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Cortinhal T, Santos C, Vaz-Pereira S, Marta A, Duarte L, Miranda V, Costa J, Sousa AB, Peter VG, Kaminska K, Rivolta C, Carvalho AL, Saraiva J, Soares CA, Silva R, Murta J, Santos LC, Marques JP. Genetic profile of syndromic retinitis pigmentosa in Portugal. Graefes Arch Clin Exp Ophthalmol 2024; 262:1883-1897. [PMID: 38189974 PMCID: PMC11106148 DOI: 10.1007/s00417-023-06360-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 12/11/2023] [Accepted: 12/28/2023] [Indexed: 01/09/2024] Open
Abstract
PURPOSE Retinitis pigmentosa (RP) comprises a genetically and clinically heterogeneous group of inherited retinal degenerations, where 20-30% of patients exhibit extra-ocular manifestations (syndromic RP). Understanding the genetic profile of RP has important implications for disease prognosis and genetic counseling. This study aimed to characterize the genetic profile of syndromic RP in Portugal. METHODS Multicenter, retrospective cohort study. Six Portuguese healthcare providers identified patients with a clinical diagnosis of syndromic RP and available genetic testing results. All patients had been previously subjected to a detailed ophthalmologic examination and clinically oriented genetic testing. Genetic variants were classified according to the American College of Medical Genetics and Genomics; only likely pathogenic or pathogenic variants were considered relevant for disease etiology. RESULTS One hundred and twenty-two patients (53.3% males) from 100 families were included. Usher syndrome was the most frequent diagnosis (62.0%), followed by Bardet-Biedl (19.0%) and Senior-Løken syndromes (7.0%). Deleterious variants were identified in 86/100 families for a diagnostic yield of 86.0% (87.1% for Usher and 94.7% for Bardet-Biedl). A total of 81 genetic variants were identified in 25 different genes, 22 of which are novel. USH2A and MYO7A were responsible for most type II and type I Usher syndrome cases, respectively. BBS1 variants were the cause of Bardet-Biedl syndrome in 52.6% of families. Best-corrected visual acuity (BCVA) records were available at baseline and last visit for 99 patients (198 eyes), with a median follow-up of 62.0 months. The mean BCVA was 56.5 ETDRS letters at baseline (Snellen equivalent ~ 20/80), declining to 44.9 ETDRS letters (Snellen equivalent ~ 20/125) at the last available follow-up (p < 0.001). CONCLUSION This is the first multicenter study depicting the genetic profile of syndromic RP in Portugal, thus contributing toward a better understanding of this heterogeneous disease group. Usher and Bardet-Biedl syndromes were found to be the most common types of syndromic RP in this large Portuguese cohort. A high diagnostic yield was obtained, highlighting current genetic testing capabilities in providing a molecular diagnosis to most affected individuals. This has major implications in determining disease-related prognosis and providing targeted genetic counseling for syndromic RP patients in Portugal.
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Affiliation(s)
- Telmo Cortinhal
- Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
| | - Cristina Santos
- Instituto de Oftalmologia Dr. Gama Pinto (IOGP), Lisboa, Portugal
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Sara Vaz-Pereira
- Department of Ophthalmology, Centro Hospitalar Universitário de Lisboa Norte (CHULN), Lisboa, Portugal
- Department of Ophthalmology, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Marta
- Department of Ophthalmology, Centro Hospitalar e Universitário de Santo António (CHUdSA), Porto, Portugal
- Instituto Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
| | - Lilianne Duarte
- Department of Ophthalmology, Centro Hospitalar de Entre Douro e Vouga (CHEDV), Santa Maria da Feira, Portugal
| | - Vitor Miranda
- Department of Ophthalmology, Centro Hospitalar de Entre Douro e Vouga (CHEDV), Santa Maria da Feira, Portugal
| | - José Costa
- Department of Ophthalmology, Hospital de Braga (HB), Braga, Portugal
| | - Ana Berta Sousa
- Medical Genetics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Lisboa Norte (CHULN), Lisboa, Portugal
| | - Virginie G Peter
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), 4031, Basel, Switzerland
- Department of Ophthalmology, University of Basel, 4031, Basel, Switzerland
- Department of Ophthalmology, Inselspital, Bern University Hospital, 3010, Bern, Switzerland
| | - Karolina Kaminska
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), 4031, Basel, Switzerland
- Department of Ophthalmology, University of Basel, 4031, Basel, Switzerland
| | - Carlo Rivolta
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), 4031, Basel, Switzerland
- Department of Ophthalmology, University of Basel, 4031, Basel, Switzerland
- Department of Genetics and Genome Biology, University of Leicester, Leicester, LE1 7RH, United Kingdom
| | - Ana Luísa Carvalho
- Medical Genetics Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- University Clinic of Medical Genetics, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
| | - Jorge Saraiva
- Medical Genetics Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- University Clinic of Pediatrics, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
| | - Célia Azevedo Soares
- Medical Genetics Department, Centro de Genética Médica Jacinto Magalhães, Centro Hospitalar e Universitário do Porto (CHUP), Porto, Portugal
- Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- Medical Science Department, Universidade de Aveiro, Aveiro, Portugal
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Rufino Silva
- Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
| | - Joaquim Murta
- Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
| | | | - João Pedro Marques
- Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal.
