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Shi L, Li LJ, Sun XY, Chen YY, Luo D, He LP, Ji HJ, Gao WP, Shen HX. Er-Dong-Xiao-Ke decoction regulates lipid metabolism via PPARG-mediated UCP2/AMPK signaling to alleviate diabetic meibomian gland dysfunction. JOURNAL OF ETHNOPHARMACOLOGY 2024; 333:118484. [PMID: 38925318 DOI: 10.1016/j.jep.2024.118484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/06/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Meibomian gland dysfunction (MGD), complicated by type 2 diabetes, is associated with a high incidence of ocular surface disease, and no effective drug treatment exists. Diabetes mellitus (DM) MGD shows a notable disturbance in lipid metabolism. Er-Dong-Xiao-Ke decoction (EDXKD) has important functions in nourishing yin, clearing heat, and removing blood stasis, which are effective in the treatment of DM MGD. AIM OF THE STUDY To observe the therapeutic effect of EDXKD on DM MGD and its underlying molecular mechanism. MATERIALS AND METHODS After establishing a type 2 DM (T2DM)-induced MGD rat model, different doses of EDXKD and T0070907 were administered. The chemical constituents of EDXKD were identified by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and the molecular mechanism of EDXKD in treating DM MGD was predicted using network pharmacology. Lipid metabolism in DM meibomian glands (MGs) was analyzed using LC-MS/MS, and lipid biomarkers were screened and identified. Histological changes and lipid accumulation in MGs were detected by staining, and Peroxisome proliferator-activated receptor gamma (PPARG) expression in MG acinar cells was detected by immunofluorescence. The expression of lipid metabolism-related factors was detected by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) or western blotting. RESULTS EDXKD reduced lipid accumulation in the MGs and improved the ocular surface index in DM MGD rats. The main active components of EDXKD had advantages in lipid regulation. Additionally, the PPARG signaling pathway was the key pathway of EDXKD in the treatment of DM MGD. Twelve lipid metabolites were biomarkers of EDXKD in the treatment of DM MGD, and glycerophospholipid metabolism was the main pathway of lipid regulation. Moreover, EDXKD improved lipid deposition in the acini and upregulated the expression of PPARG. Further, EDXKD regulated the PPARG-mediated UCP2/AMPK signaling network, inhibited lipid production, and promoted lipid transport. CONCLUSION EDXKD is an effective treatment for MGD in patients with T2DM. EDXKD can regulate lipids by regulating the PPARG-mediated UCP2/AMPK signaling network, as it reduced lipid accumulation in the MGs of DM MGD rats, promoted lipid metabolism, and improved MG function and ocular surface indices.
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Affiliation(s)
- Li Shi
- Department of Ophthalmology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Liu-Jiao Li
- Department of Ophthalmology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Xin-Yi Sun
- Department of Endocrinology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Yi-Ying Chen
- Department of Acupuncture Rehabilitation, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Dan Luo
- Department of Ophthalmology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Lu-Ping He
- Department of Ophthalmology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Hui-Jie Ji
- Department of Ophthalmology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Wei-Ping Gao
- Department of Ophthalmology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China.
| | - Hu-Xing Shen
- Department of Ophthalmology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China.
