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An artificial intelligence platform for the screening and managing of strabismus

Abstract

Objectives

Considering the escalating incidence of strabismus and its consequential jeopardy to binocular vision, there is an imperative demand for expeditious and precise screening methods. This study was to develop an artificial intelligence (AI) platform in the form of an applet that facilitates the screening and management of strabismus on any mobile device.

Methods

The Visual Transformer (VIT_16_224) was developed using primary gaze photos from two datasets covering different ages. The AI model was evaluated by 5-fold cross-validation set and tested on an independent test set. The diagnostic performance of the AI model was assessed by calculating the Accuracy, Precision, Specificity, Sensitivity, F1-Score and Area Under the Curve (AUC).

Results

A total of 6194 photos with corneal light-reflection (with 2938 Exotropia, 1415 Esotropia, 739 Vertical Deviation and 1562 Orthotropy) were included. In the internal validation set, the AI model achieved an Accuracy of 0.980, Precision of 0.941, Specificity of 0.979, Sensitivity of 0.958, F1-Score of 0.951 and AUC of 0.994. In the independent test set, the AI model achieved an Accuracy of 0.967, Precision of 0.980, Specificity of 0.970, Sensitivity of 0.960, F1-Score of 0.975 and AUC of 0.993.

Conclusions

Our study presents an advanced AI model for strabismus screening which integrates electronic archives for comprehensive patient histories. Additionally, it includes a patient-physician interaction module for streamlined communication. This innovative platform offers a complete solution for strabismus care, from screening to long-term follow-up, advancing ophthalmology through AI technology for improved patient outcomes and eye care quality.

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Fig. 1: The schematic diagram of the overall architecture of the screening system network.
Fig. 2: Interpreting DL model focus areas with the Grad-CAM heatmaps.
Fig. 3: The interface of the AI platform for the screening and managing of strabismus.

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Data availability

The data that support the findings of this study are available from the corresponding author, [LLQ], upon reasonable request.

Code availability

The algorithms of this study are available for download at: https://github.com/victor250214384/vit_strabismus.

References

  1. Repka MX, Lum F, Burugapalli B. Strabismus, Strabismus Surgery, and Reoperation Rate in the United States Analysis from the IRIS Registry. Ophthalmology. 2018;125:1646–53.

    Article  PubMed  Google Scholar 

  2. Chia A, Roy L, Seenyen L. Comitant horizontal strabismus: an Asian perspective. Br J Ophthalmol. 2007;91:1337–40.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Shah HA, Shipchandler T, Vernon D, Baumanis M, Chan D, Nunery WR, et al. Extra-ocular movement restriction and diplopia following orbital fracture repair. Am J Otolaryngol. 2018;39:34–6.

    Article  CAS  PubMed  Google Scholar 

  4. Park KA, Lyu I, Yoon J, Jeong U, Oh JE, Lim HW, et al. Muscle Union Procedure in Patients with Paralytic Strabismus. PLoS One. 2015;10:e0129035.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Cotter SA, Tarczy-Hornoch K, Song E, Lin J, Borchert M, Azen SP, et al. Fixation preference and visual acuity testing in a population-based cohort of preschool children with amblyopia risk factors. Ophthalmology. 2009;116:145–53.

    Article  PubMed  Google Scholar 

  6. Mojon-Azzi SM, Potnik W, Mojon DS. Opinions of dating agents about strabismic subjects’ ability to find a partner. Br J Ophthalmol. 2008;92:765–9.

    Article  CAS  PubMed  Google Scholar 

  7. Mojon-Azzi SM, Mojon DS. Strabismus and employment: the opinion of headhunters. Acta Ophthalmol. 2009;87:784–8.

    Article  PubMed  Google Scholar 

  8. Mojon-Azzi SM, Mojon DS. Opinion of headhunters about the ability of strabismic subjects to obtain employment. Ophthalmologica. 2007;221:430–3.

    Article  PubMed  Google Scholar 

  9. Coats DK, Paysse EA, Towler AJ, Dipboye RL. Impact of large angle horizontal strabismus on ability to obtain employment. Ophthalmology. 2000;107:402–5.

    Article  CAS  PubMed  Google Scholar 

  10. Uretmen O, Egrilmez S, Kose S, Pamukçu K, Akkin C, Palamar M. Negative social bias against children with strabismus. Acta Ophthalmol Scand. 2003;81:138–42.

    Article  PubMed  Google Scholar 

  11. Durnian JM, Noonan CP, Marsh IB. The psychosocial effects of adult strabismus: a review. Br J Ophthalmol. 2011;95:450–3.

    Article  PubMed  Google Scholar 

  12. Tenório Albuquerque Madruga Mesquita MJ, Azevedo Valente TL, de Almeida JDS, Meireles Teixeira JA, Cord Medina FM, Dos Santos AM. A mhealth application for automated detection and diagnosis of strabismus. Int J Med Inf. 2021;153:104527.

    Article  Google Scholar 

  13. Chen W, Li R, Yu Q, Xu A, Feng Y, Wang R, et al. Early detection of visual impairment in young children using a smartphone-based deep learning system. Nat Med. 2023;29:493–503.

