Ophthalmic Surgery, Lasers and Imaging Retina

Surgical Review 

Visual and Anatomical Outcomes With Vitrectomy in Posterior or Combined Persistent Fetal Vasculature in an Asian Population

Chun-Ting Yeh, MD; Kuan-Jen Chen, MD; Laura Liu, MD, PhD; Nan-Kai Wang, MD, PhD; Yih-Shiou Hwang, MD, PhD; An-Ning Chao, MD; Tun-Lu Chen, MD; Chi-Chun Lai, MD; Wei-Chi Wu, MD, PhD

Abstract

BACKGROUND AND OBJECTIVE:

To investigate clinical features and surgical outcomes of vitrectomy in posterior or combined persistent fetal vasculature (PFV) in an Asian pediatric population.

PATIENTS AND METHODS:

This study was a retrospective, noncomparative, interventional case series relating the surgical outcome of PFV. Eyes that underwent pars plicata vitrectomy and/or lensectomy for posterior or combined PFV between 2006 and 2015 were included. The main outcome measures were the anatomic and functional results as well as the complications after the vitrectomy with or without lensectomy.

RESULTS:

A total of 25 eyes of 18 patients younger than 8 years of age were included in the study. The mean age of the patients receiving first pars plicata vitrectomy and/or lensectomy was 15.2 months ± 21.7 months (range: 1 month to 83 months). Postoperatively, successful anatomic correction in the posterior segment was observed in 20 eyes (80%). In addition, 19 of the 25 eyes (76%) had visual acuity (VA) better than 20/4000, and the mean logMAR VA of these 19 eyes was 1.74 (range: 0.48 to 2.30). The mean change of axial length of the eyes receiving surgery was 0.7 mm ± 1.4 mm (range: −1.0 mm to 2.4 mm; P = .18). None of the patients ended up with phthisis or glaucoma.

CONCLUSIONS:

This study suggests that vitrectomy and/or lensectomy in patients with posterior or combined PFV with macular involvement may result in an acceptable anatomical outcome; however, the functional outcome remained poor despite surgical intervention in these patients.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:377–384.]

Abstract

BACKGROUND AND OBJECTIVE:

To investigate clinical features and surgical outcomes of vitrectomy in posterior or combined persistent fetal vasculature (PFV) in an Asian pediatric population.

PATIENTS AND METHODS:

This study was a retrospective, noncomparative, interventional case series relating the surgical outcome of PFV. Eyes that underwent pars plicata vitrectomy and/or lensectomy for posterior or combined PFV between 2006 and 2015 were included. The main outcome measures were the anatomic and functional results as well as the complications after the vitrectomy with or without lensectomy.

RESULTS:

A total of 25 eyes of 18 patients younger than 8 years of age were included in the study. The mean age of the patients receiving first pars plicata vitrectomy and/or lensectomy was 15.2 months ± 21.7 months (range: 1 month to 83 months). Postoperatively, successful anatomic correction in the posterior segment was observed in 20 eyes (80%). In addition, 19 of the 25 eyes (76%) had visual acuity (VA) better than 20/4000, and the mean logMAR VA of these 19 eyes was 1.74 (range: 0.48 to 2.30). The mean change of axial length of the eyes receiving surgery was 0.7 mm ± 1.4 mm (range: −1.0 mm to 2.4 mm; P = .18). None of the patients ended up with phthisis or glaucoma.

CONCLUSIONS:

This study suggests that vitrectomy and/or lensectomy in patients with posterior or combined PFV with macular involvement may result in an acceptable anatomical outcome; however, the functional outcome remained poor despite surgical intervention in these patients.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:377–384.]

Introduction

In 1955, Reese1 first introduced a peculiar and rare congenital ocular syndrome presented with cataract, secondary glaucoma, and retinal detachment in a micro-ophthalmic eye. Regarding the abnormal regression of primary vitreous and hyaloid vasculature in the index cases, he named the disease as persistent hyperplastic primary vitreous (PHPV). It was not until 1997 that Goldberg2 integrated iris vascular remnants and omnibus manifestations in the anterior segment into the disease spectrum and further categorized the disease into anterior, posterior, or combined anterior and posterior types based on the location of vascular malformations. To emphasize the pathogenic failure of the fetal vascular system to spontaneously apoptosis, he renamed the disease as persistent fetal vasculature (PFV).

