Toward an internationally accepted standard for reading charts.

Patients who suffer from sight-threatening eye diseases share a desire to regain a comfortable reading ability. In light of the modern advances achieved in ophthalmic diagnosis and therapy, and because a significant lack of comparability between reading charts still exists, there is an increasing need for a worldwide standard in the form of a norm for diagnostic reading charts. Already, applied advancements such as digital print, which allow a calibration of the print sizes of reading charts in correctly progressing geometric proportions by using the actual height of a lower case "x" in millimeters (x-height), and psychophysically standardizing reading charts and their test items by applying modern statistical methods have significantly contributed to establishing a norm for reading charts. In 2020, a proposal of the British delegation was accepted by the International Organization for Standardization (ISO) group "Visual Optics and Optical Instruments," and a working group was established. Bearing in mind the efforts of the ISO with regard to an international norm, this review article is intended to (a) give an overview of the historical background and related normative approaches for diagnostic reading tests used in ophthalmology and optometry, (b) explain psychophysical and technical concerns, and (c) discuss the possibilities and limits of concepts that seem relevant to developing a modern standard for reading charts.

Cognitive bias evaluation on the choice of treatment in common retinal disorders among retina specialists in 2023.

PURPOSE: The study aimed to discern the intent to treat with the therapeutic agents prescribed first or second line in the following eye conditions: neovascular age-related macular Degeneration (nAMD), diabetic macular edema (DME), retinal vein occlusion (RVO), and myopic maculopathy with choroidal neovascularization (MMNV). The study also aimed to distinguish the ophthalmologists' intended treatment for their patients from those that they would prescribe for themselves if they were affected by the above macular conditions. METHODS: The study utilized an online survey of 243 French ophthalmologists practicing medical retina, with males accounting for 54.3% of the participants. Data was obtained using a questionnaire that focused on the ophthalmologists' experience with various agents as well as their first and second line choices for nAMD, DME, RVO, and MMNV. RESULTS: The vast majority of French ophthalmologists (99%) had experience with the most widely used anti-vascular endothelial growth factors (anti-VEGFs); ranibizumab, bevacizumab, and aflibercept. Fewer than 8% reported experience with anti-VEGF drug reservoirs, biosimilars, or faricimab. The study findings also showed ranibizumab and aflibercept as the commonly prescribed first line choices for the above-mentioned ocular conditions. For the second line choice, the study showed that aflibercept and dexamethasone intravitreal implants were the most common across the four retinal conditions studied. The only difference in intent to treat for "patients" versus "yourself" was for biosimilars (0% to 0.8%, P=0.001). CONCLUSION: The findings regarding the first and second line choices for the mentioned ocular disorders were found to agree with the findings of published literature currently used in practice, with a tendency to prefer ranibizumab as first line therapy for neovascular disorders and aflibercept as first line therapy for macular edema. In addition, there were no differences between choices for first and second line therapy for patients vs. ophthalmologists.

Systematic review of clinical practice guidelines for the diagnosis and management of retinal vein occlusion.

BACKGROUND/OBJECTIVES: To assess the methodological quality of Clinical Practice Guidelines (CPG) for the diagnosis and management of Retinal Vein Occlusion (RVO). METHODS: A systematic review of CPGs for the diagnosis and management of RVO was carried out with a search in databases, metasearch engines, CPG development institutions, ophthalmology associations and CPG repositories until April 2022. Search update was performed on April 2023, with no new record available. Five CPGs published in the last 10 years in English/Spanish were selected, and 5 authors evaluated them independently, using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) instrument. An individual assessment of each CPG by domain (AGREE-II), an overall assessment of the guide, and its use with or without modifications were performed. Additionally, a meta-synthesis of the recommendations for the most relevant outcomes was carried out. RESULTS: The lowest score (mean 18.8%) was for domain 5 'applicability', and the highest score (mean 62%) was for domain 4 'clarity of presentation'. The 2019 American guideline (PPP) presented the best score (40.4%) in domain 3 'rigour of development'. When evaluating the overall quality of the CPGs analysed, all CPGs could be recommended with modifications. In the meta-synthesis, anti-VEGF therapy is the first-choice therapy for macular oedema associated with RVO, but there is no clear recommendation about the type of anti-VEGF therapy to choose. Recommendations for diagnosis and follow-up are similar among the CPGs appraised. CONCLUSION: Most CPGs for the diagnosis and management of RVO have a low methodological quality assessed according to the AGREE-II. PPP has the higher score in the domain 'rigour of development'. Among the CPGs appraised, there is no clear recommendation on the type of anti-VEGF therapy to choose.