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Wang X, Fang J, Yang L. Research progress on ocular complications caused by type 2 diabetes mellitus and the function of tears and blepharons. Open Life Sci 2024; 19:20220773. [PMID: 38299009 PMCID: PMC10828665 DOI: 10.1515/biol-2022-0773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/20/2023] [Accepted: 10/19/2023] [Indexed: 02/02/2024] Open
Abstract
The purpose of this study was to explore the related research progress of ocular complications (OCs) caused by type 2 diabetes mellitus (T2DM), tear and tarsal function, and the application of deep learning (DL) in the diagnosis of diabetes and OCs caused by it, to provide reference for the prevention and control of OCs in T2DM patients. This study reviewed the pathogenesis and treatment of diabetes retinopathy, keratopathy, dry eye disease, glaucoma, and cataract, analyzed the relationship between OCs and tear function and tarsal function, and discussed the application value of DL in the diagnosis of diabetes and OCs. Diabetes retinopathy is related to hyperglycemia, angiogenic factors, oxidative stress, hypertension, hyperlipidemia, and other factors. The increase in water content in the corneal stroma leads to corneal relaxation, loss of transparency, and elasticity, and can lead to the occurrence of corneal lesions. Dry eye syndrome is related to abnormal stability of the tear film and imbalance in neural and immune regulation. Elevated intraocular pressure, inflammatory reactions, atrophy of the optic nerve head, and damage to optic nerve fibers are the causes of glaucoma. Cataract is a common eye disease in the elderly, which is a visual disorder caused by lens opacity. Oxidative stress is an important factor in the occurrence of cataracts. In clinical practice, blood sugar control, laser therapy, and drug therapy are used to control the above eye complications. The function of tear and tarsal plate will be affected by eye diseases. Retinopathy and dry eye disease caused by diabetes will cause dysfunction of tear and tarsal plate, which will affect the eye function of patients. Furthermore, DL can automatically diagnose and classify eye diseases, automatically analyze fundus images, and accurately diagnose diabetes retinopathy, macular degeneration, and other diseases by analyzing and processing eye images and data. The treatment of T2DM is difficult and prone to OCs, which seriously threatens the normal life of patients. The occurrence of OCs is closely related to abnormal tear and tarsal function. Based on DL, clinical diagnosis and treatment of diabetes and its OCs can be carried out, which has positive application value.
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Affiliation(s)
- Xiaohong Wang
- Department of Operating Room, Xinchang County Peoples Hospital, Xinchang, 312500, Shaoxing City, Zhejiang, China
| | - Jian Fang
- Department of Ophthalmolgy, Xinchang County Peoples Hospital, Xinchang, 312500, Shaoxing City, Zhejiang, China
| | - Lina Yang
- Department of Ophthalmolgy, Xinchang County Peoples Hospital, Xinchang, 312500, Shaoxing City, Zhejiang, China
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Markoulli M, Ahmad S, Arcot J, Arita R, Benitez-Del-Castillo J, Caffery B, Downie LE, Edwards K, Flanagan J, Labetoulle M, Misra SL, Mrugacz M, Singh S, Sheppard J, Vehof J, Versura P, Willcox MDP, Ziemanski J, Wolffsohn JS. TFOS Lifestyle: Impact of nutrition on the ocular surface. Ocul Surf 2023; 29:226-271. [PMID: 37100346 DOI: 10.1016/j.jtos.2023.04.003] [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: 03/30/2023] [Accepted: 04/06/2023] [Indexed: 04/28/2023]
Abstract
Nutrients, required by human bodies to perform life-sustaining functions, are obtained from the diet. They are broadly classified into macronutrients (carbohydrates, lipids, and proteins), micronutrients (vitamins and minerals) and water. All nutrients serve as a source of energy, provide structural support to the body and/or regulate the chemical processes of the body. Food and drinks also consist of non-nutrients that may be beneficial (e.g., antioxidants) or harmful (e.g., dyes or preservatives added to processed foods) to the body and the ocular surface. There is also a complex interplay between systemic disorders and an individual's nutritional status. Changes in the gut microbiome may lead to alterations at the ocular surface. Poor nutrition may exacerbate select systemic conditions. Similarly, certain systemic conditions may affect the uptake, processing and distribution of nutrients by the body. These disorders may lead to deficiencies in micro- and macro-nutrients that are important in maintaining ocular surface health. Medications used to treat these conditions may also cause ocular surface changes. The prevalence of nutrition-related chronic diseases is climbing worldwide. This report sought to review the evidence supporting the impact of nutrition on the ocular surface, either directly or as a consequence of the chronic diseases that result. To address a key question, a systematic review investigated the effects of intentional food restriction on ocular surface health; of the 25 included studies, most investigated Ramadan fasting (56%), followed by bariatric surgery (16%), anorexia nervosa (16%), but none were judged to be of high quality, with no randomized-controlled trials.
