Normal Optic Disc Research Articles

Smartphone Aided Funduscopy in Albino Rabbits

Aims: The methodology, utility and clinical feasibility of using a smartphone camera to obtain images of ocular fundus of albino rabbits with ocular hypertension and normotension were studied. A comparative analysis of fundus images obtained from two popularly used smartphone models, android and iOS device was performed on 36 adult albino rabbits. Study Design: A cross-sectional study involving two cohorts of ocular hypertensive and normotensive albino rabbits. Place and Duration of Study: Department of Veterinary Surgery and Radiology, College of Veterinary and Animal Sciences, Mannuthy for an eight-week period (2023). Methodology: A total of 36 adult albino rabbits (18 males and 18 females; age range 6- 8 months of age) with ocular normotensive eyes and unilateral ocular hypertension-induced models were used. The conscious animals were gently restrained in an acrylic restrainer. Instillation of topical mydriatic solution (tropicamide 0.8% and phenylephrine 5%) facilitated visual examination and enhanced field of view along with auxiliary condensing lenses of 20 and 40 Diopters. A comparison of fundus images obtained from two popularly used smartphone models, android and iOS devices was performed on 36 adult albino rabbits. Results: Fundus images comprising the optic nerve head and peripapillary retina were obtained with adequate spatial resolution and detail. The variation between optic disc of ocular hypertensive eye revealed mild edema and cupping of optic disc. Normal merangiotic retina and optic disc were clearly obtained in normotensive rabbit eyes. The iOS device used in this case yielded better images in resolution and field of view compared to the android version used in this case. Conclusion: Smart phone funduscopy offered good detail in contrast and resolution even in amelanotic eyes of albino rabbits using inbuilt technology without the need for an external adapter or sophisticated additional software. It is an animal-friendly futuristic solution for digital documentation, telemedicine, teaching and clinical prognosis formulation.

Classifying and quantifying changes in papilloedema using machine learning

BackgroundMachine learning (ML) can differentiate papilloedema from normal optic discs using fundus photos. Currently, papilloedema severity is assessed using the descriptive, ordinal Frisén scale. We hypothesise that ML can quantify...

Application of metagenomic next-generation sequencing in the diagnosis of Bartonella neuroretinitis: a case report and literature review.

Cat-scratch disease (CSD) is caused by Bartonella henselae infection. In atypical cases of CSD, pathogen determination is challenging. We report a case of Bartonella neuroretinitis with neither a clear history of scratches nor typical general symptoms. The diagnosis was made using metagenomic next-generation sequencing (mNGS), a high-throughput sequencing technology. A female patient presented to the ophthalmologist with complaint of blurred vision in her right eye. Although with history of raising a cat, she reported no clear history of scratches or typical general symptoms, except a fever of unknown origin which resolved spontaneously. The best corrected visual acuity (BCVA) of the right eye was count fingers. Fundus examination showed optic disc oedema, macular exudates and inferior exudative retinal detachment. Laboratory examination results showed increased value of serum C-reactive protein and erythrocyte sedimentation rate. Ocular involvement of toxoplasmosis, syphilis and tuberculosis were excluded. To identify the possible causative pathogen of the disease, mNGS of aqueous humour sample was performed and 521 reads of B. henselae were identified. Serological test results further showed a positive immunoglobulin G (IgG) titre of 1:64. Taking the contact history, clinical manifestations, mNGS and serological results into consideration, the diagnosis of Bartonella neuroretinitis (ocular CSD) was made. After appropriatetreatment, the BCVA of the right eye improved to 20/25 in the last follow-up. Fundus examination showed a normal optic disc and macula, and the exudates had reduced. mNGS, a fast and unbiased method, can be used to detect B. henselae (if present) in intraocular fluid samples.; however, the results should be interpreted together with the clinical symptoms and other auxiliary test results.

The great escape- preserved cilioretinal artery with transient central retinal artery occlusion following snake bite

A 24-year female sustained a snake bite on the lateral side of the left ankle, followed by localized pain and blurring of vision in right eye. Her best corrected visual acuity was 20/20 in the both eyes. Relative afferent pupillary defect was noted in right eye. Fundus examination of right eye showed clear media, normal optic disc and retinal whitening with sparing of small area on macula, temporal to disc with small cilioretinal artery, suggestive of central retinal artery occlusion (CRAO) with presence of cilioretinal artery sparing. Ophthalmic manifestations following a snake bite are uncommon and can arise through diverse mechanism such as hematotoxicity from the snake bite, resulting in CRAO. Although CRAO following snake bite has been reported, we present a very rare case of snake bite induced transient CRAO with presence of spared cilioretinal artery.

