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Fredriksson A, Elving S, Saric A, Winther N, Viberg A, Behndig A. Thermographic analysis of the corneal surface in epi-on and epi-off corneal crosslinking for keratoconus. Acta Ophthalmol 2024; 102:529-534. [PMID: 37983864 DOI: 10.1111/aos.15817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/25/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE To analyse the temperature of the corneal surface in keratoconus during corneal customized crosslinking (CXL) with a preserved epithelium (epi-on) under oxygen flow, and epi-off CXL in room air, and to assess the effect of pre-heating the oxygen. METHODS This masked, intra-individual comparing randomized study included 14 participants with bilateral progressive keratoconus treated with bilateral CXL: one eye with epi-on CXL under a flow of 2.5 L/min oxygen; the fellow eye with epi-off CXL in room air. In a second setting involving 12 healthy participants, room-tempered oxygen was flushed over one eye and oxygen pre-heated to 37°C over the fellow eye. The corneal surface temperature was assessed with infrared photography. RESULTS A reduction in corneal surface temperature was seen from the pre-treatment application of topical riboflavin in the epi-off group (-1.1 ± 1.0°C, p < 0.001). The temperature increased during the first half of the CXL treatment in both groups (+0.7 ± 1.2°C, p = 0.041 for epi-on; +0.7 ± 0.9°C, p = 0.023 for epi-off CXL, respectively). In epi-on CXL an overall temperature increase was seen during the treatment (+0.8 ± 1.2°C, p = 0.016). In the second setting, pre-heating the oxygen rendered a surface temperature increase of +1.8 ± 0.2°C (p < 0.001). CONCLUSION In epi-off CXL, the application of topical room-tempered riboflavin decreases the corneal surface temperature, likely due to increased evaporation. A slight temperature increase is seen during CXL with both epi-on and epi-off CXL, albeit far below the corneal safety limit. The corneal temperature can, however, be increased by applying pre-heated oxygen, a possible approach to modify or augment the treatment effect in CXL.
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Affiliation(s)
- Anneli Fredriksson
- Department of Clinical Sciences/Ophthalmology, Umeå University, Umeå, Sweden
| | - Sofie Elving
- Department of Clinical Sciences/Ophthalmology, Umeå University, Umeå, Sweden
| | - Amanda Saric
- Department of Clinical Sciences/Ophthalmology, Umeå University, Umeå, Sweden
| | - Niclas Winther
- Department of Clinical Sciences/Ophthalmology, Umeå University, Umeå, Sweden
| | - Andreas Viberg
- Department of Clinical Sciences/Ophthalmology, Umeå University, Umeå, Sweden
| | - Anders Behndig
- Department of Clinical Sciences/Ophthalmology, Umeå University, Umeå, Sweden
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Cehelyk EK, Syed ZA. Long-term outcomes of corneal crosslinking. Curr Opin Ophthalmol 2024; 35:315-321. [PMID: 38700950 DOI: 10.1097/icu.0000000000001054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
PURPOSE OF REVIEW This manuscript summarizes contemporary research from 2018 to 2023 evaluating long-term (≥2 years) outcomes of corneal crosslinking (CXL) for progressive keratoconus (KCN). RECENT FINDINGS The standard Dresden protocol (SDP) has been utilized clinically since the early 2000 s to treat ectatic disorders, primarily progressive KCN and postrefractive ectasia. Various modifications have since been introduced including accelerated and transepithelial protocols, which are aimed at improving outcomes or reducing complications. This review summarizes data demonstrating that the SDP halts disease progression and improves various visual and topographic indices (UDVA, CDVA, Kmax, K1, K2) up to 13 years postoperatively. Accelerated and transepithelial protocols have been found to be well tolerated alternatives to SDP with similar efficacy profiles. Studies focusing on pediatric populations identified overall higher progression rates after CXL. All protocols reviewed had excellent safety outcomes in adults and children. SUMMARY Recent studies revealed that SDP successfully stabilizes KCN long term, and a variety of newer protocols are also effective. Pediatric patients may exhibit higher progression rates after CXL. Further research is required to enhance the efficacy and ease of these protocols.
