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Liao Y, Zhao W, Yang J, Wu S, Jin L, Huang F, Liang L. Vision-specific and cancer-specific quality of life in ocular graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Graefes Arch Clin Exp Ophthalmol 2023; 261:453-465. [PMID: 36029303 DOI: 10.1007/s00417-022-05812-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/20/2022] [Accepted: 08/16/2022] [Indexed: 01/17/2023] Open
Abstract
PURPOSE To compare the vision-specific and cancer-specific quality of life (QOL) between patients with and without ocular graft-versus-host disease (oGVHD) after allogeneic hematopoietic stem cell transplantation (alloHCT). METHODS This cross-sectional observational study analyzed 142 patients after alloHCT including 94 patients with oGVHD and 48 without. oGVHD was diagnosed according to International Chronic Ocular GVHD Consensus Group (ICOGCG) criteria. QOL was assessed by using the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). RESULTS Compared with non-oGVHD patients, patients with oGVHD had worse vision-specific (NEI VFQ-25: 64.3 ± 20.3 vs. 77.6 ± 19.3, P < 0.001) and cancer-specific (EORTC QLQ-C30: 59.9 ± 20.3 vs. 67.4 ± 17.5, P = 0.03) QOL, as well as impaired cognitive function (72.7 ± 22.1 vs. 82.3 ± 19.0, P = 0.01). The vision-specific QOL was significantly correlated with ICOGCG score (β = - 1.88, 95%CI: - 3.35 to - 0.41, P = 0.01) and post-alloHCT medical expense (β = - 5.70, 95%CI: - 10.35 to - 1.05, P = 0.02), while cancer-specific QOL was strikingly correlated with post-alloHCT medical expense (β = - 9.91, 95%CI: - 14.43 to - 5.39, P < 0.001), frequency of ophthalmic medication (β = - 0.93, 95%CI: - 1.64 to - 0.21, P = 0.01), education (β = - 6.97, 95%CI: - 13.31 to - 0.62, P = 0.03), and peripheral blood stem cell use (β = - 6.42, 95%CI: - 12.59 to - 0.25, P = 0.04). CONCLUSIONS Patients with oGVHD experienced significant impairment in both vision-specific and cancer-specific QOL including cognitive function when compared with those without after alloHCT. Multidimensional QOL assessment should be included in the long-term alloHCT survivorship care.
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Affiliation(s)
- Yinglin Liao
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, 510060, China
| | - Wenxin Zhao
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, 510060, China
| | - Jing Yang
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, 510060, China
| | - Shaowen Wu
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, 510060, China
| | - Ling Jin
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, 510060, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, 1838S North of Guangzhou Avenue, Guangzhou, 510515, China.
| | - Lingyi Liang
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, 510060, China.
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Yang F, Hayashi I, Sato S, Saijo-Ban Y, Yamane M, Fukui M, Shimizu E, He J, Shibata S, Mukai S, Asai K, Ogawa M, Lan Y, Zeng Q, Hirakata A, Tsubota K, Ogawa Y. Eyelid blood vessel and meibomian gland changes in a sclerodermatous chronic GVHD mouse model. Ocul Surf 2021; 26:328-341. [PMID: 34715372 DOI: 10.1016/j.jtos.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 10/10/2021] [Accepted: 10/21/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate pathological changes in blood vessels and meibomian glands (MGs) in the eyelids of sclerodermatous chronic graft-versus-host disease (cGVHD) model mice. METHODS We used an established major histocompatibility complex compatible, multiple minor histocompatibility antigen-mismatched sclerodermatous cGVHD mouse model. Blood vessels and MGs of eyelids from allogeneic bone marrow transplantation (allo-BMT) recipient mice and syngeneic bone marrow transplantation (syn-BMT) recipient mice were assessed by histopathology, immunohistochemistry and transmission electron microscopy. Peripheral blood samples from the recipients were examined by flow cytometry. RESULTS Allo-BMT samples showed dilating, tortuous and branching vessels and shrunk MGs in the eyelids; showed significantly higher expression of VEGFR2 (p = 0.029), CD133 (p = 0.016), GFP (p = 0.006), and α-SMA (p = 0.029) in the peripheral MG area; showed endothelial damage and activation, fibrotic change, and immune cell infiltration into MGs compared with syn-BMT samples. Fewer Ki-67+ cells were observed in allo- and syn-BMT samples than in wild-type samples (p = 0.030). Ultrastructural changes including endothelial injury and activation, fibroblast activation, granulocyte degranulation, immune cell infiltration into MGs, and necrosis, apoptosis of MG basal cells were found in allo-BMT samples compared with syn-BMT samples. CONCLUSION A series of our studies indicated that cGVHD can cause eyelid vessel and MGs changes, including endothelial injury and activation, neovascularization, early fibrotic changes, immune cell infiltration, MG basal cell necrosis and apoptosis, and resultant MG atrophy.