Systemic steroids in pediatric pseudotumor cerebri - A case report

Study design: Case report. Purpose: To study the efficacy of systemic steroids in pediatric pseudotumor cerebri. Introduction: Pseudotumor cerebri is a condition caused by elevated intracranial pressure presenting most commonly with headache. It is a diagnosis of exclusion. Methods: A 15-year-old girl presented in our outpatient department with a headache for 3 months, more in the posterior aspect, continuous type with severe intensity, non-radiating. On examination, the best corrected visual acuity in her right eye was 6/9, and her left eye was 6/6 parts. She had a normal anterior segment and normal Intraocular Pressure (IOP). Fundoscopy showed both optic discs edematous, pink in color with blurry disc margins, tortuous disc vessels, and edematous peripapillary area. The rest of the retina was normal. Lumbar puncture showed elevated opening CSF pressure and normal CSF composition. Hence she was diagnosed with IIH. She was started on oral prednisolone 1mg/kgbw once a day dosage, oral acetazolamide 250 mg once a day, topical nepafenac 0.1% one drop thrice a day and timolol 0.5% eye drops twice a day. Discussion: The main goals of treatment are alleviation of symptoms, including headache, and preservation of vision. Steroids were commonly used for treating IIH in the past, but cause significant long-term side effects, such as weight gain, that are undesirable in IIH patients. Furthermore, withdrawal of steroids can cause rebound intracranial hypertension. Thus, steroids should not be used routinely for IIH treatment. Results: By the end of one month, the patient was relieved of symptoms, best corrected visual acuity was 6/6 in both eyes with normal IOP, normal optic disc in both eyes. Conclusion: Steroids are an effective way of managing idiopathic intracranial hypertension in pediatric patients.

Bilateral Ocular Ischaemic Syndrome due to Carotid Artery and Cardiovascular Disease: A Case Report

Introduction : Ocular ischemic syndrome (OIS) is a rare but potentially blinding and fatal condition caused by carotid artery disease or other systemic condition results in ocular hypoperfusion.
 Case Illustration : A 62-year-old male with sudden bilateral vision loss, swelling, redness and pain of both eye for 7 days. There were dilated conjunctival and episcleral vessels, visual acuity of the right eye was hand movement and 0.05 for left eye, intraocular pressure (IOP) was 33 mmHg in right eye and 37 mmHgfor left eye. Anterior segment evaluation revealed rubeosis iris, mild anterior chamber reaction, and temporal angle neovascularization on gonioscopy. Both direct and consensual light reflexes were sluggish. Fundus examination showed normal optic disc, minimal hemorrhages at mid-periphery, narrowed arterioles, and minimal cotton wool spot. Macular OCT demonstrated discrete hyperreflectivity of inner retinal layers. From Macular Angiography OCT, ETDRS Central vessel density were 11.2% and 17.6% for the right eye and left eye, respectively. In both eyes, paracentesisof anterior chamber, intravitreal and intracameral injections of anti-VEGF were performed. Brain Magnetic Resonance Angiography Imaging revealed moderate stenosis of both distal carotid artery circulation. Percutaneous Coronary Angiography showed extensive stenosis in coronary artery, with low Ejection Fraction.
 Discussion : For the cardiovascular management, a pacemaker was implanted. One week after procedure, BCVA were 1/60 and 0.15, and IOPs of 17 and 18 mmHg, for the right and left eye, respectively. The patient was scheduled to have laser retinal photocoagulation.
 Conclusion : Quick clinical diagnosis, targeted workup for systemic associations, and prompt treatment might preserve life and sight in OIS.

The BONSAI (Brain and Optic Nerve Study with Artificial Intelligence) deep learning system can accurately identify pediatric papilledema on standard ocular fundus photographs

