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Xie JS, Ocampo V, Kaplan AJ. Anterior uveitis for the comprehensive ophthalmologist. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024:S0008-4182(24)00238-2. [PMID: 39128830 DOI: 10.1016/j.jcjo.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 07/08/2024] [Accepted: 07/24/2024] [Indexed: 08/13/2024]
Abstract
Anterior uveitis presents a diagnostic challenge due to its wide array of etiologies and clinical manifestations. This narrative review aims to equip general ophthalmologists with a comprehensive understanding of anterior uveitis epidemiology, diagnosis, and treatment. Particular emphasis is placed on developing a tailored and stepwise strategy, rather than a one-size-fits-all approach, for the workup and treatment of anterior uveitis. Chest radiography and serologic testing for syphilis, human leukocyte antigen B27, and angiotensin-converting enzyme are appropriate routine investigations in cases of severe, bilateral, recurrent, or chronic anterior uveitis. Additional testing should be guided by clinical findings and regional epidemiology, especially when considering expensive and invasive modalities. Investigations that are obtained in the absence of clinical and epidemiologic orientation are of limited utility and incur significant costs to patients and health care systems. Most cases of anatomically isolated anterior uveitis resolve with topical corticosteroids, but some patients require escalation to systemic immunomodulatory therapy (IMT). IMT should be considered in patients who respond poorly to corticosteroids, develop side effects related to corticosteroids that limit their use, require high doses to maintain disease remission, or have concomitant systemic inflammatory disease. Comprehensive ophthalmologists should feel comfortable comanaging patients that require conventional disease-modifying antirheumatic drugs/antimetabolite therapy (i.e., methotrexate, azathioprine, and mycophenolate mofetil) with rheumatologists and providing guidance on ocular dosing. When uveitis quiescence cannot be achieved despite maximally tolerated antimetabolite therapy, patients should be referred to a uveitis specialist for consultation and consideration of IMT escalation. The timing of uveitis referral may depend on local factors specific to health care jurisdictions.
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Affiliation(s)
- Jim S Xie
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Vanessa Ocampo
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada; Scarborough Health Network, Rheumatology Department, Scarborough, ON, Canada
| | - Alexander J Kaplan
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada; Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
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Tarsia M, Vitale A, Gaggiano C, Sota J, Maselli A, Bellantonio C, Guerriero S, Dammacco R, La Torre F, Ragab G, Hegazy MT, Fonollosa A, Paroli MP, Del Giudice E, Maggio MC, Cattalini M, Fotis L, Conti G, Mauro A, Civino A, Diomeda F, de-la-Torre A, Cifuentes-González C, Tharwat S, Hernández-Rodríguez J, Gómez-Caverzaschi V, Pelegrín L, Babu K, Gupta V, Minoia F, Ruscitti P, Costi S, Breda L, La Bella S, Conforti A, Mazzei MA, Carreño E, Amin RH, Grosso S, Frediani B, Tosi GM, Balistreri A, Cantarini L, Fabiani C. Effectiveness and Safety of Biosimilars in Pediatric Non-infectious Uveitis: Real-Life Data from the International AIDA Network Uveitis Registry. Ophthalmol Ther 2024; 13:761-774. [PMID: 38206518 PMCID: PMC10853125 DOI: 10.1007/s40123-023-00863-1] [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: 09/19/2023] [Accepted: 11/23/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Since many biological drug patents have expired, biosimilar agents (BIOs) have been developed; however, there are still some reservations in their use, especially in childhood. The aim of the current study is to evaluate the efficacy and safety of tumor necrosis factor (TNF) inhibitors BIOs as treatment for pediatric non-infectious uveitis (NIU). METHODS Data from pediatric patients with NIU treated with TNF inhibitors BIOs were drawn from the international AutoInflammatory Disease Alliance (AIDA) registries dedicated to uveitis and Behçet's disease. The effectiveness and safety of BIOs were assessed in terms of frequency of relapses, risk for developing ocular flares, best-corrected visual acuity (BCVA), glucocorticoids (GCs)-sparing effect, drug survival, frequency of ocular complications, and adverse drug event (AE). RESULTS Forty-seven patients (77 affected eyes) were enrolled. The BIOs employed were adalimumab (ADA) (89.4%), etanercept (ETA) (5.3%), and infliximab (IFX) (5.3%). The number of relapses 12 months prior to BIOs and at last follow-up was 282.14 and 52.43 per 100 patients/year. The relative risk of developing ocular flares before BIOs introduction compared to the period following the start of BIOs was 4.49 (95% confidence interval [CI] 3.38-5.98, p = 0.004). The number needed to treat (NNT) for ocular flares was 3.53. Median BCVA was maintained during the whole BIOs treatment (p = 0.92). A significant GCs-sparing effect was observed throughout the treatment period (p = 0.002). The estimated drug retention rate (DRR) at 12-, 24-, and 36-month follow-up were 92.7, 83.3, and 70.8%, respectively. The risk rate for developing structural ocular complications was 89.9/100 patients/year before starting BIOs and 12.7/100 patients/year during BIOs treatment, with a risk ratio of new ocular complications without BIOs of 7.1 (CI 3.4-14.9, p = 0.0003). Three minor AEs were reported. CONCLUSIONS TNF inhibitors BIOs are effective in reducing the number of ocular uveitis relapses, preserving visual acuity, allowing a significant GCs-sparing effect, and preventing structural ocular complications. TRIAL REGISTRATION ClinicalTrials.gov ID NCT05200715.
