Ultra-widefield Fluorescein Angiography Research Articles

Dynamic versus static ultra-widefield fluorescein angiography in eyes with diabetic retinopathy: a pilot prospective cross-sectional study.

To analyze differences in ultra-widefield fluorescein angiography (UWFA) findings between dynamic and static images of eyes with diabetic retinopathy (DR). This cross-sectional study included 28 eyes of 28 patients with DR undergoing UWFA. A series of UWFA images acquired from each patient were converted into a time-lapse video and used as a dynamic image. A single, clear, arteriovenous phase image was chosen as a static image. Non-perfusion index (NPI) and its correlation with vascular abnormalities in different zones were compared between dynamic and static UWFA imaging. NPI appeared to increase from the center to the far-periphery in both groups. Dynamic NPI was lower in the total retinal area (0.26 vs 0.29, P=0.009) and far-periphery (0.33 vs 0.36, adjusted P=0.042), which was contrary to the static NPI. Far-peripheral NPI was associated with intraretinal microvascular abnormality in the posterior area in both groups. Time-lapse dynamic UWFA imaging is a useful modality to differentially diagnose hypofluorescence in the most peripheral region. This modality could provide a reliable method for NPI measurement.

Multimodal imaging in infectious and noninfectious intermediate, posterior and panuveitis.

Given the heterogeneity of uveitis, markers of inflammation vary from patient to patient. Multimodal imaging has proven itself to be critical for accurate evaluation for disease activity and treatment response in uveitis. Ultra-widefield (UWF) fluorescein angiography and autofluorescence (AF) as well as optical coherence tomography angiography (OCTA) have provided insights into disease pathogenesis and monitoring not previously appreciated. In addition to structural retinal imaging, OCT can be used to assess the choroid, the posterior cortical vitreous and the retinal vasculature in eyes with uveitis. Multimodal ocular imaging in eyes with uveitis is critical for disease diagnosis and assessing response to treatment. UWF fluorescein angiography can detect retinal vasculitis even in the absence of overt vascular sheathing. UWF AF can help detect more chorioretinal lesions than clinically visible. OCT can be used to assess the posterior cortical vitreous, retina, large retinal vessels and choroid in uveitis. The use of multimodal imaging will likely be needed to determine clinical trial endpoints in studies evaluating therapeutics for uveitis.

Diabetic Macular Edema Treatment with Bevacizumab Does Not Depend on the Retinal Nonperfusion Presence.

This study evaluated the relationship between the retinal nonperfusion area (NPA) presence and the effectiveness of bevacizumab treatment (IVB) in patients with diabetic macular edema (DME). It also tested the prognostic usefulness of ultra-wide-field fluorescein angiography (UWFFA) and OptosAdvance software for diabetic retinopathy monitoring. Eighty-nine patients with DME with a macular central subfield thickness (CST) ≥ 250 μm, with (N = 49 eyes) and without (N = 49 eyes) retinal NPA, underwent nine bevacizumab injections over 12 months. NPA distribution, leakage area distribution, microaneurysm (MA) count, macular CST, diabetic retinopathy severity, and best-corrected visual acuity (BCVA) were assessed. The results show that bevacizumab reduced the macular CST from 420 to 280 μm (p < 0.001) and improved BCVA (p < 0.001) by about 10 ETDRS letters in both groups of patients. Additionally, the therapy reduced total retinal NPA from 29 (14-36) mm2 to 12 (4-18) mm2 (Me (Q1-Q3); p < 0.001) in patients with diagnosed nonperfusion. The effect of the therapy measured with vascular leakage, MA count, BCVArelative, and CSTrelative strongly depended on the zone of the retina and the NPA distribution. We conclude that the bevacizumab treatment had a positive effect on DME and BCVA in both study groups and on the size of retinal NPA in patients with retinal nonperfusion.

