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Clinical StudyThe Effects of Uncomplicated Cataract Surgery on
RetinalLayer Thickness
Ali Kurt and Raşit Kılıç
Department of Ophthalmology, Faculty of Medicine, Ahi Evran
University, Kırşehir, Turkey
Correspondence should be addressed to Ali Kurt;
[email protected]
Received 16 January 2018; Accepted 18 April 2018; Published 5
June 2018
Academic Editor: Marcel Menke
Copyright © 2018 Ali Kurt and Raşit Kılıç. )is is an open
access article distributed under the Creative Commons
AttributionLicense, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work
isproperly cited.
Purpose. Our aim was to assess changes in the total retinal
thickness (TRT), total retinal volume (TRV), and retinal layer
thicknessafter uncomplicated cataract surgery. Methods. A total of
32 eyes of 32 patients who had undergone uncomplicated
phaco-emulsification surgery and intraocular lens implantation in
one eye were enrolled. Effective phacoemulsification time (EPT)
andtotal energy (TE) were recorded. )ickness and TRV were measured
using optical coherence tomography. Data were
collectedpreoperatively and at postoperative day 1, 7, 30, 90, and
180. Results. )e study results showed a decrease in TRT, TRV, and
mostretinal layer thicknesses at the first postoperative day visit
and then increasing at week 1, and months 1 and 3, and then
relativelydecreasing at month 6 although not returning to
preoperative levels. )e least affected layers were the retinal
pigment epitheliumand outer plexiform layer. )ere was a positive
correlation between EPTand TE and ganglion cell layer in a 1mm
circle and innernuclear layer in a 1–3mm circle (p< 0.05).
Conclusion. )e results suggest that long-term follow-up of more
than 6 months isnecessary after cataract surgery to see whether
total retinal and segmental values return to preoperative levels.
)is study wasregistered with Australian New Zealand Clinical Trials
Registry (ANZCTR): ACTRN12618000763246.
1. Introduction
Cataract is the most common preventable cause of vision
lossworldwide. Pseudophakic cystoid macular edema (PCME),known as
Irvine–Gass syndrome, is one of the most commoncomplications after
cataract surgery. It is generally subclinicalin most cases and
rarely causes vision loss. Although theincidence of clinical PCME
has decreased with small incisioncataract surgery and
phacoemulsification (PE), it can stillcause unexpected vision loss
[1].)e exact pathophysiology ofPCME is not fully understood but
seems to be related to theinflammation triggered by surgery. )e
inflammatory cyto-kines and mediators break down the blood-retina
barrier andresult in increased vascular permeability and cystoid
macularedema [2, 3]. Other factors such as posterior capsule
rupture,vitreous loss, retained lens fragments, vitreomacular
traction,and iris trauma after complicated surgery can also
increase thePCME incidence [1–3].
PCME is most commonly seen 4–6 weeks after surgery[1–3]. Fundus
fluorescein angiography (FFA) reveals capillarydilatation, leakage
from the foveal capillaries, and developingpetalloid appearance.
Optical coherence tomography (OCT)is a noninvasive device which
enables detection of cysticspaces, retinal thickening, and
subretinal fluid. OCT also hasgood repeatability and
reproducibility when measuring ret-inal layer thickness at the
macula [4]. It is an excellent methodfor monitoring disease
activity [3].
)e current knowledge on the effect of postoperativeinflammation
on retinal cells and layers is limited. We arenot aware of any
study assessing the retinal segments todetect the layers that are
most affected by cataract surgerywith long-term follow-up. )e
purpose of this study was toevaluate the thickness of each retinal
segment quantitativelywith spectral domain (SD)-OCT before and
after un-complicated cataract surgery to gain additional
informationon PCME.
HindawiJournal of OphthalmologyVolume 2018, Article ID 7218639,
6 pageshttps://doi.org/10.1155/2018/7218639
mailto:[email protected]://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374949&isReview=truehttp://orcid.org/0000-0002-3893-6280http://orcid.org/0000-0001-6671-9067https://doi.org/10.1155/2018/7218639
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2. Methods
�is prospective study was conducted at the Ahi EvranTraining and
ResearchHospital betweenDecember 2016 andOctober 2017. �e study was
approved by the institutionalreview board and adhered to the tenets
of the Declaration ofHelsinki. Informed consent was obtained from
all the pa-tients. A total of 43 eyes of 43 Caucasian patients who
hadundergone uncomplicated cataract surgery and posteriorchamber
intraocular lens implantation were included.Eleven patients were
excluded due to the lack of follow-upexaminations, and the study
was nally conducted on the 32eyes of 32 patients. �e visual acuity
was evaluated witha Snellen chart, and a detailed biomicroscopic
anterior andposterior segment examination was performed with
pupil-lary dilatation. Air pu tonometry was used to measure
theintraocular pressure. �e axial length was measured usingoptical
low-coherence reectometry (Lenstar LS 900, Haag-Streit AG, Koeniz,
Switzerland). Best corrected visual acuitywas 2/20 and higher in
all patients preoperatively.