Like many rare congenital diseases, the exact proportions of three categories are inconclusive in terms of different study results, albeit the “pure” posterior PFV is extremely uncommon.3 Clinically, anterior PFV usually presents with congenital cataract, and can be treated successfully with cataract extraction and intraocular lens (IOL) implantation.4,7 Combined anterior and posterior PFV primarily constitutes the retrolenticular fibrovascular stalk, stringing from the posterior lens capsule to the vascular bundle of the optic nerve head. Considering the impacts of the fibrovascular stalk on the traction forces, posterior traction on the lens capsule results in posterior lenticonus, whereas anterior traction leads to tractional retinal detachment (TRD), macular dragging, and optic nerve hypoplasia.2,5 Statistically and prognostically speaking, eyes with minimal involvement are more common and long-term functional vision can be expected.6 On the other hand, severe forms of PFV often end up with recurrent intraocular hemorrhage, angle closure glaucoma, corneal opacity, retinal detachment, and phthisis bulbi.2 If severe PFV is left untreated, about 37% to 46% of patients progressed to no light perception.5,8,9

Previous studies have demonstrated surgical outcomes in posterior and combined PFV in Western populations,5,6,8–15 whereas there is a relative lack of data showing the clinical experiences in Asian population.16 Additionally, neither the surgical outcomes nor the timing of intervention between different studies usually tally with each other. Therefore, here we present the clinical characteristics, surgical outcomes in patients with posterior and combined PFV from Taiwan.

Patients and Methods

This was a retrospective, noncomparative, interventional case series. The institutional review board at the Chang Gung Memorial Hospital, Linkou, Taiwan approved all protocols, and the methods described were compliant with the tenets of the Declaration of Helsinki. The written informed consent was obtained from all patients' legitimate representatives.

The diagnostic criteria of PFV was in accordance with the Edward Jackson Memorial Lecture, proposed by Goldberg in 1997.2 Anterior PFV was illustrated as fibrovascular membrane around the lens or attached to the posterior capsule involving the pupillary zone, presence of retrolental vitreous membrane, and stalk reaching the optic nerve without retinal traction or detachment. In contrast, posterior PFV was characterized by the presence of retrolental vitreous membrane and stalk reaching the optic nerve with retinal traction or detachment. In cases simultaneously present with both anterior and posterior PFV, then were categorized as combined PFV. Patients with posterior or combined PFV who underwent pars plicata vitrectomy and/or lensectomy from 2006 to 2015 were included in the study. The surgical indications include visually significant lens opacity, vision-threatening vitreoretinal traction, retinal detachment with or without macular involvement, recurrent or severe intravitreal hemorrhage, progressive shallowing of the anterior chamber, and uncontrolled intraocular pressure secondary to anterior chamber angle closure.2 Patients with diagnosis of retinoblastoma, Norrie disease, familial exudative vitreoretinopathy, and retinopathy of prematurity were excluded. Meanwhile, those with missing data were also excluded. All patients completed a comprehensive ophthalmologic examination, including examination under general anesthesia, portable slit-lamp biomicroscopy, intraocular pressure (IOP) measurement with Goldmann applanation tonometry, A-scan ultrasound, dilated fundus examination, external photography, color fundus photography, and fluorescein angiography (RetCam III; Natus Medical, Pleasanton, CA) in both eyes. To convert the patients' postoperative low vision into quantified Snellen ratio, we adapted the method proposed by Bach et al.,24 which categorized “hand motion” into Snellen ratio between 20/6060 and 20/2500, and “counting fingers” into a ratio between 20/2000 and 20/1000. Form vision was defined as the vision of “counting fingers,” “fix and follow,” and “central, steady, and maintained” or better.5,15 The age at surgical intervention, duration of follow-up period, preoperative and postoperative functional and anatomical status, postoperative complications, and subsequent interventions were documented.

Surgical Procedures

All patients underwent standardized three-port vitrectomies by a single surgeon (WCW). In patients with posterior PFV, vitrectomy via pars plicata (23-gauge or 25-gauge) was performed. In patients with combined PFV, lensectomy and vitrectomy via pars plicata were conducted as primary intervention, and implantation of an IOL served as subsequently elective surgery. The stalk was divided with the high-speed vitrector, and the posterior hyaloid was removed to release the traction force at the vitreoretinal interface. Adjunctive diathermy and fluid-air exchange were performed based on the intraoperative needs.

