{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,4]],"date-time":"2026-11-04T22:47:40Z","timestamp":1793832460481,"version":"4.6.1"},"reference-count":32,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2024,12,4]],"date-time":"2024-12-04T00:00:00Z","timestamp":1733270400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,12,4]],"date-time":"2024-12-04T00:00:00Z","timestamp":1733270400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Sci Rep"],"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Accurate detection of post-refractive ectasia susceptibility is essential during preoperative evaluation for laser vision correction (LVC) due to the risk of progressive corneal ectasia and vision decline post-surgery. Despite improved screening and a reduced incidence from 0.66 to 0.033%, iatrogenic ectasia remains a concern due to the severe vision loss it can cause, highlighting the need for more accurate detection tools. A new optimized version of the Belin\/Ambr\u00f3sio Enhanced Ectasia Display version 4 (BAD-D v4) was developed and validated across 26 international centers to enhance the detection of keratoconus and very asymmetric ectasia and to assess the risk of post-refractive ectasia. Analyzing a dataset of 3,886 eyes from 3,351 patients, including normal, keratoconus (KC), and cases with very asymmetric ectasia (VAE) categories, having one eye with normal topography (VAE-NT and the fellow eye with clinical ectasia (VAE-E). The study utilized an optimized logistic regression algorithm improving diagnostic accuracy. The BAD-D v4 showed superior efficacy in differentiating normal eyes from ectatic conditions, with Area Under the Receiver Operating Characteristic Curve (AUROC) scores of 0.997 and 0.998 in training and testing samples for normal versus clinical ectasia. Additionally, in Normal vs. Disease (KC\u2009+\u2009VAE), the AUROC was 0.974 and 0.966, and in the challenging Normal vs. VAE-NT diverse group, it scored 0.905 and 0.858. These results outperformed the current version (BAD-D v3) and were comparable to the Pentacam Random Forest Index in all tested scenarios, highlighting the potential of BAD-D v4 in early ectasia detection, without altering the index scale or the end-user experience.<\/jats:p>","DOI":"10.1038\/s41598-024-81809-w","type":"journal-article","created":{"date-parts":[[2024,12,4]],"date-time":"2024-12-04T14:54:59Z","timestamp":1733324099000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":14,"title":["Enhancing corneal ectasia susceptibility detection: analysis of a new algorithm (BAD-D v4)"],"prefix":"10.1038","volume":"14","author":[{"given":"Bernardo T","family":"Lopes","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael W","family":"Belin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria A.","family":"Henriquez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"suffix":"Jr.","given":"Luis","family":"Izquierdo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Kohnen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"suffix":"Jr.","given":"Renato","family":"Ambrosio","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2024,12,4]]},"reference":[{"issue":"2","key":"81809_CR1","doi-asserted-by":"publisher","first-page":"66","DOI":"10.1080\/08820538.2019.1569075","volume":"34","author":"R Ambrosio","year":"2019","unstructured":"Ambrosio, R. Jr. Post-LASIK Ectasia: twenty years of a conundrum. Semin Ophthalmol. 34 (2), 66\u201368 (2019).","journal-title":"Semin Ophthalmol."},{"issue":"7","key":"81809_CR2","doi-asserted-by":"publisher","first-page":"1007","DOI":"10.1016\/S0886-3350(98)80057-6","volume":"24","author":"T Seiler","year":"1998","unstructured":"Seiler, T. & Quurke, A. W. Iatrogenic keratectasia after LASIK in a case of forme fruste keratoconus. J. Cataract Refract. Surg. 24 (7), 1007\u20131009 (1998).","journal-title":"J. Cataract Refract. Surg."},{"issue":"3","key":"81809_CR3","doi-asserted-by":"publisher","first-page":"312","DOI":"10.3928\/1081-597X-19980501-15","volume":"14","author":"T Seiler","year":"1998","unstructured":"Seiler, T., Koufala, K. & Richter, G. Iatrogenic keratectasia after laser in situ keratomileusis. J. Refract. Surg. 14 (3), 312\u2013317 (1998).","journal-title":"J. Refract. Surg."