1
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Ucar F. Conjunctival Autografts for Ocular Surface Reconstruction after Conjunctival Nevus Excision. Cornea 2023; 42:1206-1210. [PMID: 36731062 DOI: 10.1097/ico.0000000000003117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/02/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to evaluate the clinical and therapeutic outcomes of the cases where we used conjunctival autografts with and without the Tenon fascia for ocular surface reconstruction after conjunctival nevus excision. METHODS This study included 63 eyes of 63 patients who underwent conjunctival nevus excision between January 2013 and December 2020. Although a Tenon-free conjunctival autograft was used in 32 eyes of 32 patients in group 1, a Tenon-containing conjunctival autograft was used in 31 eyes of 31 patients in group 2. The clinical and histopathological characteristics of the nevus, complete graft epithelization, cosmetic outcomes, and postoperative complications were evaluated. RESULTS Conjunctival autografts were harvested from the contralateral eye in 3 eyes (9.3%) in group 1 and 2 eyes (6.4%) in group 2 ( P = 0.66). Postoperatively, the mean defect size at the harvest site was 5.3 ± 1.4 mm in group 1 and 5.5 ± 1.5 mm in group 2 ( P = 0.47). Graft edema was observed in only 1 case (3.1%) in group 1 and 6 cases (19.3%) in group 2 ( P = 0.04). Although a complete graft epithelization was observed in all eyes in group 1, fluorescein staining was present in 2 eyes (6.4%) in group 2 ( P = 0.14). Cosmetically, retracting and shrinking grafts were absent in group 1, whereas group 2 had in 4 eyes (12.9%) ( P = 0.03). Neither group had conjunctival scarring, symblepharon, eyelid cicatrization, dysmotility, or pannus at the donor site. CONCLUSIONS Ocular surface reconstruction with a Tenon-free conjunctival autograft after conjunctival nevus excision provides excellent cosmetic and functional results without significant complications.
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Affiliation(s)
- Fikret Ucar
- Konyagoz Eye Hospital, Ophthalmology Department, Konya, Turkey
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2
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Liu YC, Morales-Wong F, Patil M, Han SB, Lwin NC, Teo EPW, Ang HP, Yussof NZM, Mehta JS. Femtosecond laser-assisted corneal transplantation with a low-energy, liquid-interface system. Sci Rep 2022; 12:6959. [PMID: 35484198 PMCID: PMC9050694 DOI: 10.1038/s41598-022-11461-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 04/25/2022] [Indexed: 11/26/2022] Open
Abstract
Femtosecond laser-assisted keratoplasty has been proposed as a treatment option for corneal transplantation. In this study, we investigated and compared the outcomes of Ziemer Z8 femtosecond laser (FSL)-assisted penetrating keratoplasty (PK) using a liquid interface versus flat interface. Thirty fresh porcine eyes underwent FSL-assisted PK with the Z8 using different levels of energies (30%, 90% or 150%) and different interfaces (liquid or flat). The real-time intraocular pressure (IOP) changes, incision geometry, corneal endothelial damage, as well as the accuracy of laser cutting and tissue reaction, were performed and compared. We found that the overall average IOP at all laser trephination stages was significantly higher with the flat interface, regardless of the energy used (68.9 ± 15.0 mmHg versus 46.1 ± 16.6 mmHg; P < 0.001). The overall mean laser-cut angle was 86.2º ± 6.5º and 88.2º ± 1.0º, for the liquid and flat platform respectively, indicating minimal deviation from the programmed angle of 90º. When high energy (150%) was used, the endothelial denuded area was significantly greater with the flat interface than with liquid interface (386.1 ± 53.6 mm2 versus 139.0 ± 10.4 mm2P = 0.02). The FSL cutting did not cause obvious tissue reaction alongside the laser cut on histological evaluation. The results indicated a liquid interface is the preferable choice in FSL-assisted corneal transplantation.
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Affiliation(s)
- Yu-Chi Liu
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 6, Singapore, 169856, Singapore. .,Cornea and Refractive Surgery Group, Singapore Eye Research Institute, Singapore, Singapore. .,Cornea and External Eye Diseases, Singapore National Eye Centre, Singapore, Singapore. .,Duke-NUS Graduate Medical School, Ophthalmology Academic Clinical Program, Singapore, Singapore.
