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Kıvrak U, Köle MT, Akçay G, Yükselmiş U, Genç FA, Karaaslan A, Çetin C, Arsan AK, Akın Y, Şimşek Ş. Evaluation of Long-Term Posterior Segment Parameters in Children Who Had Recovered From Multisystem Inflammatory Syndrome. Ophthalmic Surg Lasers Imaging Retina 2024:1-9. [PMID: 38917398 DOI: 10.3928/23258160-20240415-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
BACKGROUND AND OBJECTIVE To evaluate long-term posterior segment findings in children recovering from multisystemic inflammatory syndrome (MIS-C) associated with severe acute respiratory syndrome coronavirus 2. PATIENTS AND METHODS Our study included 22 patients who were admitted to an intensive care unit with a diagnosis of MIS-C between November 2021 and March 2022, and 25 healthy controls. The study included pediatric patients who had an eye examination an average of 12.35 ± 2.18 months after recovery from MIS-C. Detailed eye examinations and measurements of all participants were obtained retrospectively from patient files. Posterior segment parameters were measured using swept-source optical coherence tomography (OCT) and OCT-angiography (OCT-A); these parameters included peripapillary retinal nerve fiber layer (pRNFL) thickness, central macular thickness (CMT), subfoveal choroidal thickness (SCT), macular vascular densities (VD), and foveal avascular zone (FAZ) area. RESULTS Mean age was 9.7 ± 3.6 years in the MIS-C group and 10.6 ± 2.8 years in the healthy control group (P = 0.316). There were no statistically significant differences between the MIS-C group and the healthy control group in terms of pRNFL thickness, CMT, and SCT. However, in the MIS-C group, the macular superficial vascular plexus and deep vascular plexus showed significantly lower VD in the superior, inferior, nasal, and temporal quadrants compared to the healthy controls (P < 0.05 for all). A comparison of the superficial and deep FAZ area parameters of both groups showed no statistically significant difference (P > 0.05). CONCLUSIONS We showed that patients who had recovered from MIS-C had retinal vascular damage at the long-term follow-up. Following up with these patients after recovery with OCT and OCT-A, which are noninvasive methods commonly used in the detailed evaluation of the posterior segment of the eye, could be beneficial for understanding the long-term effects of MIS-C on retinal microvasculature. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].
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Gao Y, Zhang Y, Mou K, Liu Y, Chen Q, Man S, Xu H, Zhou J, Wang T, Li Y, Chen Y, Zhang M. Assessment of alterations in the retina and vitreous in pre- and post-COVID-19 patients using swept-source optical coherence tomography and angiography: A comparative study. J Med Virol 2023; 95:e29168. [PMID: 37815403 DOI: 10.1002/jmv.29168] [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: 04/25/2023] [Revised: 08/06/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
Ocular manifestations have been well recognized in coronavirus disease 2019 (COVID-19) outbreak. Several studies have detected ocular manifestations in patients after COVID-19. However, little is known about the retinal and vitreal alterations in patients before and after COVID-19 infection. This study aimed to investigate the retinal and vitreal alterations in patients before and after contracting COVID-19 infection using swept-source optical coherence tomography (SS-OCT) and angiography (SS-OCTA). A total of 38 participants (76 eyes) were enrolled and followed-up 1 month after COVID-19 infection. Then, 26 patients (52 eyes) were evaluated 3 months after COVID-19 infection. Compared with the pre-COVID-19 status, patients with 1- and 3-month post-COVID-19 statuses had significant thinning of ganglion cell and inner plexiform layer, thickening of inner nuclear layer, a decrease in the vessel density (VD) of superficial vascular complex, and an increase in the VD of deep vascular complex. Meanwhile, alteration in parameters of foveal avascular zone (all p < 0.05) and hyper-reflective dots in the vitreous of 27 patients (54 eyes) (71.1% vs. pre-COVID-19, 34.2%, p = 0.006) were observed. These findings suggest significantly retinal and vitreal alterations occurred in patients after COVID-19 infection, possibly due to direct or indirect virus-induced injuries. Further longitudinal studies are required to investigate the long-term effects of COVID-19 infection on the human eyes.
