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Bolac R, Bas S, Ozkan EMA, Balci S, Alpogan O. Evaluation of the effect of sodium-glucose cotransporter-2 inhibitor treatment on choroidal vascular parameters in patients with type 2 diabetes mellitus. Photodiagnosis Photodyn Ther 2023; 44:103804. [PMID: 37714281 DOI: 10.1016/j.pdpdt.2023.103804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/29/2023] [Accepted: 09/12/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND To evaluate the effect of sodium-glucose cotransporter-2 inhibitor treatment on choroidal vascular parameters in patients with type 2 diabetes mellitus (T2DM). METHODS Twenty eyes of 20 patients with T2DM without diabetic retinopathy and 20 eyes of 20 age- and sex-matched patients as the control group were included in the study. The patients were evaluated using enhanced depth imaging optic coherence tomography before treatment and at the third month of treatment. The choroidal images were binarized into luminal areas (LAs) and stromal areas (SAs). The choroidal vascularity index (CVI) was defined as the ratio of the LA to the total circumscribed choroid area (TCA). RESULTS The mean age of the patients was 56.65±8.41 years. The patients' mean disease duration was 6.65±5.72 years, the mean HbA1c level was 8.89±1.62%, and the mean body mass index was 33.13±4.84 kg/m2. The subfoveal TCA, subfoveal LA, subfoveal SA, total TCA, total LA, and total SA values of the patient group were found to be significantly lower than those of the control group (p = 0.006, p = 0.003, p = 0.028, p = 0.001, p = 0.001, and p = 0.006, respectively). There was a significant increase in the subfoveal TCA, subfoveal LA, subfoveal SA, subfoveal CVI, total TCA, total LA, and total SA values after empagliflozin treatment compared to before empagliflozin treatment (p = 0.005, p = 0.003, p = 0.021, p = 0.032, p < 0.001, p < 0.001, and p = 0.001 respectively). CONCLUSIONS Empagliflozin provides an improvement in diabetic choroidal changes through its effect on choroidal vascularity parameters.
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Affiliation(s)
- Ruveyde Bolac
- University of Health Sciences, Haydarpasa Numune Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey.
| | - Suleyman Bas
- Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, Department of Internal Medicine, Istanbul, Turkey.
| | - Esma Merve Arda Ozkan
- University of Health Sciences, Haydarpasa Numune Training and Research Hospital, Department of Internal Medicine, Istanbul, Turkey
| | - Sevcan Balci
- University of Health Sciences, Haydarpasa Numune Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey
| | - Oksan Alpogan
- University of Health Sciences, Haydarpasa Numune Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey
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Alten F, Eter N, Schmitz B. Differential effects of high-intensity interval training (HIIT) on choriocapillaris perfusion in healthy adults and patients with type 1 diabetes mellitus (T1DM). Microvasc Res 2021; 135:104128. [PMID: 33417915 DOI: 10.1016/j.mvr.2020.104128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/27/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To investigate the effects of a four-week high-intensity interval training (HIIT) on choriocapillaris (CC) perfusion in young healthy adults and type 1 diabetes mellitus (T1DM) patients. METHODS Data of two HIIT studies with baseline to follow-up comparison were retrospectively analysed. Twenty healthy participants and twenty T1DM patients without clinical signs of diabetic retinopathy were included. All participants had performed a four-week all-out HIIT protocol with a total of 8 training sessions. Changes in physical fitness were assessed using power output at the individual aerobic lactate threshold (IANT). Optical coherence tomography angiography (OCTA) imaging was performed at baseline and follow-up. CC images were analysed for number, size and total area of flow deficits (FD), mean signal intensity, signal intensity standard deviation and kurtosis of signal intensity distribution. RESULTS At baseline, CC OCTA revealed a lower and more heterogeneous intensity signal in T1DM eyes (mean intensity signal and standard deviation of signal intensity, p < 0.001). Percent of CC FD area was greater in T1DM eyes (p < 0.001). While T1DM patients showed greater improvement of exercise capacity at IANT than healthy controls (group×time p = 0.0403), CC FD area and standard deviation of intensity increased in healthy controls but not in T1DM patients (group×time p ≤ 0.029). Moreover, linear regression slopes of FD region distribution differed significantly at baseline and follow-up (p = 0.0002) in healthy individuals but not in T1DM patients. CONCLUSIONS Effects of regular physical exercise performed as HIIT on CC perfusion were only seen in healthy participants, not in T1DM patients suggesting impaired CC adaptation in T1DM.
