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Shi D, Zhou Y, He S, Wagner SK, Huang Y, Keane PA, Ting DS, Zhang L, Zheng Y, He M. Cross-modality Labeling Enables Noninvasive Capillary Quantification as a Sensitive Biomarker for Assessing Cardiovascular Risk. Ophthalmol Sci 2024; 4:100441. [PMID: 38420613 PMCID: PMC10899028 DOI: 10.1016/j.xops.2023.100441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 03/02/2024]
Abstract
Purpose We aim to use fundus fluorescein angiography (FFA) to label the capillaries on color fundus (CF) photographs and train a deep learning model to quantify retinal capillaries noninvasively from CF and apply it to cardiovascular disease (CVD) risk assessment. Design Cross-sectional and longitudinal study. Participants A total of 90732 pairs of CF-FFA images from 3893 participants for segmentation model development, and 49229 participants in the UK Biobank for association analysis. Methods We matched the vessels extracted from FFA and CF, and used vessels from FFA as labels to train a deep learning model (RMHAS-FA) to segment retinal capillaries using CF. We tested the model's accuracy on a manually labeled internal test set (FundusCapi). For external validation, we tested the segmentation model on 7 vessel segmentation datasets, and investigated the clinical value of the segmented vessels in predicting CVD events in the UK Biobank. Main Outcome Measures Area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity for segmentation. Hazard ratio (HR; 95% confidence interval [CI]) for Cox regression analysis. Results On the FundusCapi dataset, the segmentation performance was AUC = 0.95, accuracy = 0.94, sensitivity = 0.90, and specificity = 0.93. Smaller vessel skeleton density had a stronger correlation with CVD risk factors and incidence (P < 0.01). Reduced density of small vessel skeletons was strongly associated with an increased risk of CVD incidence and mortality for women (HR [95% CI] = 0.91 [0.84-0.98] and 0.68 [0.54-0.86], respectively). Conclusions Using paired CF-FFA images, we automated the laborious manual labeling process and enabled noninvasive capillary quantification from CF, supporting its potential as a sensitive screening method for identifying individuals at high risk of future CVD events. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Danli Shi
- School of Optometry, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China
- Research Centre for SHARP Vision, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yukun Zhou
- Centre for Medical Image Computing, University College London, London, UK
| | - Shuang He
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Siegfried K. Wagner
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Yu Huang
- Department of Ophthalmology, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Pearse A. Keane
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Daniel S.W. Ting
- Singapore National Eye Center, Singapore Eye Research Institute, and Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Lei Zhang
- Faculty of Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Yingfeng Zheng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Mingguang He
- School of Optometry, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China
- Research Centre for SHARP Vision, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China
- Department of Ophthalmology, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, Guangzhou, China
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Danese C, Kale AU, Aslam T, Lanzetta P, Barratt J, Chou YB, Eldem B, Eter N, Gale R, Korobelnik JF, Kozak I, Li X, Li X, Loewenstein A, Ruamviboonsuk P, Sakamoto T, Ting DS, van Wijngaarden P, Waldstein SM, Wong D, Wu L, Zapata MA, Zarranz-Ventura J. The impact of artificial intelligence on retinal disease management: Vision Academy retinal expert consensus. Curr Opin Ophthalmol 2023; 34:396-402. [PMID: 37326216 PMCID: PMC10399953 DOI: 10.1097/icu.0000000000000980] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to define the "state-of-the-art" in artificial intelligence (AI)-enabled devices that support the management of retinal conditions and to provide Vision Academy recommendations on the topic. RECENT FINDINGS Most of the AI models described in the literature have not been approved for disease management purposes by regulatory authorities. These new technologies are promising as they may be able to provide personalized treatments as well as a personalized risk score for various retinal diseases. However, several issues still need to be addressed, such as the lack of a common regulatory pathway and a lack of clarity regarding the applicability of AI-enabled medical devices in different populations. SUMMARY It is likely that current clinical practice will need to change following the application of AI-enabled medical devices. These devices are likely to have an impact on the management of retinal disease. However, a consensus needs to be reached to ensure they are safe and effective for the overall population.
