Journal of Neuro-Ophthalmology最新文献

Background: This study explored ischemic stroke occurrence in patients with nonarteritic anterior ischemic optic neuropathy (NAION) and assess the link between NAION and carotid artery stenosis (CAS) as an ischemic stroke risk factor.

Methods: A retrospective (2009-2019) nationwide, population-based study was conducted using a cohort database from Clalit, the largest healthcare network in Israel. Among 1,200,000 insured individuals, 605 NAION patients without prior ischemic stroke diagnosis were included, matched with a 10-fold larger comparison group by age, sex, and cardiovascular risk factors.

Results: Results indicated a higher incidence of large-vessel ischemic stroke (18.7% vs 14.7% in the comparison group) and small-vessel ischemic stroke (4.8% vs 3.1% in the comparison group) in patients with NAION. CAS prevalence was elevated in patients with NAION both during the study and during follow-up. Multivariable analysis showed hazard ratios of 1.5 ( P = 0.002) for large-vessel ischemic strokes and 1.56 ( P = 0.031) for small-vessel ischemic strokes in patients with NAION. The cumulative probability of ischemic strokes for patients with NAION without risk factors was higher than for the comparison group without risk factors (log rank test, P = 0.017).

Conclusions: These population-based study results revealed a higher incidence of ischemic stroke after a NAION episode compared with the comparison group. This association was valid regardless of any additional vascular risk factors. There is a need to consider specific management for patients with NAION diagnosed with carotid artery stenosis because of the potential for a triadic relationship among the 3 conditions.

Background: Patients referred to ophthalmology and neuro-ophthalmology clinics often present with complex neurological and visual symptoms, such as headaches, double vision, and vision loss, requiring thorough history, comprehensive examinations, and neuroimaging to identify the underlying cause. While advances in neuroimaging have improved diagnostic accuracy, they have also introduced challenges with incidental findings and unexpected abnormalities. This study aimed to determine the prevalence, spectrum, and clinical relevance of incidental findings in neuro-ophthalmology patients evaluated at an academic center.

Methods: A retrospective, observational cohort study included 5,000 patients (59% women, 41% men; mean age 53.7 years) who underwent neuroimaging (MRI and CT) for neuro-ophthalmic symptoms at an academic neuro-ophthalmology clinic between July 2008 and June 2024. Details of imaging type, region scanned, and reason for imaging were recorded from electronic medical records. Incidental findings were defined as abnormalities unrelated to the original reason for imaging and categorized into 4 follow-up categories (none, routine, urgent, and emergency). Imaging reports were independently reviewed and categorized by an ophthalmologist and a neuro-ophthalmologist. Descriptive statistics were used to assess the prevalence of incidental findings and their clinical significance. Chi-square tests and analysis of variance were applied to assess associations between imaging modalities, age, and the presence of incidental findings.

Results: Incidental findings were present in 31% (n = 1,532) of patients; 20.6% required no follow-up, 9.6% required routine follow-up, 0.34% required urgent follow-up, and 0.1% required emergency follow-up. The most common incidental findings were microangiopathic changes (14.2%), sinus changes (6.96%), and brain atrophy (3.26%). MRI showed a higher prevalence of incidental findings than CT (31.8% vs 25.1%, P < 0.05). There was no difference in incidental findings between 1.5T vs 3T MRI. Age was significantly associated with certain findings, such as microangiopathy and brain atrophy. The most common findings by follow-up category were microangiopathic changes (no follow-up), meningiomas (routine follow-up), suspected neoplasms (urgent), and suspected metastasis (emergency).

Conclusions: Incidental findings are common in neuro-ophthalmology imaging, with the majority requiring no or routine follow-up. However, a small percentage (0.44%) of cases required urgent or emergency attention, underscoring the need for careful evaluation and management protocols. These findings emphasize the importance of developing guidelines to manage incidentalomas in neuro-ophthalmology, particularly for older patients and those undergoing MRI.