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Affiliation(s)
- Fan Yang
- Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan; Department of Ophthalmology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China; Aier School of Ophthalmology, Central South University, Changsha, China
| | - Isami Hayashi
- Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan; Department of Ophthalmology, Kyorin University, School of Medicine, Tokyo, Japan
| | - Shinri Sato
- Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan
| | - Yumiko Saijo-Ban
- Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan
| | - Mio Yamane
- Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan
| | - Masaki Fukui
- Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan
| | - Eisuke Shimizu
- Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan
| | - Jingliang He
- Eye Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Shinsuke Shibata
- Electron Microscope Laboratory, Keio University School of Medicine, Tokyo, Japan
| | - Shin Mukai
- Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women's Hospital, Harvard Medical School, Massachusetts, USA
| | - Kazuki Asai
- Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan
| | - Mamoru Ogawa
- Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan
| | - Yuqing Lan
- Department of Ophthalmology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qingyan Zeng
- Aier Eye Hosoital of Wuhan University, Wuhan, Hubei province, China
| | - Akito Hirakata
- Department of Ophthalmology, Kyorin University, School of Medicine, Tokyo, Japan
| | - Kazuo Tsubota
- Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan; Tsubota Laboratory, Inc., Tokyo, Japan.
| | - Yoko Ogawa
- Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan.
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Longitudinal Tear Protein Changes Correlate with Ocular Chronic GVHD Development in Allogeneic Hematopoietic Stem Cell Transplant Patients. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11178221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Ocular graft-versus-host disease (oGVHD) is a manifestation of chronic GVHD, frequently occurring in patients after allogeneic hematopoietic stem cell transplant (HSCT). We analyzed tear protein changes before and after allogeneic HSCT, and correlated their levels with the oGVHD development. This retrospective study included 102 patients, and data were recorded before the conditioning treatment, and after 3 to 6 months postoperatively. Tear protein analysis was performed with the Agilent-2100 Bioanalyzer on individual tears sampled by aspiration. Total protein (TP), Lysozyme-C (LYS-C), Lactoferrin (LACTO), Lipocalin-1 (LIPOC-1), Transferrin (TRANSF), Albumin (ALB), and Zinc-alpha-2-glycoprotein (ZAG-2) levels were retrieved and statistically analyzed. Following HSCT forty-three patients developed oGVHD. TP, LACTO, LYS-C, and ZAG-2 levels significantly decreased post-HSCT as compared to pre HSCT levels. In univariate analysis, TP, LACTO, and ZAG-2 decrease was associated with an increased development of oGVHD (OR = 4.49; 95% CI, 1.9 to 10.5; p < 0.001; OR = 3.08; 95% CI 1.3 to 7.6; p = 0.01; OR = 11.1; 95% CI 2.7 to 46.6; p < 0.001, respectively). TRANSF post-HSCT levels significantly increased (OR 15.7; 95% CI, 4.1 to 52.2; p = 0.0001). No pre-post-HSCT changes were shown in ALB and LIPOC-1 levels. Data suggest that TP content, LACTO, TRANSF, and ZAG-2 pre-post changes might be significant predictors of oGVHD development.
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Meftahpour V, Malekghasemi S, Baghbanzadeh A, Aghebati-Maleki A, Pourakbari R, Fotouhi A, Aghebati-Maleki L. Platelet lysate: a promising candidate in regenerative medicine. Regen Med 2021; 16:71-85. [PMID: 33543999 DOI: 10.2217/rme-2020-0065] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Human platelet lysate has attracted much interest from many researchers as it is growth-factor rich for cell expansion, which is employed as a new therapeutic strategy. Not only are human platelet lysates used for cell therapy, but they are also used for the completion of basal media in mesenchymal stem cell cultures. Due to the presence of a large number of growth factors, platelet lysates have potential roles in wound healing, treatment of ocular graft-versus-host disease, osteoarthritis, Parkinson's disease, tendon regeneration, infertility, androgenetic alopecia, nerve repair and regenerative tissue, such as bone regeneration. In this review, we summarize that platelet lysates could be valuable candidates for the treatment of a variety of diseases in regenerative medicine.
