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Esmail A, Ibrahim M, Nage S. Efficacy of topical insulin for recurrent epithelial corneal erosions. Ir J Med Sci 2023; 192:3117-3123. [PMID: 37140764 DOI: 10.1007/s11845-023-03373-y] [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: 02/26/2023] [Accepted: 04/11/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Topical insulin can promote and accelerate corneal regeneration, even in eyes with serious comorbidities, and offers several benefits over other treatment options. AIMS The aim of this study is to evaluate the effect of topical insulin in treatment of recurrent epithelial corneal erosion. METHODS Patients with recurrent epithelial erosions were included in a prospective non-randomized hospital-based study, divided into two groups, one of them received persistent epithelial defects (PEDs) conventional treatment and the other received the same treatment with insulin eye drops 4 times/day. All patients were examined carefully by slit lamp. Patients during the 1st, 2nd, 3rd, and 4th weeks as well as after 2 months. Demographics, etiology, therapy, comorbidities, and the healing time of PED were performed. RESULTS Area shows significant improvement after 2 weeks (p = 0.006), 2 months (p = 0.046), and 3 months (p = 0.002) in group II (cornetears gel and topical insulin) as compared to group I (cornetears gel). The recurrence was statistically significant decreased with cornetears gel and topical insulin (group II) by 0.0%, as compared to cornetears gel (group I) by 3 patients (21.4%). CONCLUSION Topical insulin can promote corneal reepithelization in recurrent epithelial erosion and decreases recurrence in these cases. Other advantages include excellent tolerance, availability, and cost-effectiveness.
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Affiliation(s)
- Ahmed Esmail
- Ophthalmology Department, Faculty of Medicine, Menoufia University, Menoufia, Shebin El Kom, Egypt.
| | - Mohamed Ibrahim
- Ophthalmology Department, Faculty of Medicine, Kafrelshiekh University Hospital, Kafrelshiekh, Egypt
| | - Sara Nage
- Ophthalmology Department, Faculty of Medicine, Menoufia University, Menoufia, Shebin El Kom, Egypt
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Jadczyk-Sorek K, Garczorz W, Bubała-Stachowicz B, Francuz T, Mrukwa-Kominek E. Matrix Metalloproteinases and the Pathogenesis of Recurrent Corneal Erosions and Epithelial Basement Membrane Dystrophy. BIOLOGY 2023; 12:1263. [PMID: 37759662 PMCID: PMC10525265 DOI: 10.3390/biology12091263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023]
Abstract
Matrix metalloproteinases (MMPs) are a group of proteolytic enzymes which are members of the zinc endopeptidase family. They have the ability to degrade extracellular matrix elements, allowing for the release of binding molecules and cell migration. Although metalloproteinases regulate numerous physiological processes within the cornea, overexpression of metalloproteinase genes and an imbalance between the levels of metalloproteinases and their inhibitors can contribute to the inhibition of repair processes, the development of inflammation and excessive cellular proliferation. The involvement of MMPs in the pathogenesis of dystrophic corneal diseases needs clarification. Our analyses focus on the involvement of individual metalloproteinases in the pathogenesis of recurrent corneal erosions and highlight their impact on the development of corneal epithelial basement membrane dystrophy (EBMD). We hypothesize that abnormalities observed in patients with EBMD may result from the accumulation and activation of metalloproteinases in the basal layers of the corneal epithelium, leading to basement membrane degradation. A barrier formed from degradation materials inhibits the normal migration of epithelial cells to the superficial layers, which contributes to the development of the aforementioned lesions. This hypothesis seems to be lent support by the elevated concentrations of metalloproteinases in the corneal epithelium of these patients found in our previous studies on the relationships between MMPs and recurrent corneal erosions.
