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Acet Y. Assessing blink dynamics with non-noticeable method. Cont Lens Anterior Eye 2024:102277. [PMID: 39004571 DOI: 10.1016/j.clae.2024.102277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 07/16/2024]
Abstract
PURPOSE The purpose of the study was to demonstrate the feasibility of blink dynamics with a contactless, non-noticeable method without any visible light being reflected to the participant's eye by the device, and to investigate the blink dynamics parameters in 39 participants whose blink dynamics were examined with this method. It was also aimed to explain the potential of corneal topography devices for non-noticeable blink dynamics and elucidate some tips to device manufacturers to make them practical. METHODS A one-minute real-time video image in the meibography module of the scheimpflug camera-based corneal topography device was recorded in the slow motion mode of the mobile phone. Detailed analysis of blink dynamics was made by advancing the video images manually at 10 ms intervals. Lid Closing Time (LCT), Lid Opening Time (LOT), third Interblink Interval times (IBI(3)), fifth Interblink Interval times (IBI(5)), Number of Blinks Per Minute (NoB), Number of Complete Blinks Per Minute (NoCB), Number of Incomplete Blinks Per Minute (NoICB) were investigated. RESULTS The average NoB, NoCB, and NoICB (blinks/minute) with ± standard deviation (SD) values were found to be 22.9 ± 14.4; 14.5 ± 12.4 and 8.4 ± 8, respectively. The average IBI(3) time(seconds) with ± SD was measured as 3.4 ± 4.5. The average IBI(5) time (seconds) with ± SD was 3.9 ± 3.7 The average LCT time (milliseconds) with ± SD was found to be 91.9 ± 36.9 in the 4 different blinks analyzed. The average LOT time (milliseconds) with ± SD was found to be 582.6 ± 196.5 in the 3 different blinks analyzed. CONCLUSIONS Blink dynamics can be examined in detail with corneal topography devices in a non-contact, no visible light, and most importantly, non-noticeable manner. Existing video imaging modules of corneal topography devices have the potential to investigate blink dynamics. It is anticipated that the clinical use of blink dynamics, which can be performed practically, will increase, particularly in the monitoring of ocular surface and neurological diseases.
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Affiliation(s)
- Yakup Acet
- Department of Ophthalmology, Mardin Training and Research Hospital, Mardin, Turkey.
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Ren Y, Wen H, Bai F, Huang B, Wang Z, Zhang S, Pu Y, Le Z, Gong X, Wang L, Chen W, Zheng Q. Comparison of deep learning-assisted blinking analysis system and Lipiview interferometer in dry eye patients: a cross-sectional study. EYE AND VISION (LONDON, ENGLAND) 2024; 11:7. [PMID: 38374153 PMCID: PMC10875838 DOI: 10.1186/s40662-024-00373-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 01/01/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Abnormal blinking pattern is associated with ocular surface diseases. However, blink is difficult to analyze due to the rapid movement of eyelids. Deep learning machine (DLM) has been proposed as an optional tool for blinking analysis, but its clinical practicability still needs to be proven. Therefore, the study aims to compare the DLM-assisted Keratograph 5M (K5M) as a novel method with the currently available Lipiview in the clinic and assess whether blinking parameters can be applied in the diagnosis of dry eye disease (DED). METHODS Thirty-five DED participants and 35 normal subjects were recruited in this cross-sectional study. DED questionnaire and ocular surface signs were evaluated. Blinking parameters including number of blinks, number of incomplete blinking (IB), and IB rate were collected from the blinking videos recorded by the K5M and Lipiview. Blinking parameters were individually collected from the DLM analyzed K5M videos and Lipiview generated results. The agreement and consistency of blinking parameters were compared between the two devices. The association of blinking parameters to DED symptoms and signs were evaluated via heatmap. RESULTS In total, 140 eyes of 70 participants were included in this study. Lipiview presented a higher number of IB and IB rate than those from DLM-assisted K5M (P ≤ 0.006). DLM-assisted K5M captured significant differences in number of blinks, number of IB and IB rate between DED and normal subjects (P ≤ 0.035). In all three parameters, DLM-assisted K5M also showed a better consistency in repeated measurements than Lipiview with higher intraclass correlation coefficients (number of blinks: 0.841 versus 0.665; number of IB: 0.750 versus 0.564; IB rate: 0.633 versus 0.589). More correlations between blinking parameters and DED symptoms and signs were found by DLM-assisted K5M. Moreover, the receiver operating characteristic analysis showed the number of IB from K5M exhibiting the highest area under curve of 0.773. CONCLUSIONS DLM-assisted K5M is a useful tool to analyze blinking videos and detect abnormal blinking patterns, especially in distinguishing DED patients from normal subjects. Large sample investigations are therefore warranted to assess its clinical utility before implementation.
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Affiliation(s)
- Yueping Ren
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Han Wen
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Furong Bai
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Binge Huang
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Zhenzhen Wang
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Shuwen Zhang
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Yaojia Pu
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Zhenmin Le
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Xianhui Gong
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Lei Wang
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.
| | - Wei Chen
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.
| | - Qinxiang Zheng
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.