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Affiliation(s)
- Florian Alten
- Department of Ophthalmology, University of Muenster Medical Center, Muenster, Germany.
| | - Nicole Eter
- Department of Ophthalmology, University of Muenster Medical Center, Muenster, Germany
| | - Boris Schmitz
- Institute of Sports Sciences, University of Muenster, Muenster, Germany
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Lupidi M, Cerquaglia A, Gujar R, Fruttini D, Cardillo Piccolino F, Fiore T, Coscas F, Coscas G, Chhablani J, Cagini C. Functional correlation between choroidal and retinal vascularity in low-grade diabetic retinopathy. Acta Diabetol 2020; 57:983-990. [PMID: 32201906 DOI: 10.1007/s00592-020-01507-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/14/2020] [Indexed: 11/25/2022]
Abstract
AIMS To perform an automated functional assessment of retinal and choroidal microvasculature in eyes with low-grade diabetic retinopathy (DR) using optical coherence tomography angiography (OCT-A) and to identify potential perfusion changes in case of early vascular damage. METHODS This is an observational, case-control study of consecutive diabetic patients with level 20 DR severity scale score and age-matched healthy subjects. A prototypal OCT-angiography was used to obtain the OCT-angiograms of the superficial capillary plexus (SCP), deep capillary plexus (DCP) and choriocapillaris (CC) layer. A validated automated microstructural analysis provided data on SCP, DCP and CC vascular perfusion density (VPD). A comparative assessment between different vascular layers and different groups was performed. RESULTS Twenty-nine diabetic patients (7 females, 24%) and 20 healthy controls were enrolled. VPD values were significantly lower in the DCP (25.1% vs. 26.5%; p = 0.04) and CC (71.2% vs. 86.6%; p = 0.0001) of diabetic patients compared with controls. A statistically significant negative linear correlation was reported between CC VPD and DCP VPD in diabetic patients; at the reverse, a positive linear correlation between the same parameters was noticed in controls. CONCLUSION Retinal and choroidal vascular networks, although distinct entities, seem functionally interconnected: varying the degree of perfusion may be a mutual compensatory mechanism in response to an ischemic injury.
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Affiliation(s)
- Marco Lupidi
- Department of Surgical and Biomedical Sciences, Section of Ophthalmology, University of Perugia, S. Maria della Misericordia Hospital, 06156, Perugia, Italy.
- Fondazione per la Macula Onlus, Di.N.O.G.Mi., University Eye Clinic, Viale Benedetto XV 5, 16132, Genoa, Italy.
- Centre de l'Odéon, 113 Boulevard St Germain, 75006, Paris, France.