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Affiliation(s)
| | - Zeba A Syed
- Cornea Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
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Li JPO, Maile HP, Bunce C, Kandakji L, Leucci MT, Allan BD, Tuft SJ, Pontikos N, Gore DM. A comparison of keratoconus progression following collagen cross-linkage using standard or personalised keratometry thresholds. Eye (Lond) 2024; 38:1681-1686. [PMID: 38409307 PMCID: PMC11156642 DOI: 10.1038/s41433-024-02994-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 02/04/2024] [Accepted: 02/13/2024] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVE To define how estimates of keratoconus progression following collagen cross-linking (CXL) vary according to the parameter selected to measure corneal shape. MATERIALS AND METHODS We estimated progression following CXL in 1677 eyes. We compared standard definitions of keratoconus progression based on published thresholds for Kmax, front K2, or back K2, or progression of any two of these three parameters, with the option of an increased threshold for Kmax values ≥ 55D. As corneal thickness reduces unpredictably after CXL, it was excluded from the principal analysis. We then repeated the analysis using novel adaptive estimates of progression for Kmax, front K2, or back K2, developed separately using 6463 paired readings from keratoconus eyes, with a variation of the Bland-Altman method to determine the 95% regression-based limits of agreement (LoA). We created Kaplan-Meier survival plots for both standard and adaptive thresholds. The primary outcome was progression five years after a baseline visit 9-15 months following CXL. RESULTS Progression rates were 8% with a standard (≥ 1.5D) threshold for K2 or 6% with the static multi-parameter definition. With a ≥ 1D threshold for Kmax, the progression was significantly higher at 29%. With adaptive Kmax or K2, the progression rates were similar (20%) but less than with the adaptive multi-parameter method (22%). CONCLUSIONS Estimates of keratoconus progression following CXL vary widely according to the reference criteria. Using adaptive thresholds (LoA) to define the repeatability of keratometry gives estimates for progression that are markedly higher than with the standard multi-parameter method.
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Affiliation(s)
- Ji-Peng Olivia Li
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK
| | - Howard P Maile
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
| | - Catey Bunce
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
- National Institute for Health and Care Research (NIHR) BRC at the Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Lynn Kandakji
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
| | - Marcello T Leucci
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK
| | - Bruce D Allan
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
| | - Stephen J Tuft
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK.
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK.
| | - Nikolas Pontikos
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
| | - Daniel M Gore
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
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Bordais J, Cassagne M, Touboul D, Saunier V, Butterworth J, Malecaze F, Soler V, Fournié P. Conventional Epithelial-Off Corneal Crosslinking in Patients With Progressive Keratoconus: 10-Year Outcomes. Cornea 2024; 43:00003226-990000000-00528. [PMID: 38537067 PMCID: PMC11142646 DOI: 10.1097/ico.0000000000003532] [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: 06/23/2023] [Revised: 11/23/2023] [Accepted: 01/29/2024] [Indexed: 06/02/2024]
Abstract
PURPOSE Corneal crosslinking (CXL) is the standard treatment of progressive keratoconus (KC). We evaluated the safety and 10-year outcomes of conventional "epithelial-off" CXL for progressive KC for the first time in a cohort in France. METHODS We conducted a retrospective review of patients undergoing conventional CXL (Dresden protocol) in our tertiary ophthalmology department from 2006 to 2011 with 10-year follow-up. The primary outcome was change in preoperative versus postoperative keratometry measured by maximum keratometry (Kmax), steep keratometry (K2), flat keratometry (K1), mean keratometry (Km), and topographic cylinder. Secondary outcomes were changes in visual and refractive outcomes. We report postoperative complications and adverse events. RESULTS Eighty-nine eyes from 76 patients (67% male patients, mean age 22.7 ± 7.6 years) were included. Mean Kmax (-2.31 ± 2.98 diopters (D); P < 0.00001), K2 (-2.07 ± 3.15 D; P < 0.00001), K1 (-1.00 ± 2.29 D; P = 0.00008), Km (-1.53 ± 2.47 D; P < 0.00001), and topographic cylinder (-1.15 ± 2.53 D; P = 0.00004) significantly decreased 10 years after CXL compared with preoperative baseline. Significant decreases were still observed between 5 and 10 years after for mean Kmax, mean K2, mean K1, and mean Km. Mean distance best spectacle-corrected visual acuity and mean manifest refraction spherical equivalent were significantly improved after 10 years versus before CXL. The 10-year rate of repeat CXL was n = 3/76 patients (4%) (all younger than 18 years at first CXL) and of loss of >3 lines in best spectacle-corrected visual acuity was n = 1/76 patients (1%). CONCLUSIONS Progressive KC was effectively stabilized with a prolonged flattening and maintenance of functional vision improvements after 10 years. Repeat CXL was rare and only required among younger patients.