},{"issue":"1","key":"81809_CR4","doi-asserted-by":"publisher","first-page":"37","DOI":"10.1016\/j.ophtha.2007.03.073","volume":"115","author":"JB Randleman","year":"2008","unstructured":"Randleman, J. B., Woodward, M., Lynn, M. J. & Stulting, R. D. Risk assessment for ectasia after corneal refractive surgery. Ophthalmology 115 (1), 37\u201350 (2008).","journal-title":"Ophthalmology"},{"issue":"5","key":"81809_CR5","doi-asserted-by":"publisher","first-page":"813","DOI":"10.1016\/j.ajo.2007.12.033","volume":"145","author":"JB Randleman","year":"2008","unstructured":"Randleman, J. B., Trattler, W. B. & Stulting, R. D. Validation of the Ectasia risk score system for preoperative laser in situ keratomileusis screening. Am. J. Ophthalmol. 145 (5), 813\u2013818 (2008).","journal-title":"Am. J. Ophthalmol."},{"issue":"1","key":"81809_CR6","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1186\/s40662-023-00363-0","volume":"10","author":"R Ambrosio Jr","year":"2023","unstructured":"Ambrosio, R. Jr. et al. Multimodal diagnostics for keratoconus and ectatic corneal diseases: a paradigm shift. Eye Vis. (Lond). 10 (1), 45 (2023).","journal-title":"Eye Vis. (Lond)"},{"issue":"7\u20138","key":"81809_CR7","doi-asserted-by":"publisher","first-page":"869","DOI":"10.1080\/08820538.2018.1539183","volume":"33","author":"M Bohac","year":"2018","unstructured":"Bohac, M. et al. Incidence and clinical characteristics of post LASIK ectasia: a review of over 30,000 LASIK cases. Semin Ophthalmol. 33 (7\u20138), 869\u2013877 (2018).","journal-title":"Semin Ophthalmol."},{"issue":"11","key":"81809_CR8","doi-asserted-by":"publisher","first-page":"1796","DOI":"10.1016\/S0886-3350(01)01090-2","volume":"27","author":"IG Pallikaris","year":"2001","unstructured":"Pallikaris, I. G., Kymionis, G. D. & Astyrakakis, N. I. Corneal ectasia induced by laser in situ keratomileusis. J. Cataract Refract. Surg. 27 (11), 1796\u20131802 (2001).","journal-title":"J. Cataract Refract. Surg."},{"issue":"11","key":"81809_CR9","doi-asserted-by":"publisher","first-page":"906","DOI":"10.3928\/1081597X-20100428-02","volume":"26","author":"R Ambrosio Jr","year":"2010","unstructured":"Ambrosio, R. Jr. et al. Corneal ectasia after LASIK despite low preoperative risk: tomographic and biomechanical findings in the unoperated, stable, fellow eye. J. Refract. Surg. 26 (11), 906\u2013911 (2010).","journal-title":"J. Refract. Surg."},{"issue":"2","key":"81809_CR10","doi-asserted-by":"publisher","first-page":"127","DOI":"10.3928\/1081597X-20151119-03","volume":"32","author":"V Qin","year":"2016","unstructured":"Qin, V., Saad, A. & Gatinel, D. Unilateral Post-LASIK Ectasia and contralateral spontaneous ectasia. J. Refract. Surg. 32 (2), 127\u2013130 (2016).","journal-title":"J. Refract. Surg."},{"issue":"2","key":"81809_CR11","doi-asserted-by":"publisher","first-page":"118","DOI":"10.1080\/02713683.2019.1658787","volume":"45","author":"M Zhang","year":"2020","unstructured":"Zhang, M., Zhang, F., Li, Y., Song, Y. & Wang, Z. Early diagnosis of Keratoconus in Chinese myopic eyes by combining Corvis ST with Pentacam. Curr. Eye Res. 45 (2), 118\u2013123 (2020).","journal-title":"Curr. Eye Res."},{"issue":"9","key":"81809_CR12","doi-asserted-by":"publisher","first-page":"632","DOI":"10.3928\/1081597X-20170621-09","volume":"33","author":"YM Wang","year":"2017","unstructured":"Wang, Y. M., Chan, T. C. Y., Yu, M. & Jhanji, V. Comparison of corneal dynamic and tomographic analysis in normal, Forme Fruste Keratoconic, and Keratoconic eyes. J. Refract. Surg. 33 (9), 632\u2013638 (2017).","journal-title":"J. Refract. Surg."},{"issue":"6","key":"81809_CR13","doi-asserted-by":"publisher","first-page":"383","DOI":"10.3928\/1081597X-20190417-01","volume":"35","author":"S Koh","year":"2019","unstructured":"Koh, S. et al. Detection of subclinical corneal ectasia using corneal tomographic and biomechanical assessments in a Japanese Population. J. Refract. Surg. 35 (6), 383\u2013390 (2019).","journal-title":"J. Refract. Surg."},{"issue":"12","key":"81809_CR14","doi-asserted-by":"publisher","first-page":"840","DOI":"10.3928\/1081597X-20181012-01","volume":"34","author":"J Steinberg","year":"2018","unstructured":"Steinberg, J. et al. Tomographic and Biomechanical Scheimpflug imaging for Keratoconus characterization: a validation of current indices. J. Refract. Surg. 34 (12), 840\u2013847 (2018).","journal-title":"J. Refract. Surg."