BackgroundPediatric papilledema often reflects an underlying severe neurologic disorder and may be difficult to appreciate, especially in young children. Ocular fundus photographs are easy to obtain even in young children and in nonophthalmology settings. The aim of our study was to ascertain whether an improved deep-learning system (DLS), previously validated in adults, can accurately identify papilledema and other optic disk abnormalities in children. MethodsThe DLS was tested on mydriatic fundus photographs obtained in a multiethnic pediatric population (<17 years) from three centers (Atlanta-USA; Bucharest-Romania; Singapore). The DLS’s multiclass classification accuracy (ie, normal optic disk, papilledema, disks with other abnormality) was calculated, and the DLS’s performance to specifically detect papilledema and normal disks was evaluated in a one-vs-rest strategy using the AUC, sensitivity and specificity, with reference to expert neuro-ophthalmologists. ResultsExternal testing was performed on 898 fundus photographs:447 patients; mean age, 10.33 (231 patients ≤10 years of age; 216, 11-16 years); 558 normal disks, 254 papilledema, 86 other disk abnormalities. Overall multiclass accuracy of the DLS was 89.6% (range, 87.8%-91.6%). The DLS successfully distinguished “normal” from “abnormal” optic disks (AUC 0.99 [0.98-0.99]; sensitivity, 87.3% [84.9%-89.8%]; specificity, 98.5% [97.6%-99.6%]), and “papilledema” from “normal and other” (AUC 0.99 [0.98-1.0]; sensitivity, 98.0% [96.8%-99.4%]; specificity, 94.1% (92.4%-95.9%)]. ConclusionsOur DLS reliably distinguished papilledema from normal optic disks and other disk abnormalities in children, suggesting it could be utilized as a diagnostic aid for the assessment of optic nerve head appearance in the pediatric age group.

Scanning Laser Ophthalmoscopy Demonstrates Pediatric Optic Disc and Peripapillary Strain During Horizontal Eye Rotation

Purpose: We employed automated analysis of scanning laser ophthalmoscopy (SLO) to determine if mechanical strains imposed on disc, and retinal and choroidal vessels during horizontal duction in children differ from those of adults. Methods: Thirty-one children aged 11.3 ± 2.7 (standard deviation) years underwent SLO in central gaze, and 35° ab- and adduction. Automated registration with deep learning-based optical flow analysis quantified vessel deformations as horizontal, vertical, shear, and equivalent strains. Choroidal vessel displacements in lightly pigmented fundi, and central disc vessel displacements, were also observed. Results: As in adults, strain in vessels during horizontal duction was greatest at the disc and decreased with distance from it. Strain in the pediatric disc was similar to published values in young adults, 1 but in the peripapillary region was greater and propagated significantly more peripherally to at least three disc radii from it. During adduction in children, the nasal disc was compressed and disc vessels distorted, but the temporal half experienced tensile strain, while peripapillary tissues were compressed. The pattern was similar but strains were less in abduction (p < .001). Choroidal vessels were visualized in 24 of the 62 eyes and shifted directionally opposite overlying retinal vessels. Conclusions: Horizontal duction deforms the normal pediatric optic disc, central retinal vessels, peripapillary retina, and choroid, shearing the inner retina over the choroid. These mechanical effects occur at the sites of remodeling of the disc, sclera, and choroid associated with typical adult features that later emerge later, including optic cup enlargement, temporal disc tilting, and peripapillary atrophy.

Artificial intelligence in glaucoma detection using color fundus photographs.

To explore the potential of artificial intelligence (AI) for glaucoma detection using deep learning algorithm and evaluate its accuracy for image classification of glaucomatous optic neuropathy (GON) from color fundus photographs. A total of 1375 color fundus photographs, 735 normal optic nerve head and 640 GON, were uploaded on the AI software for training, validation, and testing using deep learning model, which is based on Residual Network (Res Net) 50V2. For initial training and validation, 400 fundus images (200 normal and 200 GON) were uploaded and for the final training and testing 975 (535 normal and 440 GON) were uploaded later. Accuracy, sensitivity, and specificity were used to evaluate the image classification performance of the algorithm. Also, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were calculated. The model used in the study showed an image classification accuracy of 81.3%, sensitivity of 83%, and specificity of 80% for the detection of GON. The false-negative grading was 17% and false-positive grading was 20% for the image classification of GON. Coexistence of glaucoma in patients with high myopia, early glaucoma in a small disc, and software misclassification of GON were the reasons for false-negative results. Physiological large cupping in a large disc, myopic or titled disc, and software misclassification of normal optic disc were the reasons for false-positive results. The model employed in this study achieved a good accuracy, and hence has a good potential in detection of GON using color fundus photographs.

Prevalence of serum MOG antibody and AQP4 antibody in optic neuritis after SARS-CoV-2 infection.

