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Evans R, Nelson L, Temple T. Operational data for the risk management of victim operated explosive devices in humanitarian mine action: A Practitioner's perspective. Heliyon 2024; 10:e25311. [PMID: 38327446 PMCID: PMC10847920 DOI: 10.1016/j.heliyon.2024.e25311] [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: 01/06/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/09/2024] Open
Abstract
Since Mine Action's inception at the end of the 1980s, operators have collected limited data on the Victim Operated Explosive Devices (VOEDs) they clear. This includes not only data on the explosive ordnance itself but data on how they were found, where they were found and how they were processed and ultimately destroyed. In a context where detection of mines, boobytraps and certain Victim Operated Improvised Explosive Devices (VOIEDs) is an ongoing humanitarian and military challenge, significantly expanded operational data collection provides an achievable way to facilitate enhanced operational risk management. Risk decisions inherent in the clearance of VOEDs are better if made on the basis of extensive operational data. In the absence of a technological solution to detect and positively discriminate VOEDs from false positive indications, the collection of operational data offers the best prospect for "managing" if not "solving" the problem.
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Affiliation(s)
- R. Evans
- Cranfield University, Centre for Defence Chemistry, Defence Academy of the United Kingdom, Shrivenham, SN6 7LA, UK
| | - L. Nelson
- Cranfield University, Centre for Defence Chemistry, Defence Academy of the United Kingdom, Shrivenham, SN6 7LA, UK
| | - T. Temple
- Cranfield University, Centre for Defence Chemistry, Defence Academy of the United Kingdom, Shrivenham, SN6 7LA, UK
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Karimi A, Crouch DJ, Razaghi R, Crawford Downs J, Acott TS, Kelley MJ, Behnsen JG, Bosworth LA, Sheridan CM. Morphological and biomechanical analyses of the human healthy and glaucomatous aqueous outflow pathway: Imaging-to-modeling. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 236:107485. [PMID: 37149973 DOI: 10.1016/j.cmpb.2023.107485] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND AND OBJECTIVE Intraocular pressure (IOP) is maintained via a dynamic balance between the production of aqueous humor and its drainage through the trabecular meshwork (TM), juxtacanalicular connective tissue (JCT), and Schlemm's canal (SC) endothelium of the conventional outflow pathway. Primary open angle glaucoma (POAG) is often associated with IOP elevation that occurs due to an abnormally high outflow resistance across the outflow pathway. Outflow tissues are viscoelastic and actively interact with aqueous humor dynamics through a two-way fluid-structure interaction coupling. While glaucoma affects the morphology and stiffness of the outflow tissues, their biomechanics and hydrodynamics in glaucoma eyes remain largely unknown. This research aims to develop an image-to-model method allowing the biomechanics and hydrodynamics of the conventional aqueous outflow pathway to be studied. METHODS We used a combination of X-ray computed tomography and scanning electron microscopy to reconstruct high-fidelity, eye-specific, 3D microstructural finite element models of the healthy and glaucoma outflow tissues in cellularized and decellularized conditions. The viscoelastic TM/JCT/SC complex finite element models with embedded viscoelastic beam elements were subjected to a physiological IOP load boundary; the stresses/strains and the flow state were calculated using fluid-structure interaction and computational fluid dynamics. RESULTS Based on the resultant hydrodynamics parameters across the outflow pathway, the primary site of outflow resistance in healthy eyes was in the JCT and immediate vicinity of the SC inner wall, while the majority of the outflow resistance in the glaucoma eyes occurred in the TM. The TM and JCT in the glaucoma eyes showed 1.32-fold and 1.13-fold larger beam thickness and smaller trabecular space size (2.24-fold and 1.50-fold) compared to the healthy eyes. CONCLUSIONS Characterizing the accurate morphology of the outflow tissues may significantly contribute to constructing more accurate, robust, and reliable models, that can eventually help to better understand the dynamic IOP regulation, hydrodynamics of the aqueous humor, and outflow resistance dynamic in the human eyes. This model demonstrates proof of concept for determining changes to outflow resistance in healthy and glaucomatous tissues and thus may be utilized in larger cohorts of donor tissues where disease specificity, race, age, and gender of the eye donors may be accounted for.
