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Zhang J, Sheng X, Ding Q, Wang Y, Zhao J, Zhang J. Subretinal fibrosis secondary to neovascular age-related macular degeneration: mechanisms and potential therapeutic targets. Neural Regen Res 2025; 20:378-393. [PMID: 38819041 DOI: 10.4103/nrr.nrr-d-23-01642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/15/2024] [Indexed: 06/01/2024] Open
Abstract
Subretinal fibrosis is the end-stage sequelae of neovascular age-related macular degeneration. It causes local damage to photoreceptors, retinal pigment epithelium, and choroidal vessels, which leads to permanent central vision loss of patients with neovascular age-related macular degeneration. The pathogenesis of subretinal fibrosis is complex, and the underlying mechanisms are largely unknown. Therefore, there are no effective treatment options. A thorough understanding of the pathogenesis of subretinal fibrosis and its related mechanisms is important to elucidate its complications and explore potential treatments. The current article reviews several aspects of subretinal fibrosis, including the current understanding on the relationship between neovascular age-related macular degeneration and subretinal fibrosis; multimodal imaging techniques for subretinal fibrosis; animal models for studying subretinal fibrosis; cellular and non-cellular constituents of subretinal fibrosis; pathophysiological mechanisms involved in subretinal fibrosis, such as aging, infiltration of macrophages, different sources of mesenchymal transition to myofibroblast, and activation of complement system and immune cells; and several key molecules and signaling pathways participating in the pathogenesis of subretinal fibrosis, such as vascular endothelial growth factor, connective tissue growth factor, fibroblast growth factor 2, platelet-derived growth factor and platelet-derived growth factor receptor-β, transforming growth factor-β signaling pathway, Wnt signaling pathway, and the axis of heat shock protein 70-Toll-like receptors 2/4-interleukin-10. This review will improve the understanding of the pathogenesis of subretinal fibrosis, allow the discovery of molecular targets, and explore potential treatments for the management of subretinal fibrosis.
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Affiliation(s)
- Jingxiang Zhang
- Department of Ophthalmology, People's Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Xia Sheng
- Department of Ophthalmology, People's Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Quanju Ding
- Department of Ophthalmology, People's Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Yujun Wang
- Department of Urology, People's Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Jiwei Zhao
- Department of Ophthalmology, People's Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Jingfa Zhang
- Department of Ophthalmology, Shanghai General Hospital (Shanghai First People's Hospital), Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Eye Diseases, Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai, China
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Romano F, Cozzi E, Airaldi M, Nassisi M, Viola F, Aretti A, Milella P, Giuffrida FP, Teo KCY, Cheung CMG, Staurenghi G, Invernizzi A. Ten-Year Incidence of Fibrosis and Risk Factors for Its Development in Neovascular Age-Related Macular Degeneration. Am J Ophthalmol 2023; 252:170-181. [PMID: 37030492 DOI: 10.1016/j.ajo.2023.03.033] [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: 08/10/2022] [Revised: 03/25/2023] [Accepted: 03/27/2023] [Indexed: 04/10/2023]
Abstract
PURPOSE To report the incidence and risk factors for fibrosis at 10 years in a large cohort of persons with neovascular age-related macular degeneration (nAMD). DESIGN Retrospective, multicenter, cohort study. METHODS We included 225 naive nAMD eyes that underwent intravitreal anti-vascular endothelial growth factor treatment over 10 years of follow-up at two Italian referral centers. Demographic and clinical data were reviewed at baseline and on an annual basis. Onset of fibrosis was defined by clinically assessing photographs, fundus descriptions, or fluorescein angiograms. Optical coherence tomography (OCT) scans of fibrosis were inspected by an external reading center and graded as subretinal pigment epithelium (RPE), mixed, or subretinal. RESULTS The mean age at baseline was of 72.1 ± 6.9 years. The incidence rate of fibrosis was estimated to be 8.9 per 100 person-years, with a cumulative incidence of 62.7% at 10 years. Fibrotic lesions were sub-RPE in 46.1%, mixed in 29.8%, and subretinal in 22.7%. Independent factors associated with fibrosis included the following: larger central subfield thickness variation (P < .001), submacular hemorrhages (P = .008), higher number of injections (P = .01), and worse baseline visual acuity (VA) (P = .03). Type 2 macular neovascularization was significantly associated with mixed and subretinal fibrosis. VA significantly declined over 10 years (-16.4 Early Treatment Diabetic Retinopathy Study [ETDRS] letters), particularly in eyes with mixed and subretinal fibrosis (P < .001). CONCLUSIONS We identified a 62.7% cumulative incidence of fibrosis in a large nAMD cohort at 10 years. Fibrosis was more common with frequent reactivations and lower baseline VA; its onset had a significant impact on final VA. This supports the hypothesis that nAMD patients should be promptly treated with proactive regimens.