Results

The chart review consisted of 25 eyes of 18 children with the diagnosis of posterior or combined PFV, as detailed in Table 1. The numbers of male and female patients were 14 and four, respectively. Only the right eye was involved in four cases (22%), and only the left eye was involved in six cases (33%). Most of the patients had bilateral involvement (eight cases, 44%) (Figures 1A–1C), and seven cases underwent surgery for both eyes. One patient with bilateral involvement (Case 6) received surgery for one eye only; the other eye did not receive surgical intervention due to the clear lens with only a small retrolental stalk. A total of three eyes (12%) had clinical findings of posterior PFV, and 22 eyes (88%) had combined PFV. The median age at primary surgical intervention was 15.24 months (range: 1 month to 83 months). The average follow-up was 41.31 months ± 29.14 months (range: 0.5 months to 98 months), and 94% (17 of 18) of the patients had at least 6 months of follow-up.

Baseline Characteristics of Study Population

Table 1:

Baseline Characteristics of Study Population

External photograph and fundus photographs of a 5-month-old girl with bilateral combined persistent fetal vasculature (Case 1), preoperatively. Focal corneal opacity with prominent cataract formation was observed (A). A large stalk (white arrow) extending from the optic nerve to the posterior lens capsule with local retinal traction and macular involvement (red arrow) in the right eye (B). Similarly, a retrolental stalk (white arrow) was also observed in the left eye, with minimal retinal traction (C).

Figure 1.

External photograph and fundus photographs of a 5-month-old girl with bilateral combined persistent fetal vasculature (Case 1), preoperatively. Focal corneal opacity with prominent cataract formation was observed (A). A large stalk (white arrow) extending from the optic nerve to the posterior lens capsule with local retinal traction and macular involvement (red arrow) in the right eye (B). Similarly, a retrolental stalk (white arrow) was also observed in the left eye, with minimal retinal traction (C).

Fundus photographs of a 3-month-old boy with unilateral combined persistent fetal vasculature (Case 2). Prominent vitreous stalk (white arrow) with retinal traction (red arrowhead) was observed preoperatively (A). After vitrectomy, vitreoretinal traction was successfully released (B).

Figure 2.

Fundus photographs of a 3-month-old boy with unilateral combined persistent fetal vasculature (Case 2). Prominent vitreous stalk (white arrow) with retinal traction (red arrowhead) was observed preoperatively (A). After vitrectomy, vitreoretinal traction was successfully released (B).

A total of five eyes (20%) had preoperative corneal opacity, and one eye had band keratopathy. Twenty-three eyes (92%) had various degrees of lens opacity at initial ocular exam, partly due to the anterior stalk attachment to the posterior lens capsule. All of the patients had light perception vision before the operation.

Of the 25 eyes of 18 patients who underwent surgical intervention, 11 eyes (44%) received pars plicata vitrectomy alone, two eyes (8%) received pars plicata lensectomy alone due to relatively small stalk and mild retinal dragging, and 12 eyes (48%) received combined vitrectomy and lensectomy. Among eyes receiving vitrectomy alone, four eyes (36%) received cataract extraction and implantation of posterior chamber IOL as subsequent surgery at later date. Of note, one patient (Case 4) received vitrectomy plus phacoemulsification and IOL implantation (OU) on the same day. In contrast, all the eyes receiving lensectomy alone or combined with vitrectomy as primary surgery were left aphakic during the follow-up.

Preoperatively, 12 eyes (48%) had tractional retinal detachment, and 15 eyes (60%) had attached retina with significant reversal of retinal dragging at the last follow-up visit. Findings of a relatively successful anatomic correction in the posterior segment were observed in 20 eyes (80%), including 15 eyes with a completely attached retina and five eyes with retina open and partial attachment of the macula.27 Conversely, retinal detachment was observed in five eyes in the last visit. Twelve eyes (48%) had preoperative documentation of axial length (AL) (Table 2), and the average AL was 18.3 mm (range: 14.2 mm to 22.7 mm). For the AL comparison, a total of six eyes receiving surgery had comprehensive documentations of preoperative and postoperative AL, and a total of four healthy fellow eyes had the corresponding data during the same period of time. The mean change of AL of the eyes receiving surgery was 0.7 mm ± 1.4 mm (range: −1 mm to 2.4 mm; P = .18), and the mean change in AL of the normal-looking fellow eye was 2.4 mm ± 1.0 mm (range: 1.1 mm to 3.7 mm; P = .21). There was statistically significant difference between the eyes receiving the surgery and the healthy fellow eyes (P = .04) in terms of AL elongation.