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Affiliation(s)
- Carla Danese
- Department of Medicine – Ophthalmology, University of Udine, Udine, Italy
- Department of Ophthalmology, AP-HP Hôpital Lariboisière, Université Paris Cité, Paris, France
| | - Aditya U. Kale
- Academic Unit of Ophthalmology, Institute of Inflammation & Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham
| | - Tariq Aslam
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester School of Health Sciences, Manchester, UK
| | - Paolo Lanzetta
- Department of Medicine – Ophthalmology, University of Udine, Udine, Italy
- Istituto Europeo di Microchirurgia Oculare, Udine, Italy
| | - Jane Barratt
- International Federation on Ageing, Toronto, Canada
| | - Yu-Bai Chou
- Department of Ophthalmology, Taipei Veterans General Hospital
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Bora Eldem
- Department of Ophthalmology, Hacettepe University, Ankara, Turkey
| | - Nicole Eter
- Department of Ophthalmology, University of Münster Medical Center, Münster, Germany
| | - Richard Gale
- Department of Ophthalmology, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Jean-François Korobelnik
- Service d’ophtalmologie, CHU Bordeaux
- University of Bordeaux, INSERM, BPH, UMR1219, F-33000 Bordeaux, France
| | - Igor Kozak
- Moorfields Eye Hospital Centre, Abu Dhabi, UAE
| | - Xiaorong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin
| | - Xiaoxin Li
- Xiamen Eye Center, Xiamen University, Xiamen, China
| | - Anat Loewenstein
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, College of Medicine, Rangsit University, Rajavithi Hospital, Bangkok, Thailand
| | - Taiji Sakamoto
- Department of Ophthalmology, Kagoshima University, Kagoshima, Japan
| | - Daniel S.W. Ting
- Singapore National Eye Center, Duke-NUS Medical School, Singapore
| | - Peter van Wijngaarden
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Australia
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | | | - David Wong
- Unity Health Toronto – St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Lihteh Wu
- Macula, Vitreous and Retina Associates of Costa Rica, San José, Costa Rica
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Chou YB, Kale AU, Lanzetta P, Aslam T, Barratt J, Danese C, Eldem B, Eter N, Gale R, Korobelnik JF, Kozak I, Li X, Li X, Loewenstein A, Ruamviboonsuk P, Sakamoto T, Ting DS, van Wijngaarden P, Waldstein SM, Wong D, Wu L, Zapata MA, Zarranz-Ventura J. Current status and practical considerations of artificial intelligence use in screening and diagnosing retinal diseases: Vision Academy retinal expert consensus. Curr Opin Ophthalmol 2023; 34:403-413. [PMID: 37326222 PMCID: PMC10399944 DOI: 10.1097/icu.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
PURPOSE OF REVIEW The application of artificial intelligence (AI) technologies in screening and diagnosing retinal diseases may play an important role in telemedicine and has potential to shape modern healthcare ecosystems, including within ophthalmology. RECENT FINDINGS In this article, we examine the latest publications relevant to AI in retinal disease and discuss the currently available algorithms. We summarize four key requirements underlining the successful application of AI algorithms in real-world practice: processing massive data; practicability of an AI model in ophthalmology; policy compliance and the regulatory environment; and balancing profit and cost when developing and maintaining AI models. SUMMARY The Vision Academy recognizes the advantages and disadvantages of AI-based technologies and gives insightful recommendations for future directions.
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Affiliation(s)
- Yu-Bai Chou
- Department of Ophthalmology, Taipei Veterans General Hospital
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Aditya U. Kale
- Academic Unit of Ophthalmology, Institute of Inflammation & Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Paolo Lanzetta
- Department of Medicine – Ophthalmology, University of Udine
- Istituto Europeo di Microchirurgia Oculare, Udine, Italy
| | - Tariq Aslam
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester School of Health Sciences, Manchester, UK
| | - Jane Barratt
- International Federation on Ageing, Toronto, Canada
| | - Carla Danese
- Department of Medicine – Ophthalmology, University of Udine
- Department of Ophthalmology, AP-HP Hôpital Lariboisière, Université Paris Cité, Paris, France
| | - Bora Eldem
- Department of Ophthalmology, Hacettepe University, Ankara, Turkey
| | - Nicole Eter
- Department of Ophthalmology, University of Münster Medical Center, Münster, Germany
| | - Richard Gale
- Department of Ophthalmology, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Jean-François Korobelnik
- Service d’ophtalmologie, CHU Bordeaux
- University of Bordeaux, INSERM, BPH, UMR1219, F-33000 Bordeaux, France
| | - Igor Kozak
- Moorfields Eye Hospital Centre, Abu Dhabi, UAE
| | - Xiaorong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin
| | - Xiaoxin Li
- Xiamen Eye Center, Xiamen University, Xiamen, China
| | - Anat Loewenstein
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, College of Medicine, Rangsit University, Rajavithi Hospital, Bangkok, Thailand
| | - Taiji Sakamoto
- Department of Ophthalmology, Kagoshima University, Kagoshima, Japan
| | - Daniel S.W. Ting
- Singapore National Eye Center, Duke-NUS Medical School, Singapore
