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Alhazmi M, Alotaibi W, Almansour S, Alotaibi S, Alanazi M, Althomali M. Assessing acute nicotine impact on choroidal thickness: a randomized, double-blinded study comparing smoking cessation aids, including nicotine gum and electronic cigarettes. Int Ophthalmol 2024; 44:199. [PMID: 38662017 DOI: 10.1007/s10792-024-03137-2] [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: 12/13/2023] [Accepted: 04/11/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE To explore whether differences in choroidal thickness arise from nicotine consumption in healthy young individuals, specifically comparing the effects of nicotine gum to electronic cigarette (vaping), while maintaining a consistent 4 mg nicotine dosage. METHODS In a randomized double-blinded prospective cross-sectional study, 20 healthy participants (mean age ± standard deviation: 23 ± 2.36 years) were randomly assigned to either the nicotine gum or vaping group. Choroidal thickness (ChT) measurements were conducted using optical coherence tomography (OCT) (Topcon 3D OCT-1 Maestro System) at baseline, 30, and 60 min after ingesting 4 mg of nicotine, with ChT measurements taken from five different horizontal areas. RESULTS Neither the nicotine delivery method (gum or vaping) demonstrated a statistically significant impact on ChT mean scores among subjects in the five measured areas at baseline, 30, and 60 min (p > 0.05). However, significant differences were observed in ChT mean scores within subjects across the five areas (F (1.83, 72) = 36.43, p < 0.001), regardless of other study factors such as group, time, and visit (p > 0.05). A statistically significant interaction was identified between the factors of area and time concerning participants' ChT mean scores when stratified by the type of smoking (tobacco, vaping, and dual) (p = 0.003). CONCLUSION The results of this study revealed that nicotine, up to particular concentration of 4 mg, does not have a statistically significant vasoconstrictive effect on choroidal thickness, regardless of the delivery method, within the examined group. These findings offer valuable insights into the relationship between nicotine intake and choroidal dynamics in young adults.
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Affiliation(s)
- Mohammed Alhazmi
- Optometry Department, College of Applied Medical Sciences, King Saud University, King Abdullah Road, 4545, Riyadh, Saudi Arabia.
| | - Wafa Alotaibi
- Optometry Department, College of Applied Medical Sciences, King Saud University, King Abdullah Road, 4545, Riyadh, Saudi Arabia
| | - Saud Almansour
- Optometry Department, College of Applied Medical Sciences, King Saud University, King Abdullah Road, 4545, Riyadh, Saudi Arabia
| | - Sadeem Alotaibi
- Optometry Department, College of Applied Medical Sciences, King Saud University, King Abdullah Road, 4545, Riyadh, Saudi Arabia
| | - Muteb Alanazi
- Optometry Department, College of Applied Medical Sciences, King Saud University, King Abdullah Road, 4545, Riyadh, Saudi Arabia
| | - Mohammed Althomali
- Optometry Department, College of Applied Medical Sciences, King Saud University, King Abdullah Road, 4545, Riyadh, Saudi Arabia
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Üçer MB, Cevher S. Analysis of the Choroidal Structure in the Early Stage of Type 2 Diabetic Retinopathy. Ophthalmic Surg Lasers Imaging Retina 2024:1-8. [PMID: 38648425 DOI: 10.3928/23258160-20240408-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND AND OBJECTIVE Our aim was to evaluate the choroidal structure in the early stage of Type 2 diabetic retinopathy (DR). MATERIALS AND METHODS The study included patients with nonproliferative diabetic retinopathy (NPDR) without edema (n = 30, NPDR group), patients with diabetes without retinopathy (n = 30, No DR group), and healthy subjects (n = 33, control group). Choroidal thickness (CT), total choroidal area (TCA), luminal area (LA), stromal area (SA), and choroidal vascularity index (CVI) were evaluated. RESULTS The hypertension (HT) rate was highest in patients with NPDR (63.3%), and lowest in the control group (27.3%). Subfoveal, nasal, temporal CT, TCA, and LA were thinner in patients with diabetes compared to the control group for both patients with and without HT, although not significantly. CTs, TCA, LA, and SA were lower in hypertensive patients than patients without HT in all groups. CVI and LA/SA were significantly lower in NPDR group compared to the controls for both patients with and without HT. CONCLUSION In patients with diabetes and before clinical retinopathy develops, the thinning of the CT and CVI begins. A decrease in CVI continues as the retinopathy progresses. HT appears to be a factor that can reduce CT, TCA, LA, and SA. [Ophthalmic Surg Lasers Imaging Retina 2024;55:xx-xx.].