- The School of Ophthalmology and Optometry, Wenzhou Medical University, 270 Xueyuan West Road, Wenzhou, 325027, Zhejiang, People's Republic of China.
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Yang F, Cheng H, Zhao S, Huang Y. The effect of incomplete blinking rate on corneal epithelial remodeling after trans-PRK surgery: a six-month study. Front Med (Lausanne) 2024; 10:1305461. [PMID: 38259844 PMCID: PMC10800622 DOI: 10.3389/fmed.2023.1305461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose To evaluate the impact of incomplete blink rate on corneal epithelial thickness after transepithelial photorefractive keratectomy (Trans-PRK) surgery. Methods Trans-PRK patients were divided into two groups based on preoperative incomplete blinking rates, namely rates ≤0.5 (41 right eyes, group A) and rates >0.5 (65 right eyes, group B). We used anterior segment optical coherence tomography to measure the corneal epithelial thickness (CET) and lipiview to measure the number of blinks, incomplete blinking rate, and lipid layer thickness (LLT). Results In both groups, CET decreased at 1 week and 1 month, and the thicknesses in the IT, T, and ST regions exceeded the preoperative levels. Three months after Trans-PRK, the thickness exceeded the preoperative levels and continued to increase during subsequent follow-ups. The blinking times and LLT in both groups decreased at 1 week and gradually increased but did not return to preoperative levels. Group A maintained an incomplete blinking rate of over 0.5 at all postoperative periods. The incomplete blinking rate of group B remained above 0.5 postoperatively, although there was an improvement compared with preoperative rates. Both groups showed a correlation between changes in CET and incomplete blinking rate. There was a correlation between changes in LLT and the incomplete blinking rate after surgery. Conclusion Both groups showed uneven corneal epithelia thickening, which became more pronounced approaching the peripheral areas. In addition, changes in CET after surgery were positively correlated with the incomplete blinking rate in both patient groups. There was a negative correlation between postoperative LLT and incomplete blinking rate.
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Affiliation(s)
| | | | | | - Yue Huang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
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Wolffsohn JS. 2022 Glenn A. Fry Award lecture: Enhancing clinical assessment for improved ophthalmic management. Optom Vis Sci 2024; 101:12-24. [PMID: 38350054 DOI: 10.1097/opx.0000000000002102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
ABSTRACT Detailed clinical assessment is critical to allow sensitive evaluation of the eye and its management. As technology advances, these assessment techniques can be adapted and refined to improve the detection of pathological changes of ocular tissue and their impact on visual function. Enhancements in optical medical devices including spectacle, contact, and intraocular lenses have allowed for a better understanding of the mechanism and amelioration of presbyopia and myopia control. Advancements in imaging technology have enabled improved quantification of the tear film and ocular surface, informing diagnosis and treatment strategies. Miniaturized electronics, large processing power, and in-built sensors in smartphones and tablets capacitate more portable assessment tools for clinicians, facilitate self-monitoring and treatment compliance, and aid communication with patients. This article gives an overview of how technology has been used in many areas of eye care to improve assessments and treatment and provides a snapshot of some of my studies validating and using technology to inform better evidence-based patient management.
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Cutrupi F, De Luca A, Di Zazzo A, Micera A, Coassin M, Bonini S. Real Life Impact of Dry Eye Disease. Semin Ophthalmol 2023; 38:690-702. [PMID: 37095685 DOI: 10.1080/08820538.2023.2204931] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/26/2023]
Abstract
Dry Eye Disease (DED) is an increasingly common condition that affects between 5% and 50% of the global population. Even though DED is most frequently diagnosed in older people, it has also been diagnosed in young adults and adolescents more frequently in recent years (employees, gamers). People can experience different types of symptoms and find it challenging to read, watch TV, cook, climb stairs, and meet friends. Mild and severe dry eye can reduce quality of life similarly to mild psoriasis and moderate-to-severe angina. Furthermore, DED patients experience serious difficulties driving vehicles, especially at night, and show a decrease in work productivity, which, when combined with the relevant indirect cost that this condition produces, poses a serious challenge in our days. In addition, DED patients are more likely to develop depression and suicidal ideations and experience frequent sleep disorders. Finally, it is discussed how lifestyle changes, such as increased physical activity, blinking exercises, and a proper diet, have positive implications for the management of this condition. Our aim is to draw attention to the negative effects of dry eye in real life, which are unique to each patient, especially as they relate to the non-visual symptoms experienced by DED patients.
