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Ang T, Tong JY, Davis G, Selva D. IgG4-related Orbital Disease Presenting as an Orbital Apex Lesion. Ophthalmic Plast Reconstr Surg 2024; 40:e58-e62. [PMID: 38427841 DOI: 10.1097/iop.0000000000002585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
IgG4-related disease is an uncommon multisystem inflammatory disease characterized by tissue infiltration by IgG4 plasma cells, extensive fibrosis, and sclerosing inflammation. Diffuse orbital involvement extending to the orbital apex and cavernous sinus has been reported, but a solitary well-circumscribed lesion at the apex has not been previously reported. Herein, we report a unique case of IgG4-related orbital disease presenting as a solitary well-circumscribed orbital apex lesion causing subacute visual decline in a 45-year-old male. MRI demonstrated bilateral lacrimal gland and infraorbital nerve enlargement and an 18 × 7 mm left orbital apex lesion demonstrating homogeneous contrast enhancement and isointense signal on T2. He was initially treated with tapering systemic corticosteroid therapy with improvement in his vision; however, he experienced visual deterioration 3 months later with recurrent inflammation. He subsequently commenced high-dose systemic corticosteroid therapy and rituximab infusions with improvement of left visual acuity to 6/7.5 + 2.
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Affiliation(s)
- Terence Ang
- Discipline of Ophthalmology and Visual Sciences, The University of Adelaide
| | - Jessica Y Tong
- Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Garry Davis
- Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dinesh Selva
- Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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2
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Lai KKH, Chu WCW, Li EYM, Chan RYC, Wei Y, Jia R, Cheng ACO, Chan KKW, Chin JKY, Kwok JSW, Io IYF, Yip NKF, Li KKW, Chan WH, Lam NM, Yip WWK, Young AL, Chan E, Ko CKL, Ko STC, Yuen HKL, Tham CCY, Pang CP, Chong KKL. Radiological Determinants of Complicated Immunoglobulin G4-Related Ophthalmic Disease: A Territory-Wide Cohort Study. Asia Pac J Ophthalmol (Phila) 2022; 11:417-424. [PMID: 36179335 DOI: 10.1097/apo.0000000000000552] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/10/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To evaluate the presenting radiological features of immunoglobulin G4-related ophthalmic disease (IgG4-ROD) and their associations with IgG4-related optic neuropathy (IgG4-RON), and IgG4-related ocular adnexal lymphoma (IgG4-ROL). METHODS A territory-wide, biopsy-proven, Chinese cohort. Masked review of orbital images, medical records, and histopathology reports. RESULTS A total of 115 (94%) of the 122 patients in our cohort had preoperative orbital images (computed tomography=105, magnetic resonance imaging=40). Among them, 103/115 (90%) showed enlarged lacrimal glands, and 91 (88%) were bilateral. Nerve enlargement was observed: infraorbital in 31/115 (27%) patients and frontal in 17/115 (15%), 10 and 9 being bilateral, respectively. At least 1 or more extraocular muscle (EOM) enlargement was found in 41/115 (37%) patients, bilaterally in 20. Lateral rectus occurred in 30 (73%) of these 41 EOM patients and inferior rectus in 28 (68%). Two adjacent EOMs (inferior and lateral recti in 11 patients, inferior and medial recti in 7 patients) or multiple EOMs (at least 3) were enlarged in 23/41 (56%) and 13/41 (32%) of the patients, respectively. Intraconal lesions (67% vs 11%, P<0.05), infraorbital (83% vs 23%, P<0.005), or frontal (50% vs 15%, P<0.05) nerve enlargement was significantly associated with IgG4-RON (6 patients) by univariate analyses. Asymmetric lacrimal gland enlargement and discrete orbital mass (both P<0.05) were associated with IgG4-ROL (9 patients) by multivariate analyses. CONCLUSIONS In this IgG4-ROD cohort, most patients had bilateral enlarged lacrimal glands, and the lateral rectus is the most frequently involved EOM. For the first time, unique radiological patterns associated with the development of IgG4-RON and IgG4-ROL are found.
