The goal of this study is to compare ophthalmic emergency room (OER) visits during the Coronavirus disease-19 (Covid-19) pandemic to those during a control period. We compared all visits to the OER to Meir Medical Center in Israel, from March 15th to April 15th, 2020, during the Covid-19 pandemic and government mandated quarantine, to the same period in 2019. Factors analyzed were patient demographics, chief complaints, referral patterns, exam findings, treatments given, hospitalizations and surgical interventions. We included in this study 1311 visits of 1158 patients, 477 during the 2020 Covid-19 pandemic and 834 during the same period in 2019. The demographic distribution (age, gender, and ethnicity) was similar between the two periods. LogMAR visual acuity at presentation was worse during the Covid-19 pandemic (0.42 ± 0.6 and 0.34 ± 0.5 in 2020 and 2019 respectively; p = 0.025) and the number of emergent surgeries was higher (3.7% in 2020 vs 1.8% in 2019, p = 0.026). In 2019 there was a higher likelihood of involvement of both segments of the eye (4.82% versus 1.2%, p < 0.01) and more diagnoses were given to each patient (1 ± 0.5 versus 0.93 ± 0.35, p = 0.001; During the Covid − 19 pandemic medications (both topical and systemic) were prescribed more often (1.22 ± 0.95 in 2020 and 0.84 ± 0.67 in 2019, p < 0.001). OER visits were less frequent during the Covid − 19 pandemic as compared to 2019, though the demographics of the patients remained unchanged. Visits during the pandemic tended to be for more severe ocular conditions, with worse visual acuity at presentation and required more medical and surgical treatment which imply higher necessity of ocular evaluation. This analysis can aid healthcare resource management in similar scenarios in the future.

/pdf/ophthalmic-emergency-room-visits-during-the-covid-19-39d1c1zu7q.pdf

Ophthalmic emergency-room visits during the Covid-19 pandemic - a comparative study.

PurposeClinical decision support systems (CDSS) are an emerging frontier in teleophthalmology, drawing on heuristic decision making to augment processes such as triage and referral. We describe the development and implementation of a novel cloud-based decision tree CDSS for on-call ophthalmology consults. The objective was to standardize the triage and referral process while providing a more accurate provisional diagnosis and urgency.DesignProspective comparative cohort study.SubjectsOn-call referrals to a Canadian community ophthalmology clinic.MethodsA web-based decision tree algorithm was developed using current guidelines and expert opinion. The algorithm collected tailored information on the patient’s ophthalmic concern, and outputted a provisional diagnosis and urgency before sending an electronic referral to the on-call ophthalmology clinic. Data were described using descriptive statistics. Spearman-rho correlations and Cohen’s kappa coefficient were used to characterize the observed relationships. Post hoc analysis was conducted using analysis of contingency tables and adjusted residuals.Main Outcome MeasuresDiagnostic category, provisional diagnosis, and urgency for the referring provider, CDSS, and ophthalmologist.ResultsNinety-six referrals were processed. Referring providers included medical doctors (76.0%, n = 73), optometrists (20.8%, n = 20), and nurse practitioners (3.1%, n = 3). The CDSS (κ = 0.5898; 95% confidence interval [CI], 0.4868–0.6928; P < 0.0001) performed equally well with 66.7% agreement in determining category when compared with referring providers (κ = 0.5880; 95% CI, 0.4798–0.6961; P < 0.0001). The CDSS (agreement = 53.1%; κ = 0.4999; 95% CI, 0.4021–0.5978; P < 0.0001) performed better than referring providers (agreement = 43.8%; κ = 0.4191; 95% CI, 0.3194–0.5188; P < 0.0001) in determining a diagnosis. The CDSS (ρ = 0.5014; 95% CI, 0.3092–0.6935; P < 0.0001) also performed better than referring providers (ρ = 0.4035; 95% CI, 0.2406–0.5665; P < 0.0001) in determining urgency. The CDSS assigned a lower level of urgency in 22 cases (22.9%) compared with referring providers in 6 cases (6.3%).ConclusionsTo our knowledge, this is the first cloud-based CDSS in ophthalmology designed to augment the triage and referral process. The CDSS achieves a more accurate diagnosis and urgency, standardizes information collection, and overcomes antiquated paper-based consults. Future directions include developing a random forest model or integrating convolutional neural network-based machine learning to refine the speed and accuracy of triage and referral processes, with emphasis on increasing sensitivity of the CDSS. Clinical decision support systems (CDSS) are an emerging frontier in teleophthalmology, drawing on heuristic decision making to augment processes such as triage and referral. We describe the development and implementation of a novel cloud-based decision tree CDSS for on-call ophthalmology consults. The objective was to standardize the triage and referral process while providing a more accurate provisional diagnosis and urgency. Prospective comparative cohort study. On-call referrals to a Canadian community ophthalmology clinic. A web-based decision tree algorithm was developed using current guidelines and expert opinion. The algorithm collected tailored information on the patient’s ophthalmic concern, and outputted a provisional diagnosis and urgency before sending an electronic referral to the on-call ophthalmology clinic. Data were described using descriptive statistics. Spearman-rho correlations and Cohen’s kappa coefficient were used to characterize the observed relationships. Post hoc analysis was conducted using analysis of contingency tables and adjusted residuals. Diagnostic category, provisional diagnosis, and urgency for the referring provider, CDSS, and ophthalmologist. Ninety-six referrals were processed. Referring providers included medical doctors (76.0%, n = 73), optometrists (20.8%, n = 20), and nurse practitioners (3.1%, n = 3). The CDSS (κ = 0.5898; 95% confidence interval [CI], 0.4868–0.6928; P < 0.0001) performed equally well with 66.7% agreement in determining category when compared with referring providers (κ = 0.5880; 95% CI, 0.4798–0.6961; P < 0.0001). The CDSS (agreement = 53.1%; κ = 0.4999; 95% CI, 0.4021–0.5978; P < 0.0001) performed better than referring providers (agreement = 43.8%; κ = 0.4191; 95% CI, 0.3194–0.5188; P < 0.0001) in determining a diagnosis. The CDSS (ρ = 0.5014; 95% CI, 0.3092–0.6935; P < 0.0001) also performed better than referring providers (ρ = 0.4035; 95% CI, 0.2406–0.5665; P < 0.0001) in determining urgency. The CDSS assigned a lower level of urgency in 22 cases (22.9%) compared with referring providers in 6 cases (6.3%). To our knowledge, this is the first cloud-based CDSS in ophthalmology designed to augment the triage and referral process. The CDSS achieves a more accurate diagnosis and urgency, standardizes information collection, and overcomes antiquated paper-based consults. Future directions include developing a random forest model or integrating convolutional neural network-based machine learning to refine the speed and accuracy of triage and referral processes, with emphasis on increasing sensitivity of the CDSS. 