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Affiliation(s)
- Katarzyna Jadczyk-Sorek
- Department of Ophthalmology, University Clinical Center, Medical University of Silesia, Ceglana 35, 40-514 Katowice, Poland
- Department of Ophthalmology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Ceglana 35, 40-514 Katowice, Poland
| | - Wojciech Garczorz
- Department of Biochemistry, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medyków 18, 40-027 Katowice, Poland
| | - Beata Bubała-Stachowicz
- Department of Ophthalmology, University Clinical Center, Medical University of Silesia, Ceglana 35, 40-514 Katowice, Poland
| | - Tomasz Francuz
- Department of Biochemistry, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medyków 18, 40-027 Katowice, Poland
| | - Ewa Mrukwa-Kominek
- Department of Ophthalmology, University Clinical Center, Medical University of Silesia, Ceglana 35, 40-514 Katowice, Poland
- Department of Ophthalmology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Ceglana 35, 40-514 Katowice, Poland
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Kim MEJ, Kim DB. Implementation of the Corneal Sweep Test in the Diagnosis of Recurrent Corneal Erosion: A 2-Year Retrospective Study. Cornea 2022; 41:1248-1254. [PMID: 35249983 PMCID: PMC9473707 DOI: 10.1097/ico.0000000000002963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/24/2021] [Accepted: 11/15/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the incidence and epidemiology of recurrent corneal erosion within a clinical population using standard diagnostic techniques and a new technique called the corneal sweep test (CST). METHODS A retrospective chart review was conducted on 58 eyes of 51 patients with the diagnosis of recurrent corneal erosion from July 2018 to June 2020. All underwent a thorough history and physical examination. The CST was performed as a confirmatory test and on any patient who lacked visible corneal pathology. RESULTS The CST was necessary on 49 of the 58 eyes to help confirm the diagnosis of a corneal erosion. Among them, 34 had an occult corneal erosion, which is defined as having a normal-appearing cornea on slitlamp examination but found to have loose corneal epithelium with the CST. Clear corneal cataract surgery (28 eyes, 48.2%) was the most common presumed mechanism of injury, with 20 (71.4%) developing symptoms only after cataract surgery. All 20 eyes had an erosion located directly over a clear corneal cataract incision. CONCLUSIONS The CST is a new and effective technique to help diagnose corneal erosions in the absence of visible corneal findings. Clear corneal cataract surgery is an under-recognized but important risk factor to consider because the incision can be the source for an erosion. Using the CST could lead to a paradigm shift in the way clinicians approach RCEs and patients with a persistent ocular pain syndrome.
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Affiliation(s)
| | - Dooho Brian Kim
- Professional Eye Associates, Dalton, GA; and
- Medical College of Georgia, Augusta, GA
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Jan RL, Ho CH, Wang JJ, Tseng SH, Chang YS. A Population-Based Study of Social Demographic Factors, Associated Diseases and Recurrent Corneal Erosion in Taiwan. Front Public Health 2022; 10:832333. [PMID: 35419341 PMCID: PMC8995765 DOI: 10.3389/fpubh.2022.832333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose To investigate the association of recurrent corneal erosion (RCE) with sociodemographic factors and associated ocular conditions or systemic diseases. Methods This nationwide, population-based, retrospective, matched case-controlled study included 98,895 RCE patients, identified by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 371.42, were selected from the Taiwan National Health Insurance Research Database. The age-, sex-, and index date- matched control group included 98,895 non-RCE control group also selected from the Taiwan Longitudinal Health Insurance Database 2000. Sociodemographic factors and associated ocular conditions or systemic diseases were examined using univariate logistic regression analyses, and continuous variables were analyzed using paired t-test. The odds ratio (OR) of developing RCE were compared using adjusted logistic regression analysis. Results Patients with ocular conditions including corneal abrasion, ocular allergic conditions, and corneal dystrophy were more likely to have RCE than the control group (adjusted OR = 63.56, 95% CI = 42.06-96.06, p < 0.0001; adjusted OR = 24.27, 95% CI = 20.51-28.72, p < 0.0001; adjusted OR = 17.10, 95% CI = 5.14-59.93, p < 0.0001, respectively). Patients with systemic diseases such as diabetes mellitus, hyperlipidaemia, and atopy trait have significantly higher ORs for RCE development. Patients residing in either Northern Taiwan or a metropolis city had higher odds of developing RCE; however, there were no significant differences in income or occupation on the probability to develop RCE. Conclusion RCE is strongly associated with corneal abrasion, ocular allergic conditions, corneal dystrophy, diabetes mellitus, hyperlipidaemia, and atopy trait.