Ultra-Widefield Fluorescein Angiography to Monitor Therapeutic Response to Adalimumab in Behcet’s Uveitis

ABSTRACT Purpose To investigate the role of ultra-widefield fluorescein angiography (UWFA) for monitoring therapeutic response to adalimumab in patients with Behcet’s uveitis. Methods Patients with Behcet’s uveitis treated with adalimumab for ≥30 weeks were included. Intraocular inflammation, best-corrected visual acuity, systemic medications, and UWFA scores were evaluated. Results Thirty-eight eyes of 20 patients were included. Significant decreases in grading of anterior chamber cells and vitreous haze were observed at 6, 14, and 30 weeks after adalimumab administration (p < .001 for all). UWFA scores on vascular and capillary leakage were decreased at week 6 and further improved at weeks 14 and 30. Moreover, UWFA score further decreased at 14 and 30 weeks, even after manifest inflammation became quiescent at 6 weeks. (p = .004 and 0.001, respectively). Conclusion UWFA scores significantly improved in Behcet’s uveitis patients treated with adalimumab, and further improvement of UWFA scores was found in patients with a clinically quiescent inflammatory state.

Three cases of brolucizumab-associated retinal vasculitis treated with systemic and local steroid therapy.

To describe three Japanese cases of retinal vasculitis that occurred following intravitreal brolucizumab injections and the systemic and local steroid treatment administered. Three patients developed intraocular inflammation (IOI) and retinal vasculitis following the first injection of brolucizumab for age-related macular degeneration. For two eyes, monthly aflibercept injections did not control exudation, and therapy was changed to brolucizumab; one eye was treatment-naïve. All three patients noticed blurry vision and floaters 11-18 days after brolucizumab injections, and the treated eyes exhibited anterior chamber cells, fine keratic precipitates, vitreous cells, and vitreous haze. Ultra-widefield color images of the fundus showed retinal hemorrhage in the peripheral retina and, in two cases vascular sheathing. Ultra-widefield fluorescein angiography (FA) showed segmental vascular leakage in all eyes and leakage from the optic disc in two eyes. Vascular filling defects were noted in the peripheral retinae of two eyes. Brolucizumab-associated retinal vasculitis was diagnosed, and treated with 30 mg/day of oral prednisolone, subtenon triamcinolone acetonide injection (20 mg/0.5 ml), and 0.1% betamethasone sodium phosphate solution. After 1 week, color fundus images and FA showed improvements in vascular sheathing, leakage from retinal vessels, and optic disc leakage, but the vascular filling defects remained. Visual acuity was restored in all three eyes 6 weeks after the onset. Brolucizumab-associated IOI, including retinal vasculitis and retinal occlusion, is a rare but important adverse event that can cause severe vision loss. Prompt diagnosis with FA and treatment with systemic or local steroids should be considered.

Macular Microvascular Changes and Their Correlation With Peripheral Nonperfusion in Branch Retinal Vein Occlusion

To investigate the correlation between macular microvascular alterations on optical coherence tomography angiography (OCTA) and retinal ischemia on ultra-widefield fluorescein angiography (UWF FA) in eyes with branch retinal vein occlusion (BRVO). Cross-sectional study. This prospective study was performed from September 2019 to June 2020 at Yeungnam University Medical Center. We included 60 patients with treatment-naïve BRVO. Two independent, masked graders analyzed OCTA parameters, including vessel density, skeletal density, and fractal dimension (FD), and UWF FA parameters, including retinal nonperfusion area (NPA) and ischemic index (ISI), from various concentric regions (perimacular region, 0.5-3mm radius; near-peripheral region, 3-10mm; midperipheral region, 10-15mm; far-peripheral region, >15mm). A repeated-measures analysis of variance test and a paired t test were performed for inter-visit and inter-regional comparisons, and Pearson correlation coefficient and multivariate regression analyses were performed to examine the correlation between UWF FA and OCTA parameters. The OCTA parameters from both the superficial and deep capillary plexuses (DCP) were significantly correlated with NPA and ISI in all concentric regions. Even after adjusting for several covariates, all OCTA parameters revealed a significant association with ISI on UWF FA. Moreover, OCTA parameters from DCP were significantly correlated with concentrations of placental growth factor and vascular endothelial growth factor. Although all OCTA parameters achieved excellent results of area under the curve (AUC) > 0.9 for detecting severe retinal ischemia, defined as ISI >10%, FD reduction in DCP was the most reliable parameter (AUC= 0.948, P < .001), and 5.39% was the best cut-off point for predicting ISI > 10%. OCTA is a useful noninvasive tool not only for evaluation of macular microvasculature but for supposition of peripheral nonperfusion in eyes with BRVO.

Asymmetric diabetic retinopathy.