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Hashemi A, Nabovati P, Mortazavi A, Hashemi H, Khabazkhoob M. Subfoveal choroidal thickness in a general elderly population; Tehran geriatric eye study. BMC Ophthalmol 2024; 24:136. [PMID: 38532398 DOI: 10.1186/s12886-024-03401-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 03/18/2024] [Indexed: 03/28/2024] Open
Abstract
PURPOSE To determine the distribution of subfoveal choroidal thickness (SFCT) and its associated demographic, ocular, and systemic factors in an elderly population. METHODS This report is part of the Tehran Geriatric Eye Study (TGES); a population-based cross-sectional study that was conducted on the urban elderly population of Tehran, aged 60 years and above using multi-stage stratified random cluster sampling. Choroidal imaging was performed using Spectralis SD-OCT with enhanced depth imaging mode. RESULTS The average SFCT was 265.3 ± 25.9 μm (95% CI: 262.8-267.7) in the whole sample. According to the multiple generalized estimating equation (GEE) model, pseudophakia had a statistically significant direct relationship with SFCT (coefficient = 5.69), and history of cerebrovascular accident (CVA) was significantly inversely related to SFCT (coefficient=-4.77). Moreover, there was a significant interaction between age and sex in the average SFCT so that with increasing age, the SFCT increased in men and decreased in women. CONCLUSION The normal values of SFCT in the present study can be used as a reference database for clinical and research purposes. Age-sex interaction, pseudophakia, and history of CVA were significantly associated with SFCT in the elderly population. It is recommended that these factors be taken into account when interpreting SFCT data.
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Affiliation(s)
- Alireza Hashemi
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
| | - Payam Nabovati
- Rehabilitation Research Center, Department of Optometry, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Abolghasem Mortazavi
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Hashemi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran.
| | - Mehdi Khabazkhoob
- Department of Basic Sciences, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Jing R, Sun X, Cheng J, Li X, Wang Z. Vascular changes of the choroid and their correlations with visual acuity in diabetic retinopathy. Front Endocrinol (Lausanne) 2024; 15:1327325. [PMID: 38464970 PMCID: PMC10920230 DOI: 10.3389/fendo.2024.1327325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/08/2024] [Indexed: 03/12/2024] Open
Abstract
Objective To investigate changes in the choroidal vasculature and their correlations with visual acuity in diabetic retinopathy (DR). Methods The cohort was composed of 225 eyes from 225 subjects, including 60 eyes from 60 subjects with healthy control, 55 eyes from 55 subjects without DR, 46 eyes from 46 subjects with nonproliferative diabetic retinopathy (NPDR), 21 eyes from 21 subjects with proliferative diabetic retinopathy (PDR), and 43 eyes from 43 subjects with clinically significant macular edema (CSME). Swept-source optical coherence tomography (SS-OCT) was used to image the eyes with a 12-mm radial line scan protocol. The parameters for 6-mm diameters of region centered on the macular fovea were analyzed. Initially, a custom deep learning algorithm based on a modified residual U-Net architecture was utilized for choroidal boundary segmentation. Subsequently, the SS-OCT image was binarized and the Niblack-based automatic local threshold algorithm was employed to calibrate subfoveal choroidal thickness (SFCT), luminal area (LA), and stromal area (SA) by determining the distance between the two boundaries. Finally, the ratio of LA and total choroidal area (SA + LA) was defined as the choroidal vascularity index (CVI). The choroidal parameters in five groups were compared, and correlations of the choroidal parameters with age, gender, duration of diabetes mellitus (DM), glycated hemoglobin (HbA1c), fasting blood sugar, SFCT and best-corrected visual acuity (BCVA) were analyzed. Results The CVI, SFCT, LA, and SA values of patients with DR were found to be significantly lower compared to both healthy patients and patients without DR (P < 0.05). The SFCT was significantly higher in NPDR group compared to the No DR group (P < 0.001). Additionally, the SFCT was lower in the PDR group compared to the NPDR group (P = 0.014). Furthermore, there was a gradual decrease in CVI with progression of diabetic retinopathy, reaching its lowest value in the PDR group. However, the CVI of the CSME group exhibited a marginally closer proximity to that of the NPDR group. The multivariate regression analysis revealed a positive correlation between CVI and the duration of DM as well as LA (P < 0.05). The results of both univariate and multivariate regression analyses demonstrated a significant positive correlation between CVI and BCVA (P = 0.003). Conclusion Choroidal vascular alterations, especially decreased CVI, occurred in patients with DR. The CVI decreased with duration of DM and was correlated with visual impairment, indicating that the CVI might be a reliable imaging biomarker to monitor the progression of DR.
