Ophthalmic Surgery, Lasers and Imaging Retina

Experimental Science 

Morphological Characteristics Predict Postoperative Outcomes After Vitrectomy in Myopic Traction Maculopathy Patients

Tian-Qi Duan, MD; Wei Tan, MD; Jie Yang, MD; Fang-Ling Li, MD; Si-Qi Xiong, MD; Xiang-Gui Wang, MD; Hui-Zhuo Xu, MD

Abstract

BACKGROUND AND OBJECTIVES:

To provide the surgical indication for patients with myopic traction maculopathy (MTM) by investigating the postoperative outcomes after vitrectomy among different types of morphological characteristic groups.

PATIENTS AND METHODS:

This was a retrospective cohort study that included patients (37 eyes) diagnosed with MTM at a single institution. All 37 eyes from 37 patients with MTMs were classified into three groups: foveal retinoschisis (FS), lamellar macular hole (LMH), and foveal retinal detachment (FRD). The ratios of anatomic recovery, central retinal thickness (CRT), and best-corrected visual acuity (BCVA) were statistically analyzed among the three groups preoperatively and at 1, 3, 6, and 12 months after vitrectomy.

RESULTS:

Anatomical recovery could be found in all patients of the FS group at 6 months postoperatively and in the LMH group at 12 months postoperatively. Only 83.33% patients in the FRD group showed anatomic recovery until 12 months. The time taken for CRT to reduce to 200 µm was gradually increased between the FS, LMH, and FRD groups. Postoperative BCVA was better in the FS group than the LMH and FRD groups (P < .05), but the LMH and FDR groups had no difference (P ≥ .05) at any point. The visual acuity was significantly improved in the FS group (P < .01) and FRD group (P = .018), but not in the LMH group (P = .196) at 12 months postoperatively.

CONCLUSIONS:

The FS group achieved anatomical recovery in the shortest time and had the best postoperative BCVA. FRD patients could get visual gain but need too much time for the anatomical recovery. LMH patients experienced anatomic success with surgery, but not in BCVA. Early surgery might be considered for eyes at FS prior to the occurrence of LMH or FRD.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:574–582.]

Abstract

BACKGROUND AND OBJECTIVES:

To provide the surgical indication for patients with myopic traction maculopathy (MTM) by investigating the postoperative outcomes after vitrectomy among different types of morphological characteristic groups.

PATIENTS AND METHODS:

This was a retrospective cohort study that included patients (37 eyes) diagnosed with MTM at a single institution. All 37 eyes from 37 patients with MTMs were classified into three groups: foveal retinoschisis (FS), lamellar macular hole (LMH), and foveal retinal detachment (FRD). The ratios of anatomic recovery, central retinal thickness (CRT), and best-corrected visual acuity (BCVA) were statistically analyzed among the three groups preoperatively and at 1, 3, 6, and 12 months after vitrectomy.

RESULTS:

Anatomical recovery could be found in all patients of the FS group at 6 months postoperatively and in the LMH group at 12 months postoperatively. Only 83.33% patients in the FRD group showed anatomic recovery until 12 months. The time taken for CRT to reduce to 200 µm was gradually increased between the FS, LMH, and FRD groups. Postoperative BCVA was better in the FS group than the LMH and FRD groups (P < .05), but the LMH and FDR groups had no difference (P ≥ .05) at any point. The visual acuity was significantly improved in the FS group (P < .01) and FRD group (P = .018), but not in the LMH group (P = .196) at 12 months postoperatively.

CONCLUSIONS:

The FS group achieved anatomical recovery in the shortest time and had the best postoperative BCVA. FRD patients could get visual gain but need too much time for the anatomical recovery. LMH patients experienced anatomic success with surgery, but not in BCVA. Early surgery might be considered for eyes at FS prior to the occurrence of LMH or FRD.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:574–582.]