To evaluate the prevalence of serum myelin oligodendrocyte glycoprotein antibody (MOG-Ab) and aquaporin-4 antibody (AQP4-Ab) in optic neuritis (ON) patients after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by cell-based indirect immunofluorescence assay (CBA). In this prospective case series study, 35 patients clinically diagnosed as ON and laboratory-confirmed SARS-CoV-2 infection from 8 December 2022 to 8 February 2023 were included. All patients' clinical and laboratory data were collected and analyzed. The mean age of the 35 patients (46 eyes) was 38.2 years (ranging from 6 to 69 years), and 17 cases were female patients. Thirty-three and two cases showed positive SARS-CoV-2 RNA test results before or shortly after ON onset, respectively. ON occurred unilaterally in 24 cases and bilaterally in 11 cases. Ophthalmic examination revealed swollen optic disc in 37 eyes, normal optic disc in 6 eyes, and temporally or wholly paled optic disc in 3 eyes. CBA revealed seropositive MOG-Ab in 10 cases and AQP4-Ab in 2 cases, respectively, of which 2 AQP4-Ab-seropositive cases and 1 MOG-Ab-seropositive case had a past medical history of ON. Most ON patients showed a rapid and dramatic response to pulse steroid therapy. The median of BCVA at the onset and at the last follow-up was 20/500 (ranging from light perception to 20/20) and 20/67 (ranging from counting fingers to 20/20), respectively. Serum MOG-Ab and AQP4-Ab were detected in 28.6% (10/35) and 5.7% (2/35) ON cases after SARS-CoV-2 infection. SARS-CoV-2 infection may trigger an onset or a relapse of ON, as well as the production of MOG-Ab.

The Second Case of Bardet-Biedl syndrome from Iraq: An educational article and expert opinion

Background: Bardet-Biedl syndrome and Laurence-Moon syndrome are rare autosomal recessive disorders with a similar phenotype. They are characterized by the gradual development of phenotype which includes cone-rod retinal dystrophy, obesity, and hypogonadism in males. Other associated abnormalities include learning disability and renal abnormalities. The two conditions are differentiated clinically by the presence of spasticity and the absence of polydactyly in Laurence-Moon syndrome. In 2002, we reported the first patient with Bardet-Biedl syndrome. The boy had polydactyly, obesity, retinal degeneration, and was hospitalized at the University Hospital in Al-Kadhimiyia because of the development of chronic renal failure. Patients and methods: The case of a 9-year-old obese Kurdish girl who had polydactyly of the hands and feet associated with reduced visual acuity is described.Results: A 9-year-old obese Kurdish girl had polydactyly of the hand and feet associated with reduced visual acuity that was attributed to myopia which was partially corrected with eye glasses. The parents were unrelated, and her younger 5-year sister had polydactyly of the feet only. No other family member known to have polydactyly. Both sisters had their extra-digits removed surgically. The girl was studying at fourth grade primary school and the parents reported no learning disability. Fundoscopy showed normal optic disc and periphery of the retina. The presence of retinitis pigmentosa was excluded. However, the foveal reflex was reported to be abnormal by the oophthalmologist. Electroretinography showed evidence of cone-rod dystrophy.Conclusion: The second case of Bardet-Biedl syndrome from Iraq is reported. The current evidence-based expert opinion suggests the use of long tem supplementation of citicoline, co-enzyme Q10 and lutein with hope of retarding the progression to blindness.

Application of a Deep Learning System to Detect Papilledema on Nonmydriatic Ocular Fundus Photographs in an Emergency Department

The Fundus photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) studies showed that ED providers poorly recognized funduscopic findings in patients in the ED. We tested a modified version of the Brain and Optic Nerve Study Artificial Intelligence (BONSAI) deep learning system on nonmydriatic fundus photographs from the FOTO-ED studies to determine if the deep learning system could have improved the detection of papilledema had it been available to ED providers as a real-time diagnostic aid. Retrospective secondary analysis of a cohort of patients included in the FOTO-ED studies. The testing data set included 1608 photographs obtained from 828 patients in the FOTO-ED studies. Photographs were reclassified according to the optic disc classification system used by the deep learning system ("normal optic discs," "papilledema," and "other optic disc abnormalities"). The system's performance was evaluated by calculating the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity using a 1-vs-rest strategy, with reference to expert neuro-ophthalmologists. The BONSAI deep learning system successfully distinguished normal from abnormal optic discs (AUC 0.92 [95% confidence interval {CI} 0.90-0.93]; sensitivity 75.6% [73.7%-77.5%] and specificity 89.6% [86.3%-92.8%]), and papilledema from normal and others (AUC 0.97 [0.95-0.99]; sensitivity 84.0% [75.0%-92.6%] and specificity 98.9% [98.5%-99.4%]). Six patients with missed papilledema in 1 eye were correctly identified by the deep learning system as having papilledema in the other eye. The BONSAI deep learning system was able to reliably identify papilledema and normal optic discs on nonmydriatic photographs obtained in the FOTO-ED studies. Our deep learning system has excellent potential as a diagnostic aid in EDs and non-ophthalmology clinics equipped with nonmydriatic fundus cameras. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Retinal Nerve Fiber Layer Optical Texture Analysis: Detecting Axonal Fiber Bundle Defects in Patients with Ocular Hypertension