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Affiliation(s)
- Ruixia Jing
- Jinan Central Hospital, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
| | - Xiubin Sun
- Department of Biostatistics, School of Public Health, Cheeloo Collage of Medicine, Shandong University, Jinan, China
| | - Jimin Cheng
- Department of Ophthalmology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xue Li
- Jinan Central Hospital, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
| | - Zhen Wang
- Department of Ophthalmology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
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Hui Z, Guo X, Bulloch G, Yuan M, Xiong K, Zhang S, Chen Y, Li Y, Liao H, Huang W, Zhu Z, Wang W. Rates of choroidal loss and ganglion cell-inner plexiform layer thinning in type 2 diabetes mellitus and healthy individuals: a 2-year prospective study. Br J Ophthalmol 2023; 108:84-90. [PMID: 36385002 DOI: 10.1136/bjo-2022-321603] [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: 04/04/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022]
Abstract
AIMS To investigate longitudinal choroid and ganglion cell-inner plexiform layer (GCIPL) changes in type 2 diabetes mellitus (T2DM) patients and healthy populations across 2 years. METHODS This prospective cohort study included T2DM patients and healthy controls. T2DM patients were divided into mild non-proliferative diabetic retinopathy (NPDR) or non-DR (NDR) groups. Macular choroidal and GCIPL thickness was measured using swept-source optical coherence tomography at baseline and follow-up after 2 years. A linear-mixed effect model compared rates of change in choroidal and GCIPL thicknesses between the three groups. RESULTS 895 T2DM patients (770 in the NDR group and 125 in the NPDR group) and 847 healthy controls were included. Following 2 years, choroidal thinning occurred at a rate of -7.7±9.2 µm/year, -8.1±8.7 µm/year and -5.2±8.1 µm/year in NDR, NPDR and control groups, respectively (p<0.001). GCIPL loss occurred quickest in NPDR patients (-0.97±0.97 µm/year), followed by NDR (-0.91±0.89 µm/year) and the control group (-0.04±0.55 µm/year) (p<0.001). Following multivariate adjustment, choroidal thinning was -2.04 µm/year (95% CI: -4.05 to -0.03; p=0.047) and -1.95 µm/year (95% CI: -3.14 to -0.75; p=0.001) faster in NPDR and NDR groups than in the control group, respectively, and GCIPL thinning was -1.02 µm/year (95% CI: -1.19 to -0.84; p<0.001) and -0.88 µm/year (95% CI: -0.98 to -0.78; p<0.001) faster in the NPDR and NDR groups than in the control group, respectively. CONCLUSION Progressive choroidal and GCIPL thinning occurs in healthy individuals and T2DM patients; however, T2DM undergoes accelerated choroidal and GCIPL loss in NPDR patients.
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Affiliation(s)
- Ziwen Hui
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
- Zhongs School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Xiao Guo
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Gabriella Bulloch
- Centre for Eye Research Australia Ltd, East Melbourne, Victoria, Australia
| | - Meng Yuan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Kun Xiong
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Shiran Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | | | - Yuting Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Huan Liao
- University of Melbourne, Melbourne, Victoria, Australia
| | - Wenyong Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Zhuoting Zhu
- Centre for Eye Research Australia Ltd, East Melbourne, Victoria, Australia
| | - Wei Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
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Alterations in the Choroidal Sublayers in Relationship to Severity and Progression of Diabetic Retinopathy. OPHTHALMOLOGY SCIENCE 2022; 2:100130. [PMID: 36249687 PMCID: PMC9560641 DOI: 10.1016/j.xops.2022.100130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 12/03/2022]
Abstract
Purpose To examine the association of baseline choroidal sublayers metrics with the risk of diabetic retinopathy (DR) progression over 2 years, with adjustment for confounding factors that affect choroidal measurements. Design Prospective, observational cohort study. Participants One hundred three eyes from 62 patients with diabetes mellitus (DM). Methods Patients were followed up at 6-month intervals for at least 2 years. Choroidal metrics including choroidal area, choroidal thickness (CT), and choroidal vascularity index were measured for both (1) the choriocapillaris plus Sattler’s layer and (2) the Haller’s layer within the subfoveal and parafoveal region. Cox proportional models were constructed to estimate the relationship between baseline choroidal metrics and DR progression, adjusted for intereye correlation, established risk factors (i.e., duration of DM, glycated hemoglobin [HbA1c] level, body mass index [BMI], use of insulin, and mean arterial blood pressure [MABP]) and confounding factors of choroidal measurements (i.e., age and axial length). Additional predictive value of choroidal metrics was assessed using the C-statistic. Main Outcome Measures Hazard ratios (HRs) calculated by Cox proportional hazards model to demonstrate the associations between baseline choroidal metrics and DR progression. Results After adjusting for age, axial length, and intereye correlation, choroidal metrics in Haller’s layer at baseline that were associated with a higher risk of DR progression included increases in subfoveal choroidal area (HR, 2.033; 95% confidence interval [CI], 1.179–3.505; P = 0.011), subfoveal plus parafoveal choroidal area (HR, 1.909; 95% CI, 1.096–3.326; P = 0.022), subfoveal CT (HR, 2.032; 95% CI, 1.181–3.498; P = 0.010), and subfoveal plus parafoveal CT (HR, 1.908; 95% CI, 1.097–3.319; P = 0.022). These associations remained statistically significant after additionally adjusting for duration of DM, HbA1c level, BMI, use of insulin, and MABP. Addition of these choroidal metrics significantly improved the discrimination for DR progression when compared with established risk factors alone (e.g., duration of DM and HbA1c; increase in C-statistic ranged from 8.08% to 9.67% [P < 0.05]). Conclusions Eyes with a larger choroidal area and CT in Haller’s layer at baseline were associated with a higher risk of DR progression over 2 years.