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Affiliation(s)
- Ren-Long Jan
- College of Health Sciences, Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan, Taiwan.,Department of Pediatrics, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.,Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan.,Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan.,AI Biomed Center, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Sung-Huei Tseng
- Department of Ophthalmology, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan.,Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yuh-Shin Chang
- College of Health Sciences, Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan, Taiwan.,Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan
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Jan RL, Weng SF, Wang JJ, Tseng SH, Chang YS. Association Between Atopic Keratoconjunctivitis and the Risk of Recurrent Corneal Erosion. Front Med (Lausanne) 2021; 8:688355. [PMID: 34150819 PMCID: PMC8210667 DOI: 10.3389/fmed.2021.688355] [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: 03/30/2021] [Accepted: 05/12/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: To investigate the risk of recurrent corneal erosion (RCE) in patients with atopic keratoconjunctivitis (AKC). Methods: This national, retrospective, matched cohort study enrolled 184,166 newly-diagnosed AKC patients, selected from the Taiwan National Health Insurance Research Database and identified by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 372.05. The control group comprised 184,166 non-AKC patients matched by age, sex, and potential comorbidities and they were selected from the Taiwan Longitudinal Health Insurance Database, 2000. Information from patients was gathered from 1 January 2004 to 31 December 2011, and both groups were traced from the index date until December 2013. The incidence and risk of RCE (ICD-9-CM code 361.42) was compared between the groups. The adjusted hazard ratio (HR) for RCE was obtained by a Cox proportional hazard regression analysis. The Kaplan–Meier analysis was performed to calculate the cumulative incidence of RCE. Results: In total, 564 AKC patients and 406 non-AKC controls developed RCE during the follow-up span. The incidence of RCE was 1.45 times higher in AKC patients than in controls (95% confidence interval [CI] = 1.27–1.64; P < 0.0001). After adjusting for potential confounders, including diabetes mellitus, keratoconjunctivitis sicca, corneal transplantation, ocular blunt trauma, corneal dystrophy, and band keratopathy, AKC patients were 1.36 times more likely to develop RCE than controls (adjusted HR, 1.36; 95% CI = 1.19–1.54; p < 0.05). Conclusions: AKC Patients had an increased risk of developing RCE and should be informed of this risk.
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Affiliation(s)
- Ren-Long Jan
- Department of Pediatrics, Chi Mei Medical Center, Liouying, Tainan, Taiwan.,Graduate Institute of Medical Science, College of Health Science, Chang Jung Christian University, Tainan, Taiwan
| | - Shih-Feng Weng
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan.,Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan.,AI Biomed Center, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Sung-Huei Tseng
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yuh-Shin Chang
- Graduate Institute of Medical Science, College of Health Science, Chang Jung Christian University, Tainan, Taiwan.,Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan
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Li J, Ma Y, Huang X, Xu L, Tang S. Bandage Contact Lenses versus Deproteinized Calf Blood Extract Eye Gel for Recurrent Corneal Erosion Syndrome: A Case-Control Study. Ther Clin Risk Manag 2020; 16:1109-1115. [PMID: 33223832 PMCID: PMC7671461 DOI: 10.2147/tcrm.s277282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/21/2020] [Indexed: 11/23/2022] Open
Abstract