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Affiliation(s)
- Kenneth K H Lai
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong SAR, China
| | - Winnie C W Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, Hong Kong SAR, China
| | - Emmy Y M Li
- Hong Kong Eye Hospital, Hong Kong SAR, China
| | - Regine Y C Chan
- Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, Hong Kong SAR, China
| | - Yingying Wei
- Department of Statistics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ruofan Jia
- Department of Statistics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Andy C O Cheng
- Department of Ophthalmology, Hong Kong Sanatorium & Hospital, Hong Kong SAR, China
| | - Karen K W Chan
- Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, Hong Kong SAR, China
| | - Joyce K Y Chin
- Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, Hong Kong SAR, China
| | - Jeremy S W Kwok
- Department of Ophthalmology, Grantham Hospital, Hong Kong SAR, China
- Department of Ophthalmology, The University of Hong Kong, Hong Kong SAR, China
| | - Ida Y F Io
- Department of Ophthalmology, Caritas Medical Center, Hong Kong SAR, China
| | - Nelson K F Yip
- Department of Ophthalmology, United Christian Hospital, Hong Kong SAR, China
| | - Kenneth K W Li
- Department of Ophthalmology, United Christian Hospital, Hong Kong SAR, China
| | - Wai Ho Chan
- Department of Ophthalmology, Tuen Mun Hospital, Hong Kong SAR, China
| | - Nai Man Lam
- Hong Kong Eye Hospital, Hong Kong SAR, China
| | - Wilson W K Yip
- Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, Hong Kong SAR, China
| | - Alvin L Young
- Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, Hong Kong SAR, China
| | - Edwin Chan
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong SAR, China
| | - Callie K L Ko
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong SAR, China
| | - Simon T C Ko
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong SAR, China
| | - Hunter K L Yuen
- Hong Kong Eye Hospital, Hong Kong SAR, China
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Clement C Y Tham
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chi Pui Pang
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kelvin K L Chong
- Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, Hong Kong SAR, China
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
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Lim YJ, Lee SJ. A Case of Choroidal Folds in a Patient with Immunoglobulin G4-related Ophthalmic Disease. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2022. [DOI: 10.3341/jkos.2022.63.7.620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose: To report a case of choroidal folds caused by enlargement of the extraocular muscles (EOM) and orbital fat in a patient with immunoglobulin (Ig) G4-related ophthalmic disease. A full recovery was achieved after steroid administration.Case summary: A 56-year-old male received intravenous high-dose steroids to treat IgG4-related ophthalmic disease presenting with bilateral eyelid edema, hypertrophy of all EOM, and mild exophthalmos. After 3 months, only slight improvement was observed and azathioprine was initiated. The patient exhibited only a minimal response over the next 2 months; all medications were therefore stopped. One month later, the patient presented with aggravation of the swelling (both eyelids), exophthalmos, and visual impairment of the left eye. The corrected vision was 1.0 in the right eye and 0.2 in the left eye; choroid folds were observed in the posterior pole of the left eye. Intravenous steroid (500 mg) was given once and oral steroids prescribed as maintenance therapy. After 2 weeks, the corrected visual acuity recovered to 1.0 in both eyes, the eyelid edema and exophthalmos improved and the choroidal folds resolved completely.Conclusions: Choroidal folds associated with enlargement of EOM and orbital fat tissue can cause visual impairment in patients with IgG4-related ophthalmic disease. Steroids are effective in the acute phases and prevent irreversible visual impairment.
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Goto H, Ueda SI, Nemoto R, Ohshima KI, Sogabe Y, Kitagawa K, Ogawa Y, Oyama T, Furuta M, Azumi A, Takahira M. Clinical features and symptoms of IgG4-related ophthalmic disease: a multicenter study. Jpn J Ophthalmol 2021; 65:651-656. [PMID: 34146222 DOI: 10.1007/s10384-021-00847-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/06/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE The aim of this study was to elucidate the clinical features and symptoms of IgG4-related ophthalmic disease (IgG4-ROD). STUDY DESIGN Retrospective, multicenter study. METHODS The medical charts of 378 patients with IgG4-ROD diagnosed at 9 hospitals in Japan were reviewed. The demographic profiles, clinical findings, and ocular symptoms of the patients were analyzed. RESULTS On the basis of the diagnostic criteria for IgG4-ROD, the diagnosis was definite in 261 patients (69%), probable in 45 patients (12%), and possible in 72 patients (19%). The patients' mean age at the time of diagnosis was 60.6 ± 13.9 years; 195 (52%) were male. The mean IgG4 serum level at the time of the initial diagnosis was 578.9 mg/dL. Imaging studies showed pathologic lesions as follows: lesions in the lacrimal glands (86%), extraocular muscles (21%), trigeminal nerve (20%), and eyelids (12%); isolated orbital mass (11%); diffuse orbital lesion (8%); lesion in the perioptic nerve (8%); and lesion in the sclera (1%). The ophthalmic symptoms included dry eye (22%), diplopia (20%), decreased vision (8%), and visual field defects (5%). IgG4-ROD with extraocular lesions was observed in 182 patients (48%). CONCLUSION Although the lacrimal glands are well known to be the major pathologic site of IgG4-ROD, various ocular tissues can be affected and cause ophthalmic symptoms including visual loss.