Background: Multimodal artificial intelligence (AI) models have recently expanded into video analysis. In ophthalmology, one exploratory application is the automated detection of extraocular movement (EOM) disorders. This proof-of-concept study evaluated the feasibility of using Gemini 2.0 to recognize EOM abnormalities, identify the affected eye, and recognize specific movement limitations from publicly available, real-world clinical videos.

Methods: We retrospectively collected 114 YouTube videos of EOM disorders, including cranial nerve (CN) palsies, internuclear ophthalmoplegia (INO), supranuclear disorders, nystagmus, and ocular myasthenia gravis (MG), alongside 15 control videos demonstrating normal EOMs. Videos were trimmed to include only the pertinent clinical examinations, and audio was removed to avoid diagnostic cues. Using a standardized zero-shot prompt, Gemini 2.0 analyzed each video via the Google AI Studio platform. Gemini 2.0 was evaluated based on its ability to provide the correct diagnosis, identify the affected eye, and recognize the specific movement limitation (if any). Descriptive statistics, Spearman correlations, and comparative analyses were used to assess performance.

Results: Gemini 2.0 correctly identified the primary diagnosis in 43 of 114 videos, yielding an overall diagnostic accuracy of 37.7%. Diagnostic performance varied by condition, with the highest accuracies observed in third nerve palsy (81.1%), INO (80.0%), sixth nerve palsy (66.7%), and ocular MG (20.0%), whereas normal EOMs were correctly classified in 93.3% of cases. In misclassified cases, the correct diagnosis appeared in the differential diagnosis in 15.5% of instances. Laterality was correctly identified in 26.5% of eligible cases overall, 73.1% among correctly diagnosed cases vs. 9.6% in misclassified ones. Similarly, movement limitations were accurately identified in 30.3% of eligible cases overall, with a marked increase to 88.5% accuracy in correctly diagnosed cases compared to 9.6% in misclassified cases. Longer videos moderately correlated with longer processing time (ρ = 0.55, P < 0.001). Significant correlations were observed between correct diagnosis and correct laterality identification (ρ = 0.45, P < 0.001), correct diagnosis and correct movement limitation identification (ρ = 0.61, P < 0.001), and laterality and movement limitation (ρ = 0.51, P < 0.001). Processing time averaged 11.0 seconds and correlated with video length (ρ = 0.55, P < 0.001).

Conclusions: This proof-of-concept study demonstrates the feasibility of using Gemini 2.0 for automated recognition of EOM abnormalities in clinical videos. Although performance was stronger in overt cases, overall diagnostic accuracy remains limited. Substantial validation on standardized, clinician-annotated datasets is needed before clinical application.

Background: Papilledema and other optic neuropathies are critical findings in neuro-ophthalmology that require timely and accurate diagnosis. This study evaluates the performance of a deep learning system (DLS) to identify papilledema and other optic neuropathies, when applied to a large dataset of retinal photographs acquired prospectively with a handheld nonmydriatic camera in a neuro-ophthalmology department.

Methods: International multiethnic, multicenter study including 20,533 retinal photographs (10,647 patients) from 31 centers worldwide. The training and internal validation datasets consisted of 18,981 mydriatic retinal photographs (9,830 patients) from 22 countries. The external testing dataset included 1,552 prospectively collected retinal photographs (817 patients) acquired with a handheld camera (Aurora, Optomed, Finland). The DLS segmented the optic disc and peripapillary region, then classified each photograph as 1/"papilledema," 2/"other" optic disc abnormalities (i.e., swelling because of other causes, atrophy, etc.), or 3/"normal." The performance of the DLS in classifying optic disc appearance was evaluated using area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy. Diagnostic outcomes were evaluated at the eye level and at the patient level.