Introduction

Myopic traction maculopathy (MTM) is one of the major causes of poor vision in eyes with pathological macular lesions associated with high myopia, which are caused by traction and are discovered in 9% to 34% of high myopia and posterior staphylomas.1–4 The vision suffers damage when MTMs present manifestation including thickening of the retina, macular retinoschisis-like structures, foveal retinal detachment (FRD), and macular holes (MHs). There are many factors may affect the development of MTM,2,5,6 but the pathogenesis is not clear. Post-vitreous detachment (PVD) is more likely to occur in patients with high myopia than in normal persons due to posterior scleral expansion, increased volume of vitreous cavity, and early vitreous degeneration and liquefaction. In the early stage of PVD, part of the posterior vitreous is still adhered to the macular fovea and retinal blood vessels, causing mechanical traction on the retina and consequently damaging the retina in the process of eye movement.7,8 In addition, the dilated posterior sclera of high myopia stretches the retina, resulting in retinal thinning. The photoreceptor cell outer layer is closely connected with the retinal pigment epithelium (RPE) layer, resulting in the radial extension of the outer layer of the retina. Therefore, retinal splitting is prone to occur in high myopia.2,9 The high degree of retinal arteriosclerosis reduces the elasticity of the arteries, creating an inward traction of the retina along the arteries. The residue of high myopia posterior vitreous cortex (PVC) prolongs the attachment and traction time between retina and vitreous. The damage of the internal boundary membrane and the formation of the epiretinal membrane further lead to retinal splitting, MH, and ruptural retinal detachment.10,11

Typical optical coherence tomography images of preoperative and postoperative splitting recovery in the foveal retinoschisis (FS), foveal retinal detachment (FRD), and lamellar macular hole (LMH) groups. (A) Preoperative FS group. (B) The retinoschisis of the FS group resolved 1 month after the operation. (C) Preoperative FRD group. (D) The retinoschisis of the FRD group resolved 3 months after the operation. (E) Preoperative LMH group: myopic traction maculopathy is characterized by rupture of the retinal inner layer at the fovea (white star). (F) The retinoschisis of the LMH group resolved 1 month after the operation. A partially detached but intact epiretinal membrane (white arrowheads) and stable macular retinoschisis (white arrows) can be seen preoperatively.

Figure 1.

Typical optical coherence tomography images of preoperative and postoperative splitting recovery in the foveal retinoschisis (FS), foveal retinal detachment (FRD), and lamellar macular hole (LMH) groups. (A) Preoperative FS group. (B) The retinoschisis of the FS group resolved 1 month after the operation. (C) Preoperative FRD group. (D) The retinoschisis of the FRD group resolved 3 months after the operation. (E) Preoperative LMH group: myopic traction maculopathy is characterized by rupture of the retinal inner layer at the fovea (white star). (F) The retinoschisis of the LMH group resolved 1 month after the operation. A partially detached but intact epiretinal membrane (white arrowheads) and stable macular retinoschisis (white arrows) can be seen preoperatively.

Vitrectomy combined with internal limiting membrane (ILM) peeling,10,12,13 posterior scleral reinforcement,14–16 intraocular gas treatment,17 and a combination of these approaches18 are considered to be effective treatment for MTMs. Among these methods, vitrectomy combined with ILM peeling for MTMs has good visual and anatomic results and perceived as the preferred treatment.19–21 Recently, some scholars have found that collagen fibers and cellular components on the intimal membrane may play an important role in the formation of macular cleavage.22,23 Therefore, some researchers preferred vitrectomy combined with fovea-sparing ILM peeling for reducing the occurrence of secondary MHs.24,25 On the basis of the appeal study, this surgical technique was selected in this study.

Preoperative visual acuity (VA), foveal status, duration of symptoms, and age are important factors that affect postoperative VA in the treatment of MTM.10,26 Optical coherence tomography (OCT) is a useful way to diagnose and monitor the development of MTM. Many investigators have attempted to observe the postoperative results in different types of MTM using OCT and tried to find out the indications for surgery.10,27 No consensus has been reached regarding the standard of surgery indication, and whether FS can be considered as a candidate for surgery is controversial.10,26,28,29 Nevertheless, previous studies only concentrated on the comparison of the final results of MTM patients at some point after surgery; however, anatomical and visual recovery speed among different morphological type of MTMs has not been reported yet. In this study, 37 patients diagnosed as MTM were retrospectively analyzed, and 37 eyes were classified into three groups: foveal retinoschisis (FS), lamellar MH (LMH), and FRD based on the previous literature.10 We compared the results of different morphological type of MTM patients at 12 months after surgery, and analyzed the process of splitting healing and VA improvement preoperatively and 1, 3, 6, and 12 months after vitrectomy with ILM peeling and C3F8 tamponade. Our research performed the correlation between the morphological characteristics and anatomical and visual outcomes after vitrectomy in MTMs and provided the surgical indications of MTM.

