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  • Pediatric Ophth/Strabismus

    Review of: The BONSAI (Brain and Optic Nerve Study with Artificial Intelligence) deep learning system can accurately identify pediatric papilledema on standard ocular fundus photographs

    Lin M, Najjar R, Tang Z, et al. Journal of American Association for Pediatric Ophthalmology and Strabismus, February 2024

    Investigators evaluated an updated version of the Brain and Optic Nerve Study with Artificial Intelligence (BONSAI) deep-learning system (DLS), previously validated in adults, for its potential utility in identifying papilledema in children.

    Study Design

    The updated BONSAI DLS was tested on mydriatic fundus photographs obtained from 447 children aged <17 years from centers in the United States, Romania, and Singapore. The accuracy, sensitivity, and specificity of the DLS's ability to detect papilledema and distinguish it from normal discs were evaluated via a “one-versus-rest” strategy. Each image was also linked to a definitive diagnosis provided by expert neuro-ophthalmologists.


    Eight hundred ninety-eight images were evaluated: 558 showed normal discs, 254 showed discs with papilledema, and 86 showed other disc abnormalities (e.g., optic neuritis). The overall multiclass accuracy of the DLS was 89.6%. The DLS had a sensitivity of 87.3% and specificity of 98.5% for identifying normal discs and a sensitivity of 98.0% and specificity of 94.1% for identifying papilledema.


    The study used retrospectively obtained fundus photographs, and therefore is subject to the limitations inherent in convenience sampling, in turn reducing the generalizability of the results. In addition, all photographs were obtained from dilated eyes. Validation of a DLS in prospective, real-life studies in nonophthalmic settings is needed, along with additional studies comparing results using nonmydriatic fundus cameras. The authors emphasize that the DLS utilized in this study was intended for use in nonophthalmic settings to aid clinicians in determining the need for further consultations.

    Clinical Significance

    Papilledema in children can indicate the presence of a life-threatening neurologic condition, but it can be difficult to detect. Since obtaining ocular fundus photographs is often feasible even in the pediatric population, having a DLS that can reliably distinguish papilledema from normal optic discs and other types of disc abnormalities could facilitate diagnoses and timely interventions. In addition, it could help prevent excessive diagnoses that could lead to additional unnecessary and expensive testing.

    Financial Disclosures: Dr. Phoebe Lenhart discloses no financial relationships.