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Affiliation(s)
- Francesco Cutrupi
- Ophthalmology Complex Operative Unit, University Campus Bio-Medico, Rome, Italy
| | - Andrea De Luca
- Ophthalmology Complex Operative Unit, University Campus Bio-Medico, Rome, Italy
| | - Antonio Di Zazzo
- Research Laboratories in Ophthalmology, IRCCS Bietti Foundation, Rome, Italy
| | - Alessandra Micera
- Research Laboratories in Ophthalmology, IRCCS Bietti Foundation, Rome, Italy
| | - Marco Coassin
- Ophthalmology Complex Operative Unit, University Campus Bio-Medico, Rome, Italy
| | - Stefano Bonini
- Ophthalmology Complex Operative Unit, University Campus Bio-Medico, Rome, Italy
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Li S, Li A, Ruan F, Zhang W, Chen J, Huang C, Jie Y. Evaluation of the Clinical Characteristics of Dry Eye Secondary to Different Types of Liver Diseases. Ophthalmol Ther 2023; 12:2493-2503. [PMID: 37351838 PMCID: PMC10442014 DOI: 10.1007/s40123-023-00747-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 05/30/2023] [Indexed: 06/24/2023] Open
Abstract
INTRODUCTION This study compares the clinical characteristics of dry eye secondary to primary biliary cholangitis (PBC), drug-induced liver injury (DILI), and viral hepatitis B(HBV) to evaluate the ocular surface damage caused by different types of liver diseases. METHODS Thirty healthy people were included as control group. Sixty patients with dry eye secondary to different types of liver disease were included, including 19 cases of PBC, 18 cases of DILI, and 23 cases of HBV. All patients were evaluated by the SPEED questionnaire, corneal fluorescein staining (CFS), noninvasive tear breakup time (NIBUT), Schirmer I test (SIt), tear meniscus height test (TMH), the area of meibomian glands dropout (MG dropout), partial blinking rate (PBR), lipid layer thickness (LLT), meibum expressibility, and meibum quality. RESULTS There are statistical differences in ophthalmic examination results between different types of liver diseases and normal people (P < 0.05). Compared with DILI and HBV groups, the CFS score of PBC group score was higher (P < 0.05), the PBR was higher (P < 0.05), and the SIt was lower (P < 0.01). The TMH of PBC and DILI groups were significantly lower than the HBV group, and the difference was statistically significant (P < 0.05). Compared with the PBC group, the LLT of the DILI group decreased (P < 0.01). The area of meibomian glands dropout of the three groups had mild-to-moderate defects, but there was no significant statistical difference between groups (P > 0.05).The Meibum quality score in the DILI group was significantly higher than the HBV group (P < 0.05). CONCLUSIONS The PBC group was more prone to aqueous-deficient dry eye. The DILI group was more prone to obstructive meibomian gland dysfunction (MGD).The HBV group was more prone to nonobstructive MGD. The symptoms of dry eye in the PBC group are mild-to-moderate discomfort, but the degree of corneal damage is higher, indicating that the corneal sensitivity is reduced, which may be related to the high rate of partial blinking.
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Affiliation(s)
- Shang Li
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Ophthalmology and Visual Sciences Key Lab, Beijing Tongren Hospital, Capital Medical University, No. 1 Dong Jiao Min Xiang, Dong Cheng District, Beijing, 100730, China
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Ao Li
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Ophthalmology and Visual Sciences Key Lab, Beijing Tongren Hospital, Capital Medical University, No. 1 Dong Jiao Min Xiang, Dong Cheng District, Beijing, 100730, China
| | - Fang Ruan
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Wei Zhang
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Jie Chen
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Chunyang Huang
- Department of Ophthalmology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Ying Jie
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Ophthalmology and Visual Sciences Key Lab, Beijing Tongren Hospital, Capital Medical University, No. 1 Dong Jiao Min Xiang, Dong Cheng District, Beijing, 100730, China.
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March de Ribot F, Benitez Del Castillo JM, Geerling G, Messmer EM, Baudouin C, Alves M. Dry eye disease sustainability. Ocul Surf 2023; 30:104-106. [PMID: 37619668 DOI: 10.1016/j.jtos.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023]
Affiliation(s)
| | | | - Gerd Geerling
- Department of Ophthalmology, University Hospital Duesseldorf, Duesseldorf, Germany
| | | | - Christophe Baudouin
- Department of Ophthalmology, Quinze-Vingts National Ophthalmology Hospital, Paris, France; University Versailles St Quentin en Yvelines, Paris Saclay, IHU FOReSIGHT, F-78035, Versailles cedex, France
| | - Monica Alves
- Department of Ophthalmology and Otorhinolaryngology, University of Campinas Campinas, Brazil
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Hao L, Tian Q, Liu S, Xu Z, Yang L. Alterations of ocular surface parameters in patients with obstructive sleep apnea syndrome. Front Med (Lausanne) 2023; 10:1220104. [PMID: 37799593 PMCID: PMC10548263 DOI: 10.3389/fmed.2023.1220104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/04/2023] [Indexed: 10/07/2023] Open
Abstract
Purpose This study aimed to evaluate changes in ocular surface parameters among obstructive sleep apnea syndrome (OSAS) patients. Methods 44 healthy volunteers (88 eyes) and 27 OSAS patients (54 eyes) were recruited in our cross-sectional study. 14 patients were classified as mild&moderate OSAS, and 13 patients were classified as severe OSAS. For evaluating the ocular surface, the following tests were conducted: the height of tear meniscus (TMH), first non-invasive tear break-up time (FNITBUT), mean non-invasive tear break-up time (MNITBUT), the score of Meibomian gland dropout area (Meiboscore), the tear test of anesthesia-free Schirmer I (SIT), corneal fluorescein staining (CFS), partial blinks rate (PBR), the lipid layer thickness (LLT), ocular surface disease index (OSDI). The results obtained from the study were analyzed and compared among the groups. Results FNITBUT, MNITBUT, and TMH were lower. OSDI, CFS, Meiboscore and PBR were higher in the OSAS group than those in the control group. The mild&moderate as well as the severe OSAS subgroups had statistically significantly lower TMH, and higher OSDI and PBR than the control group. Meanwhile, we found there were no significant differences between two OSAS subgroups. CFS was higher in the severe OSAS group than the mild&moderate OSAS group. Significantly lower FNITBUT, MNITBUT and higher Meiboscore were observed in the severe OSAS subgroup than in the control group, and MNITBUT was higher in severe OSAS objects than in the mild&moderate OSAS objects. LLT and SIT did not exhibit significant differences among control and OSAS subgroups. FNITBUT and MNITBUT showed significantly negative correlations with BMI, while Meiboscore showed a significant positive correlation with AHI. Conclusion Patients with OSAS have a tendence of dry eyes, whereas control subjects do not. This indicates us that the OSAS patients should pay more attention to ocular surface care.