Patients and Methods

Ethical Approval

Each patient received and agreed with written informed consent for examination and surgery. This study followed all tenets of the Declaration of Helsinki and approved by the Institutional Review Committee of Xiangya Hospital, Central South University.

Data Source and Study of Population

This was a retrospective cohort study. This study included 37 eyes from 37 patients diagnosed with MTM in ophthalmology in Xiangya hospital from October 2017 to January 2019. The current study included eyes from patients diagnosed with MTM. The diagnosis was confirmed using fundus examination and OCT examination simultaneously at a single institution. Exclusion criteria for MTM included: (1) previous retinal surgery or trauma; (2) history of hypertension and diabetes; (3) previous history of endoscopic or laser treatment; (4) combination with retinal or optic nerve disease; (5) eye inflammation, cornea abnormality, and other ocular disease that may affect the visual acuity. The following ophthalmic examinations were performed in all patients: measurement of best-corrected VA (BCVA), intraocular pressure (IOP) measurement, slit-lamp microscopy examination, fundus examination with a 90-diopter lens, and spectral-domain OCT (SD-OCT) scanning.

Patients with surgical indications underwent 23-gauge pars plana vitrectomy performed by a senior surgeon. Under retrobulbar anesthesia, the adherent residual vitreous or epiretinal membrane were removed with the help of triamcinolone acetonide. Subsequently, a fovea-sparing ILM (2- to 3-disc-diameter) peeling was performed after staining the ILM with indocyanine green for the patients of FS and FRD groups. Patients in the LMH group were treated with ILM peeling alone.21 Finally, all the patients underwent C3F8 tamponade at the end of the surgery. All surgical patients underwent ophthalmic reexamination at 1, 3, 6, and 12 months after surgery.

All subjects underwent OCT scan using the SDOCT in the 512 × 128 mode (Cirrus; Carl Zeiss Meditec, Dublin, CA). Poor-quality scans with a strength index less than 7 and scans with misalignment or decentered were excluded. Based on foveal OCT findings, eyes were categorized into FS, LMH, and FRD groups. The FS group had foveal retinoschisis-like structures without photoreceptor detachment from the RPE or intraretinal splits, the LMH group had foveal intraretinal splits without photoreceptor detachment from RPE, and the FRD group had photoreceptor detachment from the RPE at the fovea.

The measurement of central retinal thickness (CRT) was quantified with machine software manually.30,31 The CRT was measured at the central site and was defined as the distance between the RPE and the inner retinal surface. All the measurements are carried out by two technicians separately and then the average value of choroid thickness was calculated.

Statistical Analysis

SPSS 20.0 (SPSS Inc., Chicago, IL) was used for statistical analysis. With the exception of the anatomical reduction rate of the retina at different time points and gender, which were dichotomous variables, other data are expressed as the mean ± standard deviation of continuous variables. BCVA measurements were converted to logarithm of the minimum angle of resolution (logMAR) units before analysis. The gender and anatomical reduction rate of 37 patients with MTM were analyzed by chi square test. The BCVA (logMAR) and CRT were measured by oneway analysis of variance. The difference was significant if its P value was less than .05. Additionally, we used effect size to express the magnitude of the difference between groups. Cohen's term d (Cohen's d) was used to express the effect size index of continuous variables. Cohen classified effect sizes as small (d = 0.2), medium (d = 0.5), and large (d ≥ 0.8).32 Odds ratio (OR) was used to express the effect size index of binary outcome variables.

Results

The basic information of patients (Table 1) shows that there were no significant differences in preoperative parameters including gender, age, or eye axis among the FS, LMH, and FRD groups.

