermatologists, and 4 patient representatives was assembled. Modified Delphi consensus methodology was used. Fifty-four candidate items were derived from the literature review and expert opinion focusing on five major EIMs (erythema nodosum, pyoderma gangrenosum, uveitis, peripheral arthritis, and axial arthritis) were rated in three voting rounds. RESULTS: For use in a clinical practice setting and as part of the creation of a prospective registry of patients with EIMs, the panel developed definitions for erythema nodosum, pyoderma gangrenosum, uveitis, peripheral arthritis, and axial arthritis; identified the appropriate and optimal subspecialists to diagnose and manage each; provided methods to monitor disease course; offered guidance regarding monitoring intervals; and defined resolution and recurrence. CONCLUSIONS: Consensus criteria for appropriate and optimal means of diagnosing and monitoring five EIMs have been developed as a starting point to inform clinical practice and future trial design. Key findings include straightforward diagnostic criteria, guidance regarding who can appropriately and optimally diagnose each, and monitoring options that include patient and physician-reported outcomes. These findings will be used in a national multicenter study network to optimise the management of EIMs.

Advances in Telemedicine in Ophthalmology.

Telemedicine is the provision of healthcare-related services from a distance and is poised to move healthcare from the physician's office back into the patient's home. The field of ophthalmology is often at the forefront of technological advances in medicine including telemedicine and the use of artificial intelligence. Multiple studies have demonstrated the reliability of tele-ophthalmology for use in screening and diagnostics and have demonstrated benefits to patients, physicians, as well as payors. There remain obstacles to widespread implementation, but recent legislation and regulation passed due to the devastating COVID-19 pandemic have helped to reduce some of these barriers. This review describes the current status of tele-ophthalmology in the United States including benefits, hurdles, current programs, technology, and developments in artificial intelligence. With ongoing advances patients may benefit from improved detection and earlier treatment of eye diseases, resulting in better care and improved visual outcomes.

Primary lacrimal sac diffuse large B-cell lymphoma in a child.

We report the case of a 13-year-old boy who presented with a 2-month history of left eyelid swelling, ecchymosis, and epiphora. Magnetic resonance imaging revealed a lobulated lesion in the region of the left lacrimal sac extending to the left nasolacrimal duct. Biopsy revealed diffuse large B-cell lymphoma of the lacrimal sac. Chemotherapy was initiated, consisting of rituximab, methotrexate, cytarabine, doxorubicin, cyclophosphamide, and vincristine. The lesion resolved within weeks of treatment, and the patient remained disease free at 1 year. Primary orbital lymphoma is rare in children; primary diffuse large B-cell lymphoma of the lacrimal sac in a child has not been reported previously.

Comparison of Disposable Goldmann Applanation Tonometer, ICare ic100, and Tonopen XL to Standards of Care Goldmann Nondisposable Applanation Tonometer for Measuring Intraocular Pressure.

PURPOSE: To compare intraocular pressure (IOP) measurements by Goldmann applanation tonometer (GAT), disposable Goldmann applanation prism, ICare, and Tonopen. MATERIALS AND METHODS: A total of 74 patients with varying glaucoma status were examined in our outpatient clinic and IOP was measured with 3 tonometers. The disposable Tonojet prism (dGAT), Tonopen XL, and ICare ic100 were compared with the GAT. RESULTS: There were good intraclass correlation coefficients between IOP measurements by GAT and dGAT (0.95), Tonopen (0.83), and ICare (0.77), all P<0.001. The IOP mean differences between dGAT and GAT were mean 0.80 mm Hg; 95% limits of agreement: -3.35 to 4.96 mm Hg. For Tonopen and GAT: mean, -1.67 mm Hg; limits of agreement, -8.55 to 5.21 mm Hg. For ICare and GAT: mean, 0.44 mm Hg; limits of agreement, -8.18 to 9.06 mm Hg. CONCLUSIONS: The most reliable modality, with good correlation with the Goldmann tonometer values, was the GAT with dGAT, followed in descending order by the Tonopen XL and ICare. There was good interdevice agreement and consistency between all devices. On subgroup analysis, all 3 modalities were found to be less reliable at extreme IOP values (<10 and >24 mm Hg). These disposable modalities should be avoided in extreme IOP ranges outside the normal range.

Treatment of microperforate hymen with serial dilation: a novel approach.

BACKGROUND: Microperforate and imperforate hymens are one of the most common causes of vaginal outflow obstruction in the adolescent population. To date, these hymen anomalies are traditionally treated by hymenectomy with a cruciate excision. CASES(S): We report 2 cases of adolescent women with a microperforate hymen who were successfully and minimally invasively treated with progressive dilation with Hegar cervical dilators until a number 23 dilator was reached under anesthesia in the OR. SUMMARY AND CONCLUSION: Minimally invasive treatment of microperforate hymen with the use of progressive cervical dilators may be an alternative technique to the traditional excisional hymenectomy. Our patients reported satisfaction and minimal postoperative pain or scarring at 2 weeks and 6 months after the procedure. This technique can be an additional option for all women, especially those with cultural beliefs in virginity.

Primary renal carcinoid metastatic to the orbit.

A 70-year-old man with a medical history of metastatic renal carcinoid tumor presented with several months of painless proptosis of the OS. The patient was receiving octreotide and everolimus chemotherapy. MRI revealed a well-circumscribed mass in the left lateral rectus muscle consistent with metastasis. Because the patient was asymptomatic, he was observed and maintained a stable amount of proptosis without diplopia or change in vision.

Adult rhabdomyosarcoma of the maxillary sinus with orbital extension.

A 40-year-old male presented with 2 weeks of left facial pain, nasal congestion, dysphonia, and epistaxis along with left-sided epiphora. CT showed a large infiltrative mass centered in the left maxillary sinus with extension into the left orbit, bilateral paranasal sinuses, nasal cavity, and bilateral enlarged cervical lymph nodes. Biopsy results confirmed adult alveolar rhabdomyosarcoma (RMS). Systemic workup confirmed bilateral cervical lymph node metastasis. Currently the patient is undergoing chemotherapy. We describe a rare case of adult paranasal sinus RMS with orbital invasion.

Biological effects in unirradiated human tissue induced by radiation damage up to 1 mm away.

A central tenet in understanding the biological effects of ionizing radiation has been that the initially affected cells were directly damaged by the radiation. By contrast, evidence has emerged concerning "bystander" responses involving damage to nearby cells that were not themselves directly traversed by the radiation. These long-range effects are of interest both mechanistically and for assessing risks from low-dose exposures, where only a small proportion of cells are directly hit. Bystander effects have been observed largely by using single-cell in vitro systems that do not have realistic multicellular morphology; no studies have as yet been reported in three-dimensional, normal human tissue. Given that the bystander phenomenon must involve cell-to-cell interactions, the relevance of such single-cell in vitro studies is questionable, and thus the significance of bystander responses for human health has remained unclear. Here, we describe bystander responses in a three-dimensional, normal human-tissue system. Endpoints were induction of micronucleated and apoptotic cells. A charged-particle microbeam was used, allowing irradiation of cells in defined locations in the tissue yet guaranteeing that no cells located more than a few micrometers away receive any radiation exposure. Unirradiated cells up to 1 mm distant from irradiated cells showed a significant enhancement in effect over background, with an average increase in effect of 1.7-fold for micronuclei and 2.8-fold for apoptosis. The surprisingly long range of bystander signals in human tissue suggests that bystander responses may be important in extrapolating radiation risk estimates from epidemiologically accessible doses down to very low doses where nonhit bystander cells will predominate.