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Affiliation(s)
- Linlin Hao
- Department of Ophthalmology, The Second Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qingfen Tian
- Department of Otolaryngology, Jinan Second People’s Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shaohua Liu
- Department of Ophthalmology, The Second Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zhe Xu
- Department of Ophthalmology, The Second Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Lixia Yang
- Department of Ophthalmology, The Second Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, China
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Oganov A, Yazdanpanah G, Jabbehdari S, Belamkar A, Pflugfelder S. Dry eye disease and blinking behaviors: A narrative review of methodologies for measuring blink dynamics and inducing blink response. Ocul Surf 2023; 29:166-174. [PMID: 37257694 DOI: 10.1016/j.jtos.2023.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/28/2023] [Accepted: 05/28/2023] [Indexed: 06/02/2023]
Abstract
Dry eye disease (DED) is a leading cause of ophthalmology clinical encounters with prevalence ranging from 8.7% to 64% in various populations. Blinking is an endogenous process to refresh the tear film, clear debris and maintain quality vision. Altered blinking behavior is a common feature of DED and is implicated in the pathology of the disease. However, lack of a comprehensive review on the relationship between altered blinking behavior and DED is notable in the literature. Blinking behavior may be an effect of DED due to an unstable tear film sensitizing a motor response or be its cause due to destabilization of the tear film in conditions such as benign essential blepharospasm. In this comprehensive review, we summarize the current models and theories of tear film dynamics and blinking behavior to better understand their connection to DED and introduce contemporary technologies and measurement tools used in the evaluation and induction of blinking behavior. We also describe future directions of research to better understand the relationship between DED and blinking and explore therapies that address the abnormal blinking component of DED.
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Affiliation(s)
- Anthony Oganov
- Department of Ophthalmology, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Ghasem Yazdanpanah
- Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Illinois, USA
| | - Sayena Jabbehdari
- Jones Eye Institute, University of Arkansas for Medical Sciences, Arkansas, USA
| | - Aditya Belamkar
- Indiana University School of Medicine, Indianapolis, IN, USA
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Wolffsohn JS, Lingham G, Downie LE, Huntjens B, Inomata T, Jivraj S, Kobia-Acquah E, Muntz A, Mohamed-Noriega K, Plainis S, Read M, Sayegh RR, Singh S, Utheim TP, Craig JP. TFOS Lifestyle: Impact of the digital environment on the ocular surface. Ocul Surf 2023; 28:213-252. [PMID: 37062428 DOI: 10.1016/j.jtos.2023.04.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/06/2023] [Indexed: 04/18/2023]
Abstract
Eye strain when performing tasks reliant on a digital environment can cause discomfort, affecting productivity and quality of life. Digital eye strain (the preferred terminology) was defined as "the development or exacerbation of recurrent ocular symptoms and/or signs related specifically to digital device screen viewing". Digital eye strain prevalence of up to 97% has been reported, due to no previously agreed definition/diagnostic criteria and limitations of current questionnaires which fail to differentiate such symptoms from those arising from non-digital tasks. Objective signs such as blink rate or critical flicker frequency changes are not 'diagnostic' of digital eye strain nor validated as sensitive. The mechanisms attributed to ocular surface disease exacerbation are mainly reduced blink rate and completeness, partial/uncorrected refractive error and/or underlying binocular vision anomalies, together with the cognitive demand of the task and differences in position, size, brightness and glare compared to an equivalent non-digital task. In general, interventions are not well established; patients experiencing digital eye strain should be provided with a full refractive correction for the appropriate working distances. Improving blinking, optimizing the work environment and encouraging regular breaks may help. Based on current, best evidence, blue-light blocking interventions do not appear to be an effective management strategy. More and larger clinical trials are needed to assess artificial tear effectiveness for relieving digital eye strain, particularly comparing different constituents; a systematic review within the report identified use of secretagogues and warm compress/humidity goggles/ambient humidifiers as promising strategies, along with nutritional supplementation (such as omega-3 fatty acid supplementation and berry extracts).