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Affiliation(s)
- Yuzhu Gao
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology and Research Laboratory of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Yifan Zhang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Kefan Mou
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Yilin Liu
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Qing Chen
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Shulei Man
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Hanyue Xu
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Jiaming Zhou
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Ting Wang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Yating Li
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Yi Chen
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Ming Zhang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Ophthalmology, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
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Abbati G, Fazi C, Fortunato P, Trapani S. Central retinal artery occlusion in a young child affected by COVID-19: a first case report. BMC Pediatr 2023; 23:462. [PMID: 37704960 PMCID: PMC10500751 DOI: 10.1186/s12887-023-04276-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/27/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Central retinal artery occlusion (CRAO) is an ophthalmic emergency, and its etiology is generally ascribed to vessel occlusion by a thrombus or embolus, eventually due to a hypercoagulable state. CRAO occurrence is described even in the pediatric population, but its incidence is very rare. SARS-CoV-2 infection has a multitude of presentations, and almost any organ may be involved including the ocular district. Cases of CRAO in patients affected by COVID-19 are reported in the literature in the adult population, but not in the pediatric one. CASE PRESENTATION We describe the case of a six-year-old otherwise healthy girl, who presented a sudden and complete bilateral vision loss after a one-day fever. All the clinical, ophthalmological, laboratory and instrumental investigations led to the diagnosis of a right CRAO and the suspicion of a contralateral posterior optic nerve affection. These manifestations could not be ascribed to any etiological condition apart from the documented ongoing mild SARS-CoV-2 infection. Treatment with anticoagulants and steroids was tried but the visual outcome was poor during the one-month hospitalization and at the last follow-up. CONCLUSIONS To the best of our knowledge, this is the first report of CRAO in the course of SARS-CoV-2 infection in the pediatric age. In our review of the literature, we found few cases of CRAO in adults with COVID-19; we highlighted differences in anamnestic, clinical, and interventional aspects and therefore we tried to summarize the state of the art on this topic to facilitate further studies. Even if rare, the prognosis of CRAO is poor and the thrombolytic treatment could be effective only if rapidly administered, so the disease suspicion should be high in a patient with sudden vision loss, also in pediatric age.
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Affiliation(s)
- Giulia Abbati
- Pediatric and Neonatology Unit, Santo Stefano Hospital, Prato, Italy.
| | - Camilla Fazi
- Pediatric Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Pina Fortunato
- Pediatric Ophthalmology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Sandra Trapani
- Pediatric Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
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Jiang L, Li X, Nie J, Tang K, Bhutta ZA. A Systematic Review of Persistent Clinical Features After SARS-CoV-2 in the Pediatric Population. Pediatrics 2023; 152:e2022060351. [PMID: 37476923 PMCID: PMC10389775 DOI: 10.1542/peds.2022-060351] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 07/22/2023] Open
Abstract
CONTEXT Long-term health effects after coronavirus disease 2019 (COVID-19) have been increasingly reported but their prevalence and significance in the pediatric population remains uncertain. OBJECTIVE To present the prevalence and characteristics of the long-term clinical features of COVID-19 (long COVID) in the global pediatric population. DATA SOURCES PubMed, Embase, Web of Science, Cochrane Library, WHO COVID-19 database, google scholar, medRxiv, bioRxiv, and multiple national public health databases. STUDY SELECTION Published articles and preprints from December, 2019 to December, 2022 investigating the epidemiology and characteristics of persistent clinical features at least 3 months after COVID-19 in children and adolescents (0-19 years old) were included. DATA EXTRACTION Study characteristics and detailed description of long COVID were extracted into a predefined form. RESULTS Twenty seven cohorts and 4 cross-sectional studies met the inclusion criteria and involved over 15 000 pediatric participants. A total of more than 20 persistent symptoms and clinical features were reported among children and adolescents. 16.2% (95% confidence interval 8.5% to 28.6%) of the pediatric participants experienced 1 or more persistent symptom(s) at least 3 months post COVID-19. Female gender might be associated with developing certain long COVID symptoms. LIMITATIONS Included studies presented with great heterogeneity because of significant variations in the definition of "long COVID," follow up duration, and method. There could be nonresponse and other potential bias. CONCLUSIONS Persistent clinical features beyond 3 months among children and adolescents with proven COVID-19 are common and the symptom spectrum is wide. High-quality, prospective studies with proper controls are necessary in the future.