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Affiliation(s)
- Maria Tarsia
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Antonio Vitale
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Carla Gaggiano
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Jurgen Sota
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Anna Maselli
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Chiara Bellantonio
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Silvana Guerriero
- Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy
| | - Rosanna Dammacco
- Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy
| | - Francesco La Torre
- Department of Pediatrics, Giovanni XXIII Pediatric Hospital, University of Bari, 70126, Bari, Italy
| | - Gaafar Ragab
- Internal Medicine Department, Rheumatology and Clinical Immunology Unit, Faculty of Medicine, Cairo University, Giza, Egypt
- Faculty of Medicine, Newgiza University (NGU), Giza, Egypt
| | - Mohamed Tharwat Hegazy
- Internal Medicine Department, Rheumatology and Clinical Immunology Unit, Faculty of Medicine, Cairo University, Giza, Egypt
- Faculty of Medicine, Newgiza University (NGU), Giza, Egypt
| | - Alex Fonollosa
- Department of Ophthalmology, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Barakaldo, Spain
| | - Maria Pia Paroli
- Uveitis Service, Ophthalmologic Unit, Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Emanuela Del Giudice
- Pediatric Rheumatology Unit, Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Maria Cristina Maggio
- University Department PROMISE "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Marco Cattalini
- Pediatric Clinic, University of Brescia and Spedali Civili di Brescia, Brescia, Italy
| | - Lampros Fotis
- Third Department of Paediatrics, National and Kapodistrian University of Athens, General University Hospital "Attikon", Athens, Greece
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit with Dialysis, Department of Human Pathology in Adulthood and Childhood "G. Barresi", AOU Policlinic "G. Martino", Messina University, Messina, Italy
| | - Angela Mauro
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121, Milan, Italy
| | - Adele Civino
- Pediatric Rheumatology and Immunology Unit, Vito Fazzi Hospital, 73100, Lecce, Italy
| | - Federico Diomeda
- Pediatric Rheumatology and Immunology Unit, Vito Fazzi Hospital, 73100, Lecce, Italy
| | - Alejandra de-la-Torre
- Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Carlos Cifuentes-González
- Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Samar Tharwat
- Rheumatology and Immunology Unit, Department of Internal Medicine, Faculty of Medicine, Mansoura University, El Gomhouria St, Mansoura, Dakahlia Governorate, Egypt
| | - José Hernández-Rodríguez
- Unidad Clínica de Enfermedades Autoinflamatorias y Grupo de Investigación en Vasculitis, Servicio de Enfermedades Autoimmunes, Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Verónica Gómez-Caverzaschi
- Unidad Clínica de Enfermedades Autoinflamatorias y Grupo de Investigación en Vasculitis, Servicio de Enfermedades Autoimmunes, Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Pelegrín
- Unidad Clínica de Enfermedades Autoinflamatorias y Grupo de Investigación en Vasculitis, Servicio de Enfermedades Autoimmunes, Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Kalpana Babu
- Department of Uveitis and Ocular Inflammation, Vittala International Institute of Ophthalmology and Prabha Eye Clinic and Research Centre, Bengaluru, Karnataka, India
| | - Vishali Gupta
- Advanced Eye Centre, Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Francesca Minoia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Delta 6 Building, PO Box 67100, L'Aquila, Italy
| | | | - Luciana Breda
- Department of Paediatrics, University of Chieti-Pescara, Chieti, Italy
| | - Saverio La Bella
- Department of Paediatrics, University of Chieti-Pescara, Chieti, Italy
| | | | - Maria Antonietta Mazzei
- Unit of Diagnostic Imaging, Department of Medical, Surgical and Neuro Sciences and of Radiological Sciences, University of Siena, Azienda Ospedaliero-Universitaria Senese, 53100, Siena, Italy
| | - Ester Carreño
- Department of Ophthalmology, Hospital Universitario Rey Juan Carlos, Madrid, Spain
- Department of Ophthalmology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Rana Hussein Amin
- Opthalmology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Salvatore Grosso
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Bruno Frediani
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Gian Marco Tosi
- Department of Medicine, Surgery and Neurosciences, Ophthalmology Unit, ERN RITA Center, Policlinico "Le Scotte", University of Siena, Viale Bracci 16, 53100, Siena, Italy
| | - Alberto Balistreri
- Bioengineering and Biomedical Data Science Lab, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy.
