Deep learning in ophthalmology: The technical and clinical considerations

The advent of computer graphic processing units, improvement in mathematical models and availability of big data has allowed artificial intelligence (AI) using machine learning (ML) and deep learning (DL) techniques to achieve robust performance for broad applications in social-media, the internet of things, the automotive industry and healthcare. DL systems in particular provide improved capability in image, speech and motion recognition as well as in natural language processing. In medicine, significant progress of AI and DL systems has been demonstrated in image-centric specialties such as radiology, dermatology, pathology and ophthalmology. New studies, including pre-registered prospective clinical trials, have shown DL systems are accurate and effective in detecting diabetic retinopathy (DR), glaucoma, age-related macular degeneration (AMD), retinopathy of prematurity, refractive error and in identifying cardiovascular risk factors and diseases, from digital fundus photographs. There is also increasing attention on the use of AI and DL systems in identifying disease features, progression and treatment response for retinal diseases such as neovascular AMD and diabetic macular edema using optical coherence tomography (OCT). Additionally, the application of ML to visual fields may be useful in detecting glaucoma progression. There are limited studies that incorporate clinical data including electronic health records, in AL and DL algorithms, and no prospective studies to demonstrate that AI and DL algorithms can predict the development of clinical eye disease. This article describes global eye disease burden, unmet needs and common conditions of public health importance for which AI and DL systems may be applicable. Technical and clinical aspects to build a DL system to address those needs, and the potential challenges for clinical adoption are discussed. AI, ML and DL will likely play a crucial role in clinical ophthalmology practice, with implications for screening, diagnosis and follow up of the major causes of vision impairment in the setting of ageing populations globally

Psychiatric Case Record

Bipolar Disorder-Mania: Patient was apparently normal one-month back, Then all of a sudden he developed sleep disturbances –mainly difficult in initiation of sleep. He also started abusing his family members for unwanted things. Subsequently, he started talking excessively and irritable. Sometimes he sings film songs and dances. He used to say that God Supreme exists in himself and so he has all the powers of Almighty. With that superior power he says that he can solve all the problems in this world. He also says that he has invented herbs to keep people young. For the past one week, he talks excessively without having an hour of sleep & wanders here and there & found excessively smoking. He becomes excessively spiritual and goes to near by villages for offering prayers to God. He takes only a little food everyday and he is very much keen in personal cleanliness. Paranoid Schizophrenia: She was apparently normal 8 months back, then she developed sleep disturbances in the form of difficult in falling asleep. She was found talking & smiling to herself at night & day with mirror gazing. She started saying that her neighbour & relatives are planning to kill herself by poisoning. In this context she had frequent quarrels with them and she refused to take food prepared by her mother in law. She left the home at night without informing any one and started wandering in the road side near her home. She was complaining that she hears voices as if her neighbour & relatives were talking about her among themselves She was not doing house hold activities for past 6 months and she was not taking care of her child. Her personal hygiene was very much deteriorated slowly as she used to take bath & brush, only if she was asked to do so. She started abusing & assaulting the strangers and family members. Generalised Anxiety Disorder: Six months back he was apparently normal. He is working as a system analyst in a private bank . He had once, made a mistake in his bank work for which he was given charges by his employer, followed this event he becomes very tense and afraid whenever his boss called him. He is very cautious that he should not commit any mistakes. Even though he is not doing so, he fears that he may commit some mistake in his work. At that moment he develops palpitation, giddiness, breathlessness, excessive sweating over palms and soles. Slowly these symptoms present through out the day even when he was not in his office, and he could not control his fearfulness. For the past 6 months he didn’t sleep well. His sleep is disturbed by bad dreams. Recurrent Depressive Disorder: Patient was apparently alright 2 months back. Then she developed sleep disturbances particularly early morning awakening, she use to wake up by 3.00 am and use to brood about herself and started crying. She was not doing her domestic work as before, as she felt excess tiredness and use to take frequent rests. She developed poor communication. She had lost her interest in pleasurable activities and was not interested in watching TV, and attending family gatherings. She stayed aloof most of the time & calm, quiet and withdrawn. She was expressing her helplessness and hopelessness about the future. She started to have decline in maintaining self care. 15 days back, she frequently expressed suicidal ideas and she had attempted suicide by hanging herself and was rescued by neighbours. 5 days back, she started talking in an irrelevant manner. She was smiling to self. She was assaulting her family members. She was suspicious that her neighbour had done black magic on her and also saying that people are talking about her. She reported hearing the voice of her neighbour scolding and threatening her. Organic Brain Syndrome – Dementia: Ten months back he was apparently alright. Then his relatives noticed himself frequently misplaces things inside his home. Then he started behaving aggressively. He was beating his wife without reason. He was roaming here and there, running out of home and wandering aimlessly. He was not able to come back home when he goes out. He was brought back to home by his relatives. Slowly he developed fearfulness and tremulousness while he was staying alone. He also started saying that his family members & neighbours were talking about himself, in this context he would make frequent quarrels with them. He also started hearing voices of known male voices abusing himself in third person. He sleeps for few hour only. He is passing urine and motion inside the house. He is asking about his brother and mother-in-law who were expired long back. He behaves abnormally such as pouring water in the plate while eating. And his relatives found the symptoms were worsened by evening. All these symptoms started insidiously, increased in severity through time and attained the present state. No history of loss of appetite / crying spells / suicidal tendencies / convulsions / fever / head injury