To apply retinal nerve fiber layer (RNFL) optical texture analysis (ROTA) to investigate the prevalence, patterns, and risk factors of RNFL defects in patients with ocular hypertension (OHT) who showed normal optic disc and RNFL configuration in clinical examination, normal RNFL thickness on OCT analysis, and normal visual field (VF) results. Cross-sectional study. Six hundred eyes of 306 patients with OHT. All participants underwent clinical examination of the optic disc and RNFL, OCT RNFL imaging, and 24-2 standard automated perimetry. To detect RNFL defects, ROTA was applied. The risk score for glaucoma development was calculated according to the Ocular Hypertension Treatment Study and European Glaucoma Prevention Study (OHTS-EGPS) risk prediction model. Risk factors associated with RNFL defects were analyzed using multilevel logistic regression analysis. Prevalence of RNFL defects. The average intraocular pressure (IOP) measured from 3 separate visits within 6 months was 24.9 ± 1.8 mmHg for the eye with higher IOP and 23.7 ± 1.7 mmHg for the eye with lower IOP; the respective central corneal thicknesses were 568.7 ± 30.8 μm and 568.8 ± 31.2 μm. Of 306 patients with OHT, 10.8% (33 patients, 37 eyes) demonstrated RNFL defects in ROTA in at least 1 eye. Of the 37 eyes with RNFL defects, the superior arcuate bundle was the most frequently involved (62.2%), followed by the superior papillomacular bundle (27.0%) and the inferior papillomacular bundle (21.6%). Papillofoveal bundle defects were observed in 10.8% of eyes. The smallest RNFL defect spanned 0.0° along Bruch's membrane opening margin, whereas the widest RNFL defect extended over 29.3°. Age (years) (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.03-1.13), VF pattern standard deviation (decibels [dB]) (OR, 1.82; 95% CI, 1.01-3.29), cup volume (mm3) (OR, 1.24; 95% CI, 1.01-1.53), and the OHTS-EPGS risk score (OR, 1.04; 95% CI, 1.01-1.07) were associated with RNFL defects. A considerable proportion of patients with OHT who showed no signs of optic disc and RNFL thickness abnormalities on clinical and OCT examination exhibited RNFL defects on ROTA. Axonal fiber bundle defects on ROTA may represent the earliest discernible sign of glaucoma in the glaucoma continuum. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Clinical and imaging characteristics of optic nerve tumors as the differencial diagnosis of optic neuritis