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Affiliation(s)
- Alireza Karimi
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
| | - Devon J Crouch
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L7 8TX, United Kingdom
| | - Reza Razaghi
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, AL, United States
| | - J Crawford Downs
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ted S Acott
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States; Department of Biochemistry and Molecular Biology, Oregon Health & Science University, Portland, Oregon, United States
| | - Mary J Kelley
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States; Department of Integrative Biosciences, Oregon Health & Science University, Portland, Oregon, United States
| | - Julia G Behnsen
- Department of Mechanical, Materials, and Aerospace Engineering, University of Liverpool, Liverpool, L69 6GB, United Kingdom
| | - Lucy A Bosworth
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L7 8TX, United Kingdom
| | - Carl M Sheridan
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L7 8TX, United Kingdom.
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Wang S, Li F, Jin S, Zhang Y, Yang N, Zhao J. Biomechanics of open-globe injury: a review. Biomed Eng Online 2023; 22:53. [PMID: 37226242 DOI: 10.1186/s12938-023-01117-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/19/2023] [Indexed: 05/26/2023] Open
Abstract
Open-globe injury is a common cause of blindness clinically caused by blunt trauma, sharp injury, or shock waves, characterised by rupture of the cornea or sclera and exposure of eye contents to the environment. It causes catastrophic damage to the globe, resulting in severe visual impairment and psychological trauma to the patient. Depending on the structure of the globe, the biomechanics causing ocular rupture can vary, and trauma to different parts of the globe can cause varying degrees of eye injury. The weak parts or parts of the eyeball in contact with foreign bodies rupture when biomechanics, such as external force, unit area impact energy, corneoscleral stress, and intraocular pressure exceed a certain value. Studying the biomechanics of open-globe injury and its influencing factors can provide a reference for eye-contact operations and the design of eye-protection devices. This review summarises the biomechanics of open-globe injury and the relevant factors.
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Affiliation(s)
- Songtao Wang
- Department of Ophthalmology, The Second Hospital of Jilin University, No. 4026, Yatai Street, Nanguan District, Changchun, Jilin, China
| | - Fuqiang Li
- Department of Ophthalmology, The Second Hospital of Jilin University, No. 4026, Yatai Street, Nanguan District, Changchun, Jilin, China
| | - Siyan Jin
- Department of Ophthalmology, The Second Hospital of Jilin University, No. 4026, Yatai Street, Nanguan District, Changchun, Jilin, China
| | - Yu Zhang
- Department of Ophthalmology, The Second Hospital of Jilin University, No. 4026, Yatai Street, Nanguan District, Changchun, Jilin, China
| | - Ning Yang
- Department of Ophthalmology, The Second Hospital of Jilin University, No. 4026, Yatai Street, Nanguan District, Changchun, Jilin, China
| | - Jinsong Zhao
- Department of Ophthalmology, The Second Hospital of Jilin University, No. 4026, Yatai Street, Nanguan District, Changchun, Jilin, China.