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Gün RD, Gümüş T, Kardaş ASY, Kardaş G. Acute Effect of Hyperbaric Oxygen Therapy on Macular and Choroidal Thickness in Patients with Type 2 Diabetes and Diabetic Foot Ulcers: Optical Coherence Tomography Based Study. Photodiagnosis Photodyn Ther 2022; 39:102926. [DOI: 10.1016/j.pdpdt.2022.102926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/06/2022] [Accepted: 05/20/2022] [Indexed: 11/29/2022]
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Wang W, Li L, Wang J, Chen Y, Kun X, Gong X, Wei D, Wang D, Liang X, Liu H, Huang W. Macular Choroidal Thickness and the Risk of Referable Diabetic Retinopathy in Type 2 Diabetes: A 2-Year Longitudinal Study. Invest Ophthalmol Vis Sci 2022; 63:9. [PMID: 35420642 PMCID: PMC9034727 DOI: 10.1167/iovs.63.4.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 02/19/2022] [Indexed: 11/27/2022] Open
Abstract
Purpose The purpose of this study was to evaluate the associations between choroidal thickness (CT) and the 2-year incidence of referable diabetic retinopathy (RDR). Methods This was a prospective cohort study. Patients with type 2 diabetes in Guangzhou, China, aged 30 to 80 years underwent comprehensive examinations, including standard 7-field fundus photography. Macular CT was measured using a commercial swept-source optical coherence tomography (SS-OCT) device (DRI OCT Triton; Topcon, Tokyo, Japan). The relative risk (RR) with 95% confidence intervals (CIs) was used to quantify the association between CT and new-onset RDR. The prognostic value of CT was assessed using the area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Results A total of 1345 patients with diabetes were included in the study, and 120 (8.92%) of them had newly developed RDR at the 2-year follow-up. After adjusting for other factors, the increased RDR risk was associated with greater HbA1c (RR = 1.35, 95% CI = 1.17-1.55, P < 0.001), higher systolic blood pressure (SBP; RR = 1.02, 95% CI = 1.01-1.03, P = 0.005), lower triglyceride (TG) level (RR = 0.81, 95% CI = 0.69-0.96, P = 0.015), presence of diabetic retinopathy (DR; RR = 8.16, 95% CI = 4.47-14.89, P < 0.001), and thinner average CT (RR = 0.903, 95% CI = 0.871-0.935, P < 0.001). The addition of average CT improved NRI (0.464 ± 0.096, P < 0.001) and IDI (0.0321 ± 0.0068, P < 0.001) for risk of RDR, and it also improved the AUC from 0.708 (95% CI = 0.659-0.757) to 0.761 (95% CI = 0.719-0.804). Conclusions CT thinning measured by SS-OCT is an early imaging biomarker for the development of RDR, suggesting that alterations in CT play an essential role in DR occurrence.
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Affiliation(s)
- Wei Wang
- Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Longyue Li
- School of Medicine, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Jun Wang
- Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Yifan Chen
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Xiong Kun
- Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Xia Gong
- Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Daheng Wei
- Institute of Eyes, Jinzhou Medical University, Jinzhou, Liaoning, People's Republic of China
| | - Dongning Wang
- Institute of Eyes, Jinzhou Medical University, Jinzhou, Liaoning, People's Republic of China
| | - Xiaolin Liang
- Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Hua Liu
- Institute of Eyes, Jinzhou Medical University, Jinzhou, Liaoning, People's Republic of China
| | - Wenyong Huang
- Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-Sen University, Guangzhou, People's Republic of China
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Hassan H, Cheema A, Tahir MA, Nawaz HN. Comparison of choroidal thickness in eyes of diabetic patients with eyes of healthy individuals using optical coherence tomography in a tertiary care hospital. Pak J Med Sci 2022; 38:254-260. [PMID: 35035435 PMCID: PMC8713207 DOI: 10.12669/pjms.38.1.4443] [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: 03/19/2021] [Revised: 09/02/2021] [Accepted: 09/18/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives: To compare the choroidal thickness in eyes of diabetic patients with eyes of age matched controls using optical coherence tomography in a tertiary care hospital. Methods: This Cross sectional study was conducted at the Department of Ophthalmology, Jinnah Postgraduate Medical Centre Karachi, for six months from13thJanuary 2020 to13thJuly 2020. The study group comprised of 44 patients with 88 eyes. Patients who fulfill the inclusion criteria that is age ranging from 35 to 80years, either gender, known case of diabetes mellitus and having any type