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Affiliation(s)
- Li Jiang
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Xuan Li
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Jia Nie
- Institute for Risk Assessment Science (IRAS), Utrecht University, the Netherlands
| | - Kun Tang
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
- Institute for Global Health and Development, The Aga Khan University, Karachi, Pakistan
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OCT and OCTA evaluation of vascular and morphological structures in the retina in recovered pediatric patients with COVID-19. Photodiagnosis Photodyn Ther 2022; 40:103157. [PMID: 36244680 PMCID: PMC9561386 DOI: 10.1016/j.pdpdt.2022.103157] [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: 08/30/2022] [Revised: 10/08/2022] [Accepted: 10/11/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Using OCT and OCTA imaging, we aimed to determine whether COVID-19 induces pathological changes in vascular and morphological structures in the pediatric retina. METHODS The current prospective, cross-sectional, observational clinical study included recovered pediatric patients with COVID-19 evaluated between May 2020 and June 2020. Retinal vascular (radial peripapillary, superficial, and deep capillary plexus vessel densities) and morphological (peripapillary retinal nerve fiber, ganglion cell layer, retinal, and choroidal thickness) in the optic disk and macula regions were quantitively assessed using OCT and OCTA. Data were compared between COVID-19 patients and age-matched controls. RESULTS The COVID-19 group included 32 eyes of 16 patients and the control group included 32 eyes of 16 cases. Fundus and biomicroscopic examinations revealed no signs of pathology in the COVID-19 group. Mean peripapillary retinal nerve fiber, ganglion cell layer, and choroidal thickness values were significantly greater in the COVID-19 group than in the control group (p<0.05). OCTA indicated that mean superficial and deep capillary plexus vessel densities, and choriocapillaris flow area values were significantly lower in the COVID-19 group than in the control group, whereas mean radial peripapillary capillary plexus vessel density values were significantly higher (p<0.05). CONCLUSIONS Even if fundus examination results appear normal in pediatric patients with COVID-19, vascular and morphological changes may be observed in the retina. Further studies with larger numbers of patients are needed to elucidate the clinical significance of vascular and morphological changes in this population.
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Retinal Microvascular Changes in COVID-19 Bilateral Pneumonia Based on Optical Coherence Tomography Angiography. J Clin Med 2022; 11:jcm11133621. [PMID: 35806907 PMCID: PMC9267319 DOI: 10.3390/jcm11133621] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/08/2022] [Accepted: 06/20/2022] [Indexed: 02/05/2023] Open
Abstract
The purpose of this study was to evaluate retinal and choroidal microvascular alterations with optical coherence tomography angiography (OCTA) in COVID-19 patients hospitalized because of bilateral pneumonia caused by SARS-CoV-2. The vessel density (VD) and foveal avascular zone (FAZ) of 63 patients with SARS-CoV-2 pneumonia who had positive polymerase chain reaction (PCR) tests and who recovered after receiving treatment and 45 healthy age- and gender-matched controls were evaluated and compared using OCTA in the superficial capillary plexus (SCP) and deep capillary plexus (DCP). The VD was also estimated in both groups in the choriocapillaris (CC). In COVID-19 patients, there was a statistically significant difference between the patients and a control group in both superficial (FAZs) and deep (FAZd) avascular zone (p = 0.000). The VD was significantly lower in the foveal area in choriocapillaris (p = 0.046). There were no statistically significant changes in the VD in the superior, inferior, nasal, and temporal quadrants in superficial and deep plexus, or in the choriocapillaris. The VD was not significantly lower in the foveal area in superficial or deep plexus. COVID-19 may affect the retinal vasculature, causing ischemia, enlargement of the FAZ, and lowering of the VD in the choriocapillaris area. Routine ophthalmic examination after SARS-CoV-2 infection should be considered in the course of post-infectious rehabilitation.
