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Zhang J, Sheng X, Ding Q, Wang Y, Zhao J, Zhang J. Subretinal fibrosis secondary to neovascular age-related macular degeneration: mechanisms and potential therapeutic targets. Neural Regen Res 2025; 20:378-393. [PMID: 38819041 PMCID: PMC11317958 DOI: 10.4103/nrr.nrr-d-23-01642] [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: 09/30/2023] [Revised: 12/19/2023] [Accepted: 01/15/2024] [Indexed: 06/01/2024] Open
Abstract
Subretinal fibrosis is the end-stage sequelae of neovascular age-related macular degeneration. It causes local damage to photoreceptors, retinal pigment epithelium, and choroidal vessels, which leads to permanent central vision loss of patients with neovascular age-related macular degeneration. The pathogenesis of subretinal fibrosis is complex, and the underlying mechanisms are largely unknown. Therefore, there are no effective treatment options. A thorough understanding of the pathogenesis of subretinal fibrosis and its related mechanisms is important to elucidate its complications and explore potential treatments. The current article reviews several aspects of subretinal fibrosis, including the current understanding on the relationship between neovascular age-related macular degeneration and subretinal fibrosis; multimodal imaging techniques for subretinal fibrosis; animal models for studying subretinal fibrosis; cellular and non-cellular constituents of subretinal fibrosis; pathophysiological mechanisms involved in subretinal fibrosis, such as aging, infiltration of macrophages, different sources of mesenchymal transition to myofibroblast, and activation of complement system and immune cells; and several key molecules and signaling pathways participating in the pathogenesis of subretinal fibrosis, such as vascular endothelial growth factor, connective tissue growth factor, fibroblast growth factor 2, platelet-derived growth factor and platelet-derived growth factor receptor-β, transforming growth factor-β signaling pathway, Wnt signaling pathway, and the axis of heat shock protein 70-Toll-like receptors 2/4-interleukin-10. This review will improve the understanding of the pathogenesis of subretinal fibrosis, allow the discovery of molecular targets, and explore potential treatments for the management of subretinal fibrosis.
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Affiliation(s)
- Jingxiang Zhang
- Department of Ophthalmology, People’s Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Xia Sheng
- Department of Ophthalmology, People’s Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Quanju Ding
- Department of Ophthalmology, People’s Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Yujun Wang
- Department of Urology, People’s Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Jiwei Zhao
- Department of Ophthalmology, People’s Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Jingfa Zhang
- Department of Ophthalmology, Shanghai General Hospital (Shanghai First People’s Hospital), Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Eye Diseases, Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai, China
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Schranz M, Sacu S, Reiter GS, Baratsits M, Desissaire S, Pircher M, Mylonas G, Hitzenberger C, Schmidt-Erfurth U, Roberts PK. Structure-Function Correlation of Retinal Fibrosis in Eyes with Neovascular Age-Related Macular Degeneration. J Clin Med 2024; 13:1074. [PMID: 38398387 PMCID: PMC10889582 DOI: 10.3390/jcm13041074] [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: 01/10/2024] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
Purpose: To assess retinal function in areas of presumed fibrosis due to neovascular age-related macular degeneration (nAMD), using multimodal imaging and structure-function correlation. Design: Cross-sectional observational study. Methods: 30 eyes of 30 consecutive patients with nAMD with a minimum history of one year of anti-vascular endothelial growth factor therapy were included. Each patient underwent microperimetry (MP), color fundus photography (CFP), standard spectral-domain-based OCT (SD-OCT), and polarization sensitive-OCT (PS-OCT) imaging. PS-OCT technology can depict retinal fibrosis based on its birefringence. CFP, SD-OCT, and PS-OCT were evaluated independently for the presence of fibrosis at the corresponding MP stimuli locations. MP results and morphologic findings in CFP, SD-OCT, and PS-OCT were co-registered and analyzed using mixed linear models. Results: In total, 1350 MP locations were evaluated to assess the functional impact of fibrosis according to a standardized protocol. The estimated means of retinal areas with signs of fibrosis were 12.60 db (95% confidence interval: 10.44-14.76) in CFP, 11.60 db (95% COI: 8.84-14.36) in OCT, and 11.02 db (95% COI 8.10-13.94) in PS-OCT. Areas evaluated as subretinal fibrosis in three (7.2 db) or two (10.1 db) modalities were significantly correlated with a lower retinal sensitivity than a subretinal fibrosis observed in only one (15.3 db) or none (23.3 db) modality (p < 0.001). Conclusions: CFP, SD-OCT and PS-OCT are all suited to detect areas of reduced retinal sensitivity related to fibrosis, however, a multimodal imaging approach provides higher accuracy in the identification of areas with low sensitivity in MP (i.e., impaired retinal function), and thereby improves the detection rate of subretinal fibrosis in nAMD.