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Affiliation(s)
- Francesco Romano
- From the Eye Clinic, Luigi Sacco Hospital (F.R., E.C., M.A., G.S., A.I.), Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Elisa Cozzi
- From the Eye Clinic, Luigi Sacco Hospital (F.R., E.C., M.A., G.S., A.I.), Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Matteo Airaldi
- From the Eye Clinic, Luigi Sacco Hospital (F.R., E.C., M.A., G.S., A.I.), Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Marco Nassisi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico (M.N., F.V.), Milan, Italy
| | - Francesco Viola
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico (M.N., F.V.), Milan, Italy
| | - Andrea Aretti
- Department of Clinical Sciences and Community Health (A.A., P.M., F.P.G.), University of Milan, Milan, Italy
| | - Paolo Milella
- Department of Clinical Sciences and Community Health (A.A., P.M., F.P.G.), University of Milan, Milan, Italy
| | - Francesco Pozzo Giuffrida
- Department of Clinical Sciences and Community Health (A.A., P.M., F.P.G.), University of Milan, Milan, Italy
| | - Kelvin C Y Teo
- Singapore Eye Research Institution (K.C.Y.T., C.M.G.C.), Singapore National Eye Centre, Singapore; Duke-NUS Medical School (K.C.Y.T., C.M.G.C.), National University of Singapore, Singapore
| | - Chui Ming Gemmy Cheung
- Singapore Eye Research Institution (K.C.Y.T., C.M.G.C.), Singapore National Eye Centre, Singapore; Duke-NUS Medical School (K.C.Y.T., C.M.G.C.), National University of Singapore, Singapore
| | - Giovanni Staurenghi
- From the Eye Clinic, Luigi Sacco Hospital (F.R., E.C., M.A., G.S., A.I.), Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Alessandro Invernizzi
- From the Eye Clinic, Luigi Sacco Hospital (F.R., E.C., M.A., G.S., A.I.), Department of Biomedical and Clinical Science, University of Milan, Milan, Italy; Faculty of Health and Medicine (A.I.), Save Sight Institute, University of Sydney, Sydney, NSW, Australia.