of diabetic retinopathy (HbA1c >7), non-diabetic healthy individuals (HbA1c < 7) and those giving informed consent were included in the study. However, patients having active ocular infections, history of myocardial infarction, stroke, uveitis, any ocular surgery, lasers, intravitreal injections, poor fundus view and not giving consent were excluded. A pre-designed proforma was filled. A baseline ocular examination was performed and choroidal thickness was assessed from retinal pigment epithelium to choroid sclera junction in diabetic and healthy participants of the study group using high resolution Swept source OCT (DRI-OCT-2 Triton; Topcon). Results: The average age of the patients was 39.41±15.95 years. According to our study mean central subfoveal choroidal thickness in diabetic eyes was 268.5 ± 66.22 (95% CI 240 – 297) and in non-diabetic healthy participants it was 339.3 ± 71.49 (95% CI 308 – 369) with a p-value of 0.001. However, average choroidal thickness was 261.8 ± 61.93 (95% CI 235 – 288) and 336.0 ± 74.35 (95% CI 304 – 367) in diabetic and non-diabetic healthy population with a p-value of 0.001. Choroidal thickness comparison between gender in diabetic and non-diabetic population also showed similar trend. Conclusion: In this study, mean central choroidal thickness as well as average choroidal thickness was significantly reduced in eyes having diabetic retinopathy as compared to participants with non-diabetic healthy eyes. These findings indicate that changes in choroid may be a probable route in the pathogenesis of diabetic retinopathy.
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Affiliation(s)
- Hafsa Hassan
- Hafsa Hassan, MBBS, FCPS. Jinnah Post Graduate Medical Centre, Karachi, Pakistan
| | - Alyscia Cheema
- Alyscia Cheema, MBBS, FCPS, FRCS. Professor of Ophthalmology Jinnah Post Graduate Medical Centre, Karachi, Pakistan
| | - Muhammad Ali Tahir
- Muhammad Ali Tahir, MBBS, FCPS (Ophthalmology), FCPS (Vitreoretina) Consultant Retinal Surgeon Jinnah Post Graduate Medical Centre, Karachi, Pakistan
| | - Hina Nasreen Nawaz
- Hina Nasreen Nawaz, MBBS, MRCS. TRMO, Jinnah Post Graduate Medical Centre, Karachi, Pakistan
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Zhang YS, Mucollari I, Kwan CC, Dingillo G, Amar J, Schwartz GW, Fawzi AA. Reversed Neurovascular Coupling on Optical Coherence Tomography Angiography Is the Earliest Detectable Abnormality before Clinical Diabetic Retinopathy. J Clin Med 2020; 9:jcm9113523. [PMID: 33142724 PMCID: PMC7692675 DOI: 10.3390/jcm9113523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/21/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022] Open
Abstract
Diabetic retinopathy (DR) has traditionally been viewed as either a microvasculopathy or a neuropathy, though neurovascular coupling deficits have also been reported and could potentially be the earliest derangement in DR. To better understand neurovascular coupling in the diabetic retina, we investigated retinal hemodynamics by optical coherence tomography angiography (OCTA) in individuals with diabetes mellitus (DM) but without DR (DM no DR) and mild non-proliferative DR (mild NPDR) compared to healthy eyes. Using an experimental design to monitor the capillary responses during transition from dark adaptation to light, we examined 19 healthy, 14 DM no DR and 11 mild NPDR individuals. We found that the only structural vascular abnormality in the DM no DR group was increased superficial capillary plexus (SCP) vessel density (VD) compared to healthy eyes, while mild NPDR eyes showed significant vessel loss in the SCP at baseline. There was no significant difference in inner retinal thickness between the groups. During dark adaptation, the deep capillary plexus (DCP) VD was lower in mild NPDR individuals compared to the other two groups, which may leave the photoreceptors more susceptible to ischemia in the dark. When transitioning from dark to ambient light, both diabetic groups showed a qualitative reversal of VD trends in the SCP and middle capillary plexus (MCP), with significantly decreased SCP at 5 min and increased MCP VD at 50 s compared to healthy eyes, which may impede metabolic supply to the inner retina during light adaptation. Mild NPDR eyes also demonstrated DCP dilation at 50 s and 5 min and decreased adjusted flow index at 5 min in light. Our results show altered neurovascular responses in all three macular vascular plexuses in diabetic subjects in the absence of structural neuronal changes on high resolution imaging, suggesting that neurovascular uncoupling may be a key mechanism in the early pathogenesis of DR, well before the clinical appearance of vascular or neuronal loss.