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Affiliation(s)
- Jérémy Bordais
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Myriam Cassagne
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
- University of Toulouse III, Toulouse, France; and
| | - David Touboul
- Ophthalmology Department, Anterior Segment Unit, Bordeaux University Hospital, Bordeaux, France
| | - Valentine Saunier
- Ophthalmology Department, Anterior Segment Unit, Bordeaux University Hospital, Bordeaux, France
| | - Jacqueline Butterworth
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - François Malecaze
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
- University of Toulouse III, Toulouse, France; and
| | - Vincent Soler
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
- University of Toulouse III, Toulouse, France; and
| | - Pierre Fournié
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
- University of Toulouse III, Toulouse, France; and
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Neuhann L, Vogel D, Hall J, Dreyhaupt J, Werner JU, Garip-Kuebler A, Enders C. Keratometry Changes Between Year One to Seven After Corneal Cross-Linking in Patients With Keratoconus. Cornea 2024:00003226-990000000-00468. [PMID: 38289746 DOI: 10.1097/ico.0000000000003478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/10/2023] [Indexed: 02/01/2024]
Abstract
PURPOSE We evaluated the timing at and extent to which midterm to long-term keratometric changes can occur in year 1 to 7 after corneal collagen cross-linking (CXL) in patients with keratoconus. METHODS We conducted a subgroup analysis of a retrospective cohort study of all consecutive patients who underwent CXL at our cornea center between 2007 and 2011. The inclusion criteria comprised CXL according to the Dresden protocol and a full set of keratometry parameters collected by Scheimpflug tomography preoperatively and at year 1, 3, 5, and 7 after CXL. In addition, best-corrected visual acuity was evaluated. RESULTS Sixty-three eyes of 47 patients were enrolled. Mean age was 25.46 years ±7.39 years (80.9% male patients). All relevant keratometric parameters showed significant improvement at year 1 after CXL (except for posterior astigmatism). According to mixed-effects model analysis, they all showed further significant change at different points in time between year 1, 3, 5, and 7 (except for K1). In addition, best-corrected visual acuity improved statistically significant between year 1, 3, 5, and 7. Suspected disease progression was noted in 22.2% of patients, mostly between year 1 and 3 after CXL. CONCLUSIONS After initial improvement 1 year after CXL, keratometric and functional parameters were stable until year 5 after CXL in most cases; further improvement can take place even after up to 7 years post-CXL. By contrast, in case of disease progression, changes seem to occur already between year 1 and 3 after CXL.
