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Molteni G, Ghirelli M, Sacchetto A, Fermi M, De Rossi S, Mattioli F, Presutti L, Marchioni D. Microsurgical training using an ex-vivo model: microscope vs 3D exoscope. ACTA OTORHINOLARYNGOLOGICA ITALICA 2022; 42:223-229. [PMID: 35880362 PMCID: PMC9330746 DOI: 10.14639/0392-100x-n1946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/19/2022] [Indexed: 11/23/2022]
Abstract
Objective The aim of this study is to evaluate the feasibility of the 3D exoscope in a microvascular anastomosis training setting and compare it with the gold-standard technique using the operating microscope (OM). Methods Participants were recruited among otorhinolaryngology head and neck surgery (OHNS) residents of two tertiary care hospitals. Trainees were asked to complete 4 microvascular end-to-end anastomoses on chicken thighs with the OM and VITOM 3D exoscope. The performances were scored by experienced microvascular surgeons; an objective evaluation of the anastomosis and a subjective assessment of the workload were conducted. Results 8 OHNS residents were recruited. Considering the amount of time needed to complete (TTC) the anastomosis, an improvement was shown by all the participants throughout the training program. The objective evaluation of the anastomosis did not show a significant difference. No significant differences were found by analyzing the subjective workload with the different tools. Conclusions This article represents the first attempt to compare the use of the OM and the 3D exoscope during training for microsurgery. The results of our study demonstrate the noninferiority of microsurgical training obtained using the 3D exoscope compared to that offered by the OM.
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Wang WC, Hu HW, Ciudad P, Lin BS, Chen HC, Chang CC. A Comparison of the Use of Two-Dimensional and Three-Dimensional Visualization Systems by Novice and Experienced Microsurgeons in Microsurgical Vessel Anastomosis: An Analysis Using the Chicken Model. J Reconstr Microsurg 2021; 38:313-320. [PMID: 34454410 DOI: 10.1055/s-0041-1735291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Various studies have discussed the benefits of applying three-dimensional (3D) techniques, specifically its advantages with respect to ergonomics, feasibility, and the rate of learning achievable in microsurgery training. However, no study has been conducted that compares the operator experience of using two-dimensional (2D) and 3D systems in microsurgical training. The aim of this study is to compare 2D- and 3D-assisted microsurgical training in novices based on anastomosis of chicken femoral arteries. METHODS The participants were grouped by previous microsurgical experience. Group A includes novice participants. Group B includes 2D-experienced participants. Group C includes both participants in groups A and B. A questionnaire composed of 10 parameters in the field of image quality, dexterity, ergonomic, and feasibility will be filled out after each participant finished their anastomoses by the 2D and 3D systems. RESULTS The results demonstrated 3D system was scored better on "field of view" (p = 0.004), "less tremor" (p = 0.005), "neck/upper back comfort" (p = 0.043), "lower back comfort" (p = 0.015), "technical feasibility" (p = 0.020), and "educational feasibility" (p = 0.004) in group A (N = 12). In group B (N = 9), 3D system was scored better on "field of view" (p = 0.041) but worse on "image resolution" (p = 0.031). CONCLUSION With the 3D visualization system for microsurgical anastomosis of chicken femoral model, there are significant improvements in the field of view, stability, ergonomics, and educational value compared with 2D system among all participants. Accordingly, 3D-assisted microsurgery training can be a novel and potential popular training method.