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Towler J, Consejo A, Zhou D, Romano V, Levis H, Boote C, Elsheikh A, Geraghty B, Abass A. Typical localised element-specific finite element anterior eye model. Heliyon 2023; 9:e13944. [PMID: 37101628 PMCID: PMC10123217 DOI: 10.1016/j.heliyon.2023.e13944] [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: 02/21/2022] [Revised: 11/19/2022] [Accepted: 02/15/2023] [Indexed: 03/07/2023] Open
Abstract
Purpose The study presents an averaged anterior eye geometry model combined with a localised material model that is straightforward, appropriate and amenable for implementation in finite element (FE) modelling. Methods Both right and left eye profile data of 118 subjects (63 females and 55 males) aged 22-67 years (38.5 ± 7.6) were used to build an averaged geometry model. Parametric representation of the averaged geometry model was achieved through two polynomials dividing the eye into three smoothly connected volumes. This study utilised the collagen microstructure x-ray data of 6 ex-vivo healthy human eyes, 3 right eyes and 3 left eyes in pairs from 3 donors, 1 male and 2 females aged between 60 and 80 years, to build a localised element-specific material model for the eye. Results Fitting the cornea and the posterior sclera sections to a 5th-order Zernike polynomial resulted in 21 coefficients. The averaged anterior eye geometry model recorded a limbus tangent angle of 37° at a radius of 6.6 mm from the corneal apex. In terms of material models, the difference between the stresses generated in the inflation simulation up to 15 mmHg in the ring-segmented material model and localised element-specific material model were significantly different (p < 0.001) with the ring-segmented material model recording average Von-Mises stress 0.0168 ± 0.0046 MPa and the localised element-specific material model recording average Von-Mises stress 0.0144 ± 0.0025 MPa. Conclusions The study illustrates an averaged geometry model of the anterior human eye that is easy to generate through two parametric equations. This model is combined with a localised material model that can be used either parametrically through a Zernike fitted polynomial or non-parametrically as a function of the azimuth angle and the elevation angle of the eye globe. Both averaged geometry and localised material models were built in a way that makes them easy to implement in FE analysis without additional computation cost compared to the limbal discontinuity so-called idealised eye geometry model or ring-segmented material model.
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Affiliation(s)
- Joseph Towler
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | | | - Dong Zhou
- Department of Civil Engineering and Industrial Design, School of Engineering, University of Liverpool, Liverpool, UK
| | - Vito Romano
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Medical and Surgical Specialities, Radiological Sciences, And Public Health, Ophthalmology Clinic, University of Brescia, Italy
| | - Hannah Levis
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Craig Boote
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
| | - Ahmed Elsheikh
- Department of Civil Engineering and Industrial Design, School of Engineering, University of Liverpool, Liverpool, UK
- Beijing Advanced Innovation Centre for Biomedical Engineering, Beihang University, Beijing, China
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Brendan Geraghty
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Ahmed Abass
- Department of Mechanical, Materials and Aerospace Engineering, School of Engineering, University of Liverpool, Liverpool, UK
- Department of Production Engineering and Mechanical Design, Faculty of Engineering, Port Said University, Egypt
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Explosive eye injuries: characteristics, traumatic mechanisms, and prognostic factors for poor visual outcomes. Mil Med Res 2023; 10:3. [PMID: 36631894 PMCID: PMC9835351 DOI: 10.1186/s40779-022-00438-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 12/21/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Explosions can produce blast waves, high-speed medium, thermal radiation, and chemical spatter, leading to complex and compound eye injuries. However, few studies have comprehensively investigated the clinical features of different eye injury types or possible risk factors for poor prognosis. METHODS We retrospectively reviewed all consecutive records of explosive eye injuries (1449 eyes in 1115 inpatients) in 14 tertiary referral hospitals in China over 12 years (between January 2008 and December 2019). Data on demographics, eye injury types, ocular findings, treatments, and factors affecting visual prognosis were extracted from a standardized database of eye injuries and statistically analyzed. RESULTS Mechanical ocular trauma accounted for 94.00% of explosion-related eye injuries, among which intraocular foreign bodies (IOFBs) resulted in 55.17% of open globe injuries (OGIs) and contusion caused 60.22% of close globe injuries (CGIs). Proliferative vitreous retinopathy (PVR) was more common in perforating (47.06%) and IOFB (26.84%) than in penetrating (8.79%) injuries, and more common with laceration (24.25%) than rupture (9.22%, P < 0.01). However, no difference was observed between rupture and contusion. Ultimately, 9.59% of eyes were removed and the final vision was ≤ 4/200 in 45.82% of patients. Poor presenting vision [odds ratio (OR) = 5.789], full-thickness laceration of the eyeball ≥ 5 mm (OR = 3.665), vitreous hemorrhage (OR = 3.474), IOFB (OR = 3.510), non-mechanical eye injury (NMEI, OR = 2.622, P < 0.001), rupture (OR = 2.362), traumatic optic neuropathy (OR = 2.102), retinal detachment (RD, OR = 2.033), endophthalmitis (OR = 3.281, P < 0.01), contusion (OR = 1.679), ciliary body detachment (OR = 6.592), zone III OGI (OR = 1.940), and PVR (OR = 1.615, P < 0.05) were significant negative predictors for poor visual outcomes. CONCLUSIONS Explosion ocular trauma has complex mechanisms, with multiple eyes involved and poor prognosis. In lethal level I explosion injuries, eyeball rupture is a serious condition, whereas contusion is more likely to improve. In level II injuries, IOFBs are more harmful than penetrating injuries, and level IV represents burn-related eye injuries. PVR is more associated with penetrating mechanisms than with OGI. Identifying the risk predictors for visual prognosis can guide clinicians in the evaluation and treatment of ocular blast injuries.