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McGrath OE, Aslam TM. Use of Imaging Technology to Assess the Effect of COVID-19 on Retinal Tissues: A Systematic Review. Ophthalmol Ther 2022; 11:1017-1030. [PMID: 35488102 PMCID: PMC9053559 DOI: 10.1007/s40123-022-00509-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To evaluate the effect of COVID-19 on retinal tissues by conducting a systematic review and meta-analysis of the current literature. BACKGROUND The novel coronavirus disease is not yet well understood. The orbit provides a window into the body's microvasculature, and as such, it is a non-invasive opportunity to analyse the systemic circulation in vivo. By analysing the current literature, we test the hypothesis that non-invasive imaging of the retina could provide insight into the effect of COVID-19 on the retinal microvasculature. METHODS For this systematic review and meta-analysis, we screened PubMed databases and LitCOVID19 using the search criteria: (OCTA or Optical Coherence Tomography Angiography) AND (COVID-19 or corona or SARS-CoV-2) AND (retina or fundus). Databases were searched on 11 January 2022. The primary study outcomes were studies that utilised OCTA to analyse the retina; secondary outcomes involved studies that involved other imaging modalities such as OCT, fundus photography, and fundus autofluorescence. FINDINGS The total number of studies included in this review was 32. Optical coherence tomography angiography scans show reduced central retinal vascular density, a thinner ganglion cell layer, a thicker retinal nerve fibre layer, and an enlarged foveal avascular zone. Optical coherence tomography scans demonstrate a thicker central macular thickness and other changes to the macula, ganglion cell, and inner nuclear layers. Many fundus photographs depicted cotton wool spots, microhaemorrhages, and vascular occlusions. Non-invasive imaging technology has demonstrated that COVID-19 can profoundly affect the retina. Therefore, there is a requirement for long-term follow-up of COVID-19 patients to assess whether the retinal damage caused by COVID-19 is reversible.
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Affiliation(s)
- Orlaith E. McGrath
- Manchester Royal Eye Hospital, Manchester, UK
- The University of Manchester, Manchester, UK
| | - Tariq M. Aslam
- Manchester Royal Eye Hospital, Manchester, UK
- The University of Manchester, Manchester, UK
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Akpolat C, Cetinkaya T, Kurt MM. A Pediatric COVID-19 Study: Retinal Nerve Fiber Layer, Ganglion Cell Layer, and Alterations in Choroidal Thickness in Swept-Source OCT Measurements. Klin Monbl Augenheilkd 2022; 239:916-922. [DOI: 10.1055/a-1785-3863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract
Purpose To investigate early covid measurements of central macular thickness (CMT), retinal nerve fiber layer (RNFL), ganglion cell layer (GCL) thickness, and choroidal thickness
(ChT) in children recovered from coronavirus disease 2019 (COVID-19).
Methods This cross-sectional study was carried out 4 weeks after completed COVID-19 treatment. The diagnosis of the Alpha variant COVID-19 was made by the polymerase chain reaction
test after prediagnosis with clinical, laboratory, and radiological findings. A total of 46 children were included in the study. Pediatric patients who received COVID-19 treatment comprised
the COVID-19 group (24 children), and healthy children were enrolled in the control group (22 children). Only the right eyes of the participants were enrolled in the study. All pediatric
patients in the COVID-19 group required hospitalization without the need for intubation. Swept-source optical coherence tomography (SS-OCT) was used to measure CMT, RNFL, and GCL thickness,
and ChT measurements.