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Affiliation(s)
- Wen-Chien Wang
- Department of Medical Education, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsiang-Wei Hu
- Department of Medical Education, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Pedro Ciudad
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Bor-Shyh Lin
- Institute of Imaging and Biomedical Photonics, National Yang Ming Chiao Tung University, Tainan, Taiwan
| | - Hung-Chi Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chang-Cheng Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Institute of Imaging and Biomedical Photonics, National Yang Ming Chiao Tung University, Tainan, Taiwan.,Institute of Cosmeceutics, China Medical University, Taichung, Taiwan
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Ma L, Fei B. Comprehensive review of surgical microscopes: technology development and medical applications. JOURNAL OF BIOMEDICAL OPTICS 2021; 26:JBO-200292VRR. [PMID: 33398948 PMCID: PMC7780882 DOI: 10.1117/1.jbo.26.1.010901] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/04/2020] [Indexed: 05/06/2023]
Abstract
SIGNIFICANCE Surgical microscopes provide adjustable magnification, bright illumination, and clear visualization of the surgical field and have been increasingly used in operating rooms. State-of-the-art surgical microscopes are integrated with various imaging modalities, such as optical coherence tomography (OCT), fluorescence imaging, and augmented reality (AR) for image-guided surgery. AIM This comprehensive review is based on the literature of over 500 papers that cover the technology development and applications of surgical microscopy over the past century. The aim of this review is threefold: (i) providing a comprehensive technical overview of surgical microscopes, (ii) providing critical references for microscope selection and system development, and (iii) providing an overview of various medical applications. APPROACH More than 500 references were collected and reviewed. A timeline of important milestones during the evolution of surgical microscope is provided in this study. An in-depth technical overview of the optical system, mechanical system, illumination, visualization, and integration with advanced imaging modalities is provided. Various medical applications of surgical microscopes in neurosurgery and spine surgery, ophthalmic surgery, ear-nose-throat (ENT) surgery, endodontics, and plastic and reconstructive surgery are described. RESULTS Surgical microscopy has been significantly advanced in the technical aspects of high-end optics, bright and shadow-free illumination, stable and flexible mechanical design, and versatile visualization. New imaging modalities, such as hyperspectral imaging, OCT, fluorescence imaging, photoacoustic microscopy, and laser speckle contrast imaging, are being integrated with surgical microscopes. Advanced visualization and AR are being added to surgical microscopes as new features that are changing clinical practices in the operating room. CONCLUSIONS The combination of new imaging technologies and surgical microscopy will enable surgeons to perform challenging procedures and improve surgical outcomes. With advanced visualization and improved ergonomics, the surgical microscope has become a powerful tool in neurosurgery, spinal, ENT, ophthalmic, plastic and reconstructive surgeries.
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Affiliation(s)
- Ling Ma
- University of Texas at Dallas, Department of Bioengineering, Richardson, Texas, United States
| | - Baowei Fei
- University of Texas at Dallas, Department of Bioengineering, Richardson, Texas, United States
- University of Texas Southwestern Medical Center, Department of Radiology, Dallas, Texas, United States
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Teixeira RKC, Leal RA, Sabbá MF, Yamaki VN, Lemos MVV, de Barros RSM. Evaluation of 2 Low-cost High-definition Video Systems for Venous Anastomosis. Surg Innov 2020; 27:373-377. [PMID: 32484396 DOI: 10.1177/1553350620928185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. A literature review of the use of video systems for magnification has suggested that so far, this novel magnification system has only been used to perform arterial anastomoses. The aim of this study was to evaluate the use of 2 low-cost methods of video-assisted magnification in microvascular venous anastomosis in rats. Methods. Thirty rats were randomly divided into 3 matched groups according to the magnification system used: the microscope group, with venous anastomosis performed under a microscope; the camcorder system group, with the procedures performed under a high-definition Handycam HDR-XR160; and the Photographic camera group, for which procedures were performed with an EOS Rebel T3i photographic camera. In both video system groups, a magnification system was connected to a 42-in. television by an HDMI cable. We analyzed weight, venous caliber, total surgery and anastomosis time, patency immediately and 14 days postoperatively, number of stitches, and histological analyses. Results. There were no significant differences between the groups in weight, venous caliber, or number of stitches. Anastomosis under the video systems took longer. Patency rates were similar between the groups, except for the photographic system group that has a lower patency rate at 14 days. The histological analyses were similar in all groups. Conclusion. It is possible to perform a venous anastomosis in rats through video system magnification, with a satisfactory success rate comparable with that for procedures performed under microscopes; however, the kind of video system has a great influence on the final patency.
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Affiliation(s)
| | - Rafael A Leal
- Experimental Surgery Laboratory, State University of Pará, Brazil
| | - Marcelo F Sabbá
- Experimental Surgery Laboratory, State University of Pará, Brazil
| | - Vitor N Yamaki
- Experimental Surgery Laboratory, State University of Pará, Brazil
| | - Marcos V V Lemos
- Experimental Surgery Laboratory, State University of Pará, Brazil
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The Multifactorial Contribution of Publications in Plastic Surgery Journals in Microsurgery Education. Ann Plast Surg 2019; 84:130-134. [PMID: 31688111 DOI: 10.1097/sap.0000000000002040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Microsurgery is one of the most complex operative skills. Recent restrictions on residents' working hours challenge residency program directors to ensure skill acquisition with scant time dedicated to microsurgery practice. We aimed to summarize the contribution of plastic surgery journals in microsurgical education. METHODS A comprehensive literature search was performed. RESULTS We observed an increasing number of publications on microsurgery education over the years. This could be due to the adoption of new technologies developed in the last 2 decades, the concerns about quality of resident training in the context of reduced work hours, the well-described benefit of medical simulations in other specialties, and the pressure on trainees to be proficient before operating on patients. The variety of aspects addressed in plastic surgery publications is broad: simulators, courses, skills assessment, national surveys, and technology trends. CONCLUSION There is an upward trend in the number of publications and plastic surgery journals, demonstrating a remarkable contribution to microsurgery training.