Disparities in eye clinic patient encounters among patients requiring language interpreter services.

BACKGROUND: Communication barriers are a major cause of health disparities for patients with limited English proficiency (LEP). Medical interpreters play an important role in bridging this gap, however the impact of interpreters on outpatient eye center visits has not been studied. We aimed to evaluate the differences in length of eyecare visits between LEP patients self-identifying as requiring a medical interpreter and English speakers at a tertiary, safety-net hospital in the United States. METHODS: A retrospective review of patient encounter metrics collected by our electronic medical record was conducted for all visits between January 1, 2016 and March 13, 2020. Patient demographics, primary language spoken, self-identified need for interpreter and encounter characteristics including new patient status, patient time waiting for providers and time in room were collected. We compared visit times by patient's self-identification of need for an interpreter, with our main outcomes being time spent with ophthalmic technician, time spent with eyecare provider, and time waiting for eyecare provider. Interpreter services at our hospital are typically remote (via phone or video). RESULTS: A total of 87,157 patient encounters were analyzed, of which 26,443 (30.3%) involved LEP patients identifying as requiring an interpreter. After adjusting for patient age at visit, new patient status, physician status (attending or resident), and repeated patient visits, there was no difference in the length of time spent with technician or physician, or time spent waiting for physician, between English speakers and patients identifying as needing an interpreter. Patients who self-identified as requiring an interpreter were more likely to have an after-visit summary printed for them, and were also more likely to keep their appointment once it was made when compared to English speakers. CONCLUSIONS: Encounters with LEP patients who identify as requiring an interpreter were expected to be longer than those who did not indicate need for an interpreter, however we found that there was no difference in the length of time spent with technician or physician. This suggests providers may adjust their communication strategy during encounters with LEP patients identifying as needing an interpreter. Eyecare providers must be aware of this to prevent negative impacts on patient care. Equally important, healthcare systems should consider ways to prevent unreimbursed extra time from being a financial disincentive for seeing patients who request interpreter services.

Hydroxychloroquine Dose per Ophthalmology Guidelines and the Risk of Systemic Lupus Erythematosus Flares.

This study of an academic medical center patient cohort with systemic lupus erythematosus (SLE) investigates the association between hydroxychloroquine dose based on current guidelines and risk of lupus flares.

Development of a code-free machine learning model for the classification of cataract surgery phases.

This study assessed the performance of automated machine learning (AutoML) in classifying cataract surgery phases from surgical videos. Two ophthalmology trainees without coding experience designed a deep learning model in Google Cloud AutoML Video Classification for the classification of 10 different cataract surgery phases. We used two open-access publicly available datasets (total of 122 surgeries) for model training, validation and testing. External validation was performed on 10 surgeries issued from another dataset. The AutoML model demonstrated excellent discriminating performance, even outperforming bespoke deep learning models handcrafter by experts. The area under the precision-recall curve was 0.855. At the 0.5 confidence threshold cut-off, the overall performance metrics were as follows: sensitivity (81.0%), recall (77.1%), accuracy (96.0%) and F1 score (0.79). The per-segment metrics varied across the surgical phases: precision 66.7-100%, recall 46.2-100% and specificity 94.1-100%. Hydrodissection and phacoemulsification were the most accurately predicted phases (100 and 92.31% correct predictions, respectively). During external validation, the average precision was 54.2% (0.00-90.0%), the recall was 61.1% (0.00-100%) and specificity was 96.2% (91.0-99.0%). In conclusion, a code-free AutoML model can accurately classify cataract surgery phases from videos with an accuracy comparable or better than models developed by experts.

Applications of interpretability in deep learning models for ophthalmology.

PURPOSE OF REVIEW: In this article, we introduce the concept of model interpretability, review its applications in deep learning models for clinical ophthalmology, and discuss its role in the integration of artificial intelligence in healthcare. RECENT FINDINGS: The advent of deep learning in medicine has introduced models with remarkable accuracy. However, the inherent complexity of these models undermines its users' ability to understand, debug and ultimately trust them in clinical practice. Novel methods are being increasingly explored to improve models' 'interpretability' and draw clearer associations between their outputs and features in the input dataset. In the field of ophthalmology, interpretability methods have enabled users to make informed adjustments, identify clinically relevant imaging patterns, and predict outcomes in deep learning models. SUMMARY: Interpretability methods support the transparency necessary to implement, operate and modify complex deep learning models. These benefits are becoming increasingly demonstrated in models for clinical ophthalmology. As quality standards for deep learning models used in healthcare continue to evolve, interpretability methods may prove influential in their path to regulatory approval and acceptance in clinical practice.