Exclusion criteria consisted of macular pathologies,retinal
vascular occlusion, history of any other ocular dis-orders
(including uveitis, severe dry eye, eye trauma,glaucoma, and
pseudoexfoliation syndrome) or surgery, anysystemic disorders (such
as diabetes, hypertension, asthma,or chronic obstructive pulmonary
disease), systemic in-ammation (inammatory bowel disease and
hepatitis B orC), the current use of any topical or systemic
medication oranti-inammatory agent, and intraoperative
complicationssuch as posterior capsular rupture, vitreous loss,
iris pro-lapse, and low scan quality images due to dense
cataract.
Cataract surgery was performed with the Inniti PEdevice (Alcon
Inc., Forth Worth, TX, USA) using a torsionalhandpiece. �e stop and
chop technique was used in allcases. Eective phaco time and phaco
energy were recorded.Postoperatively, all patients were prescribed
topical moxi-oxacin and dexamethasone four times a day for three
weeksand Nevanac three times a day for four weeks. �e sameauthor
(AK) performed all surgeries and examinations.
2.1. OCT Scan Protocol. All subjects underwent
pupillarydilatation with 1% tropicamide and 2.5%
phenylephrinehydrochloride eye drops prior to imaging. We used the
SD-OCT, Spectralis (Heidelberg Engineering, Heidelberg, Ger-many)
device with software version 6.3.3.0 in this study as ithas a
higher repeatability index [4]. OCT imaging was carriedout using
the following parameters: 20°×15° degrees(5.9× 4.4mm), automatic
real-time averaging of 100 frames,19 horizontal sections at 240 µm
intervals, and 512 A-scansper B-scan. We only included images with
a quality higherthan 15 dB in the study. �e image acquisition was
followedby automatic intraretinal layer segmentation performed
bythe inbuilt Spectralis software to include the retinal nerve
berlayer (RNFL), ganglion cell layer (GCL), inner plexiform
layer(IPL), inner nuclear layer (INL), outer plexiform layer
(OPL),outer nuclear layer (ONL), retina pigment epithelium
(RPE),total retinal volume (TRV), and total retina thickness
(TRT)(Figure 1). Intraretinal layer thicknesses were obtained
for
each ETDRS subeld at a central 1mm circle and 1–3mmcircles that
included the superior, temporal, inferior, and nasalsubelds (Figure
2). �e rst Spectralis scan was set asa reference image, and the
images during future visits wereacquired with real-time image
registration by follow-upmodeby the ophthalmologist. �e ETDRS grid
was centered on thefovea manually if it was not positioned
correctly automati-cally. We also checked the accuracy of retinal
layer seg-mentation in every patient. �e 3–6mm subelds were
notincluded as it exceeded the area of our imaging angle. Datawere
collected preoperatively and on postoperative day 1, 7(rst week),
30 (rst month), 90 (third month), and 180 (sixthmonth). �e mean
thickness of the 1mm and 1–3mm ringswas calculated and used for
further statistical analysis.
2.2. Statistical Analysis. �e IBM SPSS version 20.0
(IBMCorporation, Armonk, NY, USA) software was used forstatistical
analyses. Measured data were described as the
Figure 1: Borders of automatically segmented retinal layers
onOCT images. ILM, internal limiting membrane and inner border
ofthe RNFL layer; RNFL, outer border of the retinal nerve ber
layer;GCL, outer border of the ganglion cell layer; IPL, outer
border ofthe inner plexiform layer; INL, outer border of the inner
nuclearlayer; OPL, outer border of the outer nuclear layer; ELM,
externallimiting membrane—outer border of the outer nuclear layer;
RPE,retina pigment epithelium; BM, Bruch’s membrane.