Increasing prevalence of diabetes mellitus warrants recognition of factors related to asymmetric diabetic retinopathy (DR). This thematic synthesis based on an iterative literature review conducted in Medline and Google Scholar pertaining to diabetes with coexistent asymmetry of retinopathy included 45 original articles, 21 case reports and series, and 18 review articles from 1965 to 2020. Asymmetric DR is defined as proliferative DR (PDR) in one eye and nonproliferative, preproliferative, background, or no DR in the other eye lasting for at least 2 years. It is observed in 5%–10% of patients with PDR. Associated factors can be divided into (i) vascular: carotid obstructive disease, ocular ischemic syndrome, and retinal vascular diseases; (ii) Inflammatory: uveitis, endophthalmitis, and Fuchs’ heterochromic cyclitis; (iii) degenerative: posterior vitreous detachment, high myopia and anisometropia, uveal coloboma, retinal detachment, retinitis pigmentosa, and chorioretinal atrophy and scarring; (iv) cataract surgery and vitrectomy; and (v) miscellaneous: elevated intraocular pressure, glaucoma, amblyopia, retinal detachment, and optic atrophy. The gamut of diagnostic modalities for asymmetric DR includes thorough ocular examination, slit-lamp biomicroscopy, fundus photography, fundus fluorescein angiography, optical coherence tomography, and newer modalities such as ultra-widefield fluorescein angiography and optical coherence tomography angiography, along with a complete systemic evaluation and carotid Doppler studies. The differential diagnosis includes other causes of retinal neovascularization that may present in an asymmetric manner, such as sickle cell retinopathy, retinal vein occlusions, and featureless retina. This review discusses in detail the aforementioned considerations and draws a comprehensive picture of asymmetric DR in order to sensitize ophthalmologists to this important condition.

Hemoglobinopathies: ocular manifestations in children and adolescents.

Hemoglobinopathies are genetic disorders that lead to abnormal structure of the hemoglobin molecule. Sickle cell disease, the most common inherited blood disorder, is characterized by defective oxygen transport. Almost every part of the eye can be affected by sickle cell disease; however, proliferative sickle cell retinopathy is the primary cause of vision loss, either from vitreous hemorrhage or retinal detachment. Here we review the various manifestations of hemoglobinopathies on the eyes of children and adolescents, with a specific focus on sickle cell disease and its different phenotypes. Newer, more sensitive ophthalmological imaging modalities, including ultra-widefield fluorescein angiography, spectral-domain optical coherence tomography, and optical coherence tomography angiography, are available. These sensitive modalities allow for a more thorough examination of the retinal periphery where sickle cell retinopathy is often present. Utilization of such modalities will help with the early detection of the disease in children, which provide a better understanding of the pathogenesis of the disease and guide future screening and treatment regimens.

A Multiple Evanescent White Dot Syndrome–like Reaction to Concurrent Retinal Insults

To describe a clinical picture resembling classic multiple evanescent white dot syndrome (MEWDS) potentially triggered by previous or concurrent, apparently unrelated, ocular events and to provide a literature review of similar presentations. Retrospective chart series and literature review. Consecutive patients diagnosed with MEWDS at the Feinberg School of Medicine, Northwestern University, Chicago, Illinois, and the IRCCS San Raffaele Scientific Institute, Milan, Italy, between July 2019 and June2020. Charts of patients were reviewed. Ophthalmic history, best-corrected visual acuity, spectral-domain OCT results, OCT angiography results, fundus autofluorescence results, ultra-widefield fluorescein angiography results, and indocyanine green angiography results were collected. A PubMed-based search was carried out for similar presentations using the terms MEWDS and white spot syndromes. An ocular history positive for previous or concurrent ocular events in patients with MEWDS was sought in our cohort and the existing literature. Five eyes of 4 patients (2 females; age range, 16-81 years) were included. The first eye had a history of bilateral Best vitelliform dystrophy and unilateral choroidal neovascularization. The second eye had angioid streaks complicated by choroidal neovascularization and underwent prior thermal laser photocoagulation. The third eye had a history of high myopia and a scleral buckle procedure for retinal detachment. The fourth patient had bilateral idiopathic retinochoroiditis. We identified 16 case reports from 5 previous publications that support a MEWDS-like reaction to previous ocular insults. We suggest a MEWDS-like reaction may be elicited by ocular events in a subset of susceptible patients. We hypothesize that damage to the outer retina may play a role in triggering the local inflammatory response.