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Wehr F, Held J. Stereoscopic versus monoscopic displays: Learning fine manual dexterity skills using a microsurgical task simulator. APPLIED ERGONOMICS 2019; 77:40-49. [PMID: 30832777 DOI: 10.1016/j.apergo.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/18/2018] [Accepted: 01/19/2019] [Indexed: 06/09/2023]
Abstract
We investigated the learning of fine manual dexterity with a microsurgical instrument and a new simulator in a context of microsurgery. 30 subjects were divided into two groups. One (3D group) interacted with a stereoscopic and the other (2D group) with a monoscopic display. Visual information for the displays was captured from a surgical stereomicroscope. In 20 trials, both groups performed the repetitive tasks of picking up small rods from a funnel-shaped cavity and placing them outside. In analysing learning curves, we found that the initial learning process for hand-eye coordination is easier with a 3D display, and that performance persists at a higher level of proficiency than with the 2D display option. Thus stereoscopic displays can be especially beneficial for novices, for those learning new procedures, or for providing orientation to operators facing a new or altered spatial situation. Simulators with few reliefs or spatial textures should not be used for comparison between 3D and 2D viewing conditions.
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Affiliation(s)
- Franka Wehr
- University of Applied Sciences Schwäbisch Gmünd, Rektor-Klaus Str. 100, Schwäbisch Gmünd, 73525, Germany.
| | - Jürgen Held
- University of Applied Sciences Schwäbisch Gmünd, Rektor-Klaus Str. 100, Schwäbisch Gmünd, 73525, Germany.
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Lai CS, Lu CT, Liu SA, Tsai YC, Chen YW, Chen IC. Robot-assisted microvascular anastomosis in head and neck free flap reconstruction: Preliminary experiences and results. Microsurgery 2019; 39:715-720. [PMID: 30977562 DOI: 10.1002/micr.30458] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 02/21/2019] [Accepted: 03/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The da Vinci Surgical System has facilitated considerable advancements in surgery. The process and results of robot-assisted microvascular anastomosis in real clinical situations have rarely been reported. This study presents our experience of performing robot-assisted microvascular anastomosis in free flap reconstruction in patients with oropharyngeal cancer. PATIENTS AND METHODS This was a retrospective study of reconstructive operations using a free radial forearm flap for oropharyngeal defects after tumor extirpation in 15 consecutive adult patients (12 men and 3 women). In total, 17 robot-assisted microvascular vessel anastomoses (2 arteries and 15 veins) were performed; moreover, 13 arteries and 13 veins were anastomosed using the standard operating microscope and hand-sewing technique. RESULTS The recipient and donor vessel diameters were 2.5 ± 0.7 and 2.1 ± 0.8 mm, respectively. The donor blood vessel diameter selected for anastomosis using da Vinci Surgical System was significantly smaller (2.1 ± 0.8 vs. 2.5 ± 0.6 mm) than that for a standard operating microscope and hand-sewing technique (p = .021), the operating time spent (38.4 ± 10.4 vs. 28.0 ± 7.7 min) was significantly longer (p < .001). The vascular patency rate was 100%, and all flaps survived without requiring additional operation for revision. CONCLUSION Robotic surgical systems can facilitate vascular microanastomosis and provide a blood vessel patency rate comparable to that of a standard operating microscope and hand-sewing technique.