Surgical Procedures and Anatomic Outcomes of Study Population

Table 2:

Surgical Procedures and Anatomic Outcomes of Study Population

All eyes had positive light response before the operation, and postoperatively, all of the patients were referred for appropriate amblyopia therapy by the pediatric ophthalmologist. Nineteen of the 25 eyes receiving surgical intervention (76%) had VA better than 20/4000, and the mean logMAR VA of these 19 eyes was 1.74 (range: 0.48 to 2.30) (Table 3). Of the remaining six eyes, four eyes had light perception vision, and two eyes had no light perception. None of the patients developed glaucoma or phthisis bulbi at the last follow-up.

Functional Outcomes and Surgical Complications of Study Population

Table 3:

Functional Outcomes and Surgical Complications of Study Population

Discussion

The results of this study demonstrate the pars plicata vitrectomy and/or lensectomy offers acceptable anatomical outcomes in the patients with posterior or combined PFV. Stable or continual eye growth of these children may offer better cosmesis in these cases. However, the functional outcome remains unsatisfactory. Variations in surgical outcomes among previous literatures may be due to various reasons (Table 4). Most important of them, the proportion of anterior PFV, which generally speaking had a better outcome, was included in the study cohort.

Comparison of Published Surgical Outcomes for Persistent Fetal Vasculature

Table 4:

Comparison of Published Surgical Outcomes for Persistent Fetal Vasculature

The main determinant of the long-term VA in PFV is the anatomical location of the disease involvement. Following a delicate surgery, eyes with anterior PFV could reach a corrected VA up to 20/100 in most of the patients.20 Conversely, eyes with posterior or combined PFV usually have poor visual outcome even after surgical intervention.2,17 Huerta et al.25 used spectral-domain optical coherence tomography to confirm the microstructural anomalies in the patients with posterior PFV with early vitrectomy, and the authors concluded that posterior hyaloidal organization, diminished foveal contour and disruption of the ellipsoid zone were associated with worse visual outcome. Nonetheless, Dass et al.11 reported that six of 27 eyes (22%) with posterior or combined PFV achieved final VA of 20/60 to 20/800 after PPV, and Bosjolie et al.6 concluded six of 10 eyes (60%) with posterior PFV had 20/800 or better vision. The driver of improved visual outcome was attributable to the advancements in surgical techniques11 and surgical intervention at 13 months of age or younger,6 respectively. In theory, the retina has a period of “physical plasticity,” as observed in eyes with retinopathy of prematurity, when the retina can be dynamically altered to better anatomical and functional outcomes if early surgical intervention is instituted. However, the exact time frame for engaging is still under investigation. Walsh et al.3 reported surgical treatment at 8 months of age or younger led to better functional vision in patients with bilateral combined PFV. Hunt et al.21 suggested that time of surgery before 77 days of age made patients 13-times more likely to have VA of counting fingers or better than those operated on at an older age. In our study, of the 18 eyes (72%) receiving surgery before the age of 10 months, 12 eyes (67%) had VA of 20/4000 or better, including eight eyes (44%) that had VA of 20/1000 or better. For the seven eyes (28%) receiving surgery at older than 1 year of age, six eyes (86%) had VA of 20/4000 or better vision, and among them, four eyes (57%) had VA of 20/1600 or better. It seems to suggest the optimal timing of surgery may be well beyond 12 months of age, but the other possibility is the eyes with earlier surgery might be more apparent and serious that leads to early medical intervention.

Anatomically, better long-term cosmesis and eye growth was observed after surgery.22 Such cosmetic preservation is of paramount importance, especially when taking psychosocial development of the children into account. Zhang et al.26 suggested the quality of life in children after enucleation was significantly lower than the healthy children and demonstrated the impact of ocular cosmetic outcome on children's psychosocial development. The main finding in terms of preservation of ocular development in our study was steady growth in axial length. The mean change of axial length was 0.7 mm ± 1.4 mm in the eyes with surgical intervention, and none of the eyes became phthisis. Despite the fact that surgical treatment may not be effective for patients with severe microphthalmia or advanced posterior changes as foveal hypoplasia or retinal dysplasia, surgical intervention may still be considered in pursuing a better cosmetic outcome.