| | - Fernando Morales-Wong
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 6, Singapore, 169856, Singapore.,Cornea and External Eye Diseases, Singapore National Eye Centre, Singapore, Singapore.,Faculty of Medicine, University Hospital "Dr Jose Eleuterio Gonzalez", Autonomous University of Nuevo Leon, San Nicolás de los Garza, Mexico
| | - Moushmi Patil
- Cornea and External Eye Diseases, Singapore National Eye Centre, Singapore, Singapore
| | - Sang Beom Han
- Department of Ophthalmology, Kangwon National University School of Medicine, Kangwon National University Hospital, Chuncheon-si, Republic of Korea
| | - Nyein C Lwin
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 6, Singapore, 169856, Singapore
| | - Ericia Pei Wen Teo
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 6, Singapore, 169856, Singapore
| | - Heng Pei Ang
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 6, Singapore, 169856, Singapore
| | - Nur Zah M Yussof
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 6, Singapore, 169856, Singapore
| | - Jodhbir S Mehta
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 6, Singapore, 169856, Singapore.,Cornea and Refractive Surgery Group, Singapore Eye Research Institute, Singapore, Singapore.,Cornea and External Eye Diseases, Singapore National Eye Centre, Singapore, Singapore.,Duke-NUS Graduate Medical School, Ophthalmology Academic Clinical Program, Singapore, Singapore
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3
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Moscovici BK, Rodrigues PF, Freitas MMS, e Silva FB, Felberg S, Dantas PEC. Donor graft harvesting with air in pterygium surgery. Eur J Ophthalmol 2022; 32:3103-3109. [DOI: 10.1177/11206721221090802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose Report a new technique for improvement of pterygium surgery: donor graft harvesting with air. Case reports We describe a technique that was used with 138 patients who underwent surgery that included a conjunctival autograft and fibrin glue with air injection to dissect the Tenon capsule from the conjunctiva. Results No complications occurred with this technique and all patients achieved good results. Discussion The surgical time with this new technique was similar to that reported in the literature. In addition, the graft thickness was close to that reported with femtosecond laser dissection and it was thinner than that reported with aesthetic/saline dissection (unable to determine statistical significance). Conclusions and importance With the injection of an air bubble, we could easily dissect the conjunctiva from the Tenon capsule and quickly acquire thin grafts without any additional costs or complications.
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Affiliation(s)
| | | | | | | | - Sérgio Felberg
- Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
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4
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Liu YC, Setiawan M, Chin JY, Wu B, Ong HS, Lamoureux E, Mehta JS. Randomized Controlled Trial Comparing 1-Year Outcomes of Low-Energy Femtosecond Laser-Assisted Cataract Surgery versus Conventional Phacoemulsification. Front Med (Lausanne) 2022; 8:811093. [PMID: 34977102 PMCID: PMC8718704 DOI: 10.3389/fmed.2021.811093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/30/2021] [Indexed: 01/11/2023] Open
Abstract
Purpose: To compare 1-year clinical outcomes, phacoemulsification energy, aqueous profiles, and patient-reported outcomes of low-energy femtosecond laser-assisted cataract surgery (FLACS) vs. conventional phacoemulsification. Methods: The study is a randomized controlled trial (RCT) with paired-eye design. Eighty-five patients were randomized to receive FLACS (Ziemer LDV Z8) in one eye and conventional phacoemulsification in the fellow eye. Clinical data including phacoemulsification energy parameters (cumulative dissipated energy, phacoemulsification power, and phacoemulsification time), uncorrected and corrected distance visual acuities (UCDVA and BCDVA), manifest refraction spherical equivalent (MRSE), central corneal thickness (CCT), endothelial cell count (ECC), anterior chamber flare, and post-operative complications were obtained for 1 year. Aqueous humor was collected for the analysis of prostaglandin (PGE)2, cytokines and chemokines concentrations. Patients' reported-outcomes on surgical experiences were evaluated using an in-house questionnaire. Results: Compared to conventional phacoemulsification, the low-energy assisted FLACS group had significantly less ECC reduction at 3 months (1.5 ± 0.3% vs. 7.0 ± 2.4%; P < 0.01) and 1 year (8.2 ± 2.8% vs. 11.2 ± 3.6%; P = 0.03). There were no significant differences in the phacoemulsification energy parameters, UCDVA, BCDVA, MRSE, CCT, occurrence of post-operative complications between the 2 groups throughout post-operative 1 year. Patients' subjective surgical experiences, including the surgical duration and perceived inconvenience, were comparable between the 2 groups. FLACS resulted in significantly higher aqueous PGE2 (P < 0.01), interleukin (IL)-6 (P = 0.03), IL-8 (P = 0.03), and interferon (IFN)-γ (P = 0.04) concentrations and greater anterior chamber flare at 1 day (P = 0.02). Conclusions: Our RCT presented 1-year longitudinal clinical and laboratory data. The long-term ECC result was more favorable in low-energy FLACS. The rest of the intraoperative and post-operative outcomes, as well as patient-reported outcomes, were comparable between these two procedures.