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal.
- University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal.
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Marta A, Marques JP, Santos C, Coutinho-Santos L, Vaz-Pereira S, Costa J, Arede P, Félix R, Geada S, Gouveia N, Silva R, Baptista M, Lume M, Parreira R, Azevedo Soares C, Menéres MJ, Lemos C, Melo Beirão J. The socioeconomic epidemiology of inherited retinal diseases in Portugal. Orphanet J Rare Dis 2024; 19:151. [PMID: 38594754 PMCID: PMC11003026 DOI: 10.1186/s13023-024-03161-6] [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: 05/16/2023] [Accepted: 03/30/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Inherited retinal diseases (IRDs) are a group of rare degenerative disorders of the retina that can lead to blindness from birth to late middle age. Knowing the target population and its resources is essential to better plan support measures. The aim of this study was to evaluate the socioeconomic characteristics of regions in Portugal where IRD patients reside to inform the planning of vision aid and rehabilitation intervention measures. RESULTS This study included 1082 patients from 973 families, aged 3 to 92 years, with a mean age of 44.8 ± 18.1 years. Patients living with an IRD were identified in 190 of the 308 municipalities. According to this study, the estimated IRD prevalence in Portugal was 10.4 per 100,000 inhabitants, and by municipalities, it ranged from 0 to 131.2 per 100,000 inhabitants. Overall, regions with a higher prevalence of IRD have a lower population density (r=-0.371, p < 0.001), a higher illiteracy rate (r = 0.404, p < 0.001) and an overall older population (r = 0.475, p < 0.001). Additionally, there is a lower proportion of doctor per capita (r = 0.350, p < 0.001), higher social security pensions beneficiaries (r = 0.439, p < 0.001), worse water quality for human consumption (r=-0.194, p = 0.008), fewer audiences at the cinema (r=-0.315, p < 0.001) and lower proportion of foreign guests in tourist accommodations (r=-0.287, p < 0.001). CONCLUSION The number of identified patients with IRD varied between regions. Using data from national statistics (PORDATA), we observed differences in socioeconomic characteristics between regions. Multiple targeted aid strategies can be developed to ensure that all IRD patients are granted full clinical and socioeconomic support.
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Affiliation(s)
- Ana Marta
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, EPE (CHUdSA), Porto, Portugal.
- Instituto Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal.