},{"issue":"2","key":"81809_CR15","doi-asserted-by":"publisher","first-page":"136","DOI":"10.1016\/j.zemedi.2015.11.001","volume":"26","author":"BT Lopes","year":"2016","unstructured":"Lopes, B. T., Ramos, I. C., Dawson, D. G., Belin, M. W. & Ambrosio, R. Jr. Detection of ectatic corneal diseases based on pentacam. Z. Med. Phys. 26 (2), 136\u2013142 (2016).","journal-title":"Z. Med. Phys."},{"issue":"5","key":"81809_CR16","doi-asserted-by":"publisher","first-page":"445","DOI":"10.1002\/jbio.201500236","volume":"9","author":"A Luz","year":"2016","unstructured":"Luz, A., Lopes, B., Salomao, M. & Ambrosio, R. Application of corneal tomography before keratorefractive procedure for laser vision correction. J. Biophotonics. 9 (5), 445\u2013453 (2016).","journal-title":"J. Biophotonics"},{"issue":"3","key":"81809_CR17","doi-asserted-by":"publisher","first-page":"151","DOI":"10.3928\/1081597X-20140218-03","volume":"30","author":"R Ambrosio Jr","year":"2014","unstructured":"Ambrosio, R. Jr., Luz, A., Lopes, B., Ramos, I. & Belin, M. W. Enhanced ectasia screening: the need for advanced and objective data. J. Refract. Surg. 30 (3), 151\u2013152 (2014).","journal-title":"J. Refract. Surg."},{"key":"81809_CR18","doi-asserted-by":"publisher","first-page":"126","DOI":"10.1016\/j.ajo.2022.12.016","volume":"251","author":"R Ambrosio Jr","year":"2023","unstructured":"Ambrosio, R. Jr. et al. Optimized artificial intelligence for enhanced Ectasia detection using Scheimpflug-based corneal tomography and biomechanical data. Am. J. Ophthalmol. 251, 126\u2013142 (2023).","journal-title":"Am. J. Ophthalmol."},{"issue":"7","key":"81809_CR19","doi-asserted-by":"publisher","first-page":"434","DOI":"10.3928\/1081597X-20170426-02","volume":"33","author":"R Ambrosio Jr","year":"2017","unstructured":"Ambrosio, R. Jr. et al. Integration of Scheimpflug-based corneal tomography and biomechanical assessments for enhancing Ectasia Detection. J. Refract. Surg. 33 (7), 434\u2013443 (2017).","journal-title":"J. Refract. Surg."},{"key":"81809_CR20","doi-asserted-by":"crossref","unstructured":"DeLong, E. R., DeLong, D. M. & Clarke-Pearson, D. L. Comparing the areas under two or more correlated receiver operating characteristic curves: a Nonparametric Approach. Biometrics ;44(3). (1988).","DOI":"10.2307\/2531595"},{"key":"81809_CR21","doi-asserted-by":"publisher","first-page":"223","DOI":"10.1016\/j.ajo.2018.08.005","volume":"195","author":"BT Lopes","year":"2018","unstructured":"Lopes, B. T. et al. Enhanced tomographic assessment to detect corneal Ectasia based on artificial Intelligence. Am. J. Ophthalmol. 195, 223\u2013232 (2018).","journal-title":"Am. J. Ophthalmol."},{"issue":"10","key":"81809_CR22","doi-asserted-by":"publisher","first-page":"1168","DOI":"10.1097\/j.jcrs.0000000000000946","volume":"48","author":"GC Almeida Jr","year":"2022","unstructured":"Almeida, G. C. Jr. et al. New artificial intelligence index based on Scheimpflug corneal tomography to distinguish subclinical keratoconus from healthy corneas. J. Cataract Refract. Surg. 48 (10), 1168\u20131174 (2022).","journal-title":"J. Cataract Refract. Surg."},{"key":"81809_CR23","doi-asserted-by":"publisher","first-page":"140","DOI":"10.1016\/j.ajo.2017.06.031","volume":"181","author":"R Shetty","year":"2017","unstructured":"Shetty, R. et al. Keratoconus screening indices and their diagnostic ability to distinguish normal from Ectatic Corneas. Am. J. Ophthalmol. 181, 140\u2013148 (2017).","journal-title":"Am. J. Ophthalmol."},{"issue":"10","key":"81809_CR24","doi-asserted-by":"publisher","first-page":"e201900126","DOI":"10.1002\/jbio.201900126","volume":"12","author":"R Chandapura","year":"2019","unstructured":"Chandapura, R. et al. Bowman\u2019s topography for improved detection of early ectasia. J. Biophotonics. 12 (10), e201900126 (2019).","journal-title":"J. Biophotonics"},{"issue":"4","key":"81809_CR25","doi-asserted-by":"publisher","first-page":"326","DOI":"10.1097\/ICU.0000000000000379","volume":"28","author":"MQ Salomao","year":"2017","unstructured":"Salomao, M. Q. et al. Role of the corneal epithelium measurements in keratorefractive surgery. Curr. Opin. Ophthalmol. 