Gaps in standards for integrating artificial intelligence technologies into ophthalmic practice.

PURPOSE OF REVIEW: The purpose of this review is to provide an overview of healthcare standards and their relevance to multiple ophthalmic workflows, with a specific emphasis on describing gaps in standards development needed for improved integration of artificial intelligence technologies into ophthalmic practice. RECENT FINDINGS: Healthcare standards are an essential component of data exchange and critical for clinical practice, research, and public health surveillance activities. Standards enable interoperability between clinical information systems, healthcare information exchange between institutions, and clinical decision support in a complex health information technology ecosystem. There are several gaps in standards in ophthalmology, including relatively low adoption of imaging standards, lack of use cases for integrating apps providing artificial intelligence -based decision support, lack of common data models to harmonize big data repositories, and no standards regarding interfaces and algorithmic outputs. SUMMARY: These gaps in standards represent opportunities for future work to develop improved data flow between various elements of the digital health ecosystem. This will enable more widespread adoption and integration of artificial intelligence-based tools into clinical practice. Engagement and support from the ophthalmology community for standards development will be important for advancing this work.

Consensus Statement for the Management and Treatment of Sturge-Weber Syndrome: Neurology, Neuroimaging, and Ophthalmology Recommendations.

BACKGROUND: Sturge-Weber syndrome (SWS) is a sporadic, neurocutaneous syndrome involving the skin, brain, and eyes. Because of the variability of the clinical manifestations and the lack of prospective studies, consensus recommendations for management and treatment of SWS have not been published. OBJECTIVE: This article consolidates the current literature with expert opinion to make recommendations to guide the neuroimaging evaluation and the management of the neurological and ophthalmologic features of SWS. METHODS: Thirteen national peer-recognized experts in neurology, radiology, and ophthalmology with experience treating patients with SWS were assembled. Key topics and questions were formulated for each group and included (1) risk stratification, (2) indications for referral, and (3) optimum treatment strategies. An extensive PubMed search was performed of English language articles published in 2008 to 2018, as well as recent studies identified by the expert panel. The panel made clinical practice recommendations. CONCLUSIONS: Children with a high-risk facial port-wine birthmark (PWB) should be referred to a pediatric neurologist and a pediatric ophthalmologist for baseline evaluation and periodic follow-up. In newborns and infants with a high-risk PWB and no history of seizures or neurological symptoms, routine screening for brain involvement is not recommended, but brain imaging can be performed in select cases. Routine follow-up neuroimaging is not recommended in children with SWS and stable neurocognitive symptoms. The treatment of ophthalmologic complications, such as glaucoma, differs based on the age and clinical presentation of the patient. These recommendations will help facilitate coordinated care for patients with SWS and may improve patient outcomes.

Ophthalmology practice in Afghanistan during the COVID-19 pandemic.

This short communication described the actions taken in ophthalmic practice in Kabul, Afghanistan during the COVID-19 pandemic to effectively protect both patients and staff. By following World Health Organisation (WHO), international and local guidelines it has been possible to continue treating ophthalmic outpatients with minimum risk to both patients and staff. The changes which have been implemented may allow better overall infection control in the hospital which will continue to have benefits post-pandemic.

Using Lean Six Sigma techniques to improve efficiency in outpatient ophthalmology clinics.