Results: The DLS achieved an accuracy of 99.5% (95% confidence interval [CI], 99.1-99.8), a sensitivity of 81.0% (95% CI, 64.1-97.7), a specificity of 99.7% (95% CI, 99.5-99.9), and an AUC of 98.3% (95% CI, 97.6-99.9) for differentiating papilledema from "others" and healthy controls.

Conclusions: A DLS trained on a large dataset of mydriatic photographs achieved excellent diagnostic performance for detection of papilledema and other optic disc abnormalities when applied to nonmydriatic retinal photographs acquired with a handheld camera in real life conditions.

Background: Preliminary work suggests that glymphatic transit is abnormal and dynamic in idiopathic intracranial hypertension (IIH), although its incomplete characterization across the disease course has led to debate as to its pathophysiologic relevance. We seek to clarify whether glymphatic transit varies across IIH's disease course, correlates with intracranial pressure, and might be measured radiographically to aid diagnosis.

Methods: Diffusion tensor imaging along the perivascular space (ALPS) was used to measure perivascular diffusivity and generate indices of glymphatic transit (ALPS-indices). We studied healthy controls and participants with IIH cross-sectionally, the latter stratified into untreated, treated, or cured IIH. Participants with untreated IIH were substratified as "acute" if imaged <6 months from onset or "chronic" if imaged ≥6 months from onset.

Results: Forty participants were studied. We identified a positive, nonlinear correlation between ALPS-indices and disease duration in patients with untreated IIH. ALPS-indices differed between participants with chronic, treated, and acute IIH, in descending order. Healthy controls exhibited lower ALPS-indices than participants with chronic IIH and higher ALPS-indices than participants with acute IIH. ALPS-indices correlated positively with lumbar puncture opening pressures in participants with chronic IIH. Receiver-operating-characteristic curves demonstrated high areas-under-the curve in distinguishing between participants with untreated IIH and controls.

Conclusions: These data support the hypothesis that changes in glymphatic transit are likely a result rather than a cause of IIH, that radiographic indices of glymphatic transit may be leveraged diagnostically, and that ALPS-indices measuring perivascular diffusivity are likely a physiologically valid reflection of glymphatic transit in humans.

Background: High rates of mental health conditions have been reported among patients with idiopathic intracranial hypertension (IIH). Cognitive-behavioral therapy (CBT) has been suggested as a complementary treatment to help manage anxiety and headache pain in IIH. This study aims to assess the mental health of IIH patients through a psychiatric interview and to evaluate their suitability and interest in CBT.

Methods: Participants with IIH were recruited from Stanford Byers Eye Institute. Demographic and clinical characteristics were collected, and participants completed self-rated scales for depression (PHQ-9), anxiety (GAD-7), headaches (HIT-6), and disability (WHODAS-12). Diagnostic and Statistical Manual of Mental Disorders, 5th edition diagnoses, patient's suitability for CBT (SSCT scale), and preferred therapy focus were identified through a formal psychiatric interview.

Results: Fifty-three participants were enrolled and completed surveys, and 43 participants went on to have the psychiatric interview (mean age 38 years, 91% female). Among them, 76.7% had a GAD-7 score ≥5, indicating at least mild anxiety, and 76.7% of participants had a PHQ-9 score ≥5, indicating at least mild depression. In total, 81.4% of participants suffered from a mood, anxiety, or trauma- and stressor-related disorder. Participants who had received a venous stent or VP shunt had higher anxiety levels (average GAD-7 11.75 vs 6.52; P = 0.007); 81.4% were interested in CBT, and 83.7% were deemed good candidates for CBT (SSCT ≥ 30). Anxiety management most often emerged as their favored therapeutic focus.

Conclusions: Our results confirm the high prevalence of mental health conditions and symptoms among patients with IIH. A majority of patients are interested in CBT, and many would likely benefit from this approach. CBT should therefore be considered in the therapeutic management of IIH. Further research is warranted to validate the efficacy of this intervention in this specific clinical population.