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Affiliation(s)
- Yu-Chi Liu
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore.,Cornea and Refractive Surgery Group, Singapore Eye Research Institute, Singapore, Singapore.,Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Program, Duke- National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Melina Setiawan
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore
| | - Jia Ying Chin
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore
| | - Benjamin Wu
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore
| | - Hon Shing Ong
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore.,Cornea and Refractive Surgery Group, Singapore Eye Research Institute, Singapore, Singapore.,Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Program, Duke- National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Ecosse Lamoureux
- Population Health Group, Singapore Eye Research Institute, Singapore, Singapore.,Health Services and System Research Department, Population Health Research, Duke- National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Jodhbir S Mehta
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore.,Cornea and Refractive Surgery Group, Singapore Eye Research Institute, Singapore, Singapore.,Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Program, Duke- National University of Singapore (NUS) Medical School, Singapore, Singapore
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5
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Ucar F, Seyrek L, Cetinkaya S, Ture H, Kadioglu E. Facilitated Tenon-Free Conjunctival Autograft Preparation and Limited Tenon Removal Technique in Pterygium Surgery. Klin Monbl Augenheilkd 2021. [PMID: 34749412 DOI: 10.1055/a-1648-4753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The main complication of primary pterygium surgery is the recurrence of the pterygium. In the present study, we aimed to compare a classical technique and facilitated tenon-free conjunctival autograft preparation and a limited tenon removal technique in pterygium surgery in terms of recurrence rate, complications, and operation duration. MATERIAL AND METHODS This is a retrospective, comparative, observational study. Group 1 comprised 120 eyes of 115 patients who underwent pterygium excision with a new facilitated tenon-free conjunctival-limbal autograft preparation and limited tenon removal technique between May 2017 and October 2019. Group 2 comprised 117 eyes of 113 patients who underwent pterygium excision with a conventional conjunctival-limbal autograft technique between January 2016 and May 2017. RESULTS The mean follow-up time after surgery was 18.2 ± 5.8 months in group 1 and 19.1 ± 6.3 months in group 2 (p = 0.25). The mean operation duration was 5.54 ± 1.22 (4 - 7) minutes in group 1 and 8.23 ± 1.26 (8 - 10) minutes in group 2 (p = 0.02). Flap edema was present in 33 eyes (28.2%) in group 2 and in 11 eyes (9.16%) in group 1. Flap edema was significantly higher in group 2 (p < 0.001). At the end of the 1-year follow-up of the patients, we observed recurrence in only one (0.83%) eye in group 1 and 14 (11.96%) eyes in group 2. The recurrence rate of group 1 was significantly less than that of group 2 (p < 0.001). CONCLUSIONS The simplified technique of tenon-free conjunctival autograft preparation and limited tenon removal yielded better clinical outcomes without serious complications. Additionally, this technique shortened the surgical time and reduced surgeon-dependent factors.
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Affiliation(s)
- Fikret Ucar
- Ophthalmology, Private Konyagoz Hospital, Konya, Turkey
| | - Lutfi Seyrek
- Ophthalmology, Private Konyagoz Hospital, Konya, Turkey
| | | | - Huseyin Ture
- Ophthalmology, Karaman Selcuklu Hospital, Karaman, Turkey
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6
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Yang LWY, Mehta JS, Liu YC. Corneal neuromediator profiles following laser refractive surgery. Neural Regen Res 2021; 16:2177-2183. [PMID: 33818490 PMCID: PMC8354117 DOI: 10.4103/1673-5374.308666] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/02/2020] [Accepted: 01/22/2021] [Indexed: 01/07/2023] Open
Abstract
Laser refractive surgery is one of the most commonly performed procedures worldwide. In laser refractive surgery, Femtosecond Laser in Situ Keratomileusis and Refractive Lenticule Extraction have emerged as promising alternatives to microkeratome Laser in Situ Keratomileusis and Photorefractive Keratectomy. Following laser refractive surgery, the corneal nerves, epithelial and stromal cells release neuromediators, including neurotrophins, neuropeptides and neurotransmitters. Notably, nerve growth factor, substance P, calcitonin gene-related peptide and various cytokines are important mediators of neurogenic inflammation and corneal nerve regeneration. Alterations in neuromediator profiles and ocular surface parameters following laser refractive surgery are attributed to the surgical techniques and the severity of tissue insult induced. In this review, we will discuss the (1) Functions of neuromediators and their physiological and clinical significance; (2) Changes in the neuromediators following various laser refractive surgeries; (3) Correlation between neuromediators, ocular surface health and corneal nerve status; and (4) Future directions, including the use of neuromediators as potential biomarkers for ocular surface health following laser refractive surgery, and as adjuncts to aid in corneal regeneration after laser refractive surgery.
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Affiliation(s)
- Lily Wei Yun Yang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore
| | - Jodhbir S. Mehta
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore
- Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Yu-Chi Liu
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore
- Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
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7
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Shahraki T, Arabi A, Feizi S. Pterygium: an update on pathophysiology, clinical features, and management. Ther Adv Ophthalmol 2021; 13:25158414211020152. [PMID: 34104871 PMCID: PMC8170279 DOI: 10.1177/25158414211020152] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/06/2021] [Indexed: 01/16/2023] Open
Abstract
Pterygium is a relatively common ocular surface disease. The clinical aspects and
the treatment options have been studied since many years ago, but many
uncertainties still exist. The core pathologic pathway and the role of heredity
in the development of pterygium are still attractive fields for the researchers.