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Affiliation(s)
- Lukas Neuhann
- Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany
- MVZ Prof. Neuhann, Munich, Germany
| | | | | | - Jens Dreyhaupt
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany; and
| | | | - Aylin Garip-Kuebler
- Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany
- MVZ Prof. Neuhann, Munich, Germany
| | - Christian Enders
- MVZ Prof. Neuhann, Munich, Germany
- Department of Ophthalmology, Ulm University, Ulm, Germany
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Vinciguerra R, Bordignon N, Ferraro V, Mazzotta C, Rosetta P, Vinciguerra P. Corneal Collagen Cross-Linking for Progressive Keratoconus in Pediatric Patients: Up to 14 Years of Follow-up. Am J Ophthalmol 2023; 255:170-177. [PMID: 37478962 DOI: 10.1016/j.ajo.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To assess the long-term outcomes of corneal collagen cross-linking according to the Dresden protocol (S-CXL) in progressive pediatric keratoconus (KC). DESIGN Retrospective, single-center noncomparative interventional study. METHODS Patients aged <18 years who underwent S-CXL from June 2007 to January 2011 in Humanitas Clinical and Research Center, Rozzano, Milan, Italy, and completed at least 10 years of follow-up were included. Corrected distance visual acuity (CDVA), refraction, and tomography were evaluated at baseline and ≥10 years after S-CXL. Meeting 2 of the following 3 criteria indicated reprogression: progression above 95% CI for post-CXL population of A or B values or a decrease in minimal thickness C evaluated with the ABCD display. RESULTS Thirty-eight eyes of 24 patients fulfilled inclusion criteria. At a mean of 11.6 years postoperation (maximum 14 years), the CDVA improved significantly (from 0.703 ± 0.33 decimal fraction to 0.887 ± 0.2, P < .001). Similarly, the A value significantly improved from 2.550 ± 1.7 to 1.627 ± 1.68 (P = .019). Thirteen eyes (34%) showed significant postoperative progression in 2 of the 3 parameters A, B, and C. Of these, only 3 eyes (7.9%) of 3 patients showed a statistically significant change in the A value. CONCLUSIONS S-CXL proved to be a safe treatment for progressive KC in pediatric patients with an anterior curvature progression rate of up to 7.9% at ≥10 years of follow-up.
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Affiliation(s)
| | - Niccolò Bordignon
- Department of Biomedical Sciences, Humanitas University (N.B., V.F., P.V.), Milan
| | - Vanessa Ferraro
- Department of Biomedical Sciences, Humanitas University (N.B., V.F., P.V.), Milan
| | - Cosimo Mazzotta
- Departmental Ophthalmology Unit, USL Toscana Sud-Est, Campostaggia (C.M.); SienaSiena Crosslinking Center, Monteriggioni (C.M.), Siena
| | | | - Paolo Vinciguerra
- Department of Biomedical Sciences, Humanitas University (N.B., V.F., P.V.), Milan; Humanitas Clinical and Research Center, IRCCS (P.V.), Rozzano, Milan, Italy
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Li N, Liu M, Tian G, Chen T, Lin Y, Qi X, Shi W, Gao H. Effects of femtosecond laser-assisted minimally invasive lamellar keratoplasty (FL-MILK) on mild-to-moderate and advanced keratoconus. Graefes Arch Clin Exp Ophthalmol 2023; 261:2873-2882. [PMID: 37171602 DOI: 10.1007/s00417-023-06093-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/13/2023] [Accepted: 04/26/2023] [Indexed: 05/13/2023] Open
Abstract
PURPOSE To compare the outcomes of femtosecond laser-assisted minimally invasive lamellar keratoplasty (FL-MILK) for mild-to-moderate keratoconus (KC) and advanced KC. METHODS Prospective case series study. Sixty-three eyes of 56 patients with progressive KC underwent FL-MILK were divided into group 1 [mean keratometry (Kmean) ≤ 53D] and group 2 (Kmean > 53D). Best spectacle-corrected visual acuity (BSCVA), Kmean, maximum keratometry (Kmax), anterior central corneal elevation (ACE), stiffness parameter A1 (SP-A1) and deformation amplitude (DA) were evaluated preoperatively and up to 24 months postoperatively. RESULTS Mean BSCVA improved from 0.34 ± 