800
700
600
500
Retin
a thi
ckne
ss (μ
m)
400
300
200
100
0
Figure 2: ETDRS grid for 1mm and 1–3mm circles on OCTimages.
ETDRS grid on macula. C, central 1mm zone in macula;S, superior
quadrant in 1–3mm circle onmacula; I, inferior quadrantin 1–3mm
circle on macula; T, temporal quadrant in 1–3mm circleon macula; N,
nasal quadrant in 1–3mm circle on macula.
2 Journal of Ophthalmology
-
arithmetic mean± standard deviation, whereas categoricaldata
were described as percentages (%). Normal distributionof measured
data was examined by the Kolmogorov–Smirnovtest. )e one-way ANOVA
test was used for intergroupcomparison variables for repeated
measures. )e Bonferronimethod was used to correct the p value. )e
relationshipbetween EPT and TE and all thickness parameters were
an-alyzed with the Pearson correlation analysis. A statistical
levelof significance was accepted at p< 0.05.
3. Results
)emean age of the patients consisting of 25 (78%)males and7
(22%) females was 63.81± 9.0 years (range: 48–79 years).)ere were
20 right and 12 left eyes. )e mean preoperativeaxial length was
23.62± 0.9mm (range: 21.3–25.2mm). )ecataract type was nuclear
sclerosis in 16 (50%) cases, posteriorsubcapsular in 12 (37.5%)
cases, cortical in 3 (9.4%) cases, andcortical + posterior
subcapsular in one (3.1%) case.
We found statistically significant differences in TRT andTRV in
the 1mm circle and TRT, TRV, ONL, OPL, INL, IPLGCL, and NFL in the
1–3mm circle compared to the
preoperative values during the follow-up visits continuing for6
months (p< 0.05). )e study results showed a remarkabledecrease
in TRT, TRV, and the thickness of most retinal layersat the first
day visit after surgery. However, an increase wasthen observed in
all parameters and reached approximately thepreoperative values at
the first week visit.)e thickest TRTandretinal layer thickness
values were observed at the first andthird month visits. A slight
decrease, not reaching the pre-operative levels, was then seen in
almost all parameters at thesixth month visit. We also noticed that
the least affected layerswere the RPE and OPL. )e results are
presented in Table 1.
)e mean effective phacoemulsification time and totalenergy were
62.46± 45.03 seconds and 6.41± 7.34, respectively.)ere was a
positive correlation between EPTand TE and GCLin the 1mm circle and
INL in the 1–3mm circle (p< 0.05 andTable 2).)ere was no
significant correlation between EPTandTE and other retinal layers,
TRT and TRV (p> 0.05).
4. Discussion
)emain triggering factor of PCME is thought to be surgicaltrauma
of intraocular tissues by inducing the release of
Table 1: )ickness of macula TRT, TRV, and retinal layers with at
the ETDRS circle of 1 and 3 millimeters.
Preoperative Postoperativeday 1Postoperative
week 1Postoperativemonth 1
Postoperativemonth 3
Postoperativemonth 6 p
TRT 1mm circle 276.63± 27.36 272.14± 26.12∗ 274.85± 26.74
279.81± 25.80 280.65± 26.82∗ 277.85± 26.22
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inflammatory mediators although other possible mechanismssuch as
photic retinopathy or vitreous traction have also beenimplicated
[5]. Inflammatory mediators (prostaglandins,cytokines, and other
vascular permeability factors) are knownto be released from the
anterior segment of the eye aftersurgery and then diffuse into the
vitreous cavity and retina,stimulating the breakdown of the
blood-retinal barrier (BRB)and subsequent leakage of fluids across
the retinal vessel walland into the perifoveal retinal tissues,
resulting in macularedema [3]. )is edema usually resolves
spontaneously andonly about 1–3% of cases persist, corresponding to
clinicalPCME with persistent symptoms [6]. Although FFA used tobe
considered the diagnostic gold standard for PCME, OCT isnow the
method of choice, being a noninvasive technique forPCME evaluation
and follow-up [3].
Optical coherence tomography is a useful device todetect
intraretinal cysts that indicate clinical PCME and candecrease
vision noninvasively after cataract surgery [3].Assessing the
retinal layers in vivo may provide more in-formation to elucidate
the pathologic processes involved insubclinical PCME. We therefore
evaluated retinal layers byOCT after uncomplicated cataract surgery
and presentedlong-term follow-up results on TRT, TRV, and retinal
layerthickness according to the ETDRS grid. We noticed that theRPE
and OPL were the least affected layers. In general, weobserved a
decrease in TRT, TRV, and most retinal layers atthe first
postoperative day visit. An increase was then seen inall thickness
parameters and reached approximately thepreoperative levels at the
first week visit.)e largest TRTandretinal layer thickness values
were observed at the first andthird month visits. At the sixth
month visit, a slight decreasewas seen in almost all parameters.