28 (4), 326\u2013336 (2017).","journal-title":"Curr. Opin. Ophthalmol."},{"issue":"9","key":"81809_CR26","doi-asserted-by":"publisher","first-page":"1534","DOI":"10.1016\/j.ophtha.2008.02.020","volume":"115","author":"U de Sanctis","year":"2008","unstructured":"de Sanctis, U. et al. Sensitivity and specificity of posterior corneal elevation measured by Pentacam in discriminating keratoconus\/subclinical keratoconus. Ophthalmology 115 (9), 1534\u20131539 (2008).","journal-title":"Ophthalmology"},{"issue":"9","key":"81809_CR27","doi-asserted-by":"publisher","first-page":"1348","DOI":"10.1016\/j.jcrs.2013.03.023","volume":"39","author":"O Muftuoglu","year":"2013","unstructured":"Muftuoglu, O., Ayar, O., Ozulken, K., Ozyol, E. & Akinci, A. Posterior corneal elevation and back difference corneal elevation in diagnosing forme fruste keratoconus in the fellow eyes of unilateral keratoconus patients. J. Cataract Refract. Surg. 39 (9), 1348\u20131357 (2013).","journal-title":"J. Cataract Refract. Surg."},{"issue":"6","key":"81809_CR28","doi-asserted-by":"publisher","first-page":"1116","DOI":"10.1016\/j.jcrs.2010.12.049","volume":"37","author":"\u00d6\u00d6 U\u00e7akhan","year":"2011","unstructured":"U\u00e7akhan, \u00d6. \u00d6., \u00c7etinkor, V., \u00d6zkan, M. & Kanpolat, A. Evaluation of Scheimpflug imaging parameters in subclinical keratoconus, keratoconus, and normal eyes. J. Cataract Refract. Surg. 37 (6), 1116\u20131124 (2011).","journal-title":"J. Cataract Refract. Surg."},{"issue":"9","key":"81809_CR29","doi-asserted-by":"publisher","first-page":"976","DOI":"10.1097\/ICO.0b013e31819e34de","volume":"28","author":"K Mihaltz","year":"2009","unstructured":"Mihaltz, K., Kovacs, I., Takacs, A. & Nagy, Z. Z. Evaluation of keratometric, pachymetric, and elevation parameters of keratoconic corneas with pentacam. Cornea 28 (9), 976\u2013980 (2009).","journal-title":"Cornea"},{"issue":"11","key":"81809_CR30","doi-asserted-by":"publisher","first-page":"1316","DOI":"10.1097\/ICO.0000000000001295","volume":"36","author":"LM Imbornoni","year":"2017","unstructured":"Imbornoni, L. M., Padmanabhan, P., Belin, M. W. & Deepa, M. Long-term tomographic evaluation of unilateral Keratoconus. Cornea 36 (11), 1316\u20131324 (2017).","journal-title":"Cornea"},{"issue":"1","key":"81809_CR31","doi-asserted-by":"publisher","first-page":"2","DOI":"10.1097\/00003226-199101000-00002","volume":"10","author":"SE Wilson","year":"1991","unstructured":"Wilson, S. E., Lin, D. T. C. & Klyce, S. D. Corneal topography of Keratoconus. Cornea 10 (1), 2\u20138 (1991).","journal-title":"Cornea"},{"issue":"8","key":"81809_CR32","doi-asserted-by":"publisher","first-page":"542","DOI":"10.3928\/1081597X-20140711-07","volume":"30","author":"A Saad","year":"2014","unstructured":"Saad, A., Guilbert, E. & Gatinel, D. Corneal enantiomorphism in normal and keratoconic eyes. J. Refract. Surg. 30 (8), 542\u2013547 (2014).","journal-title":"J. Refract. Surg."}],"container-title":["Scientific Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.nature.com\/articles\/s41598-024-81809-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-024-81809-w","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-024-81809-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,12,4]],"date-time":"2024-12-04T15:04:39Z","timestamp":1733324679000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.nature.com\/articles\/s41598-024-81809-w"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,4]]},"references-count":32,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["81809"],"URL":"https:\/\/doi.org\/10.1038\/s41598-024-81809-w","relation":{},"ISSN":["2045-2322"],"issn-type":[{"value":"2045-2322","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,4]]},"assertion":[{"value":"7 May 2024","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"29 November 2024","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 December 2024","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"BL, MB and RA are consultants for Oculus GmbH (Wetzlar, Germany), MH, LI and TK declare no potential conflict of interest.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"30226"}}