Contrasting with the risk of glaucoma in patients with PFV without surgical intervention was reported to be as high as 23% to 32%.21,23 None of our patients developed glaucoma during the follow-up period of up to 41 months. It is likely the anterior chamber depth of these patients improved after the relieve of the pushing force from the posterior chamber and also the removal of the lens itself.

Limitations of our study include its retrospective design, small patient population, and the lack of control group. AL measurements were tried in all cases, but not all were measurable because of the anatomic abnormalities in some of the patients. Since the severe form of posterior or combined PFV is vision-threatening and relatively rare, larger, prospective, multicenter studies to pursue the optimal timing of surgery for best visual outcomes are necessary and could be a promising way forward.

We conclude that vitrectomy in patients with posterior or combined PFV may provide an acceptable anatomical outcome, continual eye growth, and better cosmesis when vitrectomy and retinal reattachment are timely performed. Functional outcome of these patients remained poor despite surgical intervention.

References

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Baseline Characteristics of Study Population

Case No. Sex Involved Eye Type of PFV Initial Cornea/AC Status Initial Lens Status Retrolental Stalk Tissue Initial TRD Initial Macular Dragging Initial VA
1 F OU OU: A/P Opacity/collapsed Cataract OU Yes No Yes LP
2 M OD A/P Clear/formed Cataract OD Yes No Yes LP
3 M OU OU: A/P Clear/formed Cataract OU Yes Yes, OU Yes LP
4 M OU OU: A/P Clear/formed Cataract OU Yes No Yes LP
5 M OU OU: A/P Clear/formed Cataract OU Yes No Yes LP
6 M OU OD: P, OS: A/P Clear/formed Clear OD, cataract OS Yes No Yes LP
7 F OU OU: A/P Clear/formed, iris NV Cataract OU Yes Yes, OU Yes LP
8 M OS A/P Opacity/collapsed Cataract OS Yes Yes, OS Yes LP
9 M OS A/P Band keratopathy/formed Cataract OS Yes Yes, OS Yes LP
10 M OD A/P Opacity/collapsed Cataract OD Yes Yes, OD Yes LP
11 M OD A/P Opacity/shallow Cataract OD Yes No Yes LP
12 M OS A/P Opacity/formed, iris NV Cataract OS Yes Yes, OS Yes LP
13 M OU OU: A/P Opacity/collapsed, iris NV Cataract OU Yes Yes, OU Yes LP
14 M OS A/P Clear/formed Cataract OS Yes No Yes LP
15 F OD P Clear/formed Clear OD Yes No Yes LP
16 M OU OU: A/P Opacity/collapsed Cataract OU Yes Yes, OU Yes LP
17 F OS P Clear/formed Clear OS Yes No Yes LP
18 M OS A/P Clear/formed Cataract OS Yes No Yes LP