However, this decreasedid not reach preoperative thickness levels.
)ere wasa significant thickness increase in all retinal layers
exceptRPE and OPL in the 1–3mm circle.
Grewing and Becker measured the retinal thicknessbefore and 0.5
hours after cataract surgery in 10 patients andreported a decrease
that was not statistically significant [7].We noticed a decrease in
TRT, TRV, and the thickness ofmost retinal layers after the first
postoperative day. Perenteet al. [8] also reported a mild
postoperative retinal thicknessthat was not statistically
significant. According to the au-thors, the decrease observed in
the first postoperative daymay be related to the previous
light-scattering effect of thecataract that was possibly disrupting
the optical quality ofthe OCTimaging [8]. However, there is not
enough evidenceor information in the literature to fully explain
the cause.
Šiško et al. [9] reported highest retinal thickness in
theETDRS grid areas one month after uncomplicated cataractsurgery.
)ey also stated mild decreasing trend in themeasurements from the
first month to the sixth month,without reaching preoperative
levels. Most studies havereported an increase in macular thickness
after un-complicated cataract surgery [8, 10–16]. Gharbiya et al.
[10]reported a significant macular thickness increase for up tosix
postoperative months in 40 healthy patients. Falcão et al.[11] also
found increased central macular thickness post-operatively and
reported this as a nonpathological change.Cagini et al. [12] found
an asymptomatic postoperative
macular thickness increase at 12 weeks in 62 eyes witha
follow-up period of 28 weeks.)ese results are all similar toours.
Gołebiewska et al. [17] reported increased retinalthickness and
retinal volume during follow-up continuingfor 6 months after
uncomplicated cataract surgery. Weobserved increased retinal volume
after surgery, like others.
Measuring each retinal layer separately makes it easier tosee
alteration in retinal structures than the TRT. It is unclearwhich
retinal layer(s) has the most effect on increasing theretinal
thickness. We found an increase in the thickness ofNFL, GCL, IPL,
INL, and ONL and a decrease in OPL, butthese changes were only
significant in the 1–3mm circle at thepostoperative sixth month
follow-up when compared to thepreoperative measurements. RPE
thicknesses were generallystable except for the first visit, but
this first-visit change wasnot significant. We found increased GCL
thickness in the1mm circle and INL thickness in the 1–3mm circle
withmore TE and EPT. Another study reported a
statisticallysignificant relationship between increased retinal
thicknessand higher perioperative phaco power [17]. However, there
isno study comparing postoperative retinal layer thickness withTE
and EPT values.
)e INL includes the nuclei of the bipolar, horizontal,amacrine,
and Muller cells. )e deep capillary plexus is alsoin this layer.
Park et al. [18] have shown that the vascularendothelial growth
factor (VEGF) has a crucial role in thevitality of the amacrine and
bipolar cells. Sigler et al. [19]have reported cystic changes in
the INL and ONL in patientswith clinical PCME. We did not find
clinical PCME andtherefore did not observe cystic changes in any of
our pa-tients; an increased thickness of the INL may be related
tothe inflammatory effects of VEGF, which is an
inflammatorymediator [20]. INL thickness was also increased in
relationto optic neuritis, which is an inflammatory disease, in
an-other study [21]. In the neurology literature, the use of INLas
a parameter to monitor the efficacy of anti-inflammatorytreatments
in multiple sclerosis has been proposed [22]. )esuperficial
capillary plexus is located in the NFL, and itshyperpermability may
have been responsible for the sig-nificantly increased thickness of
the NFL and GCL in ourstudy.
Nepafenac (Alcon Research Ltd., Fort Worth, TX, USA),a topical
ocular nonsteroidal anti-inflammatory drug(NSAID) used to treat the
pain and inflammation associatedwith cataract surgery, is available
as an ophthalmic sus-pension in concentrations of 0.1% and 0.3%
[23]. Unlikeother NSAIDs, nepafenac is a prodrug that is deaminated
toits active metabolite (amfenac) in the ocular tissues. It isa
potent inhibitor of the cyclooxygenase (COX) isoformsCOX-1 and
COX-2 and is distributed rapidly in both theanterior and posterior
segments of the eye. It is well knownthat the retinal thickness
increase is significantly lower inpatients administered an NSAID
after cataract surgery [23, 24].It may therefore be better to avoid
NSAID use when evaluatingretinal layer thickness after cataract
surgery.