| | - Claudia Fabiani
- Department of Medicine, Surgery and Neurosciences, Ophthalmology Unit, ERN RITA Center, Policlinico "Le Scotte", University of Siena, Viale Bracci 16, 53100, Siena, Italy.
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Thng ZX, Regenold J, Bromeo AJ, Akhavanrezayat A, Than NTT, Khatri A, Mohammadi SS, Tran ANT, Shin YU, Karaca I, Ghoraba HH, Or CCM, Nguyen QD. Challenges for further successful development of tumor necrosis factor targeting therapies for uveitis. Expert Opin Investig Drugs 2024; 33:95-104. [PMID: 38299551 DOI: 10.1080/13543784.2024.2311186] [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: 10/10/2023] [Accepted: 01/23/2024] [Indexed: 02/02/2024]
Abstract
INTRODUCTION Uveitis is a heterogeneous group of ocular conditions characterized by inflammation of the uveal tract and is one of the leading causes of vision impairment. In developed countries, noninfectious uveitis (NIU) represents most cases and is challenging to treat due to its severity, chronicity, and high recurrence rates. The advent of anti-tumor necrosis factor-α (anti-TNF-α) agents have dramatically improved outcomes and changed treatment paradigms in NIU. AREAS COVERED The index article summarizes the present experience of anti-TNF-α agents in NIU pharmacotherapy and highlights the barriers to further research and development of anti-TNF-α agents for uveitis. Common challenges faced in NIU clinical drugs trials, specific difficulties in anti-TNF-α drug development, and promising competitor drug candidates are discussed and evaluated. EXPERT OPINION Anti-TNF-α agents have revolutionized NIU pharmacotherapy and greatly improved outcomes with good safety profiles. The great success of systemic infliximab and adalimumab in NIU treatment has resulted in little impetus for further development of this class of medication. Attempts have been made to deliver anti-TNF-α agents intravitreally but that has not been successful thus far. With expiring patents, competition from biosimilars and newer, novel molecules, it may not be viable to continue pursuing anti-TNF-α drug development.