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Affiliation(s)
- Yi Stephanie Zhang
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (Y.S.Z.); (I.M.); (C.C.K.); (G.D.); (J.A.); (G.W.S.)
| | - Ilda Mucollari
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (Y.S.Z.); (I.M.); (C.C.K.); (G.D.); (J.A.); (G.W.S.)
| | - Changyow C. Kwan
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (Y.S.Z.); (I.M.); (C.C.K.); (G.D.); (J.A.); (G.W.S.)
| | - Gianna Dingillo
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (Y.S.Z.); (I.M.); (C.C.K.); (G.D.); (J.A.); (G.W.S.)
| | - Jaspreet Amar
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (Y.S.Z.); (I.M.); (C.C.K.); (G.D.); (J.A.); (G.W.S.)
| | - Gregory W. Schwartz
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (Y.S.Z.); (I.M.); (C.C.K.); (G.D.); (J.A.); (G.W.S.)
- Department of Physiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Amani A. Fawzi
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (Y.S.Z.); (I.M.); (C.C.K.); (G.D.); (J.A.); (G.W.S.)
- Correspondence:
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11
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Choroidal and retinal structural, cellular and vascular changes in a rat model of Type 2 diabetes. Biomed Pharmacother 2020; 132:110811. [PMID: 33069967 DOI: 10.1016/j.biopha.2020.110811] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/16/2020] [Accepted: 09/25/2020] [Indexed: 12/28/2022] Open
Abstract
Increasing evidence points to inflammation as a key factor in the pathogenesis of diabetic retinopathy (DR). Choroidal changes in diabetes have been reported and several attempts were made to validate in vivo choroidal thickness (CT) as a marker of retinopathy. We aimed to study choroidal and retinal changes associated with retinopathy in an animal model of spontaneous Type 2 diabetes, Goto-Kakizaki (GK) rats. Sclerochoroidal whole mounts and cryosections were prepared from 52-week-old GK and age-matched control Wistar Han rats. CT was measured by optical coherence tomography. Microglia reactivity, pericyte and endothelial cells distribution, and immunoreactivity of vascular endothelial growth factor (VEGF) and VEGF receptor 2 (VEGFR2) were evaluated by immunofluorescence. Choroidal vessels were visualized by direct perfusion with 1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanine perchlorate (Dil). Choroidal vascular density was evaluated by fluorescence microscopy. GK rats had increased CT (58.40 ± 1.15 μm versus 50.90 ± 1.58 μm, p < 0.001), reduced vascular density of the choriocapillaris (CC) (p = 0.045), increased Iba1+ cells density in the outer retina (p = 0.003) and increased VEGFR2 immunoreactivity in most retinal layers (p = 0.021 to 0.037). Choroidal microglial cells and pericytes showed polarity in their distribution, sparing the innermost choroid. This cell-free gap in the inner choroid was more pronounced in GK rats. In summary, GK rats have increased CT with decreased vascular density in the innermost choroid, increased VEGFR2 immunoreactivity in the retina and increased Iba1+ cells density in the outer retina.
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12
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Endo H, Kase S, Saito M, Yokoi M, Takahashi M, Ishida S, Kase M. Choroidal Thickness in Diabetic Patients Without Diabetic Retinopathy: A Meta-analysis. Am J Ophthalmol 2020; 218:68-77. [PMID: 32574782 DOI: 10.1016/j.ajo.2020.05.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE To evaluate the relationship between diabetic eyes without diabetic retinopathy and healthy eyes in subfoveal choroidal thickness. DESIGN Systematic review and meta-analysis. METHODS An independent retrospective or prospective clinical study comparing diabetic eyes without diabetic retinopathy and healthy control eyes in the subfoveal choroidal thickness was selected. This study compiled data from publications in PubMed and Web of Science between January 1, 2008, and November 15, 2019. Heterogeneity was statistically quantified by I2 statistics, and meta-analysis was performed using a random-effects model. RESULTS Seventeen related studies were identified, including a total of 4,213 eyes, which consisted of 1,197 diabetic eyes without diabetic retinopathy and 3,016 healthy eyes. Meta-analysis clearly showed that the subfoveal choroidal thickness of diabetic eyes without retinopathy was significantly thinner than that of healthy control eyes (weighted mean difference = -14.34 μm; 95% confidence interval: -24.37 to -4.32 μm; P < .005). Similar results were obtained in sub-analysis based on the adjustment of the axial length. CONCLUSIONS This study suggests that the subfoveal choroidal thickness was thin in diabetic eyes without retinopathy compared to healthy eyes. Subfoveal choroidal thickness might be an important parameter for the development of diabetic retinopathy in diabetic eyes without retinopathy.