Our study has a few limitations. First, the sample sizecould be
larger. Second, the retinal thickness values con-tinued to show a
slight decrease at the sixth month visit, andthe follow-up should
therefore be longer than 6 months.
4 Journal of Ophthalmology
-
In conclusion, we presented the six-month follow-upresults of
TRT, TRV, and retinal layer thickness after un-complicated cataract
surgery in this study.)e thickest valueswere observed at the first
and third month visits. A slightdecrease without reaching
preoperative levels was found in allthickness parameters at the
sixth month visit. )e post-operative thickness increase was more
prominent in the1–3mm circle than in the 1mm circle. On the other
hand,OPL was the only retinal layer with decreased thickness
aftersurgery. )ese findings may be useful for understanding
thepathophysiological pathways of PCME. )e results suggestthat
long-term follow-up of more than 6 months is neededto see whether
total retinal and segmental changes return topreoperative
levels.
Data Availability
)e data used to support the findings of this study areavailable
from the corresponding author upon request.
Ethical Approval
All procedures performed in studies involving human
par-ticipants were in accordance with the ethical standards of
theinstitutional and/or national research committee and with
the1964 Declaration of Helsinki and its later amendments
orcomparable ethical standards.)is study was approved by theethics
committee of Ankara Numune Training and ResearchHospital on
14.12.2016 and number 1113/2016.
Consent
Informed consent was obtained from all individual partic-ipants
included in the study.
Disclosure
)e authors declare that the manuscript has not beenpublished
previously nor under consideration for publica-tion elsewhere, in
whole or in part.
Conflicts of Interest
)e authors declare that they have no conflicts of interest.
References
[1] L. Kessel, B. Tendal, K. J. Jørgensen et al.,
“Post-cataractprevention of inflammation and macular edema by
steroidand nonsteroidal anti-inflammatory eye drops: a
systematicreview,” Ophthalmology, vol. 121, no. 10, pp. 1915–1924,
2014.
[2] Y. Yonekawa and I. K. Kim, “Pseudophakic cystoid
macularedema,” Current Opinion in Ophthalmology, vol. 23, no. 1,pp.
26–32, 2012.
[3] C. Lobo, “Pseudophakic cystoid macular edema,”
Oph-thalmologica, vol. 227, no. 2, pp. 61–67, 2012.
[4] I. Ctori and B. Huntjens, “Repeatability of foveal
measure-ments using spectralis optical coherence tomography
seg-mentation software,” PLoS One, vol. 10, no. 6, Article
IDe0129005, 2015.
[5] T. Yilmaz, M. Cordero-Coma, andM. J. Gallagher,
“Ketorolactherapy for the prevention of acute pseudophakic
cystoidmacular edema: a systematic review,” Eye, vol. 26, no. 2,pp.
252–258, 2012.
[6] L. D. Salomon, “Efficacy of topical flurbiprofen and
in-domethacin in preventing pseudophakic cystoid macularedema.
Flurbiprofen—CME study group I,” Journal of Cat-aract and
Refractive Surgery, vol. 21, pp. 73–81, 1995.
[7] R. Grewing and H. Becker, “Retinal thickness
immediatelyafter cataract surgery measured by optical coherence
to-mography,” Ophthalmic Surgery and lasers, vol. 31, pp. 215–217,
2000.
[8] I. Perente, C. A. Utine, C. Ozturker et al., “Evaluation
ofmacular changes after uncomplicated phacoemulsificationsurgery by
optical coherence tomography,” Current Eye Re-search, vol. 32, no.
3, pp. 241–247, 2007.
[9] K. Šiško, N. K. Knez, and D. Pahor, “Influence of
cataractsurgery on macular thickness: a 6-month follow-up,”
Wienerklinische Wochenschrift, vol. 127, no. 5, pp. S169–S174,
2015.
[10] M. Gharbiya, F. Cruciani, G. Cuozzo, F. Parisi, P. Russo,
andS. Abdolrahimzadeh, “Macular thickness changes evaluatedwith
spectral domain optical coherence tomography afteruncomplicated
phacoemulsification,” Eye, vol. 27, no. 5,pp. 605–611, 2013.