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Fu DJ, Hanumunthadu D, Keenan TDL, Wagner S, Balsakas K, Keane PA, Patel PJ. Characterising treatment outcomes of patients achieving quarterly aflibercept dosing for neovascular age-related macular degeneration: real-world clinical outcomes from a large tertiary care centre. Eye (Lond) 2023; 37:779-784. [PMID: 36085360 PMCID: PMC9998641 DOI: 10.1038/s41433-022-02220-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 06/09/2022] [Accepted: 08/16/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND AND OBJECTIVE To evaluate the proportion of patients achieving a 12-week (q12) aflibercept dosing interval in patients with neovascular age-related macular degeneration (nAMD). PATIENTS AND METHODS Retrospective, comparative, non-randomised electronic medical record (EMR) database study of the Moorfields database of treatment-naïve nAMD eyes. Extraction criteria included at least 7 aflibercept injections in first year of treatment, AMD in the diagnosis field of EMR, and minimum of 1 year follow-up data. RESULTS There were 2416 eyes of 2163 patients started on anti-vascular endothelial growth factor (anti-VEGF) between 01-11-2013 & 14-02-2020 who had received at least 7 aflibercept intravitreal injections (electronic database accessed March 2021). Of these, 1674 (68%) eyes of 1537 patients had at least one q12 dosing interval (>=84 and < =98 days between injections) during the first 2 years of treatment. This included 926 (61.8%) female patients and 856 (right eyes age at 1st injection), 936 (62.4%) Caucasian, and 32 (2.1%) Afro-Caribbean patients. The median time to the first q12 injection (95% confidence interval) was 1.76 years (1.70-1.86) with mean (±SD) of 11.8 (±6.0) injections. Visual acuity (ETDRS letters) of the eyes without q12 injection and eyes with a q12 injection was 57.9 ± 14.7 and 56.7 ± 14.8 respectively at baseline, 61.4 ± 18.1 and 63.0 ± 15.9 respectively at 12 months and 61.2 ± 20.1 and 61.1 ± 17.8 respectively at 24 months. CONCLUSION 68% of eyes were able to achieve a q12 injection dose within the first 2 years of treatment. Eyes achieving a q12 injection in the first 2 years achieved a similar visual acuity outcome at both 1 and 2-year follow-up to those unable to do so, with a fewer number of total injections.
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Affiliation(s)
- Dun Jack Fu
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Daren Hanumunthadu
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Tiarnan D L Keenan
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
- Division of Epidemiology and Clinical Applications, National Eye Institute, National Institutes of Health, Bethesda, MA, USA
| | - Siegfried Wagner
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Konstantinos Balsakas
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Pearse A Keane
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Praveen J Patel
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK.
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Multimodal Imaging Characteristics and Functional Correlates in Rip Healing. Retina 2022; 42:1844-1851. [DOI: 10.1097/iae.0000000000003542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gabrielle PH, Nguyen V, Arnold JJ, Bhandari S, Viola F, Tigchelaar-Besling OAM, Garay-Aramburu G, O'Toole L, Cheung CMG, Barthelmes D, Creuzot-Garcher C, Gillies M. Three-Year Outcomes of Neovascular Age-Related Macular Degeneration in Eyes That Do Not Develop Macular Atrophy or Subretinal Fibrosis. Transl Vis Sci Technol 2021; 10:5. [PMID: 34730771 PMCID: PMC8572511 DOI: 10.1167/tvst.10.13.5] [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] [Indexed: 11/24/2022] Open
Abstract
Purpose To report the 36-month treatment outcomes of eyes with neovascular age-related macular degeneration (nAMD) receiving vascular endothelial growth factor (VEGF) inhibitors in daily practice who did not develop either subretinal fibrosis (SRFi) or macular atrophy (MA). Methods This is a retrospective analysis of data from the Fight Retinal Blindness registry. Treatment-naïve eyes starting intravitreal injection of VEGF inhibitors for nAMD from January 1, 2010, to September 1, 2017, and did not have SRFI and MA at baseline were tracked. Results We identified 2478 eligible eyes, of which 1712 eyes did not develop SRFi or MA, 291 developed extrafoveal SRFI or MA, and 475 developed subfoveal SRFi or MA over 36 months. The estimated visual acuity stabilized from 6 months to 36 months in eyes that did not develop SRFI or MA with a mean (95% confidence interval [CI]) change in VA of −1 (−2, 0) letters, whereas eyes that developed extrafoveal (−3 [−5, −2] letters) or subfoveal (−10 [−11, −8] letters) SRFi or MA declined in vision in the same period. Eyes with no or extrafoveal SRFi or MA over 36 months were more likely to maintain their visual improvement from six months to 36 months (odds ratio [OR; 95% CI] = 2.3 [1.5, 3.3] for absence vs. subfoveal SRFi or MA, P ≤ 0.01 and OR = 2.0 [1.2, 3.4] for extrafoveal vs. subfoveal MA or SRFi, P = 0.01). Conclusions Treatment-naïve nAMD eyes receiving VEGF inhibitors maintain their initial six-month visual improvement over three years if they do not develop SRFI or MA. Translational Relevance The nAMD is still a major cause of blindness despite antiangiogenic treatments. We found that eyes that did not develop subretinal fibrosis or macular atrophy maintained their initial vision improvement for at least three years, suggesting that identifying treatments for these complications is the final barrier to achieving excellent outcomes in nAMD.