Objective: To investigate the clinical and imaging features of optic nerve tumors that require differential diagnosis from optic neuritis. Methods: A retrospective case series study was conducted. Clinical data of patients diagnosed with optic nerve tumors from January 2017 to December 2021 at the Second Affiliated Hospital of Zhejiang University School of Medicine were collected. A total of 29 patients (39 eyes) with clinical and magnetic resonance imaging (MRI) findings similar to optic neuritis or optic neuropathy were included. There were 15 cases of optic nerve sheath meningioma (ONSM) (17 eyes), 4 cases of optic nerve glioma (ONG) (5 eyes), and 10 cases of infiltrative optic nerve lesions (ION) (17 eyes). All patients underwent best-corrected visual acuity (BCVA), anterior and posterior segment examinations, visual field examination, and orbital or cranial MRI examination. Patient data were observed and analyzed, treatment and follow-up information were recorded, and clinical and imaging features were summarized and compared with those of optic neuritis or optic neuropathy. Results: Among the 29 patients with optic nerve tumors, 10 were male and 19 were female, with an average age of (43.3±13.8) years and a range of 11 to 72 years. The follow-up time was 6.8 (2.0, 11.0) months, with a range of 1 to 33 months. Sixteen patients (21 eyes) with optic nerve tumors were initially misdiagnosed as having acute optic neuritis and showed poor response to steroid treatment. Of these, 9 cases (11 eyes) were ONSM, 4 cases (6 eyes) were ION, and 3 cases (4 eyes) were ONG. The diagnostic delay time was 7.1 (1.5, 12.0) months, with a range of 1 to 24 months. The main clinical symptoms of all affected eyes were acute vision loss in 23 eyes, slow vision loss in 5 eyes, transient blackouts in 4 eyes, and no obvious visual symptoms in 7 eyes. The median BCVA of all affected eyes was 0.1, ranging from light perception to 1.0. Fundus examination results showed optic disc edema in 34 eyes and normal optic disc in 5 eyes among the 39 eyes with optic nerve tumors. A total of 27 patients (33 eyes) completed visual field examinations, which revealed an enlarged physiological blind spot in 11 eyes, a concentric or tubular visual field contraction in 8 eyes, a diffuse decrease in light sensitivity in 7 eyes, an arcuate scotoma in 4 eyes, and a normal visual field in 3 eyes. All affected eyes completed orbital or cranial MRI examinations, which showed mild optic nerve thickening in 22 eyes, significant thickening in 6 eyes with distortion, and no significant thickening in 6 eyes. Contrast-enhanced T1-weighted imaging (T1WI) MRI showed optic nerve parenchymal thickening in 5 eyes, all of which were ONG, and 2 of them had optic nerve parenchymal enhancement. Optic nerve sheath thickening and enhancement without optic nerve parenchymal thickening or enhancement were observed in 28 eyes, including 17 eyes of ION and 11 eyes of ONSM. There were 6 eyes with no obvious optic nerve thickening, which were all ONSM, showing mild or significant thickening and enhancement of the optic nerve sheath without optic nerve parenchymal thickening or enhancement. Conclusions: Optic nerve tumors can present with ophthalmic clinical features similar to optic neuritis, such as optic disc edema, and demonstrate MRI findings that resemble those of optic neuritis. Therefore, differentiation between the two is crucial, based on differences in their natural course and response to steroid therapy.

O114 Non-traumatic osteonecrosis of femoral head and its association with cardio-vascular disease: a case control study

Abstract Introduction Many parallels have been drawn in the past between the ischaemic process in the femoral head and in other organs like the heart (myocardial ischemia) and brain (stroke) suggesting similarities in their etio-pathogenesis. We aimed to study the relationship between coronary heart disease after non-traumatic osteonecrosis of femoral head (ONFH) by assessing the cardio-vascular profile utilizing non-invasive methods. Methods A case-control study was conducted at a tertiary care hospital to determine the association between non-traumatic ONFH and cardio-vascular pathology using non-invasive methods that assessed intravascular (lipid profile), microvascular (retinal fundoscopy) and macrovascular (ophthalmic and carotid doppler) parameters. Results 48 patients were analysed, which comprised 24 cases and 24 controls, with each group consisting of 16 males and 8 females. Mean age of cases and controls were 37.08 ± 11.81 and 37.25 ± 11.67. Steroid intake (45.83%) was the most common predisposing factor, followed by chronic alcohol intake(25%). The ophthalmic and carotid artery doppler and lipid profile measurements did not find any statistically significant difference between the cases and controls. Fundus examination revealed C/D ratio of &amp;lt;0.3, foveal reflex and normal optic disc in all cases. Conclusion Though it is believed that non-traumatic osteonecrosis of the femoral head precedes the development of coronary artery disease, our study did not identify any significant relationship between the two when assessed by colour doppler of the ophthalmic and carotid arteries. The lipid profile characteristics of cases and controls showed no statistically significant variation.

Unilateral Idiopathic Optic Perineuritis in a Normal Fundus

A 22-year-old woman of Malay ethnicity presented with severe blurred vision in the right eye and experienced periocular pain with eye movement. She had a visual field defect over the affected eye, while an examination showed clinically normal optic discs. Relative afferent pupillary defect was also present in the right eye, with reduced optic nerve function. Optic nerve imaging revealed the ‘doughnut sign’ and ‘tram track’ signs, which are characteristics of optic perineuritis. The patient was initiated on a steroid regime that was tapered off over four months. Her visual function recovered gradually during the treatment until reaching a satisfactory final visual outcome. This is a unique case where optic perineuritis occurred in a normal fundus and magnetic resonance imaging (MRI) served as an important diagnostic tool for the condition.&#x0D; Optic perineuritis (OPN) is an orbital inflammatory disease that involves the meningeal sheath surrounding the optic nerve.[1] It can be idiopathic or secondary to an underlying systemic autoimmune disorder.[1,2] Visual loss in OPN results from inflammation of the tissue surrounding the optic nerve, resulting in mechanical compression of the nerve and subsequent ischaemia.[1]&#x0D; OPN can be diagnosed using an optic nerve sheath biopsy, while magnetic resonance imaging (MRI) diagnoses OPN through perineural enhancement, making it a useful diagnostic tool.[2] Upon diagnosis, OPN should be treated with corticosteroids for a prolonged period to ensure visual recovery.[3]&#x0D; We report a unique case of unilateral OPN with severe visual loss in a young Malay woman with a normal fundoscopy who was successfully treated with prolonged corticosteroids.