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Affiliation(s)
- Maria Markoulli
- School of Optometry and Vision Science, UNSW Sydney, NSW, Australia.
| | - Sumayya Ahmad
- Icahn School of Medicine of Mt. Sinai, New York, NY, USA
| | - Jayashree Arcot
- Food and Health, School of Chemical Engineering, UNSW Sydney, Australia
| | - Reiko Arita
- Department of Ophthalmology, Itoh Clinic, Saitama, Japan
| | | | | | - Laura E Downie
- Department of Optometry and Vision Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Katie Edwards
- School of Optometry and Vision Science, Queensland University of Technology, Brisbane, Australia
| | - Judith Flanagan
- School of Optometry and Vision Science, UNSW Sydney, NSW, Australia; Vision CRC, USA
| | - Marc Labetoulle
- Ophthalmology Department, Hospital Bicêtre, APHP, Paris-Saclay University, Le Kremlin-Bicêtre, France; IDMIT (CEA-Paris Saclay-Inserm U1184), Fontenay-aux-Roses, France
| | - Stuti L Misra
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand
| | | | - Sumeer Singh
- Department of Optometry and Vision Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - John Sheppard
- Virginia Eye Consultants, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jelle Vehof
- Departments of Ophthalmology and Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Section of Ophthalmology, School of Life Course Sciences, King's College London, London, UK; Department of Ophthalmology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Piera Versura
- Cornea and Ocular Surface Analysis - Translation Research Laboratory, Ophthalmology Unit, DIMEC Alma Mater Studiorum Università di Bologna, Italy; IRCCS AOU di Bologna Policlinico di Sant'Orsola, Bologna, Italy
| | - Mark D P Willcox
- School of Optometry and Vision Science, UNSW Sydney, NSW, Australia
| | - Jillian Ziemanski
- School of Optometry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James S Wolffsohn
- College of Health & Life Sciences, School of Optometry, Aston University, Birmingham, UK
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Abbouda A, Florido A, Avogaro F, Bladen J, Vingolo EM. Identifying Meibomian Gland Dysfunction Biomarkers in a Cohort of Patients Affected by DM Type II. Vision (Basel) 2023; 7:vision7020028. [PMID: 37092461 PMCID: PMC10123711 DOI: 10.3390/vision7020028] [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: 12/13/2022] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 04/25/2023] Open
Abstract
(1) Background: Meibomian gland dysfunction (MGD) among patients with diabetes mellitus (DM) is a common manifestation of dry eye syndrome (DES). (2) Methods: The purpose of this study is to identify clinical parameters and biomarkers useful to improve the follow-up and the treatment of these patients. We have used an ocular surface disease index (OSDI) questionnaire, Schirmer test I/II, tear film break-up time (TF-BUT), fluorescein plus lissamine green staining, Marx's line (ML), and meibomian gland (MGs) morphology using Sirius® Topographer (CSO, Costruzione Strumenti Oftalmici, Florence, Italy). Blood sample analysis included glucose, glycated hemoglobin, lipid profile, cortisol, dehydroepiandrosterone sulfate (DHEA-S), androstenedione (ASD) and testosterone. (3) Results: Cortisol and ASD were positively correlated with an increase of MG tortuosity, and an Increased level of triglycerides was associated with a reduction of MGs length. DHEAS levels lowered with age and were associated with ocular surface staining. (4) Conclusions: Future studies, perhaps including meibum lipid analysis and tear cytokine levels, may also further elucidate the connection between these parameters, MG architecture and function.