Preoperative Clinical Data for Study Subjects With Macular Retinoschisis

Table 1:

Preoperative Clinical Data for Study Subjects With Macular Retinoschisis

The ratio of anatomical recovery in the FS group was significantly higher than in the FRD group at 1 month and 3 months after surgery, respectively (P1 month = .03, odds ratio [OR]1 month = 12.83; P3 month < .01, OR3 month = 36.00). The ratio of anatomical recovery in LMH group was also significantly different from that in the FRD group at 1 month and 3 months after surgery, respectively (P1 month = .034, OR1 month = 0.09; P3 month = .039, OR3 month = 0.11). There were no differences between the LMH and FS groups in ratio of anatomical recovery at 1 month and 3 months after surgery (P1 month = .582, OR1 month = 1.17; P3 month = .322, OR3 month = 4.00). At 6 and 12 months postoperatively, the ratio of anatomical recovery of these three groups were similar (P > .05, OR ≤ 1.33). Anatomical recovery could be found in all patients of the FS group at 6 months postoperatively and in the LMH group at 12 months postoperatively. However, only 83.33% patients in the FRD group showed anatomic recovery until 12 months (Table 2). Preoperative splitting height was lowered in the FS group compared to the FRD (P < .05, Cohen's d = 1.59) and LMH groups (P < .05, Cohen's d = 1.94). The splitting height of the FS group was lower than the FRD group during the postoperative follow-up (P1 month < .001, Cohen's d1 month = 1.98; P3 month < .001, Cohen's d3 month = 2.27; P6 month < .001, Cohen's d6 month = 1.88; P12 month < .05, Cohen's d12 month = 1.90). Additionally, the splitting height of the FS group was lower than that of the LMH group at 1, 3, 6, and 12 months after surgery (P1 month < .001, Cohen's d1 month = 1.87; P3 month = .001, Cohen's d3 month = 1.48; P6 month = .002, Cohen's d6 month = 1.41; P12 month = .001, Cohens'd12 month = 1.42). Additionally, there was no significant difference in splitting height in the FRD and LMH groups before or after surgery (P ≥ .05, Cohen's d ≤ 0.59) (Figure 2). Studies have shown that the average foveal thickness in normal Asians ranges from 195 µm to 252.8 µm.30,31,33 Here, we assume 200 µm served as the boundary for splitting improvement in patients with high myopia. The average CRT of the FS group decreased to 200 µm at 1 month postoperatively, whereas the average CRT of the LMH group decreased to 200 µm at 6 months postoperatively, and at 12 months postoperatively in the FRD group. Therefore, the anatomic recovery was consistent with the reduction of CRT in each group.

Comparison of Splitting Anatomic Recovery in Each Group at 1, 3, 6, and 12 Months After Surgery

Table 2:

Comparison of Splitting Anatomic Recovery in Each Group at 1, 3, 6, and 12 Months After Surgery

The mean central retinal thickness at different time points after vitrectomy for myopic foveoschisis in 37 eyes divided into three groups. Note: *P < .05; **P < .001; differences in the splitting height of the three groups determined by paired t-test. M = months; Pre = preoperative; FS = foveal retinoschisis; FRD = foveal retinal detachment; LMH = lamellar macular hole

Figure 2.

The mean central retinal thickness at different time points after vitrectomy for myopic foveoschisis in 37 eyes divided into three groups. Note: *P < .05; **P < .001; differences in the splitting height of the three groups determined by paired t-test. M = months; Pre = preoperative; FS = foveal retinoschisis; FRD = foveal retinal detachment; LMH = lamellar macular hole

In our study, BCVA measurements were converted to logMAR units for analysis. We found that the preoperative VA of logMAR in the FS group was significantly less than that in the LMH (P < .05; Cohen's d = 0.92) and FRD groups (P < .01; Cohen's d = 1.71). However, there was no obvious difference in preoperative VA of logMAR between the FRD and LMH groups (P = .056; Cohen's d = 0.84). After surgery, logMAR vision in the FS group was significantly less than that in FRD and LMH groups at 1 month, 3 months, 6 months, and 12 months of follow-up, respectively (FS vs. FRD: P1 month < .001, Cohen's d = 2.24; P3 month < .001, Cohen's d = 2.79; P6 month < .001, Cohen's d = 2.83; P12 month < .001, Cohen's d = 2.83; FS vs. LMH: P1 month < .001, Cohen's d = 1.79; P3 month < .001, Cohen's d = 2.01; P6 month < .001, Cohen's d = 2.44; P12 month < .001, Cohen's d = 2.53) (Figure 3A). The VA of the FS and FRD groups improved significantly at 12 months after surgery (FS P < .01, Cohen's d = 1.81; FRD P = .018; Cohen's d = 0.52), but there was no obvious increase in logMAR of the LMH group (LHM P = .196; Cohen's d = 0.25) (Figure 3B).