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Affiliation(s)
- Hiroshi Goto
- Department of Ophthalmology, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Shun-Ichiro Ueda
- Department of Ophthalmology, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Rei Nemoto
- Department of Ophthalmology, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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Saitakis G, Chwalisz BK. The neurology of IGG4-related disease. J Neurol Sci 2021; 424:117420. [PMID: 33845982 DOI: 10.1016/j.jns.2021.117420] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/29/2020] [Accepted: 03/24/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW IgG4-related disease (IgG4-RD) is emerging as a fibro-inflammatory entity affecting multiple organs, including manifold neurologic manifestations. This review discusses general characteristics of IgG4-RD neurologic disease including epidemiology, histology, clinical picture and treatment approaches. RECENT FINDINGS IgG4-RD is increasingly recognized as an important underlying pathophysiology in multiple disorders of neurologic interest, including orbital inflammation, infundibulo-hypophysitis, hypertrophic pachymeningitis, and even in rare cases CNS parenchymal disease and cranial vascular involvement. These were previously considered idiopathic and unrelated to any systemic disease but now known to share a common histopathology. New knowledge regarding the pathogenesis, clinical features and epidemiology of IgG4 is emerging, and new neurological manifestations continue to be described. Diagnostic progress includes CT-PET imaging, the use of flow cytometry for plasmablast quantification, and the use of reverse passive latex agglutination aiming to overcome the prozone phenomenon. Histopathologic confirmation of IgG4-RD remains the gold standard method of diagnosis but new diagnostic criteria for systemic and organ-specific disease are being proposed. Though glucorticoids remain the mainstay of therapy, relapses and incomplete recovery are frequent. Rituximab is a promising treatment in IgG4-RD that is severe, refractory or glucocorticoid dependent. Initiation of immunosuppression at an early stage of disease should be considered in order to avoid development of refractory fibrosis. SUMMARY The current review emphasizes the neurologic manifestations of IgG4-RD.
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Affiliation(s)
- G Saitakis
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, MA, USA
| | - B K Chwalisz
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.
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Wang X, Sun X, Ao R, Zeng Z, Li D, Li Y. Visual impairment in immunoglobulin G4-related disease: A case report. Exp Ther Med 2021; 21:200. [PMID: 33500695 PMCID: PMC7818535 DOI: 10.3892/etm.2021.9633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/08/2020] [Indexed: 12/19/2022] Open
Abstract
The present study reports on the case of a 50-year-old male with sinusitis, diplopia, secretory otitis media and skin eczema for >14 years. The patient presented with visual impairment in both eyes and subxiphoid pain on admission to the First Affiliated Hospital of China Medical University (Shenyang, China). Orbital CT revealed a slightly thickened left inferior rectus muscle. Due to a periocular mass, enlarged lymph nodes, elevated serum immunoglobulin G4 (IgG4) levels and enriched IgG4-positive plasma cells in the lymph nodes, the diagnosis of IgG4-related disease (IgG4-RD), possibly involving at least 10 organs, was established. Following treatment with methylprednisolone, the serum IgG4 levels decreased to normal and binocular vision returned to normal. Unlike previously reported cases, the present case exhibited no swollen masses around the optic nerve. The purpose of the present case report was to improve the understanding of IgG4-RD.