0.13 logMAR preoperatively to 0.25 ± 0.13 logMAR at 24 months postoperatively in group 1 (F = 10.10, P < .0001), and from 0.54 ± 0.31 logMAR to 0.40 ± 0.26 logMAR (F = 9.06, P = .0002) in group 2. Group 2 showed an average Kmax reduction of 10.9 D and an average Kmean reduction of 3.9 D at 24 months postoperatively (both P < .0001), whereas no significant change was observed in group 1. Average ACE decreased from 19.2 ± 10.0 to 5.2 ± 8.4 at 24 months postoperatively in group 1 (F = 28.5, P < .0001), and from 46.2 ± 16.3 to 19.1 ± 9.0 (F = 49.6, P < .0001) in group 2; SP-A1 increased from 53.8 ± 12.7 mmHg/mm to 95.9 ± 20.2 mmHg/mm in group 1 (F = 70.0, P < .0001), and from 38.6 ± 13.4 mmHg/mm to 89.3 ± 18.2 mmHg/mm (F = 96.9, P < .0001) in group 2; DA decreased from 1.30 ± 0.14 mm to 1.17 ± 0.13 mm in group 1 (F = 14.0, P < .0001), and from 1.40 ± 0.16 mm to 1.18 ± 0.10 mm (F = 27.6, P < .0001) in group 2. CONCLUSIONS FL-MILK can stabilize progressive KC in mild-to-moderate cases and advanced cases at 24-month follow-up. Steeper corneas are more likely to undergo flattening after FL-MILK. CLINICAL TRIAL Date of registration: July 16, 2017. The title of the trail: www. CLINICALTRIALS gov Trial registration number: NCT03229239. The name of the trial registry: ClinicalTrials.gov.
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Affiliation(s)
- Na Li
- Eye Hospital of Shandong First Medical University (Shandong Eye Hospital), Eye Institute of Shandong First Medical University, 372 Jingsi Road, Jinan, 250021, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Jinan, 250021, China
- School of Ophthalmology, Shandong First Medical University, Jinan, 250021, China
| | - Mingna Liu
- Eye Hospital of Shandong First Medical University (Shandong Eye Hospital), Eye Institute of Shandong First Medical University, 372 Jingsi Road, Jinan, 250021, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Jinan, 250021, China
- School of Ophthalmology, Shandong First Medical University, Jinan, 250021, China
| | - Ge Tian
- Eye Hospital of Shandong First Medical University (Shandong Eye Hospital), Eye Institute of Shandong First Medical University, 372 Jingsi Road, Jinan, 250021, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Jinan, 250021, China
- School of Ophthalmology, Shandong First Medical University, Jinan, 250021, China
| | - Tong Chen
- Eye Hospital of Shandong First Medical University (Shandong Eye Hospital), Eye Institute of Shandong First Medical University, 372 Jingsi Road, Jinan, 250021, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Jinan, 250021, China
- School of Ophthalmology, Shandong First Medical University, Jinan, 250021, China
| | - Yue Lin
- Eye Hospital of Shandong First Medical University (Shandong Eye Hospital), Eye Institute of Shandong First Medical University, 372 Jingsi Road, Jinan, 250021, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Jinan, 250021, China
- School of Ophthalmology, Shandong First Medical University, Jinan, 250021, China
| | - Xiaolin Qi
- Eye Hospital of Shandong First Medical University (Shandong Eye Hospital), Eye Institute of Shandong First Medical University, 372 Jingsi Road, Jinan, 250021, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Jinan, 250021, China
- School of Ophthalmology, Shandong First Medical University, Jinan, 250021, China
| | - Weiyun Shi
- Eye Hospital of Shandong First Medical University (Shandong Eye Hospital), Eye Institute of Shandong First Medical University, 372 Jingsi Road, Jinan, 250021, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Jinan, 250021, China
- School of Ophthalmology, Shandong First Medical University, Jinan, 250021, China
| | - Hua Gao
- Eye Hospital of Shandong First Medical University (Shandong Eye Hospital), Eye Institute of Shandong First Medical University, 372 Jingsi Road, Jinan, 250021, China.
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Jinan, 250021, China.
- School of Ophthalmology, Shandong First Medical University, Jinan, 250021, China.
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