The changes in the best-corrected visual acuity (BCVA) of all three groups. (A) The mean changes in the BCVA at different time points after vitrectomy for myopic foveoschisis in 37 eyes of three groups. (B) Comparison of changes in the preoperative and 12 months postoperative BCVA among the three groups. *P < .05; **P < .01; the differences in the BCVA among the three groups as determined by the t-test. M = months; Pre = preoperative; FS = foveal retinoschisis; LMH = lamellar macular hole; FRD = foveal retinal detachment

Figure 3.

The changes in the best-corrected visual acuity (BCVA) of all three groups. (A) The mean changes in the BCVA at different time points after vitrectomy for myopic foveoschisis in 37 eyes of three groups. (B) Comparison of changes in the preoperative and 12 months postoperative BCVA among the three groups. *P < .05; **P < .01; the differences in the BCVA among the three groups as determined by the t-test. M = months; Pre = preoperative; FS = foveal retinoschisis; LMH = lamellar macular hole; FRD = foveal retinal detachment

Discussion

At the postoperative 1-month follow-up, we found significant differences among the three groups in the anatomic reduction rate (FS: 53.85%; FRD: 9.1%; LMH: 50%). At the end of 12 months of follow-up period, we found there was no significant differences among the three groups in the reduction rate (FS: 100%; FRD: 83.33%; LMH: 100%). The results showed that the preoperative mean CRT of the FRD group was highest, whereas it was lowest in the FS group before surgery. At the 12-month follow-up, the mean CRT showed the same trend. We selected 200 µm as the boundary for splitting improvement in patients with high myopia, and anatomic recovery was consistent with the reduction of CRT in each group. Shinohara et al. showed that outer retinoschisis is mainly caused by a posteriorly pulling force — that is, the staphyloma. The inner retinoschisis is caused mainly by an anteriorly pulling force — that is, vitreous traction and vascular microfolds. The larger the pulling force is, the higher the CRT becomes, as previous study reported.3,34 When the anteriorly pulling force is surgically removed, the FRD group showed the slowest recovery during the 12-month follow-up period, followed by the LMH group, whereas the FS group with the smallest pulling force showed the fastest recovery. The splitting can heal eventually as the pulling force is relieved. Therefore, at the end of the follow-up period, the splitting height of all these eyes decreased and reached under 200 µm. To be sure, splitting recovery in FS group was the fastest, followed by LMH group, then FRD group.

Due to the early anatomical reduction in the FS group, the postoperative BCVA reached a satisfactory level and maintained good vision after surgery. However, the VA of the LMH and FRD groups did not improve significantly even though splitting gradually recovered. Analogous to a previous study, preoperative BCVA and CRT were positively correlated with postoperative BCVA.23 The FS group had the best preoperative and postoperative vision.26,35 It could be understood that the photoreceptor and neuroepithelial damage of the FS group were less than that of the LMH and FRD groups, and most photoreceptors could work again after anatomical recovery of FS group. Surgery only helps for anatomical recovery, not for retinal nerve fiber layer repair in fovea. Thus, similar to previous research,27 our results presented that no significant improvement was observed in the VA of the LMH group, even though splitting was gradually recovered, and visual outcome was not good in the LMH group after surgery. A previous study reported that if shallow retinal detachment lasts long, the damage of photoreceptors progresses would be aggravated, and therefore vision could decrease.3 Besides, Ohno-Matsui et al. proposed that photoreceptor layer defects and persistent chorioretinal degeneration may be the mechanism underlying unsatisfactory postoperative visual recovery and outcome.36 Thus, when the photoreceptor layer of FRD is separated from the RPE layer, the lack of nutrition leads to the damage of photoreceptor cells related to vision.36 Here, unlike in previous studies, the visual improvement in the FRD group was worse than the FS group, which may relate to the small sample size and long duration of symptoms in the FRD group.10 In general, although the VA of LMH was not improved dramatically, anatomical recovery was achieved after vitrectomy and MTM progression was prevented.

It is still controversial to determine the optimal timing for MTM, and the selection of surgical candidates is based on the judgment of the surgeons. Some believed FRD was a predictive factor of poor prognosis and suggested early surgical treatment of MTM before FRD occurs.10,37,38 However, other scholars pointed out the presence of FRD should be considered for surgical indication.27 Here, we concluded the FS group had the fastest anatomical recovery and visual improvement compared with the LMH and FRD groups. We believe that if the patient had visual loss before LMH or FRD, early surgery for FS can be considered.