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Affiliation(s)
- Hiroaki Endo
- Department of Ophthalmology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Satoru Kase
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Michiyuki Saito
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | | | - Mitsuo Takahashi
- Department of Ophthalmology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Susumu Ishida
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Manabu Kase
- Department of Ophthalmology, Teine Keijinkai Hospital, Sapporo, Japan
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13
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Wang W, Liu S, Qiu Z, He M, Wang L, Li Y, Huang W. Choroidal Thickness in Diabetes and Diabetic Retinopathy: A Swept Source OCT Study. Invest Ophthalmol Vis Sci 2020; 61:29. [PMID: 32324858 PMCID: PMC7401852 DOI: 10.1167/iovs.61.4.29] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Purpose Previous studies on the association between choroidal thickness (CT) and severity of diabetic retinopathy (DR) gave conflicting results. The aim of this study was to evaluate the CT changes in diabetic patients and associated factors in a large sample of Chinese patients with diabetes. Methods Type 2 diabetes mellitus patients without history of ocular treatment were recruited from the community health system in Guangzhou, China. The swept source OCT instrument was used to obtain high-definition retina and choroid images. The diabetic retinopathy (DR) status was graded based on the guidelines of the United Kingdom National Diabetic Eye Screening Programme. Univariate and multivariate linear regression analyses was used to explore the association of CT with DR severity, diabetic macular edema (DME), hemoglobin A1c, and vision function. Results A total of 1347 patients were included in the final analysis. After adjusting for other factors, the patients with stage R3 DR had significantly thinner CT (β = –29.1 µm, 95% CI –53.8 to –4.4, P = 0.021) in comparison in those with R0. After adjusting for other factors, the CTs were thicker than those in R0 patients with difference of 15.6 µm (95% CI 4.3-26.9, P = 0.007) for outer nasal sector, 15.7 µm (95% CI 3.8-25.5, P = 0.008) for outer inferior, and 12.2 µm (95% CI 0.4-24.0, P = 0.042) for inner inferior sector. The presence of DME and hemoglobin A1c levels did not significantly affect average CT. Higher average CT was significantly associated with better best corrected visual acuity, with a –0.02 LogMAR unit per 100 µm increase in average CT (95% CI –0.03 to –0.01, P < 0.001). Conclusions CT increased in the early stage of DR, and further decreased with DR progression. DME was not significantly associated with CT. These findings provide more clues to suggest that choroid alterations play a role in the pathogenesis of DR.
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Campos A, Campos EJ, Martins J, Rodrigues FSC, Silva R, Ambrósio AF. Inflammatory cells proliferate in the choroid and retina without choroidal thickness change in early Type 1 diabetes. Exp Eye Res 2020; 199:108195. [PMID: 32841650 DOI: 10.1016/j.exer.2020.108195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 07/13/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
Increasing evidence points to inflammation as a key factor in the pathogenesis of diabetic retinopathy (DR). Choroidal inflammatory changes in diabetes have been reported and in vivo choroidal thickness (CT) has been searched as a marker of retinopathy with contradictory results. We aimed to investigate the early stages in the retina and choroid in an animal model of Type 1 diabetes. Type 1 diabetes was induced in male Wistar rats via a single i.p. streptozotocin injection. At 8 weeks after disease onset, CT, choroidal vascular density, VEGF and VEGFR2 expression, microglial cell and pericyte distribution were evaluated. Diabetic rats showed no significant change in CT and choroidal vascular density. A widened pericyte-free gap between the retinal pigment epithelium and the choroid was observed in diabetic rats. The immunoreactivity of VEGFR2 was decreased in the retina of diabetic rats, despite no statistically significant difference in the immunoreactivity of VEGF. The density of microglial cells significantly increased in the choroid and retina of diabetic rats. Reactive microglial cells were found to be more abundant in the choroid of diabetic rats. Evidences of the interconnection between the superficial, intermediate, and deep plexuses of the retina were also observed. At early stages, Type 1 diabetes does not affect choroidal thickness and choroidal vascular density. Proliferation and reactivity of microglial cells occurs in the choroidal stroma and the retina. The expression of VEGFR2 decreases in the retina.
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Affiliation(s)
- António Campos
- University of Coimbra, Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal; Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; Department of Ophthalmology, Centro Hospitalar Leiria EPE, Leiria, Portugal; ciTechCare, Center for Innovative Care and Health Technology, Polytechnic Institute of Leiria, Leiria, Portugal
| | - Elisa J Campos
- University of Coimbra, Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal; Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; Association for Innovation and Biomedical Research on Light and Image (AIBILI), Coimbra, Portugal.
| | - João Martins
- University of Coimbra, Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal; Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; University of Coimbra, Coimbra Institute for Biomedical Imaging and Translational Research (CIBIT), Coimbra, Portugal; University of Coimbra, Instituto de Ciências Nucleares Aplicadas à Saúde (ICNAS), Coimbra, Portugal
| | - Flávia S C Rodrigues
- University of Coimbra, Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal; Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Rufino Silva
- University of Coimbra, Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; Association for Innovation and Biomedical Research on Light and Image (AIBILI), Coimbra, Portugal; Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
| | - António Francisco Ambrósio
- University of Coimbra, Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal; Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; Association for Innovation and Biomedical Research on Light and Image (AIBILI), Coimbra, Portugal.