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Karimi A, Halabian M, Razaghi R, Downs JC, Kelley MJ, Acott TS. Modeling the Endothelial Glycocalyx Layer in the Human Conventional Aqueous Outflow Pathway. Cells 2022; 11:3925. [PMID: 36497183 PMCID: PMC9740116 DOI: 10.3390/cells11233925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/30/2022] [Accepted: 12/03/2022] [Indexed: 12/07/2022] Open
Abstract
A layer of proteoglycans and glycoproteins known as glycocalyx covers the surface of the trabecular meshwork (TM), juxtacanalicular tissue (JCT), and Schlemm's canal (SC) inner wall of the conventional aqueous outflow pathway in the eye. This has been shown to play a role in the mechanotransduction of fluid shear stress and in the regulation of the outflow resistance. The outflow resistance in the conventional outflow pathway is the main determinant of the intraocular pressure (IOP) through an active, two-way, fluid-structure interaction coupling between the outflow tissues and aqueous humor. A 3D microstructural finite element (FE) model of a healthy human eye TM/JCT/SC complex with interspersed aqueous humor was constructed. A very thin charged double layer that represents the endothelial glycocalyx layer covered the surface of the elastic outflow tissues. The aqueous humor was modeled as electroosmotic flow that is charged when it is in contact with the outflow tissues. The electrical-fluid-structure interaction (EFSI) method was used to couple the charged double layer (glycocalyx), fluid (aqueous humor), and solid (outflow tissues). When the IOP was elevated to 15 mmHg, the maximum aqueous humor velocity in the EFSI model was decreased by 2.35 mm/s (9%) compared to the fluid-structure interaction (FSI) model. The charge or electricity in the living human conventional outflow pathway generated by the charged endothelial glycocalyx layer plays a minor biomechanical role in the resultant stresses and strains as well as the hydrodynamics of the aqueous humor.