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Affiliation(s)
- Vafa Meftahpour
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, 51656 65811, Iran
| | - Somaiyeh Malekghasemi
- Department of Basic Oncology, Oncology Institute, Hacettepe University, Sihhiye, Ankara, TR-06100, Turkey
| | - Amir Baghbanzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, 51656 65811, Iran
| | - Ali Aghebati-Maleki
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, 51656 65811, Iran
| | - Ramin Pourakbari
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, 51656 65811, Iran
| | - Ali Fotouhi
- Department of Orthopedic Surgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, 51656 65811, Iran
| | - Leili Aghebati-Maleki
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, 51656 65811, Iran.,Department of Immunology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, 51656 65811, Iran
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Shimizu E, Aketa N, Yazu H, Uchino M, Kamoi M, Sato Y, Tsubota K, Ogawa Y. Corneal higher-order aberrations in eyes with chronic ocular graft-versus-host disease. Ocul Surf 2020; 18:98-107. [DOI: 10.1016/j.jtos.2019.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/04/2019] [Accepted: 10/08/2019] [Indexed: 11/26/2022]
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Evaluation of health and quality of life in apheresis patients – data from the WAA register. Transfus Apher Sci 2019; 58:641-644. [DOI: 10.1016/j.transci.2019.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/22/2019] [Indexed: 11/19/2022]
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An S, Raju I, Surenkhuu B, Kwon JE, Gulati S, Karaman M, Pradeep A, Sinha S, Mun C, Jain S. Neutrophil extracellular traps (NETs) contribute to pathological changes of ocular graft-vs.-host disease (oGVHD) dry eye: Implications for novel biomarkers and therapeutic strategies. Ocul Surf 2019; 17:589-614. [PMID: 30965123 PMCID: PMC6721977 DOI: 10.1016/j.jtos.2019.03.010] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 03/27/2019] [Accepted: 03/28/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE To investigate the role of neutrophil extracellular traps (NETs) and NET-associated proteins in the pathogenesis of oGVHD and whether dismantling of NETs with heparin reduces those changes. METHODS Ocular surface washings from oGVHD patients and healthy subjects were analyzed. Isolated peripheral blood human neutrophils were stimulated to generate NETs and heparinized NETs. We performed in vitro experiments using cell lines (corneal epithelial, conjunctival fibroblast, meibomian gland (MG) epithelial and T cells), and in vivo experiments using murine models, and compared the effects of NETs, heparinized NETs, NET-associated proteins and neutralizing antibodies to NET-associated proteins. RESULTS Neutrophils, exfoliated epithelial cells, NETs and NET-associated proteins (extracellular DNA, Neutrophil Elastase, Myeloperoxidase, Oncostatin M (OSM), Neutrophil gelatinase-associated lipocalin (NGAL) and LIGHT/TNFSF14) are present in ocular surface washings (OSW) and mucocellular aggregates (MCA). Eyes with high number of neutrophils in OSW have more severe signs and symptoms of oGVHD. NETs (and OSM) cause epitheliopathy in murine corneas. NETs (and LIGHT/TNFSF14) increase proliferation of T cells. NETs (and NGAL) inhibit proliferation and differentiation of MG epithelial cells. NETs enhance proliferation and myofibroblast transformation of conjunctival fibroblasts. Sub-anticoagulant dose Heparin (100 IU/mL) dismantles NETs and reduces epithelial, fibroblast, T cell and MG cell changes induced by NETs. CONCLUSION NETs and NET-associated proteins contribute to the pathological changes of oGVHD (corneal epitheliopathy, conjunctival cicatrization, ocular surface inflammation and meibomian gland disease). Our data points to the potential of NET-associated proteins (OSM or LIGHT/TNFSF14) to serve as biomarkers and NET-dismantling biologics (heparin eye drops) as treatment for oGVHD.
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Affiliation(s)
- Seungwon An
- Cornea Translational Biology Laboratory, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Ilangovan Raju
- Cornea Translational Biology Laboratory, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Bayasgalan Surenkhuu
- Cornea Translational Biology Laboratory, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Ji-Eun Kwon
- Cornea Translational Biology Laboratory, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Shilpa Gulati
- Cornea Translational Biology Laboratory, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Muge Karaman
- Department of Bioengineering, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Anubhav Pradeep
- Cornea Translational Biology Laboratory, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | | | - Christine Mun
- Cornea Translational Biology Laboratory, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Sandeep Jain
- Cornea Translational Biology Laboratory, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, 60612, USA.
