Evaluation of large language models and retrieval-augmented generation for clinical reasoning in pediatric myopia: a 50-case real-world study

To evaluate the clinical reasoning ability of large language models (LLMs) and retrieval-augmented generation (RAG) systems in pediatric myopia management using a real-world, expert-annotated case set covering diverse refractive, pathological, and high-risk scenarios. Six models were tested: baseline LLMs (GPT Base, Gemini Base, Grok Base) and their RAG variants (GPT-RAG, Gemini-RAG, Grok-RAG). RAG was augmented with 41 authoritative guidelines, including IMI white papers and the LAMP study. Performance was evaluated through automated scoring by Claude 4 Opus and blinded adjudication by three senior ophthalmologists, focusing on Accuracy, Utility, and Safety. RAG-enhanced models significantly outperformed baseline models across all metrics. Notably, GPT-RAG achieved the highest weighted automated score (7.46), surpassing GPT Base (7.37). Human adjudication revealed that RAG models achieved 90-94% consensus alignment compared to 68-82% for baselines. Crucially, the probability of high-risk recommendations-those capable of causing severe vision loss-was eliminated (0%) in all RAG models, whereas baseline models exhibited high-risk error rates of 6-14%. LLM + RAG integration boosts reliability and safety in pediatric myopia care, particularly for high-risk decisions. RAG's domain knowledge incorporation advances AI clinical tools in ophthalmology, though ophthalmologist-in-the-loop refinement is essential pre-deployment.