Relationship Between Retinal Capillary Nonperfusion Area and Renal Function in Patients With Type 2 Diabetes.

PurposeWe sought to assess the relationship between retinal nonperfusion area (NPA) on ultra-widefield fluorescein angiography (UWFA) and renal function in type 2 diabetes mellitus (DM) patients with diabetic retinopathy (DR) and nephropathy.MethodsUWFA was performed in 248 eyes (124 patients) with DR, comprising 94 eyes from patients with chronic kidney disease (CKD) caused by diabetes and 154 eyes without CKD (non-CKD). Serum creatinine level (Cr), estimated glomerular filtration rate (eGFR), urine albumin/creatinine ratio (UACR), and urine protein/creatinine ratio (UPCR) were collected. On UWFA, retinal NPA was measured in an automated manner. The correlation between NPA and renal function was analyzed.ResultsThe mean NPA value of the total eye was 33.11 ± 45.77-disc diameter (DA) in non-CKD and 100.57 ± 69.52 in CKD (P < 0.001). NPA of posterior pole was 1.21 ± 3.28 DA in non-CKD and 7.99 ± 6.75 in CKD group (P < 0.001). The NPA values of both the total eye and posterior pole were significantly correlated with Cr (r = 0.585 and 0.483), eGFR (r = −0.572 and −0.524), UACR (r = 0.541 and 0.482), and UPCR (r = 0.509 and 0.529, respectively) (all P ≤ 0.001). Linear modeling encompassing all clinical factors and relative clinical factors suggested eGFR as the most important predictor for NPAs of the total eye and posterior pole.ConclusionsLarger retinal NPA on UWFA is associated with worse renal function in DM patients. Renal function can be used to predict retinal NPA in type 2 DM patients with nephropathy and DR.

Phenotyping of retinal neovascularization in ischemic retinal vein occlusion using wide field OCT angiography.

Abnormal retinal neovascularization caused by ischemic retinal vein occlusion (RVO) is a frequent cause of visually significant vitreous hemorrhage. The early detection of new vessels may be challenging and often requires the use of invasive tests such as fundus fluorescein angiography (FA). We demonstrate the use of wide-field optical coherence tomography angiography (WF-OCTA) in the detection and characterization of neovascularization secondary to ischemic RVO. We conducted a retrospective observational case series of patients diagnosed with ischemic RVO between August 2018 and March 2019, who underwent WF-SS-OCTA imaging (PLEX Elite 9000, Carl Zeiss Meditec). We performed real-life montage imaging, covering the involved area and compared the findings of WF-SS-OCTA to standard clinical examination and when available, ultrawide-field fluorescein angiography (UWF-FA, Optos 200TX). In the included 39 eyes with ischemic RVO, neovascularization elsewhere (NVE) was encountered in 16 of 39 eyes (41%) on WF-OCTA and were characterized as sea-fan type vessels and nodular type vessels, based on their appearance and localization. NVE was identified in 4/39 eyes on standard clinical examination, equating to a detection rate of 10.3%. All were of a sea-fan morphology. In one case, NVE found on WF-OCTA was not observed on UWF-FA, which was a nodular type. Neovascularization of the disc (NVD) was detected in one eye. WF-OCTA may become a useful noninvasive tool in the detection of neovascularization in patients with ischemic RVO. Furthermore, the characterization of different morphologies of neovascularization detected by WF-OCTA could be of clinical relevance.

Ultra-widefield Fluorescein Angiography Findings in Patients with Multiple Retinal Holes

Ultra-widefield Fluorescein Angiography Findings in Patients with Multiple Retinal Holes

Optical coherence tomography angiography measured area of retinal neovascularization is predictive of treatment response and progression of disease in patients with proliferative diabetic retinopathy