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Affiliation(s)
- James S Wolffsohn
- College of Health & Life Sciences, School of Optometry, Aston University, Birmingham, UK; Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand.
| | - Gareth Lingham
- Centre for Eye Research Ireland, Technological University Dublin, Dublin, Ireland
| | - Laura E Downie
- Department of Optometry and Vision Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Byki Huntjens
- Division of Optometry and Visual Sciences, City, University of London, EC1V 0HB, UK
| | - Takenori Inomata
- Department of Ophthalmology, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Saleel Jivraj
- College of Health & Life Sciences, School of Optometry, Aston University, Birmingham, UK
| | | | - Alex Muntz
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand
| | - Karim Mohamed-Noriega
- Department of Ophthalmology, University Hospital and Faculty of Medicine, Autonomous University of Nuevo León (UANL). Monterrey, 64460, Mexico
| | - Sotiris Plainis
- College of Health & Life Sciences, School of Optometry, Aston University, Birmingham, UK; Laboratory of Optics and Vision, School of Medicine, University of Crete, Greece
| | - Michael Read
- Division of Pharmacy and Optometry, The University of Manchester, Manchester, UK
| | - Rony R Sayegh
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sumeer Singh
- Department of Optometry and Vision Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Tor P Utheim
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway
| | - Jennifer P Craig
- College of Health & Life Sciences, School of Optometry, Aston University, Birmingham, UK; Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand
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Pavel IA, Bogdanici CM, Donica VC, Anton N, Savu B, Chiriac CP, Pavel CD, Salavastru SC. Computer Vision Syndrome: An Ophthalmic Pathology of the Modern Era. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020412. [PMID: 36837613 PMCID: PMC9961559 DOI: 10.3390/medicina59020412] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/08/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023]
Abstract
Digital device usage has increased significantly in last decade among all age groups, both for educational and recreational purposes. Computer vision syndrome (CVS), also known as digital eye strain (DES), represents a range of ocular, musculoskeletal, and behavioral conditions caused by prolonged use of devices with digital screens. This paper reviews the principal environmental, ocular, and musculoskeletal causes for this condition. Due to the high prevalence of DES and frequent usage of digital devices, it is important that eye care practitioners be able to provide advice and management options based on quality research evidence.
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Affiliation(s)
- Irina Andreea Pavel
- Department of Ophthalmology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No.16, 700115 Iasi, Romania
| | - Camelia Margareta Bogdanici
- Department of Ophthalmology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No.16, 700115 Iasi, Romania
- Correspondence: (C.M.B.); (V.C.D.)
| | - Vlad Constantin Donica
- Department of Ophthalmology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No.16, 700115 Iasi, Romania
- Correspondence: (C.M.B.); (V.C.D.)
| | - Nicoleta Anton
- Department of Ophthalmology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No.16, 700115 Iasi, Romania
| | - Bogdan Savu
- Department of Pediatrics, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No.16, 700115 Iasi, Romania
| | | | - Cristian Dan Pavel
- Department of Histology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No.16, 700115 Iasi, Romania
| | - Silvia Cristina Salavastru
- Department of Ophthalmology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No.16, 700115 Iasi, Romania
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Fjærvoll K, Fjærvoll H, Magno M, Nøland ST, Dartt DA, Vehof J, Utheim TP. Review on the possible pathophysiological mechanisms underlying visual display terminal-associated dry eye disease. Acta Ophthalmol 2022; 100:861-877. [PMID: 35441459 PMCID: PMC9790214 DOI: 10.1111/aos.15150] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 03/13/2022] [Accepted: 03/23/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Visual display terminal (VDT) use is a key risk factor for dry eye disease (DED). Visual display terminal (VDT) use reduces the blink rate and increases the number of incomplete blinks. However, the exact mechanisms causing DED development from VDT use have yet to be clearly described. PURPOSE The purpose of the study was to conduct a review on pathophysiological mechanisms promoting VDT-associated DED. METHODS A PubMed search of the literature investigating the relationship between dry eye and VDT was performed, and relevance to pathophysiology of DED was evaluated. FINDINGS Fifty-five articles met the inclusion criteria. Several pathophysiological mechanisms were examined, and multiple hypotheses were extracted from the articles. Visual display terminal (VDT) use causes DED mainly through impaired blinking patterns. Changes in parasympathetic signalling and increased exposure to blue light, which could disrupt ocular homeostasis, were proposed in some studies but lack sufficient scientific support. Together, these changes may lead to a reduced function of the tear film, lacrimal gland, goblet cells and meibomian glands, all contributing to DED development. CONCLUSION Visual display terminal (VDT) use appears to induce DED through both direct and indirect routes. Decreased blink rates and increased incomplete blinks increase the exposed ocular evaporative area and inhibit lipid distribution from meibomian glands. Although not adequately investigated, changes in parasympathetic signalling may impair lacrimal gland and goblet cell function, promoting tear film instability. More studies are needed to better target and improve the treatment and prevention of VDT-associated DED.