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Affiliation(s)
- Zheng Xian Thng
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jonathan Regenold
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Albert John Bromeo
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Asian Eye Institute, Makati, Philippines
| | | | - Ngoc T T Than
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Anadi Khatri
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Birat Aankha Aspatal, Biratnagar, Nepal
- Department of Ophthalmology, Birat Medical College and Teaching Hospital, Kathmandu University, Biratnagar, Nepal
| | | | - Anh N T Tran
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Yong Un Shin
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, Korea
- Department of Ophthalmology, Hanyang University Guri Hospital, Guri, Korea
| | - Irmak Karaca
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
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Jacquot R, Kodjikian L, Chapurlat R, Sève P. Targeted therapies for uveitis in spondyloarthritis: A narrative review. Joint Bone Spine 2024; 91:105697. [PMID: 38309516 DOI: 10.1016/j.jbspin.2024.105697] [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: 11/19/2023] [Revised: 01/01/2024] [Accepted: 01/23/2024] [Indexed: 02/05/2024]
Abstract
Spondyloarthritis (SpA) encompasses a group of chronic inflammatory disorders of the joints frequently associated with uveitis in almost a quarter of cases. SpA-related uveitis typically affects the eye anterior chamber with sudden onset, causing pain, redness, photophobia, and blurred vision. Ophthalmologists will describe an acute anterior unilateral uveitis. Most patients present with episodic acute anterior non-granulomatous uveitis and retain excellent visual acuity. However, systemic treatments are recommended in the event of frequent relapses (2-3/year) or in rare cases of sight-threatening with ocular complications. The improved understanding of the pathogenesis of SpA has led to the management of this disease by biologics. Here, we review the main data regarding the opportunity to target specific components in inflammatory pathways for the treatment of SpA-related uveitis. These therapies are recommended for long-term control when uveitis relapses occur too frequently despite conventional systemic treatments. Significant benefits have been obtained with the tumor necrosis factor-α inhibitors (TNFis), particularly infliximab and adalimumab. Paradoxically, a high number of uveitis occurrences have been shown on etanercept. Mixed results have been demonstrated with interleukin-17 antagonists (secukinumab) and interleukin-12/interleukin-23 antagonists (ustekinumab) in cases of failure of TNFis. JAK inhibitors seem to be a valuable class of medications for these patients in the future. Although SpA-related uveitis is typically managed with conventional local and/or systemic treatments, these biological/targeted therapies may provide avenues to control both the underlying SpA and uveitis manifestations. Thus, a close collaboration between patients, rheumatologists, internists, and ophthalmologists is needed to optimally manage ocular inflammation in SpA.
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Affiliation(s)
- Robin Jacquot
- Department of Internal Medicine, Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, University Claude-Bernard Lyon 1, Lyon, France; Inserm U1290, Research on Healthcare Performance (RESHAPE), University Claude-Bernard Lyon 1, Lyon, France.
| | - Laurent Kodjikian
- Department of Ophthalmology, Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, University Claude-Bernard Lyon 1, Lyon, France; UMR5510 MATEIS, CNRS, INSA Lyon, University Claude-Bernard Lyon 1, Villeurbanne, France
| | - Roland Chapurlat
- Department of Rheumatology, Hospices Civils de Lyon, Hôpital Universitaire Édouard-Herriot, University Claude-Bernard Lyon 1, Lyon, France
| | - Pascal Sève
- Department of Internal Medicine, Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, University Claude-Bernard Lyon 1, Lyon, France; Inserm U1290, Research on Healthcare Performance (RESHAPE), University Claude-Bernard Lyon 1, Lyon, France
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Thng ZX, Bromeo AJ, Mohammadi SS, Khatri A, Tran ANT, Akhavanrezayat A, T T Than N, Nguyen KS, Yoo WS, Mobasserian A, Or CCM, Nguyen QD. Recent advances in uveitis therapy: focus on selected phase 2 and 3 clinical trials. Expert Opin Emerg Drugs 2023; 28:297-309. [PMID: 38129984 DOI: 10.1080/14728214.2023.2293049] [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: 09/19/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Uveitis is a heterogeneous group of ocular conditions characterized by inflammation of the uveal tract. It is a leading cause of blindness in developed countries and exerts significant psychological, social, and economic impact on both patients and the larger society. While there are numerous pharmacotherapy options, posterior segment noninfectious uveitis remains a significant challenge to treat due to its severity, chronicity, and high recurrence rates. AREAS COVERED The index review highlights the unmet needs of uveitis pharmacotherapy and its research and the shortcomings of existing ocular and systemic therapeutic options for noninfectious uveitis. The more promising novel ocular drug delivery methods and therapeutic targets/drugs are discussed, and evidence from the clinical trials is evaluated. EXPERT OPINION There has been incredible growth in the number of treatment options available to uveitis patients today, especially with the new generation of biologic drugs. Available evidence suggests that these newer options may be superior to conventional immunosuppressive therapies in terms of efficacy and side effect profiles. Further high-quality research and additional clinical trials will be needed to clarify their roles in the stepladder treatment approach of noninfectious uveitis.
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Affiliation(s)
- Zheng Xian Thng
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Albert John Bromeo
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- Asian Eye Institute, Makati, Philippines
| | - S Saeed Mohammadi
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Anadi Khatri
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- Birat Aankha Aspatal, Biratnagar, Nepal
- Department of Ophthalmology, Birat Medical College and Teaching Hospital, Kathmandu University, Biratnagar, Nepal
| | - Anh N T Tran
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | | | - Ngoc T T Than
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Khiem S Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Woong-Sun Yoo
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
- Department of Ophthalmology, Gyeongsang National University College of Medicine, and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | | | | | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
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