BackgroundThe purpose of this study was to evaluate the area of retinal neovascularization in patients with treatment-naïve proliferative diabetic retinopathy (PDR) as measured by optical coherence tomography angiography (OCT-A) as a marker of subsequent treatment response after panretinal photocoagulation (PRP), and to examine if this area correlated with area of retinal neovascularization as measured by fluorescein angiography (FA).MethodsEn face OCT-A scans (4.5 × 4.5 mm) of neovascularizations were obtained at baseline (BL) before PRP and at month (M) 3 and M6 after treatment. Progression of PDR were defined as lesion growth (assessed by ophthalmoscopy and wide-field fundus photo) or increasing leakage by Optos ultra-widefield FA, and patients were divided into two groups; progression or non-progression. Mann–Whitney U test and Wilcoxon signed-rank test were used to analyse differences between groups and between time points. Areas of retinal neovascularizations (OCT-A and FA) were calculated by algorithms developed in Python (version 3.6.8, The Python Software Foundation, USA).ResultsOf 21 eyes included, 14 had progression of disease. Median OCT-A area did not differ between the two groups (progression vs. non-progression) at BL (76.40 ± 162.03 vs. 72.62 ± 94.15, p = 0.43) but were statistically significantly larger in the progression group at M6 (276.69 ± 168.78 vs. 61.30 ± 70.90, p = 0.025). Median FA area did not differ in the progression vs. the non-progression group at BL (111.42 ± 143.08 vs. 60.80 ± 54.83, p = 0.05) or at M6 (200.12 ± 91.81 vs. 123.86 ± 162.16, p = 0.62). Intraclass correlation between area by OCT-A and FA was −5.99 (95% CI: −35.28–0.993), p = 0.71.ConclusionsIn this study of patients with treatment-naïve PDR, we showed that increasing area of retinal neovascularizations measured by OCT-A at M6 indicated progression of disease after PRP treatment. Our results suggest that area by OCT-A reflects disease activity and that it can be used as an indicator to monitor the progression of PDR over time, and to evaluate treatment response six months after PRP.Trial registrationhttps://clinicaltrials.gov (identifier: NCT03113006). Registered April 13, 2017.

Vascular findings in primarily affected and fellow eyes of middle-aged patients with Coats’ disease using multimodal imaging

AimsTo investigate the retinal vascular structure and capillary anomalies of affected and fellow eyes of patients with unilateral Coats’ disease using multimodal imaging.MethodsClinical investigation of both eyes of each patient...

Longitudinal assessment of quantitative ultra-widefield ischaemic and vascular parameters in sickle cell retinopathy

PurposeTo evaluate longitudinal quantitative ischaemic and vasculature parameters, including ischaemic index, vessel area, length and geodesic distance in sickle cell retinopathy (SCR) on ultra-widefield fluorescein angiography (UWFA).MethodsOptimal UWFA images from...

UTILITY OF ORAL FLUORESCEIN ANGIOGRAPHY WITH ULTRA-WIDEFIELD IMAGING SYSTEM FOR EVALUATION OF VARIOUS RETINAL DISORDERS.

To evaluate the utility of oral fluorescein angiography with ultra-widefield imaging system (oral UWF-FA) predominantly in children. We recruited 17 patients aged 2 years to 22 years with retinal disorders. Each patient ingested a dose of fluorescein sodium set by body weight mixed with 100 mL of juice. Images were scored using four parameters as follows: branch retinal vessel identification, retinal vessels visualization, foveal avascular zone visualization, and clinically important findings such as leakage, microaneurysms, neovascularization, or significant nonperfusion area visualization. Based on the aggregate score, we classified the image quality into three grades. Sixteen of 17 patients completely ingested the fluorescein sodium, and ultra-widefield fluorescein angiography was performed. Images were classified as high quality in nine cases, moderate quality in four, and poor quality in three. In 13 cases (81.3%), images had adequate quality to evaluate retinal conditions. Of three patients with poor-quality images, 2 took 10 minutes to ingest fluorescein sodium and the other ingested only half the dose. The adverse event of a mild skin rash was noted in one patient. Oral ultra-widefield fluorescein angiography is effective in evaluating retinal pathology and is a useful alternative especially for pediatric patients who cannot tolerate intravenous line placement.