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Affiliation(s)
- Markus Schranz
- Vienna Clinical Trial Center (VTC), Department of Ophthalmology and Optometry, Medical University of Vienna, 1090 Vienna, Austria; (M.S.)
- Department of Ophthalmology and Optometry, Medical University of Vienna, 1090 Vienna, Austria
| | - Stefan Sacu
- Vienna Clinical Trial Center (VTC), Department of Ophthalmology and Optometry, Medical University of Vienna, 1090 Vienna, Austria; (M.S.)
- Department of Ophthalmology and Optometry, Medical University of Vienna, 1090 Vienna, Austria
| | - Gregor S. Reiter
- Department of Ophthalmology and Optometry, Medical University of Vienna, 1090 Vienna, Austria
| | - Magdalena Baratsits
- Vienna Clinical Trial Center (VTC), Department of Ophthalmology and Optometry, Medical University of Vienna, 1090 Vienna, Austria; (M.S.)
| | - Silvia Desissaire
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria
| | - Michael Pircher
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria
| | - Georgios Mylonas
- Department of Ophthalmology and Optometry, Medical University of Vienna, 1090 Vienna, Austria
| | - Christoph Hitzenberger
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria
| | - Ursula Schmidt-Erfurth
- Vienna Clinical Trial Center (VTC), Department of Ophthalmology and Optometry, Medical University of Vienna, 1090 Vienna, Austria; (M.S.)
- Department of Ophthalmology and Optometry, Medical University of Vienna, 1090 Vienna, Austria
| | - Philipp Ken Roberts
- Department of Ophthalmology and Optometry, Medical University of Vienna, 1090 Vienna, Austria
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Bachmeier I, Armendariz BG, Yu S, Jäger RJ, Ebneter A, Glittenberg C, Pauleikhoff D, Sadda SR, Chakravarthy U, Fauser S. Fibrosis in neovascular age-related macular degeneration: A review of definitions based on clinical imaging. Surv Ophthalmol 2023; 68:835-848. [PMID: 37023894 DOI: 10.1016/j.survophthal.2023.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
Despite the success of antiangiogenic therapy in controlling exudation in neovascular age-related macular degeneration (nAMD), the involvement of the outer retina in fibrosis results in gradual vision loss over time. The development of drugs that prevent or ameliorate fibrosis in nAMD requires that it is accurately detected and quantified with reliable endpoints and identification of robust biomarkers. Achievement of such an aim is currently challenging due to the lack of a consensus definition of fibrosis in nAMD. As a first step towards the establishment of a clear definition of fibrosis, we provide an extensive overview of the imaging modalities and criteria used to characterize fibrosis in nAMD. We observed variety in the selection of individual and combinations of imaging modalities, and criteria for detection. We also observed heterogeneity in classification systems and severity scales for fibrosis. The most commonly used imaging modalities were color fundus photography, fluorescein angiography and optical coherence tomography (OCT). A multimodal approach was frequently utilized. Our review suggests that OCT offers a more detailed, objective and sensitive characterization than color fundus photography/fluorescein angiography. Thus, we recommend it as a primary modality for fibrosis evaluation. This review provides a basis for future discussions to reach a consensus definition using standardized terms based on a detailed characterization of fibrosis, its presence and evolution, and taking into consideration impact on visual function. Achieving this goal is of paramount importance for the development of antifibrotic therapies.
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Affiliation(s)
- Isabel Bachmeier
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland.
| | - Beatriz G Armendariz
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | - Siqing Yu
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | - Ralf J Jäger
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | - Andreas Ebneter
- Department of Ophthalmology, Cantonal Hospital St. Gallen, University of Bern, Switzerland
| | - Carl Glittenberg
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | | | - SriniVas R Sadda
- Doheny Eye Institute, University of California-Los Angeles, Pasadena, 91103 CA, USA
| | - Usha Chakravarthy
- Queens University of Belfast, Institute of Clinical Science Block A, Belfast, UK
| | - Sascha Fauser
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
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Cheong KX, Cheung CMG, Teo KYC. Review of Fibrosis in Neovascular Age-Related Macular Degeneration. Am J Ophthalmol 2023; 246:192-222. [PMID: 36162537 DOI: 10.1016/j.ajo.2022.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 01/24/2023]
Abstract
PURPOSE To report the diagnosis and definitions, epidemiology, risk factors, and visual outcomes of fibrosis in neovascular age-related macular degeneration (nAMD). DESIGN Systematic review and meta-analysis. METHODS The review was performed using the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Observational studies and randomized controlled trials were included. RESULTS Identification of fibrosis is challenging. Optical coherence tomography angiography and polarization-sensitive optical coherence tomography represent novel options in multimodal imaging. The prevalence of fibrosis at baseline, 12, 24, and 60 months was 13%, 32%, 36%, and 56%, respectively. Approximately 60% of the fibrosis burden in nAMD at 5 years was present in the first year of treatment. Fibrosis development was highest in the first 12 months and slowed down over time. The risk factors of fibrosis included classic choroidal neovascularization (CNV), intra-retinal fluid, hemorrhage, hyperreflective material, CNV lesion size, and retinal thickness. Sub-retinal fluid and pigment epithelial detachment may be protective. Treatment-associated factors included disease activity and time to diagnosis. At baseline, the best corrected visual acuity in eyes with fibrosis was poorer than in eyes without fibrosis (-18.50 letters); this difference became larger at 12 months despite treatment (-26.86 letters). CONCLUSIONS There is a need to identify effective treatment strategies for fibrosis and to closely monitor at-risk patients. More studies involving multimodal imaging are required to clarify the definitions and grading criteria for fibrosis.
