Wissam Nassrallah

Purpose: The aim of this study was to compare preoperative determinants of procedure selection and long-term outcomes between anterior lamellar keratoplasty (ALK) and penetrating keratoplasty (PKP) in patients with keratoconus in the United States. Methods: A total of 10,405 eyes from patients with keratoconus undergoing corneal transplantation were included from the Intelligent Research in Sight Registry, comprising 1005 eyes that received ALK (mean age 40.0 ±15.5 years) and 9400 eyes that received PKP (mean age 44.3 ±16.4 years) between January 1, 2013, and December 31, 2020. Univariate and multivariable logistic regression analyses were performed to identify demographic and clinical factors associated with the selection of ALK versus PKP. Results: In multivariable analysis, older age (50–59 years: odds ratio [OR]: 0.05; 95% confidence interval [CI]: 0.00–0.88; ≥70 years: OR: 0.01; 95% CI: 0.00–0.44), male sex (OR: 0.28; 95% CI: 0.09–0.90), and Medicaid insurance (OR: 0.11; 95% CI: 0.02–0.55) were significantly associated with lower odds of undergoing ALK. Graft failures (as measured by the incidence of regrafts) and rejections were significantly less frequent in ALK at 90 days (failure: 3.3% vs. 12.6%, P < 0.001; rejection: 1.9% vs. 5.8%, P < 0.001) and at 1 year (failure: 5.4% vs. 12.3%, P < 0.001; rejection: 6.5% vs. 11.7%, P < 0.001), but not at 3 and 5 years. Conclusions: In the United States, younger patients are more likely to receive ALK. Other socioeconomic factors such as ethnicity and insurance coverage may also play an important role. However, our data suggest that ALK may not result in improved postoperative outcomes compared with PKP over 5 years.

Purpose: To evaluate the bidirectional association between obstructive sleep apnea (OSA) and keratoconus (KC) in young adults using matched-cohort designs. Methods: Multicenter retrospective cohort study using the TriNetX Research Network. In the forward direction, adults aged 18 to 45 with OSA (ICD-10: G47.33) and evidence of polysomnography were compared with 3 propensity-score–matched comparators: polysomnography-evaluated controls, with and without age restriction, and a general encounter control. In the reverse direction, patients with KC and evidence of corneal imaging (H18.6 with topography, anterior segment OCT, or pachymetry) were compared with 3 parallel cohorts. Comparisons used 1:1 propensity-score matching (caliper 0.2) on demographics, body mass index strata, atopic/metabolic comorbidities, and health care utilization. Hazard ratios (HRs) were estimated at 5 and 10 years. Acute appendicitis served as the prespecified negative control outcome in all comparisons; ingrown nail was additionally evaluated in the general encounter comparator. Results: The forward primary analysis matched 48,954 patients per arm. The 5-year HR for incident KC was 2.01 (95% CI: 1.21–3.32; P = 0.006), stable at 10 years (HR: 2.03, 1.28–3.21), with concordant sensitivity HRs of 1.72 and 1.88. The reverse primary analysis matched 4350 patients per arm. The 5-year HR for incident OSA was nonsignificant (HR: 1.13, 0.91–1.40); the 10-year HR was 1.29 (1.07–1.55; P = 0.008). The negative control was null in all primary comparisons. The E-value for the forward primary HR was 3.45. Conclusions: OSA with evidence of polysomnography was associated with incident KC after adjustment for measured confounders. The reverse direction showed a weaker, time-delayed association requiring cautious interpretation given detection bias. These findings support consideration of sleep evaluation in young adults with suspected corneal ectatic disease; they do not address whether treating OSA alters progression in established KC.

Purpose: To investigate if patients had a subjectively inferior experience during second-eye surgery vs first-eye surgery during immediate sequential bilateral cataract surgery (ISBCS) as both operations were performed within the same surgical visit. Setting: Multisurgeon ophthalmic surgical center. Design: Survey-based prospective design. Methods: Patients of the center undergoing routine cataract surgery who enrolled in the study completed a questionnaire immediately after surgery to describe their surgical experience for each eye. Survey questions measured patient pain, discomfort or pressure, comfort, relaxation, estimated length of surgery, and predicted visual outcome. Results: Patient-reported level of pain during the second-eye surgery was significantly greater than for the first eye ( P < .001). Furthermore, the order of surgery was found to be a strong predictor of patient-reported pain ( P < .001), more so than surgical length ( P < .008), additional anesthesia ( P < .35), patient age ( P < .44), or patient sex ( P < .88). Overall, surgery during the first eye was reported as more comfortable ( P < .001) and shorter in duration ( P < .001), while discomfort and pressure were reported as worse for the second eye ( P < .001). Conclusions: Understanding differential experiences between eyes can help surgeons when counselling patients regarding expectations for ISBCS and related visual outcomes.

Purpose: To compare the performance and cost-effectiveness of DeepSeek-R1 with OpenAI o1 in diagnosing and managing ophthalmology clinical cases. Study Design: Cross-sectional evaluation. Methods: A total of 300 clinical cases spanning 10 different ophthalmology subspecialties were collected from StatPearls. Each case presented a multiple-choice question regarding the diagnosis or management of the clinical case. DeepSeek-R1 was accessed through its public chat-based interface, while OpenAI o1 was queried via an Application Program Interface (API) with a standardized temperature setting of 0.3. Both models were prompted using the Plan-and-Solve+ (PS+) prompt engineering method, instructing them to answer multiple choice questions for each case. Performance was calculated as the proportion of correctly answered multiple choice questions. McNemar’s test was employed to compare the two models’ performance on paired data. Inter-model agreement for correct diagnoses was evaluated via Cohen’s kappa. A token-based cost analysis was performed to estimate the comparative expenditures of running each model at scale, accounting for both input prompts and model-generated output. Results: DeepSeek-R1 and OpenAI o1 both achieved an identical overall performance of 82.0% (n=246/300; 95% CI: 77.3-85.9). Subspeciality-specific analysis revealed numerical variation in performance, though none of these comparisons reached statistical significance (p>0.05). Agreement in performance between the models was moderate overall (κ=0.503, p<0.001), with substantial agreement in Refractive Management/Intervention (κ=0.698, p<0.001) and moderate agreement in Retina/Vitreous (κ=0.561, p<0.001) and Ocular Pathology/Oncology (κ=0.495, p<0.01) cases. Cost analysis indicated an approximately 15-fold reduction in per-query, token-related expenses when using DeepSeek-R1 compared with OpenAI o1 for the same workload. Conclusions: DeepSeek-R1 demonstrates robust diagnostic reasoning and management decision-making capabilities, performing comparably to OpenAI o1 across a range of ophthalmic subspecialty cases, while also offering a substantial reduction in usage costs. These findings highlight the feasibility of utilizing open-weight, reinforcement learning-augmented LLMs as an accessible, cost-effective alternative to proprietary models.