Deep learning for diabetic retinopathy analysis : a review, research challenges, and future directions

Deep learning (DL) enables the creation of computational models comprising multiple processing layers that learn data representations at multiple levels of abstraction. In the recent past, the use of deep learning has been proliferating, yielding promising results in applications across a growing number of fields, most notably in image processing, medical image analysis, data analysis, and bioinformatics. DL algorithms have also had a significant positive impact through yielding improvements in screening, recognition, segmentation, prediction, and classification applications across different domains of healthcare, such as those concerning the abdomen, cardiac, pathology, and retina. Given the extensive body of recent scientific contributions in this discipline, a comprehensive review of deep learning developments in the domain of diabetic retinopathy (DR) analysis, viz., screening, segmentation, prediction, classification, and validation, is presented here. A critical analysis of the relevant reported techniques is carried out, and the associated advantages and limitations highlighted, culminating in the identification of research gaps and future challenges that help to inform the research community to develop more efficient, robust, and accurate DL models for the various challenges in the monitoring and diagnosis of DR

Visual Impairment and Blindness

Blindness and vision impairment affect at least 2.2 billion people worldwide with most individuals having a preventable vision impairment. The majority of people with vision impairment are older than 50 years, however, vision loss can affect people of all ages. Reduced eyesight can have major and long-lasting effects on all aspects of life, including daily personal activities, interacting with the community, school and work opportunities, and the ability to access public services. This book provides an overview of the effects of blindness and visual impairment in the context of the most common causes of blindness in older adults as well as children, including retinal disorders, cataracts, glaucoma, and macular or corneal degeneration

An Etiological Analysis of Pale Optic Disc and Its Correlation with Visual Outcome in Patients attending a Tertiary Care Hospital

