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Cheloni R, Clough N, Jackson D, Moosajee M. Longitudinal structure-function analysis of molecularly-confirmed CYP4V2 Bietti Crystalline Dystrophy. Eye (Lond) 2024; 38:853-862. [PMID: 37898718 DOI: 10.1038/s41433-023-02791-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/26/2023] [Accepted: 10/10/2023] [Indexed: 10/30/2023] Open
Abstract
OBJECTIVES Bietti Crystalline Dystrophy (BCD) is an autosomal recessive progressive retinal disease caused by mutations in CYP4V2. We have characterised the natural history including structural and functional measures to identify potential outcome metrics for future clinical trials. METHODS Molecularly-confirmed BCD patients with biallelic variants in CYP4V2 were retrospectively identified from Moorfields Eye Hospital (UK). Clinical details including results of molecular genetic testing, best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (OCT) scans were extracted. From OCT scans, ellipsoid zone (EZ) measures, foveal thickness of the whole retina, outer retina and choroid were measured. Age-related changes of clinical parameters were assessed with linear mixed models. RESULTS Twenty-eight BCD patients were identified, with median age at baseline of 37 years (interquartile range [IQR]: 30-49.5). Median follow-up was 7.7 years (IQR: 3.4-14.5). Most patients (41.7%) showed chorioretinal atrophy at baseline. All OCT parameters showed significant age-related loss (p < 0.05), with EZ measures and choroidal thickness displaying the most rapid degeneration (2.3-3.3% per year vs 0.6-1.5% per year). Median BCVA was 0.2 LogMAR (IQR: 0-0.5) at baseline and showed small age-related loss ( + 0.016 LogMAR per year, p = 0.0019). Patients exhibited substantial phenotypic variability. CONCLUSIONS BCD presents between age 25 and 40, and slowly progresses to an advanced chorioretinal atrophy and vision loss by age 60. BCVA may be preserved until late, and is seemingly poorly representative of disease progression. OCT parameters capturing EZ and choroid changes may afford more suitable trial outcome measures.
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Affiliation(s)
- Riccardo Cheloni
- UCL Institute of Ophthalmology, London, EC1V 9EL, UK
- Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK
| | - Neil Clough
- Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK
| | - Daniel Jackson
- UCL Institute of Ophthalmology, London, EC1V 9EL, UK
- Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK
| | - Mariya Moosajee
- UCL Institute of Ophthalmology, London, EC1V 9EL, UK.
- Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK.
- The Francis Crick Institute, London, NW1 1AT, UK.
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Han X, Li H, Zhang D, Li H, Zou X, Sui R. Longitudinal Natural History Study of Visual Function in Bietti Crystalline Dystrophy: Implications for Early Intervention. Invest Ophthalmol Vis Sci 2024; 65:25. [PMID: 38602838 PMCID: PMC11018262 DOI: 10.1167/iovs.65.4.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 03/14/2024] [Indexed: 04/13/2024] Open
Abstract
Purpose To delineate the natural history of visual function parameters over time in individuals with Bietti crystalline dystrophy. Methods This was a single-center retrospective longitudinal cohort study. Participants (n = 29) with a clinical diagnosis of Bietti crystalline dystrophy who harbored two alleles of disease-causing variants of the cytochrome P450 family 4 subfamily V member 2 gene (CYP4V2) were enrolled. Best-corrected visual acuity (BCVA), visual field (VF), and full-field ERG (ffERG) at baseline and their changes during the follow-up period were evaluated. Annual progression rates were calculated using three methods. Results The mean age at the initial visit was 34.2 ± 7.5 years, with 5.9 ± 3.1 years follow-up. The annual progression rate from the longitudinal analysis using averaged individual progression rates was 0.079 logMAR units for BCVA, 1.14 dB for mean defect (MD) value of VF, and -18.06 µV and -5.45 µV for the b-wave amplitudes of scotopic 3.0 ERG and photopic 3.0 ERG, respectively. Mixed-model linear regression revealed annual progression rates of 0.068 logMAR units, 0.86 dB, -13.29 µV, and -3.75 µV, respectively. Cross-sectional progression rates from visual function versus age at baseline were 0.011 logMAR units, 0.47 dB, -1.85 µV, and -1.07 µV, respectively, which were significantly slower than those from the longitudinal data. Interocular symmetries for the MD values of VF and ffERG were good. Conclusions Annual BCVA, VF, and ffERG progression rates were rapid, emphasizing the need for regular follow-up and early intervention. The progression rate cannot be inferred accurately from cross-sectional data from patients of different ages.