Development of full-thickness MH from FS and LHM were observed in previous studies.39 MH was witnessed to cause poor prognosis, and most patients with MH had poor visual improvement even after surgery; thus, the purpose of surgery for MH was to avoid poor prognosis.10,26 In our observation, we lacked data from MH patients because MH patients were often lost to follow-up after surgery; we hypothesize their poor visual outcome after surgery resulted in the high missing rate. However, the loss of MH patients did not influence our conclusion because we can speculate the benefit of MH was less than that found in the LMH and FRD groups.

There are some limitations in this study. Firstly, this is a retrospective study with a relatively small sample of 37 eyes, and the sample size in each group was small. Larger future studies are needed to perform more powerful analyses. Secondly, we lacked data for patients with MH because these patients were unavailable during the follow-up. Therefore, it would also be better to compare outcomes among a patient population with different morphological characteristics in the future. Thirdly, the investigation showed that the duration of symptoms was a significant predictive factor for visual outcomes after surgery,10 and data surrounding the duration of symptoms was a deficiency in our study.

In summary, our study showed that the splitting healing rate was the fastest in the FS group, followed by the LMH and FRD groups. Consistently, the FS group achieved the best BCVA in the shortest time-frame among the three groups, and patients in the FRD and LMH groups may have poor VA after the operation. Thus, morphological characteristics could be an important indicator for prognosis after surgery and as surgical indications for MTMs. Early surgery should be considered for eyes with FS but before LMH or FRD occurs.

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Preoperative Clinical Data for Study Subjects With Macular Retinoschisis

Preoperative Type of Foveal Status P Value

FS (n = 13) FRD (n = 12) LMH (n = 12)

Gender, n .567
  Male 4 4 6
  Female 9 8 6

Age, Years .254
  Mean 55.73 55.42 59.4
  Range 44–69 47–65 51–68

Axial Length, µm .156
  Mean 28.73 28.73 28.3
  Range 28.02–31.28 27–31.27 25.09–33.35

Comparison of Splitting Anatomic Recovery in Each Group at 1, 3, 6, and 12 Months After Surgery

Preoperative Type of Foveal Status OR (95%Cl)
FS (n=13) FRD (n=12) LMH (n=12) P Value FS vs. FRD FS vs. LMH LMH vs. FRD
Recovery Within 1 Month 7 (53.85%) 1 (9.1%) 6 (50%) 0.034* 12.83* (1.26–130.51) 1.17 (0.24–5.62) 0.09* (0.01–0.94)
Recovery Within 3 Months 12 (92%) 3 (30%) 9 (75%) <0.01** 36.00** (3.19–405.89) 4 (0.36–45.10) 0.11* (0.02–0.71)
Recovery Within 6 Months 13 (100%) 9 (75%) 10 (83%) 0.17 1.33 (0.96–1.84) 1.2 (0.93–1.55) 0.6 (0.08–4.45)
Recovery Within 12 Months 13 (100%) 10 (83%) 12 (100%) 0.2 1.2 (0.93–1.55) / 0.83 (0.65–1.07)
Authors

From Eye Center of Xiangya Hospital, Central South University, Changsha, Hunan Province, China; and Hunan Key Laboratory of Ophthalmology, Changsha, Hunan Province, China.

Paper was previously published as a “preprint” article on Research Square: Duan TQ, Song K, Yang J, Li FL, Xiong SQ, Wang XG, Xu HZ. Morphological characteristics predict postoperative outcomes after vitrectomy in myopic traction maculopathy patients. Preprint. Posted online September 24, 2019. Research Square. doi:10.21203/rs.2.14742/v1

The authors report no relevant financial disclosures.

Supported by the Natural Science Foundation General Program of Hunan Province (2019JJ40528).

Drs. Duan and Tan contributed equally to this manuscript as co-first authors.

Address correspondence to Hui-Zhuo Xu, MD, Eye Center of Xiangya Hospital, Central South University, No. 87, Xiangya Road, Kaifu District, Changsha 410008, Hunan Province, China; email: xhz1030@csu.edu.cn.

Received: March 04, 2020
Accepted: July 09, 2020

10.3928/23258160-20201005-05

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