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Affiliation(s)
- Alireza Karimi
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Mahdi Halabian
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Reza Razaghi
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - J. Crawford Downs
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Mary J. Kelley
- Departments of Ophthalmology and Integrative Biosciences, Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Ted S. Acott
- Departments of Ophthalmology and Biochemistry and Molecular Biology, Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA
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Karimi A, Razaghi R, Rahmati SM, Downs JC, Acott TS, Kelley MJ, Wang RK, Johnstone M. The Effect of Intraocular Pressure Load Boundary on the Biomechanics of the Human Conventional Aqueous Outflow Pathway. Bioengineering (Basel) 2022; 9:672. [PMID: 36354583 PMCID: PMC9687513 DOI: 10.3390/bioengineering9110672] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/28/2022] [Accepted: 11/08/2022] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Aqueous humor outflow resistance in the trabecular meshwork (TM), juxtacanalicular connective tissue (JCT), and Schlemm's canal (SC) endothelium of the conventional outflow pathway actively contribute to intraocular pressure (IOP) regulation. Outflow resistance is actively affected by the dynamic outflow pressure gradient across the TM, JCT, and SC inner wall tissues. The resistance effect implies the presence of a fluid-structure interaction (FSI) coupling between the outflow tissues and the aqueous humor. However, the biomechanical interactions between viscoelastic outflow tissues and aqueous humor dynamics are largely unknown. METHODS A 3D microstructural finite element (FE) model of a healthy human eye TM/JCT/SC complex was constructed with elastic and viscoelastic material properties for the bulk extracellular matrix and embedded elastic cable elements. The FE models were subjected to both idealized and a physiologic IOP load boundary using the FSI method. RESULTS The elastic material model for both the idealized and physiologic IOP load boundary at equal IOPs showed similar stresses and strains in the outflow tissues as well as pressure in the aqueous humor. However, outflow tissues with viscoelastic material properties were sensitive to the IOP load rate, resulting in different mechanical and hydrodynamic responses in the tissues and aqueous humor. CONCLUSIONS Transient IOP fluctuations may cause a relatively large IOP difference of ~20 mmHg in a very short time frame of ~0.1 s, resulting in a rate stiffening in the outflow tissues. Rate stiffening reduces strains and causes a rate-dependent pressure gradient across the outflow tissues. Thus, the results suggest it is necessary to use a viscoelastic material model in outflow tissues that includes the important role of IOP load rate.
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Affiliation(s)
- Alireza Karimi
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Reza Razaghi
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | | | - J. Crawford Downs
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Ted S. Acott
- Departments of Ophthalmology and Biochemistry and Molecular Biology, Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Mary J. Kelley
- Departments of Ophthalmology and Integrative Biosciences, Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Ruikang K. Wang
- Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA
| | - Murray Johnstone
- Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA
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Karimi A, Razaghi R, Rahmati SM, Girkin CA, Downs JC. Relative Contributions of Intraocular and Cerebrospinal Fluid Pressures to the Biomechanics of the Lamina Cribrosa and Laminar Neural Tissues. Invest Ophthalmol Vis Sci 2022; 63:14. [PMID: 36255364 PMCID: PMC9587471 DOI: 10.1167/iovs.63.11.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/27/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose The laminar region of the optic nerve head (ONH), thought to be the site of damage to the retinal ganglion cell axons in glaucoma, is continuously loaded on its anterior and posterior surfaces by dynamic intraocular pressure (IOP) and orbital cerebrospinal fluid pressure (CSFP), respectively. Thus, translaminar pressure (TLP; TLP = IOP-CSFP) has been proposed as a glaucoma risk factor. Methods Three eye-specific finite element models of the posterior human eye were constructed, including full 3D microstructures of the load-bearing lamina cribrosa (LC) with interspersed laminar neural tissues (NTs), and heterogeneous, anisotropic, hyperelastic material formulations for the surrounding peripapillary sclera and adjacent pia. ONH biomechanical responses were simulated using three combinations of IOP and CSFP loadings consistent with posture change from sitting to supine. Results Results show that tensile, compressive, and shear stresses and strains in the ONH were higher in the supine position compared to the sitting position (P < 0.05). In addition, LC beams bear three to five times more TLP-driven stress than interspersed laminar NT, whereas laminar NT exhibit three to five times greater strain than supporting LC (P < 0.05). Compared with CSFP, IOP drove approximately four times greater stress and strain in the LC, NT, and peripapillary sclera, normalized per mm Hg pressure change. In addition, IOP drove approximately three-fold greater scleral canal expansion and anterior-posterior laminar deformation than CSFP per mm Hg (P < 0.05). Conclusions Whereas TLP has been hypothesized to play a prominent role in ONH biomechanics, the IOP and CSFP effects are not equivalent, as IOP-driven stress, strain, and deformation play a more dominant role than CSFP effects.
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Affiliation(s)
- Alireza Karimi
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Reza Razaghi
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | | | - Christopher A. Girkin
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - J. Crawford Downs
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama, United States
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