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Affiliation(s)
- Xiaoxu Han
- Department of Ophthalmology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huajin Li
- Department of Ophthalmology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dingding Zhang
- Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Li
- Department of Ophthalmology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuan Zou
- Department of Ophthalmology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ruifang Sui
- Department of Ophthalmology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Kiraly P, Seitz IP, Abdalla Elsayed MEA, Downes SM, Patel CK, Charbel Issa P, Birtel J, Mautone L, Dulz S, Atiskova Y, Herrmann P, Vrabič N, Jarc-Vidmar M, Hawlina M, Fischer MD. Morphological and functional parameters in X-linked retinoschisis patients-A multicentre retrospective cohort study. Front Med (Lausanne) 2024; 10:1331889. [PMID: 38351967 PMCID: PMC10864009 DOI: 10.3389/fmed.2023.1331889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/12/2023] [Indexed: 02/16/2024] Open
Abstract
Introduction X-linked retinoschisis (XLRS) is a potential target for gene supplementation approaches. To establish potential structural and functional endpoints for clinical trials, a comprehensive understanding of the inter-eye symmetry, relationship between structural and functional parameters, and disease progression is vital. Methods In this retrospective multicentre study, 118 eyes of 59 XLRS patients with RS1 mutations were assessed. Information from center databases included: RS1 variant; age at presentation; best-corrected visual acuity (BCVA), central retinal thickness (CRT), macular volume (MV) at presentation and at the last follow up; full-field electroretinogram (ERG) findings; presence of peripheral retinoschisis and complications (vitreous hemorrhage, retinal detachment); treatment with systemic or topical carbonic anhydrase inhibitors (CAI). Results Inter-eye symmetry revealed strong correlation in CRT (r = 0.77; p < 0.0001) and moderate correlations in MV (r = 0.51, p < 0.0001) and BCVA (r = 0.49; p < 0.0001). Weak or no correlations were observed between BCVA and structural parameters (CRT, MV). Peripheral retinoschisis was observed in 40 (68%), retinal detachment in 9 (15%), and vitreous hemorrhage in 5 (8%) patients, respectively. Longitudinal examinations (mean, 4.3 years) showed no BCVA changes; however, a reduction of the CRT (p = 0.02), and MV (p = 0.01) was observed. Oral and/or topical CAI treatment did not significantly alter the CRT (p = 0.34). Discussion The XLRS phenotype demonstrates a strong CRT symmetry between the eyes within individual patients and stable BCVA over several years. BCVA exhibits a weak correlation with the morphological parameters of retinal thickness (CRT MV). In our cohort, longitudinal functional changes were not significant, likely attributed to the short average follow-up period. Furthermore, CAI treatment didn't influence both morphological and functional outcomes.
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Affiliation(s)
- Peter Kiraly
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Laboratory of Ophthalmology, University of Oxford, Oxford, United Kingdom
| | - Immanuel P. Seitz
- Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany
| | | | - Susan M. Downes
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Laboratory of Ophthalmology, University of Oxford, Oxford, United Kingdom
| | - Chetan K. Patel
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Peter Charbel Issa
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Laboratory of Ophthalmology, University of Oxford, Oxford, United Kingdom
| | - Johannes Birtel
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Laboratory of Ophthalmology, University of Oxford, Oxford, United Kingdom
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Luca Mautone
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon Dulz
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yevgeniya Atiskova
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Herrmann
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Nika Vrabič
- Eye Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Marko Hawlina
- Eye Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - M. Dominik Fischer
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Laboratory of Ophthalmology, University of Oxford, Oxford, United Kingdom
- Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany
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Li Q, Wang C, Zhang S, Fu Z, Jiao X, Jin ZB, Hejtmancik JF, Peng X. Bietti's crystalline dystrophy: genotyping and deep qualitative and quantitative phenotyping in preparation for clinical trials. Br J Ophthalmol 2023:bjo-2022-322673. [PMID: 37963713 DOI: 10.1136/bjo-2022-322673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/02/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE To qualitatively and quantitatively characterise the genotypes and phenotypes of Bietti's crystalline dystrophy (BCD) in a cohort of patients. DESIGN Cross-sectional and observational study. METHODS Clinically confirmed BCD patients were recruited for genotyping and phenotyping. Multiple retinal imaging modalities were employed. Atrophy in the fovea was adopted as major consideration for staging strategy, while percentage area of autofluorescence (AF) atrophy (PAFA) in the macula was determined for quantitation. RESULTS In 74 clinically diagnosed BCD patients, c.802-8_810del17insGC was shown the predominant variant of the CYP4V2 gene (allele frequency 55.4%). Sixty-two cases (123 eyes) with full imaging data were classified according to a modified criterion into stages 1 (n=8, 6.50%), 2A (n=9, 7.32%), 2B (n=17, 13.82%), 3A (n=30, 24.39%) and 3B (n=59, 47.97%). The eyes of the stage 2B were particularly deemed 'high risk' due to atrophy near fovea, while in stage 3A, though with remarkable foveal atrophy, preserved retinal pigment epithelium/photoreceptor islands near the fovea were found in 14 eyes. A tendency of increase in PAFA with age was found (rs=0.31, p=0.014). Significant PAFA increase was shown through stages 1 to 3B, and best-corrected visual acuity (BCVA, Logarithm of the Minimum Angle of Resolution) was shown to moderately correlate with PAFA (rs=0.56, p<0.001). CONCLUSION The PAFA might be an efficient biomarker for BCD severities correlating with BCVA. The highly heterogeneous chorioretinopathy and BCVA of BCD cases appear to be associated with disease stages, progression types and patients' ages. Foveal involvement should be of a major concern for consideration of potential therapeutic intervention.