The role of pterygium in corneal irregularities, in addition to the refractive
properties of pterygium removal, has been increasingly recognized through
numerous studies. The association between pterygium and ocular surface neoplasia
is challenging the traditional beliefs regarding the safe profile of the
disease. The need for a comprehensive clinical classification system has
encouraged homogenization of trials and prediction of the recurrence rate of the
pterygium following surgical removal. Evolving surgical methods have been
associated with some complications, whose diagnosis and management are necessary
for ophthalmic surgeons. According to the review, the main risk factor of
pterygium progression remains to be the ultraviolet exposure. A major part of
the clinical evaluation should consist of differentiating between typical and
atypical pterygia, where the latter may be associated with the risk of ocular
surface neoplasia. The effect of pterygium on astigmatism and the aberrations of
the cornea may evoke the need for an early removal with a purpose of reducing
secondary refractive error. Among the surgical methods, conjunctival or
conjunctival-limbal autografting seems to be the first choice for ophthalmic
surgeons because the recurrence rate following the procedure has been reported
to be lower, compared with other procedures. The use of adjuvant options is
supported in the literature, where intraoperative and postoperative mitomycin C
has been the adjuvant treatment of choice. The efficacy and safety of
anti–vascular endothelial growth factor agents and cyclosporine have been
postulated; however, their exact role in the treatment of the pterygium requires
further studies.
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Affiliation(s)
- Toktam Shahraki
- Ophthalmic Research Center, Department of Ophthalmology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Arabi
- Ophthalmic Research Center, Department of Ophthalmology, Shahid Beheshti University of Medical Sciences, Tehran, 16666, Iran
| | - Sepehr Feizi
- Ophthalmic Research Center, Department of Ophthalmology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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8
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Cosmetic outcome of femtosecond laser-assisted pterygium surgery. EYE AND VISION 2021; 8:7. [PMID: 33673873 PMCID: PMC7936441 DOI: 10.1186/s40662-021-00230-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 02/15/2021] [Indexed: 11/10/2022]
Abstract
Background To examine the cosmetic outcome of femtosecond laser-assisted pterygium surgery (FLAPS) with conjunctival autograft (CAG) and its potential predictive factors. Methods This was a prospective interventional case series (NCT02866968). We included 29 patients (29 eyes) with primary pterygium who underwent FLAPS. Cosmetic outcome was graded by two graders (an ophthalmology resident and an experienced ophthalmologist) using Hirst classification system (1–4 = excellent–poor). Weighted Cohen’s kappa analysis was performed to examine the intra- and inter-rater reliability. The relationship between cosmetic outcome and various factors were determined by Spearman’s correlation coefficients (r). Results The preoperative severity of pterygium (Tan grading system) was mild/atrophic (7%), moderate/intermediate (62%), and severe/fleshy (31%). An ultrathin CAG (mean thickness of 74.5 ± 9.8 μm) was fashioned intraoperatively. An excellent cosmetic outcome of FLAPS (median ± IQR) was observed at 3 months (1.0 ± 1.0) and remained similar at 6 months (1.0 ± 0.0) and 12 months (1.0 ± 0.0) postoperatively. At final follow-up, 27 (93%) patients achieved good-to-excellent cosmetic outcome, with 1 (3%) patient having a poor outcome due to incomplete pterygium removal. Weighted kappa analysis of Hirst grading system showed excellent intra-rater (κ = 0.86–0.95) and inter-rater reliability (κ = 0.84–0.88). There was a weak and borderline significant correlation between good cosmetic outcome and reduced postoperative CAG thickness (r = 0.38, P = 0.06) but not with age, gender, preoperative pterygium severity, or intraoperative CAG thickness. Conclusions FLAPS can result in an excellent cosmetic outcome, which may be attributed to the beneficial effect of an ultrathin CAG. Trial registration ClinicalTrials.gov, NCT02866968. Registered in July 2016, Supplementary Information The online version contains supplementary material available at 10.1186/s40662-021-00230-w.