Classifying Papilledema Using Machine Learning – Modernizing Frisén Grading (S12.001)

<h3>Objective:</h3> We hypothesize that machine learning (ML) can quantify papilledema and detect a treatment effect on papilledema due to idiopathic intracranial hypertension (IIH). <h3>Background:</h3> ML can differentiate papilledema from normal optic discs. Currently, papilledema severity is assessed using the descriptive, ordinal Frisén scale. <h3>Design/Methods:</h3> We trained a convolutional neural network (CNN) to autonomously assign a Frisén grade using 2608 fundus photos from fellow eyes of 158 participants in the IIH Treatment Trial (IIHTT) and both eyes from eight clinic patients with grade 4 or 5 papilledema. Experts in classifying papilledema previously graded the photos. Our validation set consisted of 2969 photos of the IIHTT study eyes (for each participant, the eye with worse vision). To investigate the change over time, we divided study eyes into treatment groups, acetazolamide + diet (ACZ) vs. placebo + diet. <h3>Results:</h3> ML produced continuous values from 0–5, which identified photos that contained features from more than one Frisén grade. Activation maps showed the model focused on the optic disc. The average predicted Frisén grade correlated strongly with ground truth (r = 0.80, p &lt; 0.001; mean absolute error = 0.49). At presentation, treatment groups had similar ML Frisén grades. The average ML Frisén grade for the ACZ treatment group (1.6, 95% CI 1.5–1.8) was significantly lower (p &lt; 0.01) than for the placebo group (2.2, 95% CI 1.9–2.5) at the six month trial outcome. This difference was noted as early as one month (p = 0.03). <h3>Conclusions:</h3> Supervised ML of fundus photos successfully grades the degree of papilledema and tracks the changes, reflecting the effects of ACZ therapy. Given the increasing availability of fundus photography, neurologists will be able to utilize ML to quantify papilledema on a continuous scale that incorporates the descriptive features of the Frisén grade to monitor treatment of papilledema. <b>Disclosure:</b> Mr. Branco has nothing to disclose. Jui-Wang Wang has nothing to disclose. Dr. Elze has nothing to disclose. Mona Garvin has nothing to disclose. Mr. Szanto has nothing to disclose. Dr. Kardon has received personal compensation in the range of $50,000-$99,999 for serving as an Expert Witness for 19 different law firms. The institution of Dr. Kardon has received research support from NIH. The institution of Dr. Kardon has received research support from Veterans Administration RR&amp;D Division. Dr. Kardon has received intellectual property interests from a discovery or technology relating to health care. Dr. Pasquale has received personal compensation for serving as an employee of Eyenovia. Dr. Pasquale has received personal compensation for serving as an employee of Twenty Twenty. Dr. Pasquale has received personal compensation for serving as an employee of Skye Biosciences. Dr. Pasquale has received personal compensation for serving as an employee of Character Biosciences. Dr. Pasquale has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for The Glaucoma Foundation. The institution of Dr. Pasquale has received personal compensation in the range of $50,000-$99,999 for serving on a Scientific Advisory or Data Safety Monitoring board for The Glaucoma Foundation. The institution of Dr. Pasquale has received research support from NEI. Dr. Kupersmith has nothing to disclose.

Comparison of Cirrus spectral domain OCT with disc-macula distance to disc diameter ratio in diagnosing congenital optic nerve hypoplasia.