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Affiliation(s)
- Qian Li
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Cong Wang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | | | - Zhongjie Fu
- Department of Ophthalmology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Xiaodong Jiao
- Ophthalmic Genetics and Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Zi-Bing Jin
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
- Beijing Institute of Ophthalmology, Beijing, China
| | - James Fielding Hejtmancik
- Ophthalmic Genetics and Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Xiaoyan Peng
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
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Saatci AO, Ataş F, Çetin GO, Kayabaşı M. Diagnostic and Management Strategies of Bietti Crystalline Dystrophy: Current Perspectives. Clin Ophthalmol 2023; 17:953-967. [PMID: 36998515 PMCID: PMC10046287 DOI: 10.2147/opth.s388292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 03/15/2023] [Indexed: 04/01/2023] Open
Abstract
Bietti crystalline dystrophy (BCD) is a rare, genetically determined chorioretinal dystrophy presenting with intraretinal crystalline deposits and varying degrees of progressive chorioretinal atrophy commencing at the posterior pole. In some cases, there can be concomitant corneal crystals noted first in the superior or inferior limbus. CYP4V2 gene, a member of the cytochrome P450 family is responsible for the disease and more than 100 mutations have been defined thus far. However, a genotype-phenotype correlation has not been established yet. Visual impairment commonly occurs between the second and third decades of life. By the fifth or sixth decade of life, vision loss can become so severe that the patient may potentially become legally blind. Multitudes of multimodal imaging modalities can be utilized to demonstrate the clinical features, course, and complications of the disease. This present review aims to reiterate the clinical features of BCD, update the clinical perspectives with the help of multimodal imaging techniques, and overview its genetic background with future therapeutic approaches.
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Affiliation(s)
- Ali Osman Saatci
- Department of Ophthalmology, Dokuz Eylul University, Izmir, Turkey
- Correspondence: Ali Osman Saatci, Department of Ophthalmology, Dokuz Eylul University, Mustafa Kemal Sahil Bulvari, No: 73 A Blok, Daire 9, Narlidere, Izmir, Turkey, Tel +90 5327437071, Email
| | - Ferdane Ataş
- Department of Ophthalmology, Çerkezköy State Hospital, Tekirdağ, Turkey
| | - Gökhan Ozan Çetin
- Department of Medical Genetics, Pamukkale University, Denizli, Turkey
| | - Mustafa Kayabaşı
- Department of Ophthalmology, Dokuz Eylul University, Izmir, Turkey
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Jenny LA, Liu PK, Kolesnikova M, Duong J, Kim AH, Levi SR, Greenstein VC, Tsang SH. Foveolar thickness as potential standardized structural outcome measurement in studies of Bietti crystalline dystrophy. Sci Rep 2022; 12:14706. [PMID: 36038562 PMCID: PMC9424222 DOI: 10.1038/s41598-022-16563-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
Bietti crystalline dystrophy (BCD) is an ultra-rare orphan disorder that can lead to blindness. Because of the variable rates of progression of the disease, it is necessary to identify suitable outcome measurements for tracking progression in BCD. A retrospective analysis of patients with a clinical and genetic diagnosis of BCD was conducted. Four measurements of spectral domain-optical coherence tomography were compared to patients’ best corrected visual acuity. We observed that patients with higher measurements of foveolar thickness, choroidal thickness in the foveolar region, ellipsoid zone band length and the outer nuclear layer + area, had on average better visual acuity. Future studies are needed to validate the structural–functional correlations we observed in BCD and to propose a sensitive and clinically meaningful outcome measurement for tracking this rare, variable disease.