| | - João Pedro Marques
- Centro de Responsabilidade Integrado de Oftalmologia do Centro Hospitalar e Universitário de Coimbra, EPE (CRIO-CHUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra, Coimbra, Portugal
- Faculty of Medicine, University Clinic of Ophthalmology, University of Coimbra (FMUC), Coimbra, Portugal
| | - Cristina Santos
- Instituto de Oftalmologia Dr. Gama Pinto (IOGP), Lisboa, Portugal
- Faculdade de Ciências Médicas, NMS, FCM, NOVA Medical School, Universidade NOVA de Lisboa, 7 iNOVA4Health, Lisboa, Portugal
| | | | - Sara Vaz-Pereira
- Department of Ophthalmology, Centro Hospitalar Universitário de Lisboa Norte (CHULN), Lisboa, Portugal
- Department of Ophthalmology, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - José Costa
- Department of Ophthalmology, Hospital de Braga (HB), Braga, Portugal
| | - Pedro Arede
- Department of Ophthalmology, Centro Hospitalar Lisboa Ocidental, EPE (CHLO), Lisboa, Portugal
| | - Raquel Félix
- Centro de Responsabilidade Integrado de Oftalmologia do Centro Hospitalar e Universitário de Coimbra, EPE (CRIO-CHUC), Coimbra, Portugal
| | - Sara Geada
- Centro de Responsabilidade Integrado de Oftalmologia do Centro Hospitalar e Universitário de Coimbra, EPE (CRIO-CHUC), Coimbra, Portugal
| | - Nuno Gouveia
- Centro de Responsabilidade Integrado de Oftalmologia do Centro Hospitalar e Universitário de Coimbra, EPE (CRIO-CHUC), Coimbra, Portugal
| | - Rui Silva
- Department of Ophthalmology, Hospital de Braga (HB), Braga, Portugal
| | - Margarida Baptista
- Department of Ophthalmology, Centro Hospitalar Lisboa Ocidental, EPE (CHLO), Lisboa, Portugal
| | - Miguel Lume
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, EPE (CHUdSA), Porto, Portugal
| | - Ricardo Parreira
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, EPE (CHUdSA), Porto, Portugal
| | - Célia Azevedo Soares
- Medical Genetics Department, Centro de Genética Médica Jacinto Magalhães, Centro Hospitalar Universitário de Santo António, EPE (CHUdSA), Porto, Portugal
- Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- Medical Science Department, Universidade de Aveiro, Aveiro, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Maria João Menéres
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, EPE (CHUdSA), Porto, Portugal
- Instituto Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
| | - Carolina Lemos
- Instituto Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
- Centro Hospitalar Universitário de Santo António, EPE (CHUdSA), Largo do Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - João Melo Beirão
- Department of Ophthalmology, Centro Hospitalar Universitário de Santo António, EPE (CHUdSA), Porto, Portugal
- Instituto Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
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Mees L, Li M, Antonio-Aguirre B, Liu TYA, Wu A, Kong X, Singh MS. Frequency and Distribution of Ophthalmic Surgical Procedures among Patients with Inherited Retinal Diseases. Ophthalmol Retina 2024:S2468-6530(24)00109-X. [PMID: 38485090 DOI: 10.1016/j.oret.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE In this study, we aimed to characterize the frequency and distribution of ocular surgeries in patients with inherited retinal diseases (IRDs) and evaluate associated patient and disease factors. DESIGN Retrospective cohort. PARTICIPANTS Subjects aged ≥ 18 years who were followed at the Johns Hopkins Genetic Eye Disease Center. METHODS We studied a retrospective cohort of patients with an IRD diagnosis to analyze the occurrence of laser and incisional surgeries. Subjects were categorized into 2 groups: central dysfunction (macular/cone/cone-rod dystrophy, "MCCRD group") and panretinal or peripheral dysfunction (retinitis pigmentosa-like, "RP group"). Genetic testing status was recorded. The association of patient and disease factors on the frequency, distribution, and timing of surgeries was analyzed. MAIN OUTCOME MEASURES Prevalence, prevalence odds ratio (POR), hazard ratio (HR) of ophthalmic procedures by phenotype. RESULTS A total of 1472 eyes of 736 subjects were evaluated. Among them, 31.3% (n = 230) had undergone ocular surgery, and 78.3% of those (n = 180/230) had a history of more than 1 surgery. A total of 602 surgical procedures were analyzed. Cataract extraction with intraocular lens implantation (CEIOL) was the most common (51.2%), followed by yttrium aluminum garnet capsulotomy, refractive surgery, retinal surgery, and others. Cataract extraction with intraocular lens implantation occurred more frequently in RP than in MCCRD subjects (POR, 2.59; P = 0.002). Retinitis pigmentosa subjects underwent CEIOL at a younger age than patients with MCCRD (HR, 2.11; P < 0.001). CONCLUSIONS Approximately one-third of patients with IRD had a history of laser or incisional surgery. Cataract extraction with intraocular lens implantation was the most common surgery; its frequency and timing may be associated with the IRD phenotype. This data may inform the design of prospective research. Such efforts may illuminate routine clinical decision-making and contribute to surgical strategy development for cell and gene therapy delivery. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Lukas Mees
- Retina Division, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland
| | - Mingyi Li
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California; Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Bani Antonio-Aguirre
- Retina Division, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland
| | - Tin Yan Alvin Liu
- Retina Division, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland
| | - Adela Wu
- Retina Division, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland; Department of Neurosurgery, Stanford Health Care, Stanford, California
| | - Xiangrong Kong
- Retina Division, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland; Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Mandeep S Singh
- Retina Division, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland; Department of Genetic Medicine, Johns Hopkins University, Baltimore, Maryland.