Background The clinical efficacy of eye drops in the treatment of recurrent corneal erosion syndrome (RCES) is not satisfactory. Many studies have confirmed the positive effect of the bandage contact lens (BCL) in corneal diseases, but not many in patients with RCES. The purpose of this study is to investigate the efficacy of the BCL compared with deproteinized calf blood extract eye gel in the initial treatment of RCES. Methods Forty-seven patients with RCES treated in our hospital from September 2010 to September 2018 were retrospectively analyzed, including 24 cases (26 eyes) in the bandage contact lenses (BCLs) group wearing bandage contact lens and 23 cases (24 eyes) in the drug group treated with deproteinized calf blood extract eye gel. The efficacy was evaluated after 3 months of treatment, with a mean follow-up time of 21.15 ± 1.71 months in the BCL group and 20.87 ± 1.89 months in the drug group. Corneal erosion resolution, pain relief, visual acuity recovery time, recurrence and complications were observed. Results After 3 months of treatment, 22 eyes (22/26, 84.6%) in the BCLs group achieved complete resolution, compared with 14 eyes (14/24, 58.3%) in the drug group (P <0.05). The corneal healing time in the BCLs group was 4.77 ± 4.51 weeks, which was significantly shorter than that in the drug group (9.83 ± 5.93 weeks (P <0.01)). At 1 and 2 months after treatment, the visual analogue score (VAS) in the BCLs group (3.28 ± 1.15 at 1 month and 1.90 ± 0.77 at 2 months) decreased more significantly than that in the drug group (4.54 ± 0.89 at 1 month and 2.43 ± 0.93 at 2months, P =0.000 at 1 month and P=0.034 at 2 months). At 3 months after treatment, the mean BCVA in the BCL group (logMAR 0.03±0.08) improved more significantly than that in the drug group (logMAR 0.14±0.12,P=0.001). The complete recovery time of visual acuity was 5.46 ± 4.43 weeks in the BCLs group, compared with 10.33 ± 6.12 weeks in the drug group (P =0.003). During further follow-up, recurrence was observed in 2 eyes (2/22, 9.1%) of the BCLs group and 6 eyes (6/14, 42.8%) of the drug group. No patient in both groups developed adverse side effects. Conclusion Bandage contact lenses are safe and effective in the initial treatment of RCES. Compared with topical deproteinized calf blood extract eye gel, the use of BCLs can provide a higher cure rate, better pain control, faster visual recovery and lower recurrence rate. Trial Registration Chinese Clinical Trial Registry, ChiCTR2000031241. Registered 25 March 2020- Retrospectively registered, http://www.chictr.org.cn/edit.aspx?pid=51309andhtm=4.
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Affiliation(s)
- Jing Li
- Department of Ophthalmology, Beijing Jishuitan Hospital, Beijing, People's Republic of China
| | - Yu Ma
- Department of Ophthalmology, Beijing Jishuitan Hospital, Beijing, People's Republic of China
| | - Xiaohan Huang
- Department of Ophthalmology, Beijing Jishuitan Hospital, Beijing, People's Republic of China
| | - Lanfang Xu
- Department of Ophthalmology, Beijing Jishuitan Hospital, Beijing, People's Republic of China
| | - Shaohua Tang
- Department of Ophthalmology, Beijing Jishuitan Hospital, Beijing, People's Republic of China
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Cataract incision-related corneal erosion: recurrent corneal erosion because of clear corneal cataract surgery. J Cataract Refract Surg 2020; 46:1436-1440. [PMID: 32818355 DOI: 10.1097/j.jcrs.0000000000000345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Three patients developed recurrent corneal erosions (RCEs) over their cataract surgery corneal incisions. These cataract incision-related corneal erosions (CIRCEs) resulted in pain after cataract surgery. None had any physical findings for corneal erosion; thus, a new technique called the corneal sweep test was developed to identify the erosion. To the authors' knowledge, this is the first time this association between the clear corneal cataract incision and RCEs has been reported. Considering the high number of cataract surgeries performed around the world, it is important for ophthalmologists to recognize CIRCEs as a potential cause of ocular discomfort after clear corneal cataract surgery.