[11] M. S. Falcão, N. M. Gonçalves, P. Freitas-Costa et
al.,“Choroidal and macular thickness changes induced by cat-aract
surgery,” Clinical Ophthalmology, vol. 8, pp. 55–60,2014.
[12] C. Cagini, T. Fiore, B. Iaccheri, F. Piccinelli, M. A.
Ricci, andD. Fruttini, “Macular thickness measured by optical
co-herence tomography in a healthy population before and
afteruncomplicated cataract phacoemulsification surgery,” Cur-rent
Eye Research, vol. 34, no. 12, pp. 1036–1041, 2009.
[13] S. Nicholas, A. Riley, H. Patel, B. Neveldson, G. Purdie,
andA. P. Wells, “Correlations between optical coherence to-mography
measurement of macular thickness and visualacuity after cataract
extraction,” Clinical and ExperimentalOphthalmology, vol. 34, no.
2, pp. 124–129, 2006.
[14] B. Von Jagow, C. Ohrloff, and T. Kohnen, “Macular
thicknessafter uneventful cataract surgery determined by optical
co-herence tomography,” Graefe’s Archive for Clinical and
Ex-perimental Ophthalmology, vol. 245, no. 12, pp.
1765–1771,2007.
[15] Z. Biro, Z. Balla, and B. Kovacs, “Change of foveal
andperifoveal thickness measured by OCT after phacoemulsifi-cation
and IOL implantation,” Eye, vol. 22, no. 1, pp. 8–12,2008.
[16] T. Kusbeci, L. Eryigit, G. Yavas, and U. U. Inan,
“Evaluation ofcystoid macular edema using optical coherence
tomographyand fundus fluorescein angiography after
uncomplicatedphacoemulsification surgery,” Current Eye Research,
vol. 37,no. 4, pp. 327–333, 2012.
[17] J. Gołebiewska, D. Kęcik, M. Turczyńska, J.
Moneta-Wielgoś,D. Kopacz, and K. Pihowicz-Bakoń, “Evaluation of
macularthickness after uneventful phacoemulsification in
selectedpatient populations using optical coherence
tomography,”Klinika Oczna, vol. 116, pp. 242–247, 2014.
[18] H. Y. Park, J. H. Kim, and C. K. Park, “Neuronal cell death
inthe inner retina and the influence of vascular endothelialgrowth
factor inhibition in a diabetic rat model,” AmericanJournal of
Pathology, vol. 184, no. 6, pp. 1752–1762, 2014.
[19] E. J. Sigler, J. C. Randolph, and D. F. Kiernan,
“Longitudinalanalysis of the structural pattern of pseudophakic
cystoidmacular edema using multimodal imaging,” Graefe’s
Archive
Journal of Ophthalmology 5
-
for Clinical and Experimental Ophthalmology, vol. 254, no. 1,pp.
43–51, 2016.
[20] Y. B. Shaik-Dasthagirisaheb, G. Varvara, G. Murmura et
al.,“Vascular endothelial growth factor (VEGF), mast cells
andinflammation,” International Journal of Immunopathologyand
Pharmacology, vol. 26, no. 2, pp. 327–335, 2013.
[21] M. Kaushik, C. Y. Wang, M. H. Barnett et al., “Inner
nuclearlayer thickening is inversely proportional to retinal
ganglioncell loss in optic neuritis,” PLoS One, vol. 8, no. 10,
Article IDe78341, 2013.
[22] B. Knier, P. Schmidt, L. Aly et al., “Retinal inner nuclear
layervolume reflects response to immunotherapy in
multiplesclerosis,” Brain, vol. 139, no. 11, pp. 2855–2863,
2016.
[23] R. P. Singh, G. Staurenghi, A. Pollack et al., “Efficacy
ofnepafenac ophthalmic suspension 0.1% in improving
clinicaloutcomes following cataract surgery in patients with
diabetes:an analysis of two randomized studies,” Clinical
Ophthal-mology, vol. 11, pp. 1021–1029, 2017.
[24] J. E. Chastain, M. E. Sanders, M. A. Curtis et al.,
“Distributionof topical ocular nepafenac and its active metabolite
amfenacto the posterior segment of the eye,” Experimental Eye
Re-search, vol. 145, pp. 58–67, 2016.
6 Journal of Ophthalmology
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