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Affiliation(s)
- Ketil Fjærvoll
- Institute of Clinical Medicine, Faculty of MedicineUniversity of OsloOsloNorway,Department of Medical BiochemistryOslo University HospitalOsloNorway,Department of Plastic and Reconstructive SurgeryOslo University HospitalOsloNorway
| | - Haakon Fjærvoll
- Institute of Clinical Medicine, Faculty of MedicineUniversity of OsloOsloNorway,Department of Medical BiochemistryOslo University HospitalOsloNorway,Department of Plastic and Reconstructive SurgeryOslo University HospitalOsloNorway
| | - Morten Magno
- Institute of Clinical Medicine, Faculty of MedicineUniversity of OsloOsloNorway,Department of Medical BiochemistryOslo University HospitalOsloNorway,Department of Plastic and Reconstructive SurgeryOslo University HospitalOsloNorway,Department of Ophthalmology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | | | - Darlene A. Dartt
- Schepens Eye Research Institute of Massachusetts Eye and EarHarvard Medical SchoolBostonMassachusettsUSA
| | - Jelle Vehof
- Department of Ophthalmology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands,Department of Twin Research & Genetic EpidemiologyKing's College LondonSt Thomas' HospitalLondonUK,Department of Epidemiology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Tor P. Utheim
- Department of Medical BiochemistryOslo University HospitalOsloNorway,Department of Plastic and Reconstructive SurgeryOslo University HospitalOsloNorway,Department of OphthalmologyOslo University HospitalOsloNorway,Department of OphthalmologySørlandet Hospital ArendalArendalNorway,Department of Quality and Health Technology, The Faculty of Health SciencesUniversity of StavangerStavangerNorway,Department of OphthalmologyStavanger University HospitalStavangerNorway,Department of Computer ScienceOslo Metropolitan UniversityOsloNorway,Department of Clinical Medicine, Faculty of MedicineUniversity of BergenBergenNorway
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Structural and functional alterations in corneal nerves following single-step transepithelial photorefractive keratectomy. J Cataract Refract Surg 2021; 48:778-783. [PMID: 34864776 DOI: 10.1097/j.jcrs.0000000000000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/24/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the relationship between structural and functional changes of corneal subbasal nerves after single-step transepithelial photorefractive keratectomy (TransPRK). SETTING Tianjin Medical University Eye Hospital. DESIGN Prospective observational study. METHODS Fifty-one eligible candidates who underwent TransPRK for moderate myopia were recruited. The regeneration of corneal subbasal nerves were evaluated by In Vivo Confocal Microscopy (IVCM) prior to surgery at 1 week, 1, 3, 6, and 12 months postoperatively. Meanwhile, the corneal sensitivity was measured by Cochet-Bonnet esthesiometer. The number of complete and incomplete blinks were recorded by LipiView interferometer. A correlation analysis was performed between these variables. RESULTS IVCM revealed the density and length of corneal nerve decrease immediately, and do not return to preoperative levels by 12 months post-TransPRK (P<0.01). Mean corneal sensitivity was slightly lower compared with preoperative levels at 1 week after surgery(P=0.001), then increases to baseline preoperatively within 1 month after surgery. Mean total blink frequency and the partial blink rates had no significant change postoperatively(P=0.087). There was no direct correlation between postoperative recovery of corneal sensitivity, changes of blink and regeneration of sub-basal corneal nerve. CONCLUSIONS The significant and prolonged decrease in corneal subbasal nerve morphology was accompanied by only a slight and transient reduction in corneal sensitivity to mechanical stimuli within 1 month after TransPRK. The results demonstrated that the structural changes of subbasal nerves were not parallel to their function after TransPRK.
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14
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Auffret É, Gomart G, Bourcier T, Gaucher D, Speeg-Schatz C, Sauer A. [Digital eye strain. Symptoms, prevalence, pathophysiology, and management]. J Fr Ophtalmol 2021; 44:1605-1610. [PMID: 34657757 DOI: 10.1016/j.jfo.2020.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/14/2020] [Accepted: 10/20/2020] [Indexed: 10/20/2022]
Abstract
The digital revolution, which has been underway since the 1980's, is disrupting our daily routines with an exponential increase in the use of screens, which has not been without consequence to our visual system. Digital eye strain (DES), or computer vision syndrome (CVS), includes all the visual symptoms secondary to the use of digital devices. DES is present in at least 50% of regular users of digital media and is defined by blurred vision, difficulty focusing, ocular irritation or burning, dry eye, visual fatigue, headaches and increased sensitivity to light. Exposure time, age, female gender, and work environment are the main factors increasing its prevalence. Its pathophysiology, still poorly understood, is felt to be multifactorial and includes disturbances in the accommodative-convergence balance and changes in the ocular surface. Regarding accommodation and convergence, the studies are mostly old and their results heterogeneous. Conversely, many studies have shown an increase in the prevalence of dry eye in screen users. Although the retinal toxicity of blue light has been proven in in vitro models, the low level of evidence in the available studies does not allow it to be clearly correlated with the symptoms of DES. The objective of this review is to condense the knowledge available in the literature on the symptoms, prevalence, pathophysiology and management of DES.