Results The COVID-19 and control groups had similar mean values of visual acuity, intraocular pressure, spherical equivalent, axial length, and CMT (p > 0.05 for all). RNFL
thickening, GCL, and choroidal thinning were observed in all SS-OCT measurements of COVID-19 children. However, RNFL thickening was significant only in the global and nasal peripapillary
quadrants. GCL thinning was significant in the nasal/inferior sector (p < 0.002 for all). Some significant correlations were observed between the mean levels of inflammatory markers and
OCT measurements (p < 0.002).
Conclusion This study may be among the first reports of SS-OCT examination of COVID-19 children. OCT measurements showed changes in retinal and ChT in the COVID-19 children as in
adult patients.
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Affiliation(s)
- Cetin Akpolat
- Ophthalmology, Sisli Hamidiye Etfal Egitim ve Arastirma Hastanesi, Halaskargazi cd. Etfal sok., Istanbul, Turkey
| | - Tugba Cetinkaya
- Ophthalmology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Muhammed M. Kurt
- Ophthalmology, Samsun Education and Research Hospital, Samsun, Turkey
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Beni AN, Dehghani A, Kianersi F, Ghanbari H, Habibi Z, Memarzadeh E, Beni ZN. Retinal findings of COVID-19 patients using Ocular coherence tomography angiography two to three months after infection: Ocular appearance recovered COVID-19 patient. Photodiagnosis Photodyn Ther 2022; 38:102726. [PMID: 35051664 PMCID: PMC8762816 DOI: 10.1016/j.pdpdt.2022.102726] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/10/2022] [Accepted: 01/14/2022] [Indexed: 02/06/2023]
Abstract
Purpose The aim of this study was to evaluate the ocular disorders in COVID-19 patients, two to three months after infection. Methods In this cross-sectional, historically controlled study, fifty-one COVID-19 patients were compared with thirty-seven age, and gender-matched healthy individuals. After complete ophthalmological examination, all participants underwent peripapillary and macular optical coherence tomography, and optical coherence tomography angiography (OCTA) measurements (OptoVue Inc, Freemont, CA, USA). Results The time between the initial onset of symptoms, and ophthalmologic examination was 63.31±15.21 (40–95 days). Ophthalmic examination of all the recovered COVID-19 patients was within normal range. None of the peripapillary and macular OCTA parameters were significantly different between the two groups with pairwise comparisons, but after adjusting for age, gender, axial length, and signal strength index (SSI), recovered COVID-19 eyes showed a significant increase in peripapillary retinal nerve fiber (RNFL) thickness, superficial, and deep macular vessel densities in parafoveal and perifoveal regions compared with healthy control eyes (p<= 0.05). Inner retinal thickness overall is higher in recovered COVID-19 eyes compared to healthy eyes after adjustment. Conclusion Patients with moderate-intensity SARS-CoV-2 pneumonia had altered peripapillary and macular vessel density compared to healthy subjects. Further investigation is warranted to analyze the correlation of these changes with disease severity as well as evolution of these changes over time.
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Affiliation(s)
- Afsaneh Naderi Beni
- Isfahan Eye Research Center, Department of ophthalmology, Isfahan University of medical sciences, Isfahan, Iran.
| | - Alireza Dehghani
- Isfahan Eye Research Center, Department of ophthalmology, Isfahan University of medical sciences, Isfahan, Iran
| | - Farzan Kianersi
- Isfahan Eye Research Center, Department of ophthalmology, Isfahan University of medical sciences, Isfahan, Iran
| | - Heshmatollah Ghanbari
- Isfahan Eye Research Center, Department of ophthalmology, Isfahan University of medical sciences, Isfahan, Iran
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