| | - Peter van Wijngaarden
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Australia
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | | | - David Wong
- Unity Health Toronto – St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Lihteh Wu
- Macula, Vitreous and Retina Associates of Costa Rica, San José, Costa Rica
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Ting DS, Al-Aswad LA. Augmented Intelligence in Ophthalmology: The Six Rights. Asia Pac J Ophthalmol (Phila) 2021; 10:231-233. [PMID: 34261103 PMCID: PMC9167642 DOI: 10.1097/apo.0000000000000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Daniel S.W. Ting
- Singapore National Eye Center, Singapore Eye Research Institute, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore
| | - Lama A. Al-Aswad
- Department of Ophthalmology, New York University Grossman School of Medicine, New York University Langone Health, New York, NY 10016
- Department of Population health, New York University Grossman School of Medicine, New York University Langone Health, New York, NY 10016
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Khor WB, Yip L, Zhao P, Foo VH, Lim L, Ting DS, Loon SC, Wong E, Yong V, Tan C, Wong TY, Wong HT. Evolving Practice Patterns in Singapore's Public Sector Ophthalmology Centers During the COVID-19 Pandemic. Asia Pac J Ophthalmol (Phila) 2020; 9:285-290. [PMID: 32657805 PMCID: PMC7402564 DOI: 10.1097/apo.0000000000000306] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/04/2020] [Indexed: 01/06/2023] Open
Abstract
Coronavirus disease 19 (COVID-19) was first reported in Wuhan, China, in December 2019, and has since become a global pandemic. Singapore was one of the first countries outside of China to be affected and reported its first case in January 2020. Strategies that were deployed successfully during the 2003 outbreak of severe acute respiratory syndrome have had to evolve to contain this novel coronavirus. Like the rest of the health care services in Singapore, the practice of ophthalmology has also had to adapt to this rapidly changing crisis. This article discusses the measures put in place by the 3 largest ophthalmology centers in Singapore's public sector in response to COVID-19, and the challenges of providing eye care in the face of stringent infection control directives, staff redeployments and "social distancing." The recently imposed "circuit breaker," effectively a partial lockdown of the country, has further limited our work to only the most essential of services. Our staff are also increasingly part of frontline efforts in the screening and care of patients with COVID-19. However, this crisis has also been an opportunity to push ahead with innovative practices and given momentum to the use of teleophthalmology and other digital technologies. Amidst this uncertainty, our centers are already planning for how ophthalmology in Singapore will be practiced in this next stage of the COVID-19 pandemic, and beyond.
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Affiliation(s)
- Wei Boon Khor
- Singapore National Eye Center, Singapore Health Services, Singapore
| | - Leonard Yip
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, National Healthcare Group, Singapore
| | - Paul Zhao
- Department of Ophthalmology, National University Hospital, National University Health System, Singapore
| | | | - Louis Lim
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, National Healthcare Group, Singapore
| | - Daniel S.W. Ting
- Singapore National Eye Center, Singapore Health Services, Singapore
| | - Seng Chee Loon
- Department of Ophthalmology, National University Hospital, National University Health System, Singapore
| | - Edmund Wong
- Singapore National Eye Center, Singapore Health Services, Singapore
| | - Vernon Yong
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, National Healthcare Group, Singapore
| | - Clement Tan
- Department of Ophthalmology, National University Hospital, National University Health System, Singapore
| | - Tien Yin Wong
- Singapore National Eye Center, Singapore Health Services, Singapore
| | - Hon Tym Wong
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, National Healthcare Group, Singapore
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Wong RL, Ting DS, Wan KH, Lai KH, Ko CN, Ruamviboonsuk P, Huang SS, Lam DS, Tham CC. COVID-19: Ocular Manifestations and the APAO Prevention Guidelines for Ophthalmic Practices. Asia Pac J Ophthalmol (Phila) 2020; 9:281-284. [PMID: 32739937 PMCID: PMC7480794 DOI: 10.1097/apo.0000000000000308] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/02/2020] [Indexed: 01/08/2023] Open
Abstract
The World Health Organization declared the Coronavirus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 a "Pandemic" on March 11, 2020. As of June 1, 2020, Severe Acute Respiratory Syndrome Coronavirus 2 has infected >6.2 million people and caused >372,000 deaths, including many health care personnel. It is highly infectious and ophthalmologists are at a higher risk of the infection due to a number of reasons including the proximity between doctors and patients during ocular examinations, microaerosols generated by the noncontact tonometer, tears as a potential source of infection, and some COVID-19 cases present with conjunctivitis. This article describes the ocular manifestations of COVID-19 and the APAO guidelines in mitigating the risks of contracting and/or spreading COVID-19 in ophthalmic practices.