http://www.ophthalmologyscience.org/article/S2666914522001208/pdf

Development of a Cloud-Based Clinical Decision Support System for Ophthalmology Triage Using Decision Tree Artificial Intelligence

BackgroundCarotid-cavernous fistulas (CCFs) are commonly misdiagnosed on computed tomography angiography (CTA).PurposeThis study sought to identify the most sensitive and specific imaging features ...

CT angiogram findings in carotid-cavernous fistulas: stratification of imaging features to help radiologists avoid misdiagnosis.

A 48-year-old woman presented with bilateral non-pulsatile proptosis and ophthalmoplegia after 3 days following blunt orbital trauma. It was associated with fever, malaise and loss of vision in right eye. She was provisionally diagnosed with cavernous sinus thrombosis and was treated with intravenous antibiotics with no improvement. A subtle bruit was present on examination, and digital subtraction angiography revealed a right direct (type A) carotid-cavernous fistula (CCF). The patient underwent right coil embolisation of direct CCF. On follow-up at 4 months, her proptosis resolved completely and extraocular movements improved.

https://casereports.bmj.com/content/bmjcr/12/3/e227757.full.pdf

Post-traumatic carotid-cavernous fistula with bilateral proptosis simulating cavernous sinus thrombosis

Objective This study was conducted to analyse data from emergency ophthalmology referrals after-hours from different hospitals to identify the most common pathologies and compare accuracy of diagnoses. The primary objective was to identify common presenting entities and common causes of misdiagnosis in the emergency department to help guide education initiatives. Design This was a retrospective chart review that looked at consults occurring between September 1, 2015, and October 21, 2016. Methods Emergency ophthalmology consults were reviewed and the date, time, age, sex, and provisional diagnosis were recorded. Ophthalmic diagnosis was compared with provisional diagnosis to compare agreement rate. Diagnoses were categorized to determine most frequent etiologies presenting on an emergent basis. Results A total of 697 consults were reviewed. The most common consults by diagnostic category were anterior segment (36.4%) and posterior segment (27.4%) pathologies. Together, these categories accounted for over 60% of all consults. Agreement between provisional diagnosis and final ophthalmology diagnosis was 65.8%. Conclusions There was a reasonable agreement rate between referring services diagnosis and ophthalmology diagnosis. The retrospective nature of this study and use of categories to determine agreement are potential biases and the agreement rate may not reflect clinical practice. Most common diagnoses were similar to previous studies. The authors noted several diagnostic categories that could be targeted as areas for medical education to help increase recognition in the primary care setting and facilitate appropriate ophthalmic referral.