| | - Alessio Cerquaglia
- Department of Surgical and Biomedical Sciences, Section of Ophthalmology, University of Perugia, S. Maria della Misericordia Hospital, 06156, Perugia, Italy
| | - Ramkailash Gujar
- Department of Surgical and Biomedical Sciences, Section of Ophthalmology, University of Perugia, S. Maria della Misericordia Hospital, 06156, Perugia, Italy
| | - Daniela Fruttini
- Department of Internal Medicine, University of Perugia, S. Maria della Misericordia Hospital, 06156, Perugia, Italy
| | - Felice Cardillo Piccolino
- Fondazione per la Macula Onlus, Di.N.O.G.Mi., University Eye Clinic, Viale Benedetto XV 5, 16132, Genoa, Italy
| | - Tito Fiore
- Department of Surgical and Biomedical Sciences, Section of Ophthalmology, University of Perugia, S. Maria della Misericordia Hospital, 06156, Perugia, Italy
| | - Florence Coscas
- Centre de l'Odéon, 113 Boulevard St Germain, 75006, Paris, France
| | - Gabriel Coscas
- Centre de l'Odéon, 113 Boulevard St Germain, 75006, Paris, France
| | - Jay Chhablani
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Carlo Cagini
- Department of Surgical and Biomedical Sciences, Section of Ophthalmology, University of Perugia, S. Maria della Misericordia Hospital, 06156, Perugia, Italy
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Ryu G, Kim I, Sagong M. Topographic analysis of retinal and choroidal microvasculature according to diabetic retinopathy severity using optical coherence tomography angiography. Graefes Arch Clin Exp Ophthalmol 2020; 259:61-68. [PMID: 32648156 DOI: 10.1007/s00417-020-04785-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/14/2020] [Accepted: 06/01/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To investigate the topographic changes in the retinal capillary plexus and the choriocapillaris according to the severity of diabetic retinopathy (DR) using optical coherence tomography angiography (OCTA). METHODS Subjects were recruited and classified into one of the following four groups: normal controls (n = 52), diabetes without DR (n = 49), non-proliferative DR (n = 51) and proliferative DR (n = 38). Using OCTA, the superficial capillary plexus (SCP), deep capillary plexus (DCP) and the choriocapillaris vessel densities were measured and compared in different macular areas: the fovea (1-mm diameter circular area), parafovea (1-3-mm diameter ring) and perifovea (3-6-mm ring). RESULTS With DR progression, vessel densities in the SCP and DCP as well as the choriocapillaris decreased, while the foveal avascular zone area increased (p < 0.001 for all). Compared with controls, the SCP and DCP vessel densities of the diabetes without DR group were decreased in all areas of the macula (p < 0.020 for all), while the choriocapillaris vessel density was decreased only in the perifoveal area (p = 0.823 for the foveal area; p = 0.631 for the parafoveal area; p = 0.039 for the perifoveal area). Multivariate linear regression analyses revealed that all retinal and choroidal microvascular indices were significantly associated with the DR severity. CONCLUSION The morphological changes in the macular microvasculature were associated with DR severity. Also, the changes were found to be more vulnerable in the retinal capillary plexuses than the choriocapillaris.
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Affiliation(s)
- Gahyung Ryu
- Department of Ophthalmology, Yeungnam University College of Medicine, #170 Hyunchungro, Nam-gu, Daegu, 42415, South Korea
| | - Inhye Kim
- Department of Ophthalmology, Yeungnam University College of Medicine, #170 Hyunchungro, Nam-gu, Daegu, 42415, South Korea
| | - Min Sagong
- Department of Ophthalmology, Yeungnam University College of Medicine, #170 Hyunchungro, Nam-gu, Daegu, 42415, South Korea.
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Yang J, Wang E, Zhao X, Xia S, Yuan M, Chen H, Zhang X, Chen Y. Optical coherence tomography angiography analysis of the choriocapillary layer in treatment-naïve diabetic eyes. Graefes Arch Clin Exp Ophthalmol 2019; 257:1393-1399. [PMID: 31089870 DOI: 10.1007/s00417-019-04326-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/07/2019] [Accepted: 04/12/2019] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To evaluate the capillary flow density (CFD) of choriocapillary (CC) microvasculature using optical coherence tomography angiography (OCT-A) in diabetic eyes and the association of CFD and systemic and metabolic factors. METHODS Cross-sectional study. This study enrolled 282 eyes of 146 subjects, including 43 healthy control eyes, 56 diabetic eyes without diabetic retinopathy (DR), 43 eyes with mild nonproliferative DR (NPDR), 54 eyes with moderate NPDR, 38 eyes with severe NPDR, and 48 eyes with proliferative DR (PDR). CFD was measured in the CC layer. Clinical data were collected. Multiple linear regression analyses were performed to identify associated clinical variables. RESULTS CFD in the CC layer presented a downward trend with DR progression. Comparisons of CFD in the CC layer between adjacent stages of DR revealed significant differences between severe NPDR and PDR using both 3-mm and 6-mm scan patterns (P = 0.003, P = 0.001). CFD in the CC layer in DR with diabetic macular edema (DME) was less than that in DR without DME using both 3-mm and 6-mm scan patterns (P < 0.001, P < 0.001). Coronary artery disease and atherosclerosis in other locations, estimated glomerular filtration rate, and increased HbA1c were associated with CFD in the CC layer using both 3-mm and 6-mm scan patterns (all P values < 0.05). CONCLUSIONS OCT-A revealed decreased CFD in the CC layer in the PDR stage and the presence of DME. Diabetic patients with apparently decreased CFD should be assessed carefully under general conditions.