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Affiliation(s)
- Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Republic of China
| | - Chen-Te Lu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Republic of China
| | - Shih-An Liu
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Republic of China
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Republic of China
| | - Yueh-Chi Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Republic of China
| | - Yen-Wei Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Republic of China
| | - I-Chen Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Republic of China
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Belykh E, George L, Zhao X, Carotenuto A, Moreira LB, Yağmurlu K, Bozkurt B, Byvaltsev VA, Nakaji P, Preul MC. Microvascular anastomosis under 3D exoscope or endoscope magnification: A proof-of-concept study. Surg Neurol Int 2018; 9:115. [PMID: 30105125 PMCID: PMC6070836 DOI: 10.4103/sni.sni_36_18] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/06/2018] [Indexed: 12/03/2022] Open
Abstract
Background: Extracranial–intracranial bypass is a challenging procedure that requires special microsurgical skills and an operative microscope. The exoscope is a tool for neurosurgical visualization that provides view on a heads-up display similar to an endoscope, but positioned external to the operating field, like a microscope. The authors carried out a proof-of-concept study evaluating the feasibility and effectiveness of performing microvascular bypass using various new exoscopic tools. Methods: We evaluated microsurgical procedures using a three-dimensional (3D) endoscope, hands-free robotic automated positioning two-dimensional (2D) exoscope, and an ocular-free 3D exoscope, including surgical gauze knot tying, surgical glove cutting, placental vessel anastomoses, and rat vessel anastomoses. Image quality, effectiveness, and feasibility of each technique were compared among different visualization tools and to a standard operative microscope. Results: 3D endoscopy produced relatively unsatisfactory resolution imaging. It was shown to be sufficient for knot tying and anastomosis of a placental artery, but was not suitable for anastomosis in rats. The 2D exoscope provided higher resolution imaging, but was not adequate for all maneuvers because of lack of depth perception. The 3D exoscope was shown to be functional to complete all maneuvers because of its depth perception and higher resolution. Conclusion: Depth perception and high resolution at highest magnification are required for microvascular bypass procedures. Execution of standard microanastomosis techniques was unsuccessful using 2D imaging modalities because of depth-perception-related constraints. Microvascular anastomosis is feasible under 3D exoscopic visualization; however, at highest magnification, the depth perception is inferior to that provided by a standard operative microscope, which impedes the procedure.
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Affiliation(s)
- Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.,Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Laeth George
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Alessandro Carotenuto
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Leandro Borba Moreira
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kaan Yağmurlu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Baran Bozkurt
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Vadim A Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Chen YQ, Tao JW, Su LY, Li L, Zhao SX, Yang Y, Shen LJ. Cooperative robot assistant for vitreoretinal microsurgery: development of the RVRMS and feasibility studies in an animal model. Graefes Arch Clin Exp Ophthalmol 2017; 255:1167-1171. [PMID: 28389702 DOI: 10.1007/s00417-017-3656-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 03/12/2017] [Accepted: 03/22/2017] [Indexed: 10/19/2022] Open
Abstract
PURPOSE The purpose of the study was to describe the development of a robotic aided surgical system named RVRMS (robotic vitreous retinal microsurgery system) and to evaluate the capability for using it to perform vitreoretinal surgery. METHODS The RVRMS was designed and built to include the key components of two independent arms. End-effectors of each arm fix various surgical instruments and perform intraocular manipulation. To evaluate properly the RVRMS, robot-assisted 23-gauge surgical tasks including endolaser for retinal photocoagulation, pars plana vitrectomy (PPV), retinal foreign body removal and retinal vascular cannulation were performed in two different sizes of an animal model. Endolaser was performed in the eye of a living Irish rabbit and the other tasks were done in a harvested porcine eye. For each evaluation, the duration and the successful completion of the task was assessed. RESULTS Robot-assisted vitreoretinal operations were successfully performed in nine rabbit eyes and 25 porcine eyes without any iatrogenic complication such as retinal tear or retinal detachment. In the task of using an endolaser, three rows of burns around the induced retinal hole were performed in nine rabbit eyes with half size intervals of laser spots. Nine procine eyes underwent PPV followed by successful posterior vitreous detachment (PVD) induction assisted with triamcinolone acetonide (TA). Nine porcine eyes completed removal of a fine stainless steel wire, which was inserted into prepared retinal tissue. Finally, retinal vascular cannulation with a piece of stainless steel wire (6mm length, 45 μm pipe diameter and one end cut to ∼30° slope) was successfully achieved in seven porcine eyes. The average duration of each procedure was 10.91±1.22 min, 11.68±2.11min, 5.90±0.46 min and 13.5±6.2 min, respectively. CONCLUSIONS Maneuverability, accuracy and stability of robot-assisted vitreoretinal microsurgery using the RVRMS were demonstrated in this study. Wider application research of robotic surgery and improvement of a robotic system should be continued.
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Affiliation(s)
- Yi-Qi Chen
- Eye Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China.,Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ji-Wei Tao
- Eye Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China
| | - Ling-Ya Su
- Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Liang Li
- Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Shi-Xin Zhao
- Eye Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China
| | - Yang Yang
- School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Li-Jun Shen
- Eye Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China. .,Wenzhou Medical University, Wenzhou, Zhejiang, China.
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