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Affiliation(s)
- Kai Xiong Cheong
- From Singapore Eye Research Institute, Singapore National Eye Centre, Singapore (K.X.C, C.M.G.C, K.Y.C.T)
| | - Chui Ming Gemmy Cheung
- From Singapore Eye Research Institute, Singapore National Eye Centre, Singapore (K.X.C, C.M.G.C, K.Y.C.T); Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore (C.M.G.C, K.Y.C.T)
| | - Kelvin Yi Chong Teo
- From Singapore Eye Research Institute, Singapore National Eye Centre, Singapore (K.X.C, C.M.G.C, K.Y.C.T); Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore (C.M.G.C, K.Y.C.T).
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Fursova AZ, Nikulich IF, Dmitrieva EI, Gusarevich OG, Derbeneva AS, Vasilyeva MA, Kozhevnikova OS, Kolosova NG, Rabota FK. [Prognosis criteria of optical coherence tomography angiography for the long-term efficacy of anti-VEGF therapy of neovascular age-related macular degeneration]. Vestn Oftalmol 2023; 139:50-58. [PMID: 38235630 DOI: 10.17116/oftalma202313906150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
PURPOSE The study aimed to determine the most significant optical coherence tomography angiography (OCTA) parameters in terms of predicting anti-VEGF therapy effectiveness during long-term (3-year) follow-up of patients with neovascular age-related macular degeneration (nAMD). MATERIAL AND METHODS The study included 122 patients (122 eyes) with mean age of 73.4±6.6 years who were diagnosed with nAMD. Subgroup analysis included 50 patients (50 eyes) with detailed OCT angiography examination of macular neovascularization (MNV) characteristics and their changes in the course of the follow-up, which lasted 144 weeks. All patients were treated by angiogenesis inhibitor (aflibercept 2 mg), most of them - according to Treat-and-Extend protocol. RESULTS Treatment response (either 'good' or 'partial') was achieved in all patients, and the proportion of the response types was similar in both types 1 and 2 MNV. Key OCTA parameters associated with the number of injections, as well as morphological and functional response (best-corrected visual acuity, retinal neuroepithelium and pigment epithelium detachment), were vascular network area and MNV area assessed at baseline and three months after treatment initiation. Both of these parameters were closely related in both MNV types during the follow-up. Key parameter with maximum number of clinically significant correlations ('very high' strength, p<0.05) in eyes with 'good' response was MNV area, in eyes with 'partial' response - vascular density and greatest vascular caliber. CONCLUSIONS Vascular network area and MNV area assessed at baseline and after three loading doses were determined as the most significant OCTA characteristics for predicting the number of injections and treatment response based on functional and morphological parameters. MNV area was found to be the most clinically significant marker in 'good' response, vascular density and greatest vascular caliber - in 'partial' response.
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Affiliation(s)
- A Zh Fursova
- Novosibirsk State Regional Hospital, Novosibirsk, Russia
- Novosibirsk State Medical University, Novosibirsk, Russia
- Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - I F Nikulich
- Novosibirsk State Regional Hospital, Novosibirsk, Russia
- Novosibirsk State Medical University, Novosibirsk, Russia
- Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - E I Dmitrieva
- Novosibirsk State Medical University, Novosibirsk, Russia
| | - O G Gusarevich
- Novosibirsk State Medical University, Novosibirsk, Russia
| | - A S Derbeneva
- Novosibirsk State Regional Hospital, Novosibirsk, Russia
- Novosibirsk State Medical University, Novosibirsk, Russia
- Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - M A Vasilyeva
- Novosibirsk State Regional Hospital, Novosibirsk, Russia
- Novosibirsk State Medical University, Novosibirsk, Russia
| | - O S Kozhevnikova
- Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - N G Kolosova
- Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - F K Rabota
- Novosibirsk State Medical University, Novosibirsk, Russia
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Jia H, Lu B, Zhao Z, Yu Y, Wang F, Zhou M, Sun X. Prediction of the short-term efficacy of anti-VEGF therapy for neovascular age-related macular degeneration using optical coherence tomography angiography. EYE AND VISION 2022; 9:16. [PMID: 35505390 PMCID: PMC9066856 DOI: 10.1186/s40662-022-00287-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 04/08/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
To evaluate whether the specific choroidal neovascularization (CNV) characteristics measured using optical coherence tomography angiography (OCTA) can predict the 6-month prognosis of neovascular age-related macular degeneration (nAMD) after anti-vascular endothelial growth factor (anti-VEGF) therapy.