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9
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Dimacali VG, Liu YC, Ong HS, Ting DSJ, Mehta JS. Femtosecond laser-assisted excision of conjunctival melanocytic lesions: Cosmetic and long-term outcomes. Clin Exp Ophthalmol 2021; 49:312-315. [PMID: 33570816 PMCID: PMC8248140 DOI: 10.1111/ceo.13907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 12/05/2022]
Affiliation(s)
| | - Yu-Chi Liu
- Department of Cornea and External Diseases, Singapore National Eye Centre, Singapore.,Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore
| | - Hon Shing Ong
- Department of Cornea and External Diseases, Singapore National Eye Centre, Singapore.,Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore
| | - Darren S J Ting
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore.,Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jodhbir S Mehta
- Department of Cornea and External Diseases, Singapore National Eye Centre, Singapore.,Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore
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10
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Liu YC, Ke L, Yang SWQ, Nan Z, Teo EPW, Lwin NC, Lin MTY, Lee IXY, Chan ASY, Schmetterer L, Mehta JS. Safety profiles of terahertz scanning in ophthalmology. Sci Rep 2021; 11:2448. [PMID: 33510290 PMCID: PMC7843699 DOI: 10.1038/s41598-021-82103-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/15/2021] [Indexed: 01/20/2023] Open
Abstract
Terahertz (THz) technology has emerged recently as a potential novel imaging modality in biomedical fields, including ophthalmology. However, the ocular biological responses after THz electromagnetic exposure have not been investigated. We conducted a rabbit study to evaluate the safety profiles of THz scanning on eyes, at a tissue, cellular, structural and functional level. Eight animals (16 eyes) were analysed after excessive THz exposure (control, 1 h, 4 h, and 1 week after continuous 4-h exposure; THz frequency = 0.3 THz with continuous pulse generated at 40 µW). We found that at all the time points, the corneas and lens remained clear with no corneal haze or lens opacity formation clinically and histopathologically. No thermal effect, assessed by thermographer, was observed. The rod and cone cell-mediated electroretinography responses were not significantly altered, and the corneal keratocytes activity as well as endothelial viability, assessed by in-vivo confocal microscopy, was not affected. Post-exposed corneas, lens and retinas exhibited no significant changes in the mRNA expression of heat shock protein (HSP)90AB1), DNA damage inducible transcript 3 (DDIT3), and early growth response (EGR)1. These tissues were also negative for the inflammatory (CD11b), fibrotic (fibronectin and α-smooth muscle actin), stress (HSP-47) and apoptotic (TUNEL assay) responses on the immunohistochemical analyses. The optical transmittance of corneas did not change significantly, and the inter-fibrillar distances of the corneal stroma evaluated with transmission electron microscopy were not significantly altered after THz exposure. These results provide the basis for future research work on the development of THz imaging system for its application in ophthalmology.
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Affiliation(s)
- Yu-Chi Liu
- Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 12, Singapore, 169856, Singapore. .,Singapore National Eye Centre, Singapore, Singapore. .,Ophthalmology and Visual Science Academic Clinical Research Program, Duke-NUS Medical School, Singapore, Singapore.
| | - Lin Ke
- Institute of Materials Research and Engineering, Agency for Science, Technology and Research, Singapore, Singapore
| | - Steve Wu Qing Yang
- Institute of Materials Research and Engineering, Agency for Science, Technology and Research, Singapore, Singapore
| | - Zhang Nan
- Institute of Materials Research and Engineering, Agency for Science, Technology and Research, Singapore, Singapore
| | - Ericia Pei Wen Teo
- Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 12, Singapore, 169856, Singapore
| | - Nyein Chan Lwin
- Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 12, Singapore, 169856, Singapore
| | - Molly Tzu-Yu Lin
- Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 12, Singapore, 169856, Singapore
| | - Isabelle Xin Yu Lee
- Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 12, Singapore, 169856, Singapore
| | - Anita Sook-Yee Chan
- Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 12, Singapore, 169856, Singapore.,Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology and Visual Science Academic Clinical Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Leopold Schmetterer
- Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 12, Singapore, 169856, Singapore.,Ophthalmology and Visual Science Academic Clinical Research Program, Duke-NUS Medical School, Singapore, Singapore.,School of Chemical and Biomedcial Engineering, Nanyang Technological University, Singapore, Singapore.,Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria.,Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland
| | - Jodhbir S Mehta
- Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower, Level 12, Singapore, 169856, Singapore.,Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology and Visual Science Academic Clinical Research Program, Duke-NUS Medical School, Singapore, Singapore
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11
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The effects of laser displacement on femtosecond laser-assisted conjunctival autograft preparation for pterygium surgery. PLoS One 2021; 16:e0245223. [PMID: 33444405 PMCID: PMC7808670 DOI: 10.1371/journal.pone.0245223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 12/25/2020] [Indexed: 11/19/2022] Open
Abstract
AIMS To evaluate the effects of no-suction femtosecond laser (FSL) stability on conjunctival autograft (CAG) dissection in pterygium surgery. METHODS Prospective analysis of 35 eyes from 34 subjects who underwent femtosecond laser-assisted pterygium surgery with the Ziemer Z8 laser (Ophthalmic Systems AG, Switzerland). Intraoperative absolute FSL displacements were measured and correlated with the duration and ease of CAG peel, CAG thickness, measured with intraoperative optical coherence tomography, and deviation from intended graft thickness. RESULTS The median absolute FSL displacement was 22 μm (interquartile range [IQR] 14.7 to 60.8), while median vertical FSL displacement was 14.7 μm (IQR 7.3 to 44) and median horizontal FSL displacement was 22.0 μm (IQR 14.7 to 44). 65.7% had a grade 1 peel, 11.4% had grade 2 peel, 14.3% had grade 3 peel and 8.6% had grade 4 peel. The median duration of CAG peel was 5.4 seconds (IQR 3 to 21.4). The median CAG thickness was 69 μm (IQR 60.3 to 78.5), and the median deviation from targeted graft thickness was 9 μm (IQR 1 to 16). Eyes with more difficult peels and longer duration of CAG peels had significantly greater vertical FSL displacements (p = 0.04 and 0.02 respectively), but not horizontal displacement, age, ethnicity, CAG thickness or deviation from original thickness, compared to those with better quality and shorter duration peels. 1 eye (2.9%) had an incomplete CAG peel with a buttonhole and 2 eyes had graft tears (5.7%). CONCLUSION Micro-displacements during the suction-free CAG preparation are common but they did not affect the quality of the CAG peel, duration of peel, or CAG thickness. However, vertical globe displacement during FSL-assisted CAG creation was significantly associated with a more difficult and longer CAG peel duration. This highlights the importance of the cornea traction suture fixation to ensure stability of the eye during FSL application.