INTRODUCTION: The death of the retinal ganglion cell axons that comprise the optic nerve leads to optic atrophy and giving the resultant picture of a pale optic nerve. The term optic atrophy describes a group of clinical conditions which have an abnormal pallor of the disc as a common physical sign. Optic atrophy is not a disease; it is the end result any pathological process that damages the retinal ganglion cells and axons of reticulogeniculate pathway. The axons of the retinal ganglion cells make up the optic nerve and continue onto the optic chiasm, optic tract and up to the lateral geniculate body where they synapse. Injury to the retinal ganglion cells and axons anywhere along their course from the retina to the lateral geniculate body may result in optic atrophy. Clinically, optic atrophy is associated with a decrease in visual acuity and visual field defect. There are numerous causes of optic nerve damage anywhere along the path from the retina to the lateral geniculate. The etiological factors like intracranial tumors, meningitis, optic neuritis and toxic atrophy could lead to optical atrophy. AIM OF THE STUDY: Pale optic disc is mainly due to damage to optic nerve anywhere from retinal ganglion cells to lateral geniculate body. The need for identifying etiological cause of pale optic disc is important as each optic nerve disease is different and also has varied prognosis and visual outcome. The pale optic disc may due to many causes like ischemic optic neuropathy, optic neuritis, infectious neuropathy, infiltrative neuropathy, toxic or nutritional neuropathy, hereditary neuropathy, any compressive lesions of optic nerve, traumatic neuropathy, long standing papilloedema due to intracranial lesion. This study was conducted to analyse the etiology of pale optic disc and its visual outcome MATERIALS AND METHODS: Study was conducted at the Department of Ophthalmology, Coimbatore Medical College Hospital, Coimbatore. This was a prospective observational study. A total of 50 patients with nonglaucomatous pale optic disc were included in the study. Detailed history including the past medical history was recorded. A comprehensive Opthalmological examination is done including visual acuity, colour vision, visual fields, slitlamp biomicroscopy, ophthalmoscope examination, fundus photograph, Contrast sensitivity Biochemical investigations and neuroimaging were ordered when indicated to identify etiology and patients were followed up over a period of 6 months for visual outcome. RESULTS: The main etiology observed for pale optic disc among the study population was traumatic optic neuropathy. Majority of study population were young adults and observation of traumatic optic neuropathy may be attributed to their age group. Improvement of visual outcome was less in the study population when compared with other similar studies .Best corrected visual acuity of atleast one line improvement in Snellen’s chart after 6 months was observed only in 34% of study population which was contributed by 16% Optic neuritis, 12% Tumour, 3% Trauma etiology. Hence visual acuity outcome can be concluded to be poor among study population after treatment. CONCLUSION: Definitive diagnosis of optic disc pallor which itself is a sign of an underlying disease is very important. Identification of actual cause of optic disc pallor will help in its appropriate management

RETINAL IMAGING IN CEREBROVASCULAR DISEASE AND DEMENTIA

Ph.DDOCTOR OF PHILOSOPH

Age-Related Macular Degeneration and Diabetic Retinopathy

This reprint includes contributions from leaders in the field of personalized medicine in ophthalmology. The contributions are diverse and cover pre-clinical and clinical topics. We hope you enjoy reading the articles

Machine learning of structured and unstructured healthcare data

The widespread adoption of Electronic Health Records (EHR) systems in healthcare institutions in the United States makes machine learning based on large-scale and real-world clinical data feasible and affordable. Machine learning of healthcare data, or healthcare data analytics, has achieved numerous successes in various applications. However, there are still many challenges for machine learning of healthcare data both structured and unstructured. Longitudinal structured clinical data (e.g., lab test results, diagnoses, and medications) have an enormous variety of categories, are collected at irregularly spaced visits, and are sparsely distributed. Studies on analyzing longitudinal structured EHR data for tasks such as disease prediction and visualization are still limited. For unstructured clinical notes, existing studies mostly focus on disease prediction or cohort selection. Studies on mining clinical notes with the direct purpose to reduce costs for healthcare providers or institutions are limited. To fill in these gaps, this dissertation has three research topics.The first topic is about developing state-of-the-art predictive models to detect diabetic retinopathy using longitudinal structured EHR data. Major deep-learning-based temporal models for disease prediction are studied, implemented, and evaluated. Experimental results on a large-scale dataset show that temporal deep learning models outperform non-temporal random forests models in terms of AUPRC and recall.The second topic is about clustering temporal disease networks to visualize comorbidity progression. We propose a clustering technique to outline comorbidity progression phases as well as a new disease clustering method to simplify the visualization. Two case studies on Clostridioides difficile and stroke show the methods are effective.The third topic is clinical information extraction for medical billing. We propose a framework that consists of two methods, a rule-based and a deep-learning-based, to extract patient history information directly from clinical notes to facilitate the Evaluation and Management Services (E/M) billing. Initial results of the two prototype systems on an annotated dataset are promising and direct us for potential improvements