Methods
Patients with type 1, type 2, or mixed-type neovascularization (NV) were prospectively included. Participants underwent an initial loading phase of three consecutive monthly intravitreal injections of Conbercept (0.5 mg) and were switched to a pro re nata (PRN) treatment strategy. OCTA images were evaluated for eyes that underwent follow-up assessments for more than 6 months. CNV lesions were manually segmented, and the CNV area, vessel area, greatest vascular caliber (GVC), and greatest linear dimension (GLD) were compared between responders and non-responders. Two masked graders independently measured the above-mentioned parameters using OCTA, and consistency was assessed using the intraclass correlation coefficient (ICC) values. Multiple logistic regression analysis was performed to evaluate the effect of a 3-month change in the CNV area, GLD, and GVC on the 6-month response to anti-VEGF agents.
Results
Among the 60 eyes of 60 patients with nAMD, 39 were responders and 21 were non-responders. The proportion of CNV types was significantly different between responders and non-responders (P = 0.009). Patients with type 2 or mixed NV seemed more likely to respond to the treatment (28.2% vs. 0.0%, and 30.8% vs. 23.8%, respectively). The change in GVC showed a significant difference between responders (− 4.98 ± 17.17 μm) and non-responders (11.01 ± 14.10 μm) after three monthly intravitreal anti-VEGF injections. Multiple logistic regression analysis showed that only the change in GVC remained significant after controlling for baseline GVC, injection number, and CNV type (adjusted OR = 1.083; P = 0.008).
Conclusions
Type 2 and mixed-type NV were significantly associated with a better response to anti-VEGF therapy. Changes in GVC after 3 months of treatment were significantly associated with a response to anti-VEGF therapy at 6 months.
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Schmidt-Erfurth U, Reiter GS, Riedl S, Seeböck P, Vogl WD, Blodi BA, Domalpally A, Fawzi A, Jia Y, Sarraf D, Bogunović H. AI-based monitoring of retinal fluid in disease activity and under therapy. Prog Retin Eye Res 2021; 86:100972. [PMID: 34166808 DOI: 10.1016/j.preteyeres.2021.100972] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 12/21/2022]
Abstract
Retinal fluid as the major biomarker in exudative macular disease is accurately visualized by high-resolution three-dimensional optical coherence tomography (OCT), which is used world-wide as a diagnostic gold standard largely replacing clinical examination. Artificial intelligence (AI) with its capability to objectively identify, localize and quantify fluid introduces fully automated tools into OCT imaging for personalized disease management. Deep learning performance has already proven superior to human experts, including physicians and certified readers, in terms of accuracy and speed. Reproducible measurement of retinal fluid relies on precise AI-based segmentation methods that assign a label to each OCT voxel denoting its fluid type such as intraretinal fluid (IRF) and subretinal fluid (SRF) or pigment epithelial detachment (PED) and its location within the central 1-, 3- and 6-mm macular area. Such reliable analysis is most relevant to reflect differences in pathophysiological mechanisms and impacts on retinal function, and the dynamics of fluid resolution during therapy with different regimens and substances. Yet, an in-depth understanding of the mode of action of supervised and unsupervised learning, the functionality of a convolutional neural net (CNN) and various network architectures is needed. Greater insight regarding adequate methods for performance, validation assessment, and device- and scanning-pattern-dependent variations is necessary to empower ophthalmologists to become qualified AI users. Fluid/function correlation can lead to a better definition of valid fluid variables relevant for optimal outcomes on an individual and a population level. AI-based fluid analysis opens the way for precision medicine in real-world practice of the leading retinal diseases of modern times.
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Affiliation(s)
- Ursula Schmidt-Erfurth
- Department of Ophthalmology Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Gregor S Reiter
- Department of Ophthalmology Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Sophie Riedl
- Department of Ophthalmology Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Philipp Seeböck
- Department of Ophthalmology Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Wolf-Dieter Vogl
- Department of Ophthalmology Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Barbara A Blodi
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI, USA.
| | - Amitha Domalpally
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI, USA.
| | - Amani Fawzi
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Yali Jia
- Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA.
| | - David Sarraf
- Stein Eye Institute, University of California Los Angeles, Los Angeles, CA, USA.
| | - Hrvoje Bogunović
- Department of Ophthalmology Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
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