    Article  CAS  PubMed  Google Scholar 

  14. Ma S, Guan Y, Yuan Y, Tai Y, Wang T. A One-Step, Streamlined Children’s Vision Screening Solution Based on Smartphone Imaging for Resource-Limited Areas: Design and Preliminary Field Evaluation. JMIR Mhealth Uhealth. 2020;8:e18226.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Mao K, Yang Y, Guo C, Zhu Y, Chen C, Chen J, et al. An artificial intelligence platform for the diagnosis and surgical planning of strabismus using corneal light-reflection photos. Ann Transl Med. 2021;9:374.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Cheng W, Lynn MH, Pundlik S, Almeida C, Luo G, Houston K. A smartphone ocular alignment measurement app in school screening for strabismus. BMC Ophthalmol. 2021;21:150.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Huang X, Lee SJ, Kim CZ, Choi SH. An improved strabismus screening method with combination of meta-learning and image processing under data scarcity. PLoS One. 2022;17:e0269365.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Kang YC, Yang HK, Kim YJ, Hwang JM, Kim KG. Automated Mathematical Algorithm for Quantitative Measurement of Strabismus Based on Photographs of Nine Cardinal Gaze Positions. Biomed Res Int. 2022;2022:9840494.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Zheng C, Yao Q, Lu J, Xie X, Lin S, Wang Z, et al. Detection of Referable Horizontal Strabismus in Children’s Primary Gaze Photographs Using Deep Learning. Transl Vis Sci Technol. 2021;10:33.

    Article  PubMed  PubMed Central  Google Scholar 

  20. de Figueiredo LA, Dias JVP, Polati M, Carricondo PC, Debert I. Strabismus and Artificial Intelligence App: Optimizing Diagnostic and Accuracy. Transl Vis Sci Technol. 2021;10:22.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Pang Y, Gnanaraj L, Gayleard J, Han G, Hatt SR. Interventions for intermittent exotropia. Cochrane Database Syst Rev. 2021;9:Cd003737.

    PubMed  Google Scholar 

  22. Kazemi V, Sullivan J, IEEE, editors. One Millisecond Face Alignment with an Ensemble of Regression Trees. In: 27th IEEE Conference on Computer Vision and Pattern Recognition (CVPR). New York: IEEE; 2014.

  23. King DE. Dlib-ml: A Machine Learning Toolkit. J Mach Learn Res. 2009;10:1755–8.

    Google Scholar 

  24. Selvaraju RR, Cogswell M, Das A, Vedantam R, Parikh D, Batra D, et al., editors. Grad-CAM: Visual Explanations from Deep Networks via Gradient-based Localization. In: 16th IEEE International Conference on Computer Vision (ICCV). New York: IEEE; 2017.

  25. Vaswani A, Shazeer N, Parmar N, Uszkoreit J, Jones L, Gomez AN, et al., editors. Attention Is All You Need. In: 31st Annual Conference on Neural Information Processing Systems (NIPS). Long Beach, CA: NIPS; 2017.

  26. Resnikoff S, Lansingh VC, Washburn L, Felch W, Gauthier TM, Taylor HR, et al. Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs? Br J Ophthalmol. 2020;104:588–92.

    Article  PubMed  Google Scholar 

  27. Kang L, Ballouz D, Woodward MA. Artificial intelligence and corneal diseases. Curr Opin Ophthalmol. 2022;33:407–17.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Ting DSJ, Foo VH, Yang LWY, Sia JT, Ang M, Lin H, et al. Artificial intelligence for anterior segment diseases: Emerging applications in ophthalmology. Br J Ophthalmol. 2021;105:158–68.

    Article  PubMed  Google Scholar 

  29. Nagasato D, Tabuchi H, Ohsugi H, Masumoto H, Enno H, Ishitobi N, et al. Deep-learning classifier with ultrawide-field fundus ophthalmoscopy for detecting branch retinal vein occlusion. Int J Ophthalmol. 2019;12:94–9.

    PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Contributions

Dawen Wu was responsible for data collection, neural network construction, and was a major contributor in writing the manuscript. Yanfei Li and Haixian Zhang were responsible for code development and manuscript writing. Xubo Yang, Bingjie Chen, Guoyuan Yang, Liang Chen, Yan Nie, and Zeyi Yang were involved in dataset selection. Yiji Mao, Yi Feng, Xingyu Zou, Teng Yin, Jingyu Liu, and Wenyi Shang contributed to the development of the applet. Guoyuan Yang was responsible for manuscript writing and manuscript editing. Longqian Liu was responsible for research design, manuscript writing, manuscript editing and funding support. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Guoyuan Yang or Longqian Liu.

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Competing interests

The authors declare no competing interests.

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Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Supplementary Material Figure 1 Data collection for model training and testing

Supplementary Material Figure 2 The 68 facial landmarks detected by Dlib

Supplementary Material Figure 3 The distribution of subtypes of strabismus in training set and testing set

Supplementary material Figure 4 The distribution of continuous variables in training dataset

Supplementary material Figure 5 The distribution of continuous variables in testing dataset

Supplementary material Figure 6 The performance of the DL model in training set

Supplementary material Figure 7 Confusion Matrix for DL model on Internal Validation Set and External Test Set

Supplementary material Figure 8 Performance Metrics of AUC in 5-Fold Cross-Validation Set and Test Set

41433_2024_3228_MOESM9_ESM.docx

Table 1 The demographic composition of the study subjects and the key image attributes across the training and test datasets

Eye Checklist

Supplementary Material Figures Captions

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Wu, D., Li, Y., Zhang, H. et al. An artificial intelligence platform for the screening and managing of strabismus. Eye (2024). https://doi.org/10.1038/s41433-024-03228-5

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