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Affiliation(s)
- Pierre-Henry Gabrielle
- The University of Sydney, Sydney Medical School, Discipline of Ophthalmology, Save Sight Institute, Sydney, Australia.,Department of Ophthalmology, Dijon University Hospital, Dijon, France
| | - Vuong Nguyen
- The University of Sydney, Sydney Medical School, Discipline of Ophthalmology, Save Sight Institute, Sydney, Australia
| | | | - Sanjeeb Bhandari
- The University of Sydney, Sydney Medical School, Discipline of Ophthalmology, Save Sight Institute, Sydney, Australia
| | - Francesco Viola
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | | | | | - Louise O'Toole
- Department of Ophthalmology, Mater Private Hospital, Dublin, Ireland
| | | | - Daniel Barthelmes
- The University of Sydney, Sydney Medical School, Discipline of Ophthalmology, Save Sight Institute, Sydney, Australia.,Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Mark Gillies
- The University of Sydney, Sydney Medical School, Discipline of Ophthalmology, Save Sight Institute, Sydney, Australia
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Phan LT, Broadhead GK, Hong TH, Chang AA. Predictors of Visual Acuity After Treatment of Neovascular Age-Related Macular Degeneration - Current Perspectives. Clin Ophthalmol 2021; 15:3351-3367. [PMID: 34408393 PMCID: PMC8364912 DOI: 10.2147/opth.s205147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/28/2021] [Indexed: 12/30/2022] Open
Abstract
Visual acuity is a key outcome measure in the treatment of neovascular age-related macular degeneration (nAMD) using anti-vascular endothelial growth factor agents. Large variations in visual responses between individuals within clinical trials and real-world studies may relate to underlying differences in patient and treatment factors. Most notably, a better baseline visual acuity, younger age and smaller choroidal neovascularization lesion size have been strongly associated with achieving better visual outcomes. In addition, there is emerging evidence for other roles including genetic factors and anatomical variables such as fluid status. Apart from patient-related factors, treatments that favor a higher number of injections tend to provide better visual outcomes. Overall, the identification of predictive factors does not currently play an essential role in the clinical management of patients with nAMD. However, they have allowed for the understanding that early detection, timely management and close monitoring of the disease are required to achieve optimal visual outcomes. Further investigation into predictive factors alongside the development of novel therapeutic agents may one day provide a means to accurately predict patient outcomes. Treatment regimens that offer flexible dosing patterns such as the treat-and-extend strategy currently provide a degree of personalization during treatment.