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Mansoor H, Liu YC, Ang M, Mehta JS. Conjunctival sparing femtosecond laser-assisted conjunctival autografts for double-headed pterygium surgery. Clin Exp Ophthalmol 2020; 48:1115-1118. [PMID: 32918377 DOI: 10.1111/ceo.13860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/28/2020] [Accepted: 09/06/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Hassan Mansoor
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore.,Cornea and External Disease Service, Singapore National Eye Centre, Singapore.,Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan
| | - Yu-Chi Liu
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore.,Cornea and External Disease Service, Singapore National Eye Centre, Singapore.,Ophthalmology Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore
| | - Marcus Ang
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore.,Cornea and External Disease Service, Singapore National Eye Centre, Singapore.,Ophthalmology Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore
| | - Jodhbir S Mehta
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore.,Cornea and External Disease Service, Singapore National Eye Centre, Singapore.,Ophthalmology Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore.,School of Material Science and Engineering, Nanyang Technological University, Singapore
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13
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Application of Femtosecond Laser in Anterior Segment Surgery. J Ophthalmol 2020; 2020:8263408. [PMID: 32351726 PMCID: PMC7171667 DOI: 10.1155/2020/8263408] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/12/2020] [Indexed: 11/24/2022] Open
Abstract
Femtosecond laser (FSL) is a near-infrared laser that can create reliable and reproducible tissue cutting with minimal damage to adjacent tissue. As the laser can also create incisions with various orientations, depths, and shapes, it is expected to be a useful tool for anterior segment surgery, such as cornea, refractive, and cataract surgery. In this review, the authors will introduce the application of FSL in various anterior segment surgeries and discuss the results of studies regarding the efficacy and safety of FSL in cornea, refractive, and cataract surgery. Experimental studies regarding the potential use of FSL will also be introduced. The studies discussed in this review suggest that FSL may be a useful tool for improving the prognosis and safety of surgeries of the anterior segment.
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Liu YC, Ji AJS, Tan TE, Fuest M, Mehta JS. Femtosecond Laser-assisted Preparation of Conjunctival Autograft for Pterygium Surgery. Sci Rep 2020; 10:2674. [PMID: 32060326 PMCID: PMC7021803 DOI: 10.1038/s41598-020-59586-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/16/2019] [Indexed: 11/09/2022] Open
Abstract
Femtosecond laser-assisted conjunctival autografts (CAG) preparation was recently proposed. This study reports the outcomes of the first clinical trial on the use of laser to prepare CAG in pterygium surgery, and to compare the outcomes with those of manual technique. Forty eyes undergoing primary pterygium excision with laser-assisted CAG transplantation were prospectively included (L group). Two historical matched cohorts whose CAGs were prepared manually were compared (n = 78 eyes by the same experienced surgeon, M group; n = 78 eyes by trainees; TM group). We found the laser-created CAGs had only 11 μm deviation from the targeted thickness. The best-corrected visual acuity improved, and the astigmatism significantly decreased after surgery, with comparable efficacy across 3 groups. The 1-year recurrence rate was 2.5%, 3.8% and 7.7% in the L, M and TM groups, respectively (P = 0.12). There was no significant difference between the L and M groups in the complication rate (5.0% and 1.3%, respectively), surgical time (19.4 ± 5.1 and 19.1 ± 6.2 minutes, respectively), and postoperative discomfort scores (0.1 ± 0.3 and 0.2 ± 0.3, respectively), but these outcomes were significantly less favorable in the TM group. The results of this first comparative clinical trial suggest that femtosecond laser-assisted CAG preparation can be considered as an alternative technique for CAGs preparation.