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Soares RM, Carvalho AL, Simão S, Soares CA, Raimundo M, Alves CH, Ambrósio AF, Murta J, Saraiva J, Silva R, Marques JP. Eyes Shut Homolog-Associated Retinal Degeneration: Natural History, Genetic Landscape, and Phenotypic Spectrum. Ophthalmol Retina 2023:S2468-6530(23)00054-4. [PMID: 36764454 DOI: 10.1016/j.oret.2023.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/12/2023] [Accepted: 02/02/2023] [Indexed: 06/18/2023]
Abstract
PURPOSE To describe the natural history, genetic landscape, and phenotypic spectrum of Eyes shut homolog (EYS)-associated retinal degeneration (EYS-RD). DESIGN Retrospective, single-center cohort study complemented by a cross-sectional examination. SUBJECTS Patients with biallelic EYS variants were recruited at an inherited RD referral center in Portugal. METHODS Every patient underwent a cross-sectional examination comprising a comprehensive ophthalmic examination including best-corrected visual acuity (BCVA), dilated slit-lamp anterior segment, and fundus biomicroscopy; ultrawide-field color fundus photography and fundus autofluorescence imaging; and spectral domain-OCT. In the setting of a retinitis pigmentosa (RP) diagnosis, every patient was classified as typical or atypical RP according to imaging criteria. Baseline demographics, age at onset of symptoms, family history, history of consanguinity, symptoms, age at diagnosis, BCVA at baseline and throughout follow-up, and EYS variants were collected from each individual patient file. MAIN OUTCOME MEASURES Clinical/demographic, genetic, multimodal imaging data, and BCVA variation were compared between typical and atypical RP. Additionally, BCVA variation during follow-up was used as an endpoint to describe EYS-RD natural history. RESULTS Fifty-eight patients (59% men; mean age 52 ± 14 years) from 48 White families of Portuguese ancestry were included. Twenty distinct EYS variants were identified, 8 of which are novel. In 32.8% of patients, onset of symptoms was in early adulthood (21-30 years). A clinical diagnosis of RP was established in 57 patients and cone-rod dystrophy in 1 patient. Regarding RP, 75.0% of the patients were graded as typical and 25.0% as atypical. Atypical EYS-RP commonly presents with inferior crescent-shaped macular atrophy with superior midperipheral sparing. In EYS-RD, a negative correlation was found between age and BCVA (r = -0.50; P < 0.001), with an average loss of 1.45 letters per year. When stratifying for RP phenotype, lower average loss of letters per year (P < 0.001), higher BCVA (P < 0.001), and larger ellipsoid zone widths (P < 0.001) were found in atypical RP. CONCLUSIONS This study expands the genetic spectrum of EYS-RD by reporting 8 novel variants. A high frequency of atypical phenotypes was identified. These patients have better BCVA and larger ellipsoidal zone widths, thus presenting an overall better prognosis. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Ricardo Machado Soares
- Department of Ophthalmology, Centro Hospitalar de Vila Nova de Gaia e Espinho (CHVNGE), Gaia, Portugal
| | - Ana Luísa Carvalho
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; Medical Genetics Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal; University Clinic of Medical Genetics, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
| | - Sílvia Simão
- Ophthalmology Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
| | - Célia Azevedo Soares
- Centro de Genética Médica Jacinto Magalhães, Centro Hospitalar Universitário do Porto (CHUP), Porto, Portugal; Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciências Biomédicas Abel Salazar/Universidade do Porto, Porto, Portugal; Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Miguel Raimundo
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; Ophthalmology Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal; University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
| | - C Henrique Alves
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal; Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra (UC), Coimbra, Portugal; Association for Innovation and Biomedical Research on Light and Image (AIBILI), Coimbra, Portugal
| | - António Francisco Ambrósio
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal; Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra (UC), Coimbra, Portugal; Association for Innovation and Biomedical Research on Light and Image (AIBILI), Coimbra, Portugal
| | - Joaquim Murta
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; Ophthalmology Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal; University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
| | - Jorge Saraiva
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; Medical Genetics Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal; University Clinic of Pediatrics, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
| | - Rufino Silva
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; Ophthalmology Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal; University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal; Association for Innovation and Biomedical Research on Light and Image (AIBILI), Coimbra, Portugal
| | - João Pedro Marques
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal; Ophthalmology Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal; University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal; Association for Innovation and Biomedical Research on Light and Image (AIBILI), Coimbra, Portugal.
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