NONPERFUSION AREA QUANTIFICATION IN BRANCH RETINAL VEIN OCCLUSION

To precisely quantify retinal nonperfusion areas (NPAs) in branch retinal vein occlusion using widefield optical coherence tomography angiography (OCTA) and examine their association with neovascular complications. We enrolled 26 patients with treatment-naïve branch retinal vein occlusion and prospectively examined them for 12 months. After 3 monthly ranibizumab injections to treat macular edema, each patient underwent ultra-widefield (UWF) fluorescein angiography (FA) and OCTA. Ultra-widefield FA was additionally performed at Month 12. For UWF FA, the retinal NPA was measured using the equipment's built-in software. For OCTA, we used panoramic image montaged from 5 single 12 × 12 mm2 images and quantified the retinal NPA using a Gullstrand eye with a grid scale at each patient. Measurements were expressed in terms of actual values and disc area units. The retinal NPAs as measured using single OCTA and panoramic OCTA were significantly associated with that measured using UWF FA (P < 0.001 for both). Retinal neovascularization lesions were observed in 4 (15.4%) of 26 eyes. For patients with accompanying neovascularization, the retinal NPA measured using UWF FA, single OCTA, and panoramic OCTA were 187.9 ± 39.5 mm2 (109.9 ± 21.4 disc area), 34.3 ± 13.7 mm2 (19.9 ± 7.7 disc area), and 106.6 ± 24.5 mm2 (62.4 ± 13.6 disc area), respectively, which were larger than for those without neovascularization (P < 0.001, 0.014, and <0.001, respectively). Using widefield OCTA, we could quantify the retinal NPA of eyes with branch retinal vein occlusion. These could serve as valid references to assess the risk of neovascular complications.

Trends in optical coherence tomography angiography use in university clinic and private practice setting between 2014-2018

ABSTRACT Background The aim was to assess the trends in optical coherence tomography angiography (OCTA) use compared with fluorescein angiography (FA). Methods A bilateral patient’s exam on a single day was considered one examination. A total of 3680 and 700 OCTA examinations and 3387 and 439 FA examinations were performed between 2014 and 2018 in a university clinic and private practice, respectively. A regression analysis was completed. Results The use of OCTA procedures grew 17-fold from 2015 till 2018. In a university clinic, ultrawide-field FA accounted for 2% of all FA examinations performed in 2015, and its use increased to 68% in 2018 while the number of narrow-field FA examinations dropped from 617 in 2014 to 220 in 2018. This decrease inversely correlated with the rise of diabetic retinopathy cases diagnosed with FA (R= −0.86, p= 0.02). In private practice, the increase in the use of OCTA was a primary driver of the decline of the FA use from 127 in 2015 to 27 in 2018, while the number of OCTA examinations was 344 in 2018 (R= −0.99, p= 0.06). Conclusion The results of the study indicate that OCTA is a valuable tool capable of replacing FA in some selected cases.

Ultra-Widefield Fluorescein Angiographic Patterns, Retinal Microvascular Anomalies and Retinal Ischemic Index in Branch Retinal Vein Occlusions with Established Retinal Neovascularization.

PurposeTo share the experience of using ultra-widefield fluorescein angiography (UWF-FA) in recognizing the potential signs for retinal neovascularizations (NVE) development in branch retinal vein occlusions (BRVO).MethodsReporting angiographic findings in 60 BRVO eyes presenting with NVE and vitreous hemorrhage using UWF-FA investigation. Angiographic retinal ischemic index (ARI) was also calculated from UWF-FA as the ratio of digitally mapped ischemic retina area against area of optic disc, termed unit of disc diameter (DD).ResultsWe observed emerging angiographic features common to these patients: pattern of a localized non-perfused retina at early phase of UWF-FA remaining non-perfused at the late phase (black retinal ischemia, black-RI) (100%); presence of retinal microvascular anomalies (RMAs) at the “water-shed-border” of black-RI (100%); site of NVEs observed at either the same “water-shed-border” (42%) or from the main vessel branch within the black-RI (30%), or from both sites (28%); multiple NVEs were observed in all eyes except two with single active NVE. Median ARI size was 114 DD (SD 80 DD), range 5–354 DD.ConclusionWe report a recurring angiographic pattern common to eyes with active BRVO-NVEs from UWF-FA, and NVEs in this clinical group can develop from varied ARI sizes. Further studies would be needed to establish the role of UWF-FA in predicting angiographic risk factors for BRVO-NVE.

Efficacy of intravitreal AFlibercept injection For Improvement of retinal Nonperfusion In diabeTic retinopathY (AFFINITY study)

IntroductionTo evaluate the effects of intravitreal aflibercept injection on retinal nonperfusion in patients with diabetic retinopathy (DR) using ultrawide field (UWF) fluorescein angiography (FA).Research design and methodsThirty-eight eyes of 38...