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Affiliation(s)
- Yu-Chi Liu
- Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, Singapore, Singapore.,Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - Angel Jung Se Ji
- Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, Singapore, Singapore
| | - Tien-En Tan
- Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore, Singapore
| | - Matthias Fuest
- Department of Ophthalmology, RWTH Aachen University, Aachen, Germany
| | - Jodhbir S Mehta
- Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, Singapore, Singapore. .,Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore, Singapore. .,Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore. .,School of Material Science and Engineering, Nanyang Technological University, Singapore, Singapore.
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15
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Zhong X, Tang J, Li H, Shi X, Wu Y, Xia D, Zhang H, Ye J, Wu H. MiR-3175 promotes epithelial-mesenchymal transition by targeting Smad7 in human conjunctiva and pterygium. FEBS Lett 2019; 594:1207-1217. [PMID: 31774554 DOI: 10.1002/1873-3468.13698] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/17/2019] [Accepted: 11/20/2019] [Indexed: 12/22/2022]
Abstract
MicroRNAs (miRNAs) are involved in the post-transcriptional regulation of mRNAs. However, the function of miRNAs is unclear in epithelial-mesenchymal transition (EMT) of pterygium, a disease characterized by abnormal fibrovascular proliferation and invasion on the ocular surface. Since MiR-3175 is upregulated in pterygium tissues compared to normal conjunctival tissues, in this study, we investigated the role of MiR-3175 in EMT of a cultured human conjunctival epithelium cell line (CCL) and further validated the findings in pterygium tissues from patients. Our study demonstrates that MiR-3175 promotes proliferation, migration, invasion, and EMT of CCL cells by directly inhibiting Smad7. In conclusion, our data suggested that the MiR-3175-Smad7 axis may play a critical role in pathogenesis and development of pterygium.
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Affiliation(s)
- Xincao Zhong
- Department of Ophthalmology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinlong Tang
- Department of Ophthalmology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongyi Li
- The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Shi
- Department of Ophthalmology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yihua Wu
- Department of Toxicology of School of Public Health, Zhejiang University School of Medicine, Hangzhou, China.,Department of Gynecologic Oncology of Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dajing Xia
- Department of Toxicology of School of Public Health, Zhejiang University School of Medicine, Hangzhou, China.,Department of Gynecologic Oncology of Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huina Zhang
- Department of Ophthalmology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Juan Ye
- Department of Ophthalmology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Han Wu
- Department of Ophthalmology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Liu YC, Devarajan K, Tan TE, Ang M, Mehta JS. Optical Coherence Tomography Angiography for Evaluation of Reperfusion After Pterygium Surgery. Am J Ophthalmol 2019; 207:151-158. [PMID: 30959005 DOI: 10.1016/j.ajo.2019.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 03/29/2019] [Accepted: 04/01/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To describe the use of optical coherence tomography angiography (OCTA) to quantitatively monitor the conjunctival graft revascularization after pterygium excision and conjunctival autograft (CAG) transplantation. DESIGN Prospective, interventional case series. METHODS Ten patients undergoing pterygium excision and femtosecond laser-assisted CAG transplantation were included. OCTA was performed at 1 week, 1 and 3 months postoperatively at the CAG transplantation site and harvested area. The vessel density at three different depths: conjunctival epithelium or CAG epithelium, conjunctival stroma or CAG stroma, and episclera, was evaluated and quantified. The revascularization rate was assessed and correlated with the postoperative CAG thickness. RESULTS No intraoperative and postoperative complications occurred. Reperfusion of the CAGs was observed at 1 week, and early reperfusion within the first month accounted for more than half of graft revascularization. The vessel regrowth density was 9.6±2.6 % and 11.1±2.8 % between 1 week and 1 month, and was 9.8±1.8 % and 11.9±1.9 % between 1 and 3 months, at the CAG and underlying episcleral levels, respectively. All the CAGs were well-perfused at 3 months. The vessel regrowth density was significantly and strongly correlated with the changes of CAG thickness in a negative relationship (γ = -0.94, P = 0.019). At the harvested site, the vascular network of episclera was not affected, and the conjunctival vascularization was restored at 1 month. CONCLUSIONS OCTA is a promising tool to evaluate the vascularization or revascularization of conjunctiva, conjunctival graft and episclera, in a quantitative and serial manner, helping in diseases diagnosis and treatment monitoring. The graft revascularization rate was predictive of postoperative graft deswelling.