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Westekemper H, Scholz SL, Thomasen H, Halfwassen C, Steuhl KP. [Ocular graft versus host disease : Corneal complications]. Ophthalmologe 2017; 114:697-702. [PMID: 28439655 DOI: 10.1007/s00347-017-0488-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ocular graft-versus-host disease (GvHD) following allogeneic blood stem cell transplantation leads to immunologically induced alterations in many ocular tissues, particularly at the ocular surface. Within the framework of the main topic, this article focuses primarily on corneal complications in chronic ocular GvHD. OBJECTIVE This article aims to promote understanding of the influencing factors, diagnostics, and therapeutic options pertaining to corneal complications in ocular GvHD. Furthermore, the possibilities for prevention are discussed. MATERIALS AND METHODS This analysis is based on a literature review as well as on data from the Ophthalmology Clinic at the University Hospital Essen. RESULTS Corneal complications often occur secondarily in ocular GvHD, as a consequence of severe inflammatory alterations of the conjunctiva or eyelid. Spontaneous corneal perforations associated with only mild symptoms are less common during the course of disease. From the ophthalmologist's perspective, it is important that the inflammatory activity of all the different ocular tissues is considered. Treatment may follow a stepwise scheme that includes substitution, immunosuppression, and surgical rehabilitation. CONCLUSION Systematic diagnosis of ocular GvHD helps to prevent corneal complications or support early therapeutic intervention. An interdisciplinary approach to diagnosis and treatment planning is recommended, in order to optimize local and systemic immunosuppressive therapy.
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Affiliation(s)
- H Westekemper
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Hufelandstr. 55, 45134, Essen, Deutschland.
| | - S L Scholz
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Hufelandstr. 55, 45134, Essen, Deutschland
| | - H Thomasen
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Hufelandstr. 55, 45134, Essen, Deutschland
| | - C Halfwassen
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Hufelandstr. 55, 45134, Essen, Deutschland
| | - K-P Steuhl
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Hufelandstr. 55, 45134, Essen, Deutschland
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Pezzotta S, Del Fante C, Scudeller L, Rossi GC, Perotti C, Bianchi PE, Antoniazzi E. Long-term safety and efficacy of autologous platelet lysate drops for treatment of ocular GvHD. Bone Marrow Transplant 2016; 52:101-106. [PMID: 27595285 DOI: 10.1038/bmt.2016.221] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 07/13/2016] [Accepted: 07/18/2016] [Indexed: 11/09/2022]
Abstract
Current ocular GvHD (oGvHD) treatments are suboptimal. We investigated the safety and efficacy of long-term continuous treatment with autologous platelet lysate (PL) drops in patients with oGvHD Dry Eye Syndrome (DES) score 2-3 refractory to topical conventional therapy. Ophthalmic evaluation was performed at 6 month intervals. Symptoms were assessed using the Glaucoma Symptom Scale (GSS). Patients were defined 'responders' when showing a reduction at least one grade on National Institutes of Health Eye Score from baseline at the 6 month visit. Thirty-one patients were included, and 16 (51%) completed 36 months of follow-up (range 6.5-72.7). At 6 months all patients were classified as responders: median GSS symptom score decreased from 70 to 41 (33 at 36 months), median GSS function score reduced from 68 to 46 (33 at 36 months) (all P<0.001). Median Tear Break Up Time improved from 3 to 6 s after 6 months and was maintained over time. All signs improved at 6 and 36 months (clinical and statistical significance). No severe adverse events occurred. Long-term treatment with PL drops is secure and effective for oGvHD and can be an efficient therapy option from initial stages of oGvHD to prevent permanent ocular impairment and improving quality of life.
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Affiliation(s)
- S Pezzotta
- Department of Ophthalmology, University Eye Clinic of Pavia, IRCCS Policlinico S Matteo Foundation, Pavia, Italy
| | - C Del Fante
- Immunohaematology and Transfusion Service, Apheresis Unit, IRCCS Policlinico S Matteo Foundation, Pavia, Italy
| | - L Scudeller
- Biostatistic and clinical epidemiology unit, Scientific Direction, IRCCS Policlinic San Matteo Foundation, Pavia, Italy
| | - G C Rossi
- Department of Ophthalmology, University Eye Clinic of Pavia, IRCCS Policlinico S Matteo Foundation, Pavia, Italy
| | - C Perotti
- Immunohaematology and Transfusion Service, Apheresis Unit, IRCCS Policlinico S Matteo Foundation, Pavia, Italy
| | - P E Bianchi
- Department of Ophthalmology, University Eye Clinic of Pavia, IRCCS Policlinico S Matteo Foundation, Pavia, Italy
| | - E Antoniazzi
- Department of Ophthalmology, University Eye Clinic of Pavia, IRCCS Policlinico S Matteo Foundation, Pavia, Italy
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