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Affiliation(s)
- Xue Wang
- Department of Gastroenterology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110000, P.R. China
| | - Xuren Sun
- Department of Gastroenterology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110000, P.R. China
| | - Ran Ao
- Department of Gastroenterology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110000, P.R. China
| | - Zilu Zeng
- Department of Gastroenterology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110000, P.R. China
| | - Dan Li
- Department of Gastroenterology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110000, P.R. China
| | - Yiling Li
- Department of Gastroenterology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110000, P.R. China
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Kim SJ, Lee SU, Kang MS, Ahn JH, Shin J, Park CY, Lee JE. IgG4-related disease presenting as recurrent scleritis combined with optic neuropathy. BMC Ophthalmol 2021; 21:5. [PMID: 33402162 PMCID: PMC7784029 DOI: 10.1186/s12886-020-01774-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 12/16/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND We report a case of atypical presentation of IgG4-related disease (IgG4-RD) with recurrent scleritis and optic nerve involvement. CASE PRESENTATION A 61-year-old male presented with ocular pain and injection in his left eye for 2 months. Ocular examination together with ancillary testing led to the diagnosis of scleritis, which relapsed in spite of several courses of steroid treatment. After cessation of steroid, the patient complained of severe retro-orbital pain and blurred vision. His best corrected vision was count finger, the pupil was mid-dilated and a relative afferent pupillary defect was found. Funduscopic examination demonstrated disc swelling. Magnetic resonance imaging (MRI) showed enhancing soft tissue encasing the left globe, medial rectus muscle and optic nerve. Systemic work-up revealed multiple nodules in right lower lung and a biopsy showed histopathological characteristics of IgG4-RD. Long-term treatment with corticosteroids and a steroid-sparing agent (methotrexate) led to significant improvement in signs and symptoms with no recurrence for 2 years. CONCLUSIONS This case highlights the significance of IgG4-RD in the differential diagnosis of recurrent scleritis. IgG4-RD may cause optic neuropathy resulting in visual loss. Early diagnosis and proper treatment can prevent irreversible organ damage and devastating visual morbidity.
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Affiliation(s)
- Su Jin Kim
- Department of Ophthalmology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Seung Uk Lee
- Department of Ophthalmology, School of Medicine, Kosin University, #34 Amnam-dong, Seo-gu, Busan, 602-702, South Korea
| | - Min Seung Kang
- Department of Ophthalmology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Jung Hyo Ahn
- Department of Ophthalmology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Jonghoon Shin
- Department of Ophthalmology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Choul Yong Park
- Department of Ophthalmology, Dongguk University Ilsan Hospital, #27 Dongguk-ro, Ilsandong-gu, Goyang, 10326, South Korea.,Sensory Organ Research Center, Dongguk University, Goyang, South Korea
| | - Ji Eun Lee
- Department of Ophthalmology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea. .,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea.
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Abstract
PURPOSE OF REVIEW Orbital disease represents a diverse spectrum of pathology and can result in a variety of neuro-ophthalmic manifestations. The aim of this review is to provide updates on recent advances in our understanding of orbital disease secondary to thyroid eye disease, myositis, IgG4-related disease, sarcoidosis, granulomatosis with polyangiitis and various tumours. RECENT FINDINGS With regards to thyroid eye disease, there have been recent advances in the development of steroid-sparing therapies, new modalities for objectively monitoring disease activity and increased understanding of the role of environmental risk factors. There has been interest in characterizing the clinical course and underlying mechanism of optic nerve disease secondary to orbital disorders, which has led to advances in how we monitor for and prevent permanent vision loss. Increased knowledge of orbital tumour subtype histopathology and the development of novel classification systems has had prognostic value and aided medical decision-making. SUMMARY Orbital disease occurs secondary to a wide variety of diseases and can lead to neuro-ophthalmic manifestations with significant morbidity. Advances in our understanding of different subtypes of orbital disease have improved our ability to treat these potentially debilitating conditions.
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Affiliation(s)
| | | | - Suzanne K Freitag
- Department of Ophthalmology
- Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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Lai KKH, Chan RYC, Chin JKY, Li KKW, Young AL, Yuen HKL, Ko STC, Chong KKL. Upper Cranial Nerve Involvement and Immunoglobulin G4-Related Optic Neuropathy. Ophthalmology 2019; 127:699-703. [PMID: 31980249 DOI: 10.1016/j.ophtha.2019.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/11/2019] [Accepted: 11/18/2019] [Indexed: 01/27/2023] Open
Affiliation(s)
- Kenneth K H Lai
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong
| | - Regine Y C Chan
- Department of Ophthalmology and Visual Sciences, Princess of Wales Hospital, Wales, United Kingdom
| | - Joyce K Y Chin
- Department of Ophthalmology and Visual Sciences, Princess of Wales Hospital, Wales, United Kingdom
| | - Kenneth K W Li
- Department of Ophthalmology, United Christian Hospital, Hong Kong
| | - Alvin L Young
- Department of Ophthalmology and Visual Sciences, Princess of Wales Hospital, Wales, United Kingdom
| | | | - Simon T C Ko
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong
| | - Kelvin K L Chong
- Department of Ophthalmology and Visual Sciences, Princess of Wales Hospital, Wales, United Kingdom; Department of Ophthalmology and Visual Sciences, Chinese University of Hong Kong, Hong Kong.
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