Retrospective analysis of ophthalmology consults to a tertiary academic teaching centre

Carotid cavernous fistula (CCF) is an abnormal vascular shunt from the carotid artery to the cavernous sinus. They are commonly classified based on hemodynamics, etiology or anatomically. Hemodynamic classification refers to whether the fistula is high or low flow. Etiology is commonly secondary to trauma or can occur spontaneously in the setting of aneurysm or medical conditions predisposing to arterial wall defects. Bilateral carotid cavernous fistulas are rare. We present a case of bilateral CCF secondary to trauma. Ophthalmology was urgently consulted to assess the patient in the intensive care unit (ICU) for red eye. The patient was found to have decreased vision, increased intraocular pressure, an afferent pupillary defect, proptosis, chemosis, and ophthalmoplegia. Subsequent neuro-imaging confirmed a bilateral CCF. The patient underwent two endovascular embolization procedures. Trauma is the most common cause of CCF and accounts for up to 75% of cases. Most common signs of CCF depend on whether it is high or low flow. High-flow CCF may present with chemosis, proptosis, cranial nerve palsy, increased intraocular pressure, diplopia, and decreased vision. Cerebral angiography is the gold standard diagnostic modality. First-line treatment consists of endovascular embolization with either a metallic coil, endovascular balloon or embolic agent. It is unclear in the literature if bilateral cases are more difficult to treat or have a different prognosis. Our patient required two endovascular procedures suggesting that endovascular intervention may have reduced efficacy in bilateral cases.

Bilateral carotid cavernous sinus fistula: a case report and review of the literature.

Objective This study was conducted to analyze data from emergency ophthalmology referrals after hours from different hospitals to identify the most common pathologies and compare accuracy of diagnoses. Additionally, examination findings, including visual acuity (VA), intraocular pressure (IOP), and pupils from referring service and ophthalmic examination, were compared to assess agreement. Design This was a prospective study that reviewed information collected from referring services to the emergency on-call ophthalmology service and compared it with ophthalmic examination between February 2017 and July 2017. Methods The number of referrals from each hospital was reviewed. Referring physician provisional diagnosis, VA, IOP, and pupil assessment were collected to analyze the agreement between ophthalmic examination and diagnosis. Results The observed agreement rate was 67.0% between referring source and ophthalmic diagnosis. Posterior vitreous detachment (12.2%) was the most common diagnosis, followed by corneal abrasion (7.4%) and retinal detachment (5.3%). Referring services measured VA to be worse than on-call ophthalmology service (right eye Z = −5.47, p Conclusion Data suggest that there is moderate agreement for diagnostic category between referring service and ophthalmology examination in regard to provisional diagnosis and pupillary assessment. Both VA and IOP were measured to be higher by referring services. This study highlights common emergency ophthalmic referrals and suggests potential areas for teaching initiatives for primary care physicians assessing ophthalmic emergency patients.

Prospective analysis of emergency ophthalmic referrals in a Canadian tertiary teaching hospital.

A 58-year-old woman was referred to the outpatient ophthalmology clinic with progressive bilateral eye redness and vision loss. She had presented 2 weeks earlier with an episode of hypertensive emergency. CT angiography revealed bilateral superior ophthalmic vein (SOV) dilation, prompting further workup with a cerebral angiogram. Subsequent imaging revealed an indirect (type D) carotid-cavernous fistula (CCF) with venous drainage into both SOVs and cavernous sinuses. Successful treatment of the CCF with coil embolisation required interdisciplinary teamwork between ophthalmologists and interventional neuroradiologists. The patient made a substantial visual recovery following treatment.

Dural carotid cavernous fistula following hypertensive emergency.

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Bilateral carotid cavernous sinus fistula: a case report and review of the literature.

Prospective analysis of emergency ophthalmic referrals in a Canadian tertiary teaching hospital.

Dural carotid cavernous fistula following hypertensive emergency.