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Affiliation(s)
- É Auffret
- Service d'ophtalmologie, Centre hospitalo-universitaire de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg, France.
| | - G Gomart
- Service d'ophtalmologie, Centre hospitalo-universitaire de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg, France
| | - T Bourcier
- Service d'ophtalmologie, Centre hospitalo-universitaire de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg, France
| | - D Gaucher
- Service d'ophtalmologie, Centre hospitalo-universitaire de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg, France
| | - C Speeg-Schatz
- Service d'ophtalmologie, Centre hospitalo-universitaire de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg, France
| | - A Sauer
- Service d'ophtalmologie, Centre hospitalo-universitaire de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg, France
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15
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Al-Mohtaseb Z, Schachter S, Shen Lee B, Garlich J, Trattler W. The Relationship Between Dry Eye Disease and Digital Screen Use. Clin Ophthalmol 2021; 15:3811-3820. [PMID: 34531649 PMCID: PMC8439964 DOI: 10.2147/opth.s321591] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/30/2021] [Indexed: 11/23/2022] Open
Abstract
Dry eye disease is characterized by tear film instability that can result in ocular surface damage. Patients with dry eye disease may experience ocular pain/discomfort and visual disturbances that may negatively impact quality of life. Increased use of digital screens for work, communication, and entertainment, especially during times of pandemic, may contribute to dry eye. Extensive cross-sectional studies have shown that digital screen use duration is associated with an increased risk of severe symptoms and clinical diagnosis of dry eye disease in adults. Smartphone use duration has also been found to be greater in school-age children with dry eye disease than in those without dry eye disease. A commonly accepted hypothesis for the relationship between digital screen use and dry eye disease is that digital screen use changes blinking dynamics, leading to ocular dryness. This review describes evidence that digital screen use is associated with dry eye disease, that digital device use alters blinking dynamics, and that dry eye affects mental health and work productivity in digital screen users. Helpful prevention and management strategies for dry eye disease exist for those who use digital screens.
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Affiliation(s)
- Zaina Al-Mohtaseb
- Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, TX, USA
| | - Scott Schachter
- Presbyopia and Ocular Surface Disease, Allergan, an AbbVie Company, Irvine, CA, USA
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García-Ayuso D, Di Pierdomenico J, Moya-Rodríguez E, Valiente-Soriano FJ, Galindo-Romero C, Sobrado-Calvo P. Assessment of dry eye symptoms among university students during the COVID-19 pandemic. Clin Exp Optom 2021; 105:507-513. [PMID: 34279190 DOI: 10.1080/08164622.2021.1945411] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
CLINICAL RELEVANCE The synchronous hybrid learning environment is associated with increased time spent by students working with VDT and increased prevalence of dry eye symptoms in a university-based population. BACKGROUND To assess the prevalence of dry eye symptoms using the ocular surface disease index (OSDI) questionnaire in university students and to identify whether factors such as the synchronous hybrid learning environment as a preventive measure of COVID-19, video display terminal use, gender or contact lens wear influence dry eye symptomatology. METHODS This study was performed using a web-based questionnaire that was distributed to university students to assess questions related to class attendance, to the use of video display terminals, the need for optical correction and, finally, the OSDI questionnaire. RESULTS A total of 676 university students with an average age of 20.7 ± 2.9 years completed the questionnaire, of which 72.6% (491) were females and 27.4% (185) were males. Only 10.2% of the participants attended face to face classes. Of the participants, 35.5% were contact lens wearers. The mean OSDI score of the study population was 27.68 ± 20.09 and the prevalence of symptomatic dry eye disease (OSDI score above 22) was 51.8%. Female gender (X2(3) = 38.605, p < 0.001), online class attendance (X2(1) = 20.31; p < 0.001), increased hours of online class attendance (X2(2) = 26.84, p < 0.001) and contact lens wear (X2(2) = 15.264, p < 0.05) were associated with a higher incidence of symptomatic dry eye disease. CONCLUSION The synchronous hybrid learning environment increases the time students spend working with video display terminals and the prevalence of dry eye symptoms. Female gender and contact lens wear were also associated with a higher prevalence of dry eye symptoms. It should not be ignored that dry eye could also affect academic performance.