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15
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Prousali E, Dastiridou A, Ziakas N, Androudi S, Mataftsi A. Choroidal thickness and ocular growth in childhood. Surv Ophthalmol 2020; 66:261-275. [PMID: 32634443 DOI: 10.1016/j.survophthal.2020.06.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 12/22/2022]
Abstract
The involvement of the choroid in ocular growth regulation has been postulated in studies showing that refractive errors correlate with alterations in choroidal thickness (ChT). The advent of optical coherence tomography imaging has enabled qualitative and quantitative assessment of the choroid. In children, ChT changes correlate with a number of ocular pathologies, including myopia, retinopathy of prematurity, and amblyopia. We synthesize mechanisms and evidence regarding choroidal thickness variation during childhood. Subfoveal ChT is influenced by a number of factors including age, ethnicity, gender, axial length, and intraocular pressure. Myopic eyes have thinner choroids compared to emmetropic and hyperopic eyes. ChT may in fact serve as a marker of myopic progression, as ChT thinning occurs early during myopic development, but this association has not been established quantitatively. In addition, subfoveal ChT appears thicker in amblyopic eyes, while prematurity and retinopathy of prematurity may be associated with thinner ChT. Overall, both animal models and clinical research indicate that ChT induces or reflects physiological changes in the eye pertaining to ocular growth or maturation.
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Affiliation(s)
- Efthymia Prousali
- 2(nd) Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna Dastiridou
- 2(nd) Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Ziakas
- 2(nd) Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sofia Androudi
- Department of Ophthalmology, University of Thessaly, Larissa, Greece
| | - Asimina Mataftsi
- 2(nd) Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Abadia B, Bartol-Puyal FDA, Calvo P, Verdes G, Isanta C, Pablo LE. Mapping choroidal thickness in patients with type 2 diabetes. Can J Ophthalmol 2019; 55:45-51. [PMID: 31712028 DOI: 10.1016/j.jcjo.2019.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/08/2019] [Accepted: 06/24/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine and compare topographic features of the choroidal thickness (CT) between patients with type 2 diabetes (T2D) and age-matched healthy controls based on swept source-optical coherence tomography (SS-OCT). DESIGN Cross-sectional study. PARTICIPANTS 96 T2D patients and 33 healthy individuals aged above 18 years and with an axial length (AL) lower than 26 mm were included. METHODS A macular 6 × 6 mm cube, comprising 900 200 × 200 µm cubes, was scanned with SS-OCT. The choroid was automatically segmented using the segmentation algorithm. Three-dimensional maps were created to represent the choroid. The scanned area was divided into different zones based on CT, and equivalent zones were compared between groups. RESULTS Mean age (standard deviation) in the control group was 66.83 (7.3) years, and that of the T2D group was 67.94 (7.9) years (p = 0.48). Both groups were similar regarding AL and spherical equivalent. Overall, CT was significantly thinner in the T2D group; it was 203.78 (53.40) in healthy individuals and 169.98 (63.22) in T2D patients (p = 0.01). Outside the fovea, the mean CT was thicker in the superior hemiretina and decreased inferiorly, temporally, and nasally, with minimum thickness in the most distant points from the fovea. CONCLUSIONS Choroidal thickness follows an ellipsoid pattern in both nondiabetic and diabetic eyes, with diabetic eyes showing thinner measurements diffusely. Understanding these differences is important for future studies aimed at understanding the pathophysiological underpinnings of diabetic retinopathy.
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Affiliation(s)
- Beatriz Abadia
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain; Miguel Servet Ophthalmology Innovative and Research Group (GIMSO), Aragón Institute for Health Research (IIS-Aragón), Zaragoza, Spain
| | - Francisco de Asís Bartol-Puyal
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain; Miguel Servet Ophthalmology Innovative and Research Group (GIMSO), Aragón Institute for Health Research (IIS-Aragón), Zaragoza, Spain.
| | - Pilar Calvo
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain; Miguel Servet Ophthalmology Innovative and Research Group (GIMSO), Aragón Institute for Health Research (IIS-Aragón), Zaragoza, Spain
| | - Guayente Verdes
- Department of Endocrinology, Alcañiz Hospital, Teruel, Spain
| | - Carlos Isanta
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain; Miguel Servet Ophthalmology Innovative and Research Group (GIMSO), Aragón Institute for Health Research (IIS-Aragón), Zaragoza, Spain
| | - Luis E Pablo
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain; Miguel Servet Ophthalmology Innovative and Research Group (GIMSO), Aragón Institute for Health Research (IIS-Aragón), Zaragoza, Spain; Surgery, Gynecology and Obstetrics Department, University of Zaragoza, Zaragoza, Spain
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