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Affiliation(s)
- Jingyuan Yang
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Erqian Wang
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Xinyu Zhao
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Song Xia
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Mingzhen Yuan
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Huan Chen
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Xiao Zhang
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Youxin Chen
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China.
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Horváth H, Kovács I, Sándor GL, Czakó C, Mallár K, Récsán Z, Somogyi A, Nagy ZZ, Ecsedy M. Choroidal thickness changes in non-treated eyes of patients with diabetes: swept-source optical coherence tomography study. Acta Diabetol 2018; 55:927-934. [PMID: 29876669 DOI: 10.1007/s00592-018-1169-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 05/27/2018] [Indexed: 11/26/2022]
Abstract
AIMS To measure choroidal thickness (CT) in diabetic eyes and its correlation with metabolic status and the severity of diabetic retinopathy (DR). MATERIALS AND METHODS Prospective cross-sectional study using swept-source optical coherence tomography. CT maps of 96 treatment naïve eyes of 48 patients with diabetes were compared to 46 eyes of 23 healthy controls. CT changes and their relation to diabetes, age, gender, disease duration, hypertension (HT), hemoglobin A1c level, type and severity of DR were evaluated. RESULTS A significantly thinner choroid was measured in patients with diabetes compared to controls (p < 0.009). In the diabetic group age, gender, disease duration and HT were significantly correlated with CT in univariable regression models (p < 0.05). In multivariable analysis, the duration of diabetes significantly negatively correlated with CT (p = 0.02). According to analysis of variance, there was a significant difference among means of CT in different stages of DR (p = 0.002), with thinner CT in cases with more advanced DR. In a multivariable predictive model, thinner CT was associated with an increased risk for the presence of DR (p = 0.02). CONCLUSIONS Diabetes mellitus itself and the severity of DR affect CT significantly, even after adjusting for the effects of confounding systemic factors. Disease duration seems to be associated with a reduction of choroidal thickness. Decreased CT proved to be correlated with the severity of DR.
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Affiliation(s)
- Hajnalka Horváth
- Department of Ophthalmology, Semmelweis University, Mária 39, Budapest, 1085, Hungary.
| | - Illés Kovács
- Department of Ophthalmology, Semmelweis University, Mária 39, Budapest, 1085, Hungary
| | - Gábor László Sándor
- Department of Ophthalmology, Semmelweis University, Mária 39, Budapest, 1085, Hungary
| | - Cecília Czakó
- Department of Ophthalmology, Semmelweis University, Mária 39, Budapest, 1085, Hungary
| | - Klaudia Mallár
- Department of Ophthalmology, Semmelweis University, Mária 39, Budapest, 1085, Hungary
| | - Zsuzsanna Récsán
- Department of Ophthalmology, Semmelweis University, Mária 39, Budapest, 1085, Hungary
| | - Anikó Somogyi
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi 46, Budapest, 1088, Hungary
| | - Zoltán Zsolt Nagy
- Department of Ophthalmology, Semmelweis University, Mária 39, Budapest, 1085, Hungary
| | - Mónika Ecsedy
- Department of Ophthalmology, Semmelweis University, Mária 39, Budapest, 1085, Hungary
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Endo H, Kase S, Takahashi M, Yokoi M, Isozaki C, Katsuta S, Kase M. Alteration of layer thickness in the choroid of diabetic patients. Clin Exp Ophthalmol 2018. [PMID: 29655280 DOI: 10.1111/ceo.13199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/06/2018] [Accepted: 03/27/2018] [Indexed: 11/26/2022]
Abstract