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Affiliation(s)
- Diego García-Ayuso
- Departamento de Oftalmología, Facultad de Medicina, Universidad de Murcia and Instituto Murciano de Investigación Biosanitaria Hospital Virgen de la Arrixaca (IMIB-virgen de la Arrixaca), Murcia, Spain.,Facultad de Óptica y Optometría, Universidad de Murcia, Murcia, Spain
| | - Johnny Di Pierdomenico
- Departamento de Oftalmología, Facultad de Medicina, Universidad de Murcia and Instituto Murciano de Investigación Biosanitaria Hospital Virgen de la Arrixaca (IMIB-virgen de la Arrixaca), Murcia, Spain.,Facultad de Óptica y Optometría, Universidad de Murcia, Murcia, Spain
| | | | - Francisco J Valiente-Soriano
- Departamento de Oftalmología, Facultad de Medicina, Universidad de Murcia and Instituto Murciano de Investigación Biosanitaria Hospital Virgen de la Arrixaca (IMIB-virgen de la Arrixaca), Murcia, Spain.,Facultad de Óptica y Optometría, Universidad de Murcia, Murcia, Spain
| | - Caridad Galindo-Romero
- Departamento de Oftalmología, Facultad de Medicina, Universidad de Murcia and Instituto Murciano de Investigación Biosanitaria Hospital Virgen de la Arrixaca (IMIB-virgen de la Arrixaca), Murcia, Spain.,Facultad de Óptica y Optometría, Universidad de Murcia, Murcia, Spain
| | - Paloma Sobrado-Calvo
- Departamento de Oftalmología, Facultad de Medicina, Universidad de Murcia and Instituto Murciano de Investigación Biosanitaria Hospital Virgen de la Arrixaca (IMIB-virgen de la Arrixaca), Murcia, Spain.,Facultad de Óptica y Optometría, Universidad de Murcia, Murcia, Spain
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Wang MTM, Muntz A, Mamidi B, Wolffsohn JS, Craig JP. Modifiable lifestyle risk factors for dry eye disease. Cont Lens Anterior Eye 2021; 44:101409. [PMID: 33485806 DOI: 10.1016/j.clae.2021.01.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/22/2020] [Accepted: 01/12/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE To examine the association between modifiable lifestyle factors and dry eye disease. METHODS Three hundred and twenty-two community residents (186 females, 136 males; mean ± SD age, 41 ± 22 years) with no major systemic or ophthalmic conditions (other than dry eye disease) were recruited in a cross-sectional study. A lifestyle factor questionnaire was administered, and dry eye symptomology, ocular surface characteristics, and tear film quality were evaluated for each participant within a single clinical session, in accordance with the global consensus recommendations of the TFOS DEWS II reports. RESULTS A total of 111 (34 %) participants fulfilled the TFOS DEWS II diagnostic criteria for dry eye disease. Multivariate regression analysis demonstrated that advancing age, female sex, East Asian ethnicity, and increased digital screen exposure time were positive risk factors for dry eye disease (all p < 0.05), while increased caffeine consumption was a protective factor (p = 0.04). CONCLUSIONS Increased digital screen exposure time and reduced caffeine consumption were modifiable lifestyle factors associated with higher odds of dry eye disease. These findings might contribute to informing the design of future prospective research investigating the efficacy of preventative intervention and risk factor modification strategies.
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Affiliation(s)
- Michael T M Wang
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand
| | - Alex Muntz
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand
| | - Brinda Mamidi
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand; Department of Optometry and Vision Science, New Zealand National Eye Centre, The University of Auckland, New Zealand
| | - James S Wolffsohn
- Ophthalmic Research Group, School of Life and Health Sciences, Aston University, Birmingham, United Kingdom
| | - Jennifer P Craig
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand; Ophthalmic Research Group, School of Life and Health Sciences, Aston University, Birmingham, United Kingdom.
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Abstract
Prolonged and continuous daily use of digital screens, or visual display terminals (VDTs), has become the norm in occupational, educational, and recreational settings. An increased global dependence on VDTs has led to a rise in associated visual complaints, including eye strain, ocular dryness, burning, blurred vision, and irritation, to name a few. The principal causes for VDT-associated visual discomfort are abnormalities with oculomotor/vergence systems and dry eye (DE). This review focuses on the latter, as advances in research have identified symptomology and ocular surface parameters that are shared between prolonged VDT users and DE, particularly the evaporative subtype. Several mechanisms have been implicated in VDT-associated DE, including blink anomalies, damaging light emission from modern devices, and inflammatory changes. The presence of preexisting DE has also been explored as an inciting and exacerbating factor. We review the associations between digital screens and DE, mechanisms of damage, and therapeutic options, hoping to raise awareness of this entity with the goal of reducing the global morbidity and economic impact of screen-associated visual disability.
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Affiliation(s)
- Divy Mehra
- Surgical Services, Miami Veterans Affairs Medical Center, Miami, FL
- Bascom Palmer Eye Institute, University of Miami, Miami, FL
| | - Anat Galor
- Surgical Services, Miami Veterans Affairs Medical Center, Miami, FL
- Bascom Palmer Eye Institute, University of Miami, Miami, FL
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19
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Craig JP, Wang MT, Ambler A, Cheyne K, Wilson GA. Characterising the ocular surface and tear film in a population-based birth cohort of 45-year old New Zealand men and women. Ocul Surf 2020; 18:808-813. [DOI: 10.1016/j.jtos.2020.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/26/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
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