Machine learning-assisted prediction of trabeculectomy outcomes among patients of juvenile glaucoma by using 5-year follow-up data.

OBJECTIVE: To develop machine learning (ML) models, using pre and intraoperative surgical parameters, for predicting trabeculectomy outcomes in the eyes of patients with juvenile-onset primary open-angle glaucoma (JOAG) undergoing primary surgery. SUBJECTS: The study included 207 JOAG patients from a single center who met the following criteria: diagnosed between 10 and 40 years of age, with an IOP of >22 mmHg in the eyes on two or more occasions, open angle on gonioscopy in both eyes, with glaucomatous optic neuropathy, and requiring a trabeculectomy for IOP control. Only the patients with a minimum 5-year follow-up after surgery were included in the study. METHODS: A successful surgical outcome was defined as IOP ≤18 mmHg (criterion A) or 50% reduction in IOP from baseline (criterion B) 5 years after trabeculectomy. Feature selection techniques were used to select the most important contributory parameters, and tenfold cross-validation was used to evaluate model performance. The ML models were evaluated, compared, and prioritized based on their accuracy, sensitivity, specificity, Matthew correlation coefficient (MCC) index, and mean area under the receiver operating characteristic curve (AUROC). The prioritized models were further optimized by tuning the hyperparameters, and feature contributions were evaluated. In addition, an unbiased relationship analysis among the parameters was performed for clinical utility. RESULTS: Age at diagnosis, preoperative baseline IOP, duration of preoperative medical treatment, Tenon's thickness, scleral fistulation technique, and intraoperative mitomycin C (MMC) use, were identified as the main contributing parameters for developing efficient models. The three models developed for a consensus-based outcome to predict trabeculectomy success showed an accuracy of >86%, sensitivity of >90%, and specificity of >74%, using tenfold cross-validation. The use of intraoperative MMC and a punch for scleral fistulation compared to the traditional excision with scissors were significantly associated with long-term success of trabeculectomy. CONCLUSION: Optimizing surgical parameters by using these ML models might reduce surgical failures associated with trabeculectomy and provide more realistic expectations regarding surgical outcomes in young patients.

In vivo identification of angle dysgenesis and its relation to genetic markers associated with glaucoma using artificial intelligence.

PURPOSE: To predict the presence of angle dysgenesis on anterior-segment optical coherence tomography (ADoA) by using deep learning (DL) and to correlate ADoA with mutations in known glaucoma genes. PARTICIPANTS: In total, 800 high-definition anterior-segment optical coherence tomography (AS-OCT) images were included, of which 340 images were used to build the machine learning (ML) model. Images used to build the ML model included 170 scans of primary congenital glaucoma (16 patients), juvenile-onset open-angle glaucoma (62 patients), and adult-onset primary open-angle glaucoma eyes (37 patients); the rest were controls (n = 85). The genetic validation dataset consisted of another 393 images of patients with known mutations that were compared with 320 images of healthy controls. METHODS: ADoA was defined as the absence of Schlemm's canal, the presence of hyperreflectivity over the region of the trabecular meshwork, or a hyperreflective membrane. DL was used to classify a given AS-OCT image as either having angle dysgenesis or not. ADoA was then specifically looked for on AS-OCT images of patients with mutations in the known genes for glaucoma. RESULTS: The final prediction, which was a consensus-based outcome from the three optimized DL models, had an accuracy of >95%, a specificity of >97%, and a sensitivity of >96% in detecting ADoA in the internal test dataset. Among the patients with known gene mutations, ( MYOC, CYP1B1, FOXC1, and LTBP2 ) ADoA was observed among all the patients in the majority of the images, compared to only 5% of the healthy controls. CONCLUSION: ADoA can be objectively identified using models built with DL.

Bilateral congenital stromal iris cyst with secondary glaucoma.

PURPOSE: To report a case of bilateral congenital stromal iris cyst in a neonate. OBSERVATIONS: A one-month-old male child was brought with complaints of watering in both eyes and enlargement of the left eye since birth. Examination under anesthesia revealed an elevated IOP in both the eyes. The left eye had buphthalmos with hazy cornea and central corneal scarring. Ultrasound biomicroscopy revealed the presence of a stromal cyst in both the eyes and a cataractous lens in the left eye. While the right eye responded to topical glaucoma medications, the left eye continued to have a high IOP and hence, it was managed surgically. CONCLUSIONS AND IMPORTANCE: This rare case of bilateral stromal iris cyst in a neonate presented with a unique diagnostic and management challenge.

In Vivo Imaging of the Schlemm's Canal and the Response to Selective Laser Trabeculoplasty.