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Affiliation(s)
- Long T Phan
- Sydney Retina, Sydney, New South Wales, Australia.,Discipline of Orthoptics, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Geoffrey K Broadhead
- Sydney Retina, Sydney, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Andrew A Chang
- Sydney Retina, Sydney, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
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Gonzalez-Buendia L, Delgado-Tirado S, An M, O'Hare M, Amarnani D, A B Whitmore H, Zhao G, Ruiz-Moreno JM, Arboleda-Velasquez JF, Kim LA. Treatment of Experimental Choroidal Neovascularization via RUNX1 Inhibition. THE AMERICAN JOURNAL OF PATHOLOGY 2021; 191:418-424. [PMID: 33345998 PMCID: PMC7931615 DOI: 10.1016/j.ajpath.2020.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/06/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Abstract
Choroidal neovascularization (CNV) is a prevalent cause of vision loss in patients with age-related macular degeneration. Runt-related transcription factor 1 (RUNX1) has been identified as an important mediator of aberrant retinal angiogenesis in proliferative diabetic retinopathy and its modulation has proven to be effective in curbing pathologic angiogenesis in experimental oxygen-induced retinopathy. However, its role in CNV remains to be elucidated. This study demonstrates RUNX1 expression in critical cell types involved in a laser-induced model of CNV in mice. Furthermore, the preclinical efficacy of Ro5-3335, a small molecule inhibitor of RUNX1, in experimental CNV is reported. RUNX1 inhibitor Ro5-3335, aflibercept-an FDA-approved vascular endothelial growth factor (VEGF) inhibitor, or a combination of both, were administered by intravitreal injection immediately after laser injury. The CNV area of choroidal flatmounts was evaluated by immunostaining with isolectin B4, and vascular permeability was analyzed by fluorescein angiography. A single intravitreal injection of Ro5-3335 significantly decreased the CNV area 7 days after laser injury, and when combined with aflibercept, reduced vascular leakage more effectively than aflibercept alone. These data suggest that RUNX1 inhibition alone or in combination with anti-VEGF drugs may be a new therapy upon further clinical validation for patients with neovascular age-related macular degeneration.
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Affiliation(s)
- Lucia Gonzalez-Buendia
- Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Santiago Delgado-Tirado
- Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Miranda An
- Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Michael O'Hare
- Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Dhanesh Amarnani
- Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Hannah A B Whitmore
- Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Guannan Zhao
- Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Jose M Ruiz-Moreno
- Department of Ophthalmology, Castilla la Mancha University, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain; Vissum Corporation, Alicante, Spain
| | - Joseph F Arboleda-Velasquez
- Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts.
| | - Leo A Kim
- Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts.
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Hoffmann L, Rossouw P, Guichard MM, Hatz K. Strongest Correlation Between Contrast Sensitivity and Morphological Characteristics in Bilateral nAMD. Front Med (Lausanne) 2021; 7:622877. [PMID: 33585517 PMCID: PMC7876058 DOI: 10.3389/fmed.2020.622877] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/30/2020] [Indexed: 11/13/2022] Open
Abstract
In patients with neovascular age-related macular degeneration (nAMD) there is often an inconsistency between their subjective visual impairment and a still relatively preserved standard Early Treatment of Diabetic Retinopathy Study (ETDRS) best corrected visual acuity. Therefore, in order to better capture the specific functional defects in nAMD, other tests need to be evaluated. In a previous study, we reported contrast sensitivity of the better eye to best correlate with near distance and distance vision related quality of life in patients with bilateral nAMD. Here, we evaluated Pelli-Robson contrast sensitivity, ETDRS visual acuity, low luminance visual acuity and Radner maximum reading speed and correlated them with several morphologic parameters as measured on fundus autofluorescence imaging, optical coherence tomography and optical tomography angiography in 54 patients. A multiple regression analysis was performed which correlated each visual function parameter with the anatomic features. The results showed the strongest correlations between the total area of macular geographic atrophy as well as the percentage of geographic atrophy in the central 1 mm and contrast sensitivity. Further, the regression model selected the total area of macular geographic atrophy, the photoreceptor inner and outer segments interface disruption score, the presence of subretinal fibrosis in the central 1 mm and the central retinal thickness as the variables that explained 71% of the variation in contrast sensitivity when including all eyes. Hence, our results suggest that among the evaluated measures of vision, contrast sensitivity is best correlated with the morphologic impairment in bilateral nAMD. Thus, contrast sensitivity may complement ETDRS visual acuity in clinical trials and serve as a standard diagnostic tool in clinical practice.
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Affiliation(s)
| | - Petra Rossouw
- Vista Klinik, Binningen, Switzerland.,Department of Vision Science and Optometry, University of Aalen, Aalen, Germany
| | | | - Katja Hatz
- Vista Klinik, Binningen, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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