IMPORTANCE Choroidal thickness changes in diabetic retinopathy improve understanding the pathophysiology and managements of this disease. BACKGROUND To examine the choroidal layer thickness in diabetes mellitus (DM) patients and normal individuals, and to compare the findings based on medical history of systemic DM treatments, and stage of diabetic retinopathy (DR). DESIGN Case control study. PARTICIPANTS Two hundred sixty eight eyes of 134 DM patients and age-matched 72 healthy controls of 92 eyes. METHODS Central choroidal layer thickness (total, inner, and outer layers) was measured using enhanced depth imaging OCT. DM patients were divided into two groups; the DM treated group (88 cases), and the untreated group (46 cases). These two groups were further classified into four groups; no DR (NDR), mild/moderate non-proliferative DR (mNPDR), severe NPDR and PDR. MAIN OUTCOME MEASURES Comparison of subfoveal choroid layer thickness in control and diabetic patient groups. RESULTS Choroidal thickness measurements of diabetic eyes had strong correlation between masked raters in choroidal layers, proving high reproducibility. The total and outer choroid thicknesses in mNPDR in the DM untreated group were significantly thinner than normal controls (each P<0.05). Choroidal outer layer thickness of the severe NPDR in the DM untreated group was significantly thicker than normal controls (P<0.05). In the DM treatment group, there were no significant differences from the control group regarding choroidal layer thicknesses and all stages of DR. CONCLUSIONS AND RELEVANCE The choroidal thickness significantly changed in the DM untreated group, and the main anatomical changes might result from the outer layer.
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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
| | - Mitsuo Takahashi
- Department of Ophthalmology, Teine Keijinkai Hospital, Sapporo, Japan
| | | | - Chisato Isozaki
- Department of Ophthalmology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Satoshi Katsuta
- Department of Ophthalmology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Manabu Kase
- Department of Ophthalmology, Teine Keijinkai Hospital, Sapporo, Japan
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Melancia D, Vicente A, Cunha JP, Abegão Pinto L, Ferreira J. Diabetic choroidopathy: a review of the current literature. Graefes Arch Clin Exp Ophthalmol 2016; 254:1453-1461. [PMID: 27109344 DOI: 10.1007/s00417-016-3360-8] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/12/2016] [Accepted: 04/14/2016] [Indexed: 12/26/2022] Open
Abstract
Diabetic retinopathy is an increasingly prevalent disease, and a leading contributor to the burden of all-cause blindness worldwide. In addition to retinal changes, choroidal abnormalities are common in patients with diabetes. The first studies concerning this vascular structure were based on histologic, indocyanine angiography and laser Doppler flowmetry techniques, but the development of new optical coherence tomography (OCT) technologies and imaging software for enhanced depth imaging (EDI)-OCT in recent years has made it possible to provide more detailed images of the choroidal anatomy and topography.In diabetic patients, several choroidal changes have been described in the literature throughout the years; the recent focus is choroidal thickness, which is significantly different from that in healthy patients. However, understanding choroidal manifestations of diabetic eye disease remains a real challenge, and this gap is hindering efforts towards better defining choroidal evaluation as a predictive factor for disease evolution and treatment response.This review aims to summarize the recent literature concerning changes in choroidal structure in diabetic patients, the relationship to diabetic retinal disease progression, and finally, the current and potential application of the measurement of variations in choroidal thickness for patient management.
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Affiliation(s)
- Diana Melancia
- Neurology Department, Central Lisbon Hospital Center, Lisbon, Portugal.,Institute of Pharmacology and Neurosciences, Faculty of Medicine of Lisbon University, Lisbon, Portugal
| | - André Vicente
- Ophthalmology Department, Central Lisbon Hospital Center, Lisbon, Portugal.,Faculty of Medicine of Lisbon University, Lisbon, Portugal
| | - João Paulo Cunha
- Ophthalmology Department, Central Lisbon Hospital Center, Lisbon, Portugal.,Faculty of Medical Sciences of New University, Lisbon, Portugal
| | - Luís Abegão Pinto
- Ophthalmology Department, Northern Lisbon Hospital Center, Lisbon, Portugal.,Visual Sciences Study Center, Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - Joana Ferreira
- Ophthalmology Department, Central Lisbon Hospital Center, Lisbon, Portugal. .,Faculty of Medical Sciences of New University, Lisbon, Portugal.
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