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Affiliation(s)
- Alessandro Abbouda
- Department of Ophthalmology, Alfredo Fiorini Hospital, 04019 Terracina, Italy
| | - Antonio Florido
- Department of Ophthalmology, Alfredo Fiorini Hospital, 04019 Terracina, Italy
- Department of Biotechnology and Medical-Surgical Sciences, "Sapienza" University of Rome, 04100 Latina, Italy
| | - Filippo Avogaro
- Department of Ophthalmology, Alfredo Fiorini Hospital, 04019 Terracina, Italy
- Department of Biotechnology and Medical-Surgical Sciences, "Sapienza" University of Rome, 04100 Latina, Italy
| | - John Bladen
- Oculoplastic Department King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Enzo Maria Vingolo
- Department of Ophthalmology, Alfredo Fiorini Hospital, 04019 Terracina, Italy
- Department of Biotechnology and Medical-Surgical Sciences, "Sapienza" University of Rome, 04100 Latina, Italy
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Silva-Viguera MC, Pérez-Barea A, Bautista-Llamas MJ. Tear film layers and meibomian gland assessment in patients with type 1 diabetes mellitus using a noninvasive ocular surface analyzer: a cross-sectional case–control study. Graefes Arch Clin Exp Ophthalmol 2022; 261:1483-1492. [PMID: 36512089 PMCID: PMC10148784 DOI: 10.1007/s00417-022-05934-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/15/2022] Open
Abstract
Abstract
Purpose
To assess the tear film layers and Meibomian glands by a noninvasive ocular surface analyzer in patients with and without type 1 diabetes mellitus (T1DM).
Methods
Eighty-eight participants were enrolled in this study: 44 patients with T1DM without diabetic retinopathy, and 44 patients as a control group, between 18 and 49 years old. Limbal and bulbar redness classification, lipid layer thickness (LLT), tear meniscus height (TMH), first and mean noninvasive tear break-up time (FNIBUT and MNIBUT, respectively), and Meibomian glands loss (MGL) were assessment through the ICP Ocular Surface Analyzer (OSA). Schirmer’s I test (SIT), the fluorescein tear break-up time test (TFBUT), OSDI and SPEED questionnaires, and percentage of glycosylated hemoglobin (HbA1c) were also tested.
Results
The T1DM group showed higher limbal and bulbar redness (p = 0.010) and lower LLT (p < 0.001), TMH (p < 0.001), FNIBUT (p < 0.001), MNIBUT (p < 0.001), SIT (p = 0.001), and TFBUT (p < 0.001) than the control group. A higher percentage of MGL was found in the T1DM group in the upper (p = 0.097) and lower (p < 0.001) eyelids. No significant differences were found in dry eye symptoms across the OSDI and SPEED questionnaires between the two groups.
Conclusion
Patients with T1DM without signs of retinopathy showed involvement of the mucoaqueous and lipid layers of the tear film, as well as a higher percentage of MGL, using a noninvasive analyzer. Dry eye disease in people with T1DM cannot be ruled out by anamnesis and subjective symptom questionnaires alone; therefore, these patients should undergo regular anterior pole examinations.
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Affiliation(s)
- María-Carmen Silva-Viguera
- Department of Physics of Condensed Matter, Optics Area, Physics Faculty, University of Seville, Reina Mercedes St, Seville, Spain
- Vision Research Group (CIVIUS), University of Seville, Seville, Spain
| | - Alicia Pérez-Barea
- Department of Physics of Condensed Matter, Optics Area, Physics Faculty, University of Seville, Reina Mercedes St, Seville, Spain
| | - María-José Bautista-Llamas
- Department of Physics of Condensed Matter, Optics Area, Physics Faculty, University of Seville, Reina Mercedes St, Seville, Spain.
- Vision Research Group (CIVIUS), University of Seville, Seville, Spain.