BACKGROUND: Increasing patient numbers, complexity of patient management, and healthcare resource limitations have resulted in prolonged patient wait times, decreased quality of service, and decreased patient satisfaction in many outpatient services worldwide. This study investigated the impact of Lean Six Sigma, a service improvement methodology originally from manufacturing, in reducing patient wait times and increasing service capacity in a publicly-funded, tertiary referral outpatient ophthalmology clinic. METHODS: This quality improvement study compared results from two five-months audits of operational data pre- and post-implementation of Lean Six Sigma. A baseline audit was conducted to determine duration and variability of patient in-clinic time and number of patients seen per clinic session. Staff interviews and a time-in-motion study were conducted to identify issues reducing clinic service efficiency. Solutions were developed to address these root causes including: clinic schedule amendments, creation of dedicated postoperative clinics, and clear documentation templates. A post-implementation audit was conducted, and the results compared with baseline audit data. Significant differences in patient in-clinic time pre- and post-solution implementation were assessed using Mann-Whitney test. Differences in variability of patient in-clinic times were assessed using Brown-Forsythe test. Differences in numbers of patients seen per clinic session were assessed using Student's t-test. RESULTS: During the baseline audit period, 19.4 patients were seen per 240-minute clinic session. Median patient in-clinic time was 131 minutes with an interquartile range of 133 minutes (84-217 minutes, quartile 1- quartile 3). Targeted low/negligible cost solutions were implemented to reduce in-clinic times. During the post-implementation audit period, the number of patients seen per session increased 9% to 21.1 (p = 0.016). There was significant reduction in duration (p < 0.001) and variability (p < 0.001) of patient in-clinic time (median 107 minutes, interquartile range 91 minutes [71-162 minutes]). CONCLUSIONS: Lean Six Sigma techniques may be used to reduce duration and variability of patient in-clinic time and increase service capacity in outpatient ophthalmology clinics without additional resource input.

Recommendations for ophthalmologic practice during the easing of COVID-19 control measures.

In the context of the COVID-19 pandemic, this paper provides recommendations for medical eye care during the easing of control measures after lockdown. The guidelines presented are based on a literature review and consensus among all Spanish Ophthalmology Societies regarding protection measures recommended for the ophthalmologic care of patients with or without confirmed COVID-19 in outpatient, inpatient, emergency and surgery settings. We recommend that all measures be adapted to the circumstances and availability of personal protective equipment at each centre and also highlight the need to periodically update recommendations as we may need to readopt more restrictive measures depending on the local epidemiology of the virus. These guidelines are designed to avoid the transmission of SARS-CoV-2 among both patients and healthcare staff as we gradually return to normal medical practice, to prevent postoperative complications and try to reduce possible deficiencies in the diagnosis, treatment and follow-up of the ophthalmic diseases. With this update (5th ) the Spanish Society of Ophthalmology is placed as one of the major ophthalmology societies providing periodic and systematized recommendations for ophthalmic care during the COVID-19 pandemic.

A traffic perimetry test that adheres to the European visual field requirements.

PURPOSE: European visual requirements for driving generally follow the standards of the European Union (EU), but the lack of a uniform perimetry algorithm leads to differing practices in enforcing visual field regulations. The purpose of this study was to develop a perimetry algorithm for group 1 driving licenses (car and motorcycle) that adheres to the European requirements. METHODS: We determined the features of a traffic perimetry algorithm complying with the EU directive 2009/113/EC and the underlying scientific report by the Eyesight Working Group. The final algorithm was a binocular, supra-threshold test with 37 central and 86 peripheral test points within 140º x 40º. It was created as a custom test for an Octopus 900 perimeter and tested on participants with known visual field defects. Findings were compared with the Esterman program in reference to British and Norwegian regulations, which both recommend the Esterman program for assessing fitness to drive but differ in definition of negative and positive results. RESULTS: Twenty-five participants were examined. In comparison with the traffic perimetry algorithm, sensitivity and specificity of the British regulations were 0.78 (95% confidence interval (CI) 0.40-0.97) and 1.00 (95% CI 0.79-1.00). Similarly, sensitivity and specificity of the Norwegian regulations were 0.89 (95% CI 0.52-1.00) and 0.81 (95% CI 0.54-0.96). CONCLUSION: The lack of a perimetry algorithm that conforms to the scientific recommendations challenges the fundamental right of European drivers for legal equality. This study demonstrates a binocular supra-threshold test that adheres to the European visual field requirements for group 1 driving licenses.

Predatory Publishing in Ophthalmology: A Call for Awareness and Action.

PURPOSE: To describe the phenomenon of predatory publishing, its impact on the field of ophthalmology, and specific characteristics associated with predatory journals for authors to review prior to selecting a journal for submission of scientific work. DESIGN: Descriptive editorial article. METHODS: Literature review of currently published literature regarding the topic. RESULTS: Predatory publishing has had a significant impact on the quality of literature in the scientific world, on funding opportunities across countries and institutions, and on individual physician and scientist careers. There are a significant number of predatory journals in ophthalmology, but fewer than in other specialties. CONCLUSION: We must raise awareness about the existence of predatory publishing within ophthalmology, and must individually act to limit contributing to its growth by critically appraising each publisher and journal prior to submitting our scientific work.