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Affiliation(s)
- Laura A Jenny
- Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA.,Jonas Children's Vision Care and Bernard & Shirlee Brown Glaucoma Laboratory, Department of Ophthalmology, Columbia University, New York, NY, USA
| | - Pei-Kang Liu
- Jonas Children's Vision Care and Bernard & Shirlee Brown Glaucoma Laboratory, Department of Ophthalmology, Columbia University, New York, NY, USA.,Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Masha Kolesnikova
- Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA.,Jonas Children's Vision Care and Bernard & Shirlee Brown Glaucoma Laboratory, Department of Ophthalmology, Columbia University, New York, NY, USA
| | - Jimmy Duong
- Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA
| | - Angela H Kim
- Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA.,Jonas Children's Vision Care and Bernard & Shirlee Brown Glaucoma Laboratory, Department of Ophthalmology, Columbia University, New York, NY, USA
| | - Sarah R Levi
- Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA.,Jonas Children's Vision Care and Bernard & Shirlee Brown Glaucoma Laboratory, Department of Ophthalmology, Columbia University, New York, NY, USA
| | | | - Stephen H Tsang
- Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA. .,Jonas Children's Vision Care and Bernard & Shirlee Brown Glaucoma Laboratory, Department of Ophthalmology, Columbia University, New York, NY, USA. .,Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA. .,Institute of Human Nutrition, Columbia University, New York, NY, USA. .,Columbia University Stem Cell Initiative, New York, NY, USA.
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Britten‐Jones AC, O'Hare F, Edwards TL, Ayton LN. Victorian evolution of inherited retinal diseases natural history registry (VENTURE study): Rationale, methodology and initial participant characteristics. Clin Exp Ophthalmol 2022; 50:768-780. [PMID: 35621151 PMCID: PMC9796389 DOI: 10.1111/ceo.14110] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/28/2022] [Accepted: 05/15/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Emerging treatments are being developed for inherited retinal diseases, requiring a clear understanding of natural progression and a database of potential participants for clinical trials. This article describes the rationale, study design and methodology of the Victorian Evolution of inherited retinal diseases NaTUral history REgistry (VENTURE), including data from the first 150 participants enrolled. METHODS VENTURE collects retrospective and prospective data from people with inherited retinal diseases. Following registration, participants are asked to attend a baseline examination using a standardised protocol to confirm their inherited retinal disease diagnosis. Examination procedures include (i) retinal function, using visual acuity and perimetry; (ii) retinal structure, using multimodal imaging and (iii) patient-reported outcomes. Participants' molecular diagnoses are obtained from their clinical records or through targeted-panel genetic testing by an independent laboratory. Phenotype and genotype data are used to enrol participants into disease-specific longitudinal cohort sub-studies. RESULTS From 7 July 2020 to 30 December 2021, VENTURE enrolled 150 registrants (138 families) and most (63%) have a rod-cone dystrophy phenotype. From 93 participants who have received a probable molecular diagnosis, the most common affected genes are RPGR (13% of all registrants), USH2A (10%), CYP4V2 (7%), ABCA4 (5%), and CHM (5%). Most participants have early to moderate vision impairment, with over half (55%) having visual acuities of better than 6/60 (20/200) at registration. CONCLUSIONS The VENTURE study will complement existing patient registries and help drive inherited retinal disease research in Australia, facilitating access to research opportunities for individuals with inherited retinal diseases.
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Affiliation(s)
- Alexis Ceecee Britten‐Jones
- Department of Optometry and Vision Sciences, Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleAustralia,Department of Surgery (Ophthalmology), Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleAustralia,Centre for Eye Research AustraliaRoyal Victorian Eye and Ear HospitalMelbourneAustralia
| | - Fleur O'Hare
- Department of Optometry and Vision Sciences, Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleAustralia,Department of Surgery (Ophthalmology), Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleAustralia,Centre for Eye Research AustraliaRoyal Victorian Eye and Ear HospitalMelbourneAustralia
| | - Thomas L. Edwards
- Department of Surgery (Ophthalmology), Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleAustralia,Centre for Eye Research AustraliaRoyal Victorian Eye and Ear HospitalMelbourneAustralia
| | - Lauren N. Ayton
- Department of Optometry and Vision Sciences, Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleAustralia,Department of Surgery (Ophthalmology), Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleAustralia,Centre for Eye Research AustraliaRoyal Victorian Eye and Ear HospitalMelbourneAustralia
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