Surgical Procedures and Anatomic Outcomes of Study Population

Case No. Age at Surgery (Months) Type of Surgery and Laterality Subsequent Surgery and Laterality Final Lens Status Final Fundus Exam Initial AL (mm) Final AL (mm)
OD OS OD OS
1 5 23G PPV+PPL OD, 23G PPV OS None Aphakia OD, phakia OS TRD OD, attached retina OS Failed 20.67 Failed 21
2 3 23G PPV OD CE-IOL OD Pseudophakia OD Attached retina OD 18.01 19.21* Failed 22.95*
3 5 23G PPV OD, 23G PPL OS None Phakia OD, aphakia OS Attached retina OD, Retina open OS 21.0 19.0 20.0 18.0
4 48 23G PPV OU, CE-IOL OU None Pseudophakia OU Attached retina OD, TRD OS NA NA NA NA
5 4 25G PPV OU None Phakia OU Attached retina OU 16.0 17.0 NA NA
6 42 25G PPV OS CE-IOL OS Phakia OD, pseudophakia OS Attached retina OU 21.22 19.06 21.4 21.4
7 21 23G PPV+PPL OU None Aphakia OU Retina open OU NA NA 19.0 NA
8 10 23G PPV+PPL OS None Aphakia OS No view OS NA* NA Same* Same
9 20 23G PPV+PPL OS None Aphakia OS Retina open OS NA* NA 24.4* 22.9
10 10 25G PPV+PPL OD None Aphakia OD Retina open OD 14.2 20.2* NA NA*
11 1 23G PPL OD None Aphakia OD TRD OD NA NA* NA NA*
12 4 23G PPV+PPL OS None Aphakia OS Attached retina OS 19.84* 17.5 NA* NA
13 2 23G PPV+PPL OU None Aphakia OU TRD OU NA NA 15.0 15.0
14 2 23G PPV OS Lensectomy+IOL Pseudophakia OS Attached retina OS 19.66* 18.61 22.5* 21.02
15 7 23G PPV OD None Cataract OD Attached retina OD 17.5 20.36* NA NA*
16 2 23G PPV+PPL OU 23G PPV OS Aphakia OU Attached retina OU NA NA 23.5 24.5
17 83 23G PPV OS None Clear OS Attached retina OS 22.82* 22.65 23.91* 23.8
18 5 23G PPV+PPL OS None Aphakia OS Attached retina OS 20.34* Failed 22.32* 20.0

Functional Outcomes and Surgical Complications of Study Population

Case No. Final VA (Snellen Ratio) Final VA (logMAR) Glaucoma at Last F/U Phthisis at last F/U Length of F/U (Months)
OD OS OD OS
1 20/4000 20/250 2.30 1.10 No No 54
2 20/1400 20/20* 1.85 0* No No 36
3 20/1600 20/1000 1.90 1.70 No No 33
4 20/1600 20/4000 1.90 2.30 No No 75
5 LP LP LP LP No No 1
6 20/1000 20/1000 1.70 1.70 No No 20
7 20/1400 20/2000 1.85 2.00 No No 93
8 NA* NLP NA* NLP No No 69
9 NA* NLP NA* NLP No No 98
10 20/1000 NA* 1.70 NA* No No 18
11 20/1000 NA* 1.70 NA* No No 30
12 20/1000* NA 1.70* NA No No 24
13 20/1000 20/1000 1.70 1.70 No No 38
14 20/20* 20/2000 0* 2.00 No No 54
15 20/1400 20/100* 1.85 0.70* No No 24
16 LP LP LP LP No No 76
17 NA* 20/60 NA* 0.48 No No 17
18 20/200* 20/1000 1* 1.70 No No 29

Comparison of Published Surgical Outcomes for Persistent Fetal Vasculature

Study (Year) No. of Eyes Undergoing Surgery and Location Median Age at Time of Surgery (Months) Bilateral Cases No. of Eyes With Postoperative VA > 20/400 No. of Eyes With Postoperative VA > Form Vision* Mean F/U Duration (Months)
Sisk et al.5 (2010) 26 anterior, 7 posterior, 37 combined 2.75 3 (4.3%) 15 (21.4%) 49 (70.0%) 47
Bosjolie et al.4 (2015) 11 posterior 7 0 5 (45.5%) 7 (63.6%) 36
Liu et al.17 (2017) 53 anterior, 16 posterior, 49 combined 22 13 (12.4%) 29 (24.6%) Not reported 17
Karacorlu et al.16 (2018) 5 anterior, 5 posterior, 34 combined 3 3 (6.8%) 11 (25.0%) 35 (79.5%) 37
Current study 3 posterior, 22 combined 15 8 (44.4%) 2 (8.0%) 17 (68.0%) 41
Authors

From the Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan (CTY, KJC, LL, NKW, YSH, ANC, TLC, CCL, WCW); and Chang Gung University, College of Medicine, Taoyuan, Taiwan (KJC, LL, NKW, YSH, ANC, TLC, CCL, WCW).

Supported by Chang Gung Memorial Hospital research grants (CMRPG3G30581 and CMRPG3F0191∼3) and a Ministry of Science and Technology grant (MOST 106-2314-B-182A-040-MY3). These funding organizations play no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

The authors report no relevant financial disclosures.

Address correspondence to Wei-Chi Wu, MD, PhD, No. 5, Fu-Hsin Rd., Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan 333; email: weichi666@gmail.com.

Received: June 17, 2018
Accepted: November 05, 2018

10.3928/23258160-20190605-06

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