OBJECTIVE: To evaluate the presence of angle dysgenesis on ASOCT (anterior segment optical coherence tomography) (ADoA) as a predictive factor in determining outcomes of selective laser trabeculoplasty (SLT). DESIGN: A prospective clinical cohort study. SUBJECTS: Patients with juvenile-onset open-angle glaucoma (JOAG) without angle dysgenesis on gonioscopy. METHOD: JOAG patients with uncontrolled intraocular pressure (IOP), who were to undergo SLT, were evaluated for the presence or absence of ADoA, which was defined as the absence of Schlemm's canal (SC) and/or presence of a hyperreflective membrane (HM) over the trabecular meshwork, as identified on ASOCT before the SLT procedure. Furthermore, the number of ASOCT B-scans in which SC was identified as present, were then quantified. Success of SLT was defined as a reduction of IOP by 20% or more from pre-laser value at 6-month follow-up without any further IOP-lowering medication or surgery. Only 1 repeat SLT was admissible for defining SLT success over the 6-month period. A successful reduction in IOP at 6-month follow-up was correlated with the extent of ADoA. RESULTS: In comparison to pre-SLT IOP, 57.1% eyes (20/35) showed more than 20% reduction in IOP at 6 months with a mean reduction of 7.6 ± 1.8 mm Hg (29.6%). When all 3 observers agreed, SC was identified in 90% eyes (18/20) with success vs 26.6% eyes (4/15) with failure (P < .001). All eyes (5/5) with presence of HM showed failure (P < .001). All eyes (19/19) in which SC was present in >50% ASOCT B scans (>25/50 scans/eye) showed success (P < .001). On a bias-reduced regression analysis, the identification of SC on any 2 consecutive scans increased the chances of success at 6 months by 8.3 times, whereas the identification of SC in >50% of ASOCT scans was associated with a 21.4 times greater chance of success. CONCLUSIONS: The presence of SC on ASOCT is a strong predictor for successful IOP reduction after SLT in JOAG eyes.

Rapid spontaneous resolution of corneal hydrops in post-CXL keratitis.

An 11-year-old boy presented with right eye post-Corneal Collagen Cross-Linking (CXL) keratitis, which was complicated by acute corneal hydrops (CH). Keratitis was managed by topical antibiotics, and CH was managed conservatively. Cornea was monitored with serial anterior segment optical coherence tomography (ASOCT) scans. Spontaneous resolution of CH usually takes 8-12 weeks, but in this case it completely resolved in 3 weeks. Rapid resolution of CH after post-CXL keratitis could be attributed to a thinner cornea, increased interlamellar cohesive strength between collagen fibrils of corneal stroma coupled with normal functioning endothelial pump.

Managing vitreoretinal surgeries during COVID-19 lockdown in India: Experiences and future implications.

PURPOSE: The study aims to describe the clinical and demographic profile of patients who required vitreoretinal surgeries during the novel coronavirus disease-2019 (COVID-19) lockdown in India. It also reports our operating protocols and initial experience while performing vitreoretinal surgeries during COVID-19 times at a government tertiary eye care hospital. METHODS: This is a retrospective cross-sectional observational study of patients requiring emergent/urgent vitreoretinal surgeries between March 25, 2020 and May 31, 2020. A modified working protocol focussing on the enforcement of standard COVID-19 precautions, OT sterilization, and formation of dedicated infection control and disease surveillance committee was adopted. Patients underwent standard vitreoretinal procedures under general/local anesthesia. Relevant demographic and clinical data were recorded and analyzed. Surveillance data of healthcare workers (HCW) was also analyzed. RESULTS: Eighty six patients were considered for vitreoretinal surgery in this period. Finally, 83 patients underwent surgery. The mean age of the patients was 38.4 ± 20.1 years (Range, 1 month - 75 years). Majority of them were males (66%) and adults (82.6%). Majority of them came from nearby hotspot areas. Most common indications were acute retinal detachment (38.5%) and diabetic vitrectomies (22.9%). Trauma-related cases (14.4%) were less. Surgery was deferred in 3 patients who turned out to be COVID-19 positive. 4 HCWs were quarantined but none of them developed COVID-19 disease. CONCLUSION: During COVID-19 lockdown, vitreoretinal surgeries were most commonly performed for retinal detachment and diabetic complications. Proper implementation of infection control protocols helps in delivering adequate patient care while ensuring the safety of caregivers during this pandemic.

Macular hole following phakic intraocular lens implantation and its management.

A 28-year-old male presented to retina clinic with complains of blurring and distortion in right eye for past 1 week. There was history of implantation of phakic intraocular lens (pIOL) bilaterally 4 months back. Ophthalmic examination revealed a full-thickness macular hole in the right eye. Pars plana vitrectomy with inverted internal limiting membrane flap was planned. Post-operatively, patient had a good gain in vision (20/40) with closure of the hole. Macular hole is an unusual complication of pIOL. A detailed pre-operative fundus screening is indispensable. Early presentation and timely intervention can optimize the visual outcome.