Diagnosis of congenital optic nerve hypoplasia (CONH) can be challenging in children or uncooperative individuals. Misdiagnosis can lead to inappropriate treatment; thus, it is important to identify an objective and reliable measurement. The purpose of this study was to evaluate whether Cirrus spectral domain optical coherence tomography (SD-OCT) is a valid test for diagnosing CONH by comparing it to the disc-macula distance to disc diameter (DM:DD) ratio. A total of 93 participants (64 controls and 29 CONH) underwent comprehensive eye examinations, fundus photography and Cirrus SD-OCT. Receiver operating characteristic (ROC) curves for the DM:DD ratio and OCT disc area were constructed for CONH and control eyes. Mean (±SD) OCT disc area was 1.46 (±0.42) mm2 and 1.89 (±0.38) mm2 for CONH and control eyes, respectively (p < 0.0001). The area under the curve for the DM:DD ratio was 0.97 (95% confidence interval: 0.91-0.99) and 0.79 for OCT disc area (95% confidence interval: 0.70-0.86), which were significantly different (p = 0.0005). The optimal cut-off value for OCT disc area was 1.66 mm2 (76% sensitivity, 70% specificity), while the optimal cut-off for DM:DD ratio was 3.10 (85% sensitivity and 95% specificity). The Cirrus SD-OCT showed a tendency to overestimate disc size, especially in cases with no light perception (NLP) or segmental CONH. Although the DM:DD ratio is superior to OCT in diagnosing CONH with a higher sensitivity and specificity, the ratio is subject to inter-examiner variability and can be challenging to obtain. We found the Cirrus SD-OCT to be a valid objective test for diagnosing CONH. Caution is advised when using SD-OCT in segmental CONH or in an eye with NLP. We suggest 1.66 mm2 as the optimal cut-off value for Cirrus SD-OCT disc area to differentiate a hypoplastic from a normal optic disc.

Ethambutol and its ophthalmic effects; is screening and collaboration the new way forward?

AimTo screen patients on ethambutol and evaluate its role on visual functions and toxic optic neuropathy. Setting and designRetrospective, observational single tertiary centre cohort of 80 patients. Methods and materialA total of 69 from the initial 80 patients with visual complaints were categorised into two groups A and B; ongoing anti-tubercular therapy with ethambutol and having stopped ethambutol for greater than six months respectively. All patients underwent vision (V) testing on ETDRS chart and anterior and posterior segment evaluation. Additionally, patients in group A recorded color vision (CV) on Ishihara chart and visual evoked potential (VEP). Statistical analysis usedP value was calculated using Chi square test (SPSS ver. 20). ResultsOut of 69 patients in our study, 58 (84.05%) patients recorded reduced visual acuity. The mean visual acuity was 0.58 logMAR units. 33 out of our 58 (57%) patients with reduced visual acuity showed normal optic discs while 25 out of 58 (43%) showed altered optic discs. In group B, 14 out of 32 patients with vision of less than 20/20 also had optic disc pallor (p = 0.02). 12 out of 15 patients in group A recorded an altered color vision and also had a vision of less than 20/20 (p = 0.023). 15 patients who recorded altered VEP also had vision of less than 20/20 (p = 0.037). ConclusionVisual acuity, color vision and vep are sensitive and sustainable tools which can be implemented in regular screening. Ethambutol toxicity is a real problem and a collaborative approach is necessary to establish screening protocols and prevent ethambutol induced toxic optic neuropathy.

The second case of Bardet-Biedl syndrome from Iraq: An educational article and expert opinion

Background: Bardet-Biedl syndrome and Laurence-Moon syndrome are rare autosomal recessive disorders with a similar phenotype. They are characterized by the gradual development of phenotype which includes cone-rod retinal dystrophy, obesity, and hypogonadism in males. Other associated abnormalities include learning disability and renal abnormalities. The two conditions are differentiated clinically by the presence of spasticity and the absence of polydactyly in Laurence-Moon syndrome. In 2002, we reported the first patient with Bardet-Biedl syndrome. The boy had polydactyly, obesity, retinal degeneration, and was hospitalized at the University Hospital in Al-Kadhimiyia because of the development of chronic renal failure. Patients and methods: The case of a 9-year-old obese Kurdish girl who had polydactyly of the hands and feet associated with reduced visual acuity is described. Results: A 9-year-old obese Kurdish girl had polydactyly of the hand and feet associated with reduced visual acuity that was attributed to myopia which was partially corrected with eye glasses. The parents were unrelated, and her younger 5-year sister had polydactyly of the feet only. No other family member known to have polydactyly. Both sisters had their extra-digits removed surgically. The girl was studying at fourth grade primary school and the parents reported no learning disability. Fundoscopy showed normal optic disc and periphery of the retina. The presence of retinitis pigmentosa was excluded. However, the foveal reflex was reported to be abnormal by the oophthalmologist. Electroretinography showed evidence of cone-rod dystrophy. Conclusion: The second case of Bardet-Biedl syndrome from Iraq is reported. The current evidence-based expert opinion suggests the use of long tem supplementation of citicoline, co-enzyme Q10 and lutein with hope of retarding the progression to blindness.