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Wang X, Fan X, Wu Y, Mou Y, Min J, Jin X. Rear 4-min Schirmer test, a modified indicator of Schirmer test in diagnosing dry eye. Sci Rep 2022; 12:6272. [PMID: 35428766 PMCID: PMC9012812 DOI: 10.1038/s41598-022-09791-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 03/17/2022] [Indexed: 11/24/2022] Open
Abstract
This study aims to investigate the reliability and efficacy of rear 4-min Schirmer test, as a supplement indicator, in assessing tear secretion and diagnosing dry eye. 180 participants were enrolled in this study. Schirmer test I without anaesthesia was performed once on both eyes to determine the value of normal Schirmer test. The values of tear secretion were recorded at each minute. Other examinations included the following: the ocular surface disease index (OSDI), the standard patient evaluation of eye dryness (SPEED), fluorescein stain, tear film break-up time (BUT), and Meibomian gland (MG) secretion grading. The participants were divided into dry eye (DE) group and non-dry eye (ND) group. The values of the 2-min Schirmer test, rear 3-min Schirmer test, rear 4-min Schirmer test, and 5-min Schirmer test were 5.36 ± 4.63, 5.57 ± 2.11, 7.21 ± 4.13, and 10.93 ± 6.30, respectively, in the DE group. These indicators were 8.25 ± 6.80, 2.73 ± 2.31, 7.36 ± 3.42, and 11.84 ± 6.16, respectively, in the ND group. The rear 4-min Schirmer test had a significant correlation with OSDI and SPEED in the DE group (r = − 0.242/ − 0.183) and in the ND group (r = − 0.316/ − 0.373). Meanwhile, the rear 4-min Schirmer test had a stronger connection with fBUT (r = 0.159) and MG secretion (r = − 0.162) in the DE group and also had higher accuracy in diagnosing severe DE and borderline DE. In conclusion, the rear 4-min Schirmer test may be a supplement indicator in assessing tear secretion and diagnosing DE.
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Affiliation(s)
- Xin Wang
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88# Jiefang Road, Hangzhou, 310009, Zhejiang Province, People's Republic of China
| | - Xiaojing Fan
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88# Jiefang Road, Hangzhou, 310009, Zhejiang Province, People's Republic of China.,The Fifth People's Hospital of Yuhang District, 60 Baojian Road, Hangzhou, 311100, People's Republic of China
| | - Yaying Wu
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88# Jiefang Road, Hangzhou, 310009, Zhejiang Province, People's Republic of China
| | - Yujie Mou
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88# Jiefang Road, Hangzhou, 310009, Zhejiang Province, People's Republic of China
| | - Jinjin Min
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88# Jiefang Road, Hangzhou, 310009, Zhejiang Province, People's Republic of China
| | - Xiuming Jin
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88# Jiefang Road, Hangzhou, 310009, Zhejiang Province, People's Republic of China.
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Kuo YK, Shao SC, Lin ET, Pan LY, Yeung L, Sun CC. Tear function in patients with diabetes mellitus: A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2022; 13:1036002. [PMID: 36339435 PMCID: PMC9633841 DOI: 10.3389/fendo.2022.1036002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 09/29/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To examine tear function in patients with diabetes mellitus (DM). DESIGN Systematic review and meta-analysis. METHOD We searched Embase and PubMed from database inception to March 16, 2022. We included observational studies that compared tear function between patients with and without DM. Tear function was measured using invasive tear breakup time (ITBUT) and Schirmer's 1 test. Pooled results are presented as standard mean difference (SMD) with 95% confidence interval (CI) based on random-effects models. RESULTS We included 59 studies (7,234 eyes) comparing the tear function between patients with and without DM. This meta-analysis indicated that patients with DM had worse tear function than those without DM (ITBUT: SMD: -0.98, 95% CI: -1.27 to -0.69; Schirmer's 1 test: SMD: -0.45, 95% CI: -0.64 to -0.26), and the results remained consistent in patients with different types of DM (e.g., type 1 DM and type 2 DM) and from different ethnic backgrounds (e.g., Asian vs. non-Asian). Patients with DM under poor glycemic control had worse tear function than those of the non-DM group (ITBUT: SMD: -1.26, 95% CI: -1.86 to -0.66; Schirmer's 1 test: SMD: -0.25, 95% CI: -0.48 to -0.02), whereas there were no significant differences in tear function between patients with DM under optimal glycemic control and non-DM groups. CONCLUSIONS We found that patients with type 1 or type 2 DM had significantly reduced tear function. The level of tear function could be determined by glycemic control, and therefore, our findings suggest that glycemic control in patients with DM is critical for maintaining tear function. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero, identifier CRD42021250498.
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Affiliation(s)
- Yu-Kai Kuo
- Department of Ophthalmology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Chieh Shao
- Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Erh-Tsan Lin
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Li-Yen Pan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Ophthalmology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ling Yeung
- Department of Ophthalmology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Chin Sun
- Department of Ophthalmology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- *Correspondence: Chi-Chin Sun,
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