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Outcomes of Vertical Split Conjunctival Autograft Using Fibrin Glue in Treatment of Primary Double-Headed Pterygia. J Ophthalmol 2018; 2018:9341846. [PMID: 30671262 PMCID: PMC6317119 DOI: 10.1155/2018/9341846] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/22/2018] [Accepted: 12/10/2018] [Indexed: 11/18/2022] Open
Abstract
Purpose To evaluate the efficiency of pterygium excision with the vertical split conjunctival technique using fibrin glue in treatment of primary double-headed pterygia. Patients and Methods 15 eyes of 15 patients with primary double-headed pterygia that underwent vertical split conjunctival autograft pterygium surgery were retrospectively reviewed. Recurrence was defined as fibrovascular proliferation over the limbus onto the cornea. Results The patients' mean age was 36.92 ± 10.8 years. At 12-month follow-up, recurrence was not seen in any cases. Regarding postoperative cosmetic grading, grade 1 (the appearance of the operated site is not different from the normal appearance) was found in 12 eyes (80%) and grade 2 (some fine episcleral vessels in the excised area extending up to but not beyond the limbus and without fibrous tissue) was found in 3 eyes (20%). None of the cases showed conjunctival scarring or fibrosis at the conjunctival donor area. Preoperative Sim K astigmatism at the central 3 mm and BCVA were 3.05 ± 1.5 diopters (D) and 0.64 ± 0.26 logMAR, which improved significantly to 1.15 ± 0.84 D and 0.26 ± 0.18 logMAR at 12-month follow-up postoperatively, respectively. Conclusion Vertical split conjunctival autograft using fibrin glue is an effective technique with good cosmetic results and low to no recurrence for primary double-headed pterygia treatment. This trial is registered with NCT03507283.
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Tey ML, Liu YC, Chan ASY, Mehta JS. Excision of conjunctival melanosis and conjunctival autografting by femtosecond laser. Clin Exp Ophthalmol 2017; 46:432-434. [DOI: 10.1111/ceo.13091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/03/2017] [Accepted: 09/23/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Min Li Tey
- Tissue Engineering and Stem Cell Group; Singapore Eye Research Institute; Singapore
- Yong Loo Lin School of Medicine; National University of Singapore; Singapore
| | - Yu-Chi Liu
- Tissue Engineering and Stem Cell Group; Singapore Eye Research Institute; Singapore
- Department of Cornea and External Eye Disease; Singapore National Eye Centre; Singapore
- Ophthalmology and Visual Sciences Academic Clinical Programme; Duke-NUS Medical School; Singapore
| | - Anita SY Chan
- Department of Cornea and External Eye Disease; Singapore National Eye Centre; Singapore
- Ophthalmology and Visual Sciences Academic Clinical Programme; Duke-NUS Medical School; Singapore
- Department of Anatomical Pathology and Cytology, Pathology Division; Singapore General HospitalSingapore; Singapore
| | - Jodhbir S Mehta
- Tissue Engineering and Stem Cell Group; Singapore Eye Research Institute; Singapore
- Department of Cornea and External Eye Disease; Singapore National Eye Centre; Singapore
- Ophthalmology and Visual Sciences Academic Clinical Programme; Duke-NUS Medical School; Singapore
- School of Material Science and Engineering; Nanyang Technological University Singapore; Singapore
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Coroneo MT. Paradigm shifts, peregrinations and pixies in ophthalmology. Clin Exp Ophthalmol 2017; 46:280-297. [PMID: 28715851 DOI: 10.1111/ceo.13023] [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: 01/27/2017] [Revised: 06/28/2017] [Accepted: 07/05/2017] [Indexed: 12/21/2022]
Abstract
Human ingenuity is challenged by defending vision, our highest bandwidth sense. Special challenges are presented by the replacement or repair of highly specialized but scarce tissue within the constraints of transparency, tissue shape and alignment, tissue borders and pressure maintenance. Many, mostly destructive, surgical procedures were developed prior to an understanding of underlying pathophysiology. For a number of conditions, both reconstructive and destructive procedures co-exist, yet there are few guidelines as to the better approach. Because the consequences of these procedures may take many years to surface (consistent with a stem cell role in long-term tissue maintenance), guidance may be provided by the elucidation of underlying principles from these approaches. Illustrative examples from clinical, basic research and biotechnology, particularly relating to pterygium, ocular surface squamous neoplasia, dry-eye syndrome, corneal rehabilitation and replacement, cataract surgery, strabismus surgery and bionic eye research, are described. An unexpected consequence of bionic device development has been an appreciation of the sophistication of tissues being replaced, given the limitations of available biomaterials. Examples of how this has provided insights into ocular disease will be illustrated. Stem cell and biomaterial technologies are starting to impact at a time when cost-effectiveness is under scrutiny. Both efficacy and cost will need to be considered as these interventions are introduced. It appears that the paradigm shift rate is accelerating and there is evidence of this in ophthalmology. Lessons learned from the areas of destructive versus reconstructive surgery and the limitations of development of bionic replacements will be used to illustrate how new procedures and technologies can be developed.
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Affiliation(s)
- Minas T Coroneo
- Department of Ophthalmology, University of New South Wales at Prince of Wales Hospital, Sydney, Australia.,Ophthalmic Surgeons, Sydney, Australia.,East Sydney Private Hospital, Sydney, Australia.,Look for Life Foundation, Sydney, Australia
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21
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Fuest M, Mehta JS, Coroneo MT. New treatment options for pterygium. EXPERT REVIEW OF OPHTHALMOLOGY 2017. [DOI: 10.1080/17469899.2017.1324297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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