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Affiliation(s)
- Raymond L.M. Wong
- C-MER Dennis Lam & Partners Eye Center, C-MER International Eye Care Group, Hong Kong
- C-MER (Shenzhen) Dennis Lam Eye Hospital, Shenzhen, Guangdong, China
- Department of Ophthalmology, The University of Hong Kong, Hong Kong
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Daniel S.W. Ting
- Singapore Health Service (SingHealth), Duke-NUS Medical School, Singapore
| | - Kelvin H. Wan
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Kenny H.W. Lai
- C-MER Dennis Lam & Partners Eye Center, C-MER International Eye Care Group, Hong Kong
- C-MER (Shenzhen) Dennis Lam Eye Hospital, Shenzhen, Guangdong, China
| | - Chung-Nga Ko
- C-MER Dennis Lam & Partners Eye Center, C-MER International Eye Care Group, Hong Kong
- C-MER (Shenzhen) Dennis Lam Eye Hospital, Shenzhen, Guangdong, China
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Suber S. Huang
- Retina Center of Ohio, Cleveland, OH, USA
- Bascom Palmer Eye Institute, Miami, FL
| | - Dennis S.C. Lam
- C-MER Dennis Lam & Partners Eye Center, C-MER International Eye Care Group, Hong Kong
- C-MER (Shenzhen) Dennis Lam Eye Hospital, Shenzhen, Guangdong, China
- International Eye Research Institute of The Chinese University of Hong Kong (Shenzhen), Shenzhen, China
| | - Clement C.Y. Tham
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong
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Ting DS, Peng L, Varadarajan AV, Keane PA, Burlina PM, Chiang MF, Schmetterer L, Pasquale LR, Bressler NM, Webster DR, Abramoff M, Wong TY. Deep learning in ophthalmology: The technical and clinical considerations. Prog Retin Eye Res 2019; 72:100759. [DOI: 10.1016/j.preteyeres.2019.04.003] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 04/21/2019] [Accepted: 04/23/2019] [Indexed: 12/22/2022]
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Lim G, Lim ZW, Xu D, Ting DS, Wong TY, Lee ML, Hsu W. Feature Isolation for Hypothesis Testing in Retinal Imaging: An Ischemic Stroke Prediction Case Study. ACTA ACUST UNITED AC 2019. [DOI: 10.1609/aaai.v33i01.33019510] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Ischemic stroke is a leading cause of death and long-term disability that is difficult to predict reliably. Retinal fundus photography has been proposed for stroke risk assessment, due to its non-invasiveness and the similarity between retinal and cerebral microcirculations, with past studies claiming a correlation between venular caliber and stroke risk. However, it may be that other retinal features are more appropriate. In this paper, extensive experiments with deep learning on six retinal datasets are described. Feature isolation involving segmented vascular tree images is applied to establish the effectiveness of vessel caliber and shape alone for stroke classification, and dataset ablation is applied to investigate model generalizability on unseen sources. The results suggest that vessel caliber and shape could be indicative of ischemic stroke, and sourcespecific features could influence model performance.
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Affiliation(s)
- Li Lian Foo
- Singapore Eye Research Institute; Singapore National Eye Center; Singapore
| | - Daniel S.W. Ting
- Singapore Eye Research Institute; Singapore National Eye Center; Singapore
| | - Wei Yan Ng
- Singapore Eye Research Institute; Singapore National Eye Center; Singapore
| | - Boon Long Quah
- Singapore Eye Research Institute; Singapore National Eye Center; Singapore
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Ting DS, Tay-Kearney ML, Constable I, Lim L, Preen DB, Kanagasingam Y. Retinal Video Recording. Ophthalmology 2011; 118:1588-93. [DOI: 10.1016/j.ophtha.2011.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Revised: 03/16/2011] [Accepted: 04/05/2011] [Indexed: 11/25/2022] Open
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