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Song MY, Chung JL, Kim KY, Hwang KY, Kwon YA, Song SW, Kim BY, Koh K. Combined Phototherapeutic Keratectomy and Peripheral Anterior Stromal Puncture for the Treatment of Recurrent Corneal Erosion Syndrome. KOREAN JOURNAL OF OPHTHALMOLOGY 2020; 34:297-303. [PMID: 32783422 PMCID: PMC7419241 DOI: 10.3341/kjo.2020.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/03/2020] [Accepted: 04/16/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To investigate the efficacy of the combined phototherapeutic keratectomy (PTK) and peripheral anterior stromal puncture (ASP) compared with that of PTK alone in patients with recurrent corneal erosion syndrome (RCES). METHODS The medical records of 25 patients (25 eyes) who underwent combined treatment of PTK and peripheral ASP for RCES from March 2016 to May 2017 were retrospectively reviewed. Twenty-three patients (23 eyes) treated with PTK alone from March 2015 to February 2016 served as a control group. All surgeries were performed by a single surgeon. This retrospective clinical study comprised 48 patients (48 eyes) who were followed up for more than 18 months. Clinical records of age, sex, laterality, etiology of RCES, and history of recurrence after treatment were evaluated. RESULTS Twenty-five eyes were treated with combined PTK and ASP, and 23 eyes were treated with PTK only. The mean follow-up period was 19.63 ± 2.97 and 19.75 ± 6.83 months, respectively. There were no differences in baseline parameters between the groups. In the combined treatment group, one patient experienced recurrence 6 months after the surgery. In the single treatment group, five patients showed recurrence at 4, 7, 8, 11, and 13 months after the surgery, respectively. Compared to the single treatment group, the combined treatment group showed significantly lower recurrence rate (p < 0.05). All recurred patients required no additional treatment except temporary therapeutic contact lenses and topical lubricants. CONCLUSIONS Our findings suggest that combined treatment of PTK and peripheral ASP is effective in alleviation of symptoms and prevention of recurrence in refractory RCES compared with treatment using PTK alone.
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Affiliation(s)
- Mi Yeon Song
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | | | - Kook Young Kim
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Kyu Yeon Hwang
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Young A Kwon
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Sang Wroul Song
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Byung Yeop Kim
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Kyungmin Koh
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea.
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Jan RL, Tai MC, Ho CH, Chu CC, Wang JJ, Tseng SH, Chang YS. Risk of recurrent corneal erosion in patients with diabetes mellitus in Taiwan: a population-based cohort study. BMJ Open 2020; 10:e035933. [PMID: 32565466 PMCID: PMC7311018 DOI: 10.1136/bmjopen-2019-035933] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To investigate the risk of recurrent corneal erosion (RCE) in patients with diabetes mellitus (DM). DESIGN, SETTING AND PARTICIPANTS This retrospective, nationwide, matched cohort study included 239 854 patients with DM recruited between 2003 and 2005 from the Longitudinal Cohort of Diabetes Patients database. The control group included the same number of age-matched and sex-matched patients without DM selected from the Taiwan Longitudinal Health Insurance Database, 2000. Data for each patient were collected from the index date until December 2013. MAIN OUTCOMES AND MEASURES The incidence and risk of RCE were compared between the two groups. Cox proportional hazards regression was used to calculate the HR for RCE after adjustment for potential confounders. The cumulative RCE incidence rate was calculated using Kaplan-Meier analysis. RESULTS In total, 1236 patients with DM and 884 controls developed RCE during the follow-up period, resulting in an incidence rate of RCE in patients with DM (5.87/10 000 person-years (PY)) higher than that in the controls (4.23/10 000 PY). After adjustment for potential confounders, including hypertension, hyperlipidaemia, chronic renal disease and keratoconjunctivitis sicca, patients with DM were 1.35 times (95% CI, 1.24 to 1.48) more likely to develop RCE than the total sample cohort. CONCLUSIONS DM increases the risk of RCE, which is an interdisciplinary issue. Therefore, close collaboration between endocrinologists and ophthalmologists is important in managing RCE following DM.
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Affiliation(s)
- Ren-Long Jan
- Department of Pediatrics, Chi Mei Medical Center, Liouying, Tainan, Taiwan
- Graduate Institute of Medical Science, College of Health Science, Chang Jung Christian University, Tainan, Taiwan
| | - Ming-Cheng Tai
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Chin-Chen Chu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
- Department of Recreation and Health-Care Management, Chia-Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Sung-Huei Tseng
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yuh-Shin Chang
- Graduate Institute of Medical Science, College of Health Science, Chang Jung Christian University, Tainan, Taiwan
- Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan
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