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Treatment Strategies for Neuroretinitis: Current Options and Emerging Therapies

  • Aaron M. Fairbanks
  • Matthew R. Starr
  • John J. Chen
  • M. Tariq BhattiEmail author
Neurologic Ophthalmology and Otology (R Shin and D Gold, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Neurologic Ophthalmology and Otology

Abstract

Purpose of review

To explore and critically appraise the published data on the current and emerging treatment modalities for neuroretinitis.

Recent findings

The optimum treatment strategy for neuroretinitis due to Bartonella henselae in immunocompetent individuals is not clear and a matter of debate. The role of systemic corticosteroids in infectious neuroretinitis and the optimum immunosuppressive regimen for use in recurrent idiopathic neuroretinitis also remains ill defined.

Summary

There is no class 1 evidence to support a specific treatment strategy for neuroretinitis. For uncomplicated B. henselae–associated neuroretinitis in immunocompetent patients, initiation of antibiotic and corticosteroid therapy remains controversial. In patients with severe vision loss and/or moderate to severe systemic symptoms, a 4- to 6-week regimen of doxycycline or azithromycin with rifampin may provide some benefit. The routine use of systemic corticosteroids in infectious neuroretinitis is not recommended. Targeted antimicrobial agents should be instituted in cases of neuroretinitis due to specific infectious etiologies (e.g., syphilis, Lyme disease, tuberculosis). Azathioprine may be beneficial in cases of recurrent idiopathic neuroretinitis. There is a need for collaborative, multicenter prospective studies to provide definitive guidelines regarding the use of antibiotics and corticosteroids and to evaluate future therapies in infectious and recurrent idiopathic neuroretinitis.

Keywords

Neuroretinitis Bartonella Disc edema Macular star Cat scratch optic neuropathy 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

Dr. Bhatti participated in the following two studies that involved human subjects: Schmalfuss IM, Dean CW, Sistrom C, Bhatti MT. Optic neuropathy secondary to cat scratch disease: distinguishing MR imaging features from other types of optic neuropathies. AJNR Am J Neuroradiol. 2005;26 (6):1310–6; Chi SL, Stinnett S, Eggenberger E, Foroozan R, Golnik K, Lee MS, et al. Clinical characteristics in 53 patients with cat scratch optic neuropathy. Ophthalmology. 2012;119 (1):183–7.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    •• Abdelhakim A, Rasool N. Neuroretinitis: a review. Curr Opin Ophthalmol. 2018;29(6):514–9. The most up-to-date review on all aspects of neuroretinitis including the different etiologies as well as treatment options. The authors discuss the pros and cons of antibiotics vs no antibiotics for the management of cat scratch neuroretinitis.PubMedGoogle Scholar
  2. 2.
    Pahor D. Leber’s idiopathic stellate neuroretinitis. Can J Ophthalmol. 2001;36(6):347–9.PubMedGoogle Scholar
  3. 3.
    Gass JD. Diseases of the optic nerve that may simulate macular disease. Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol. 1977;83(5):763–70.PubMedGoogle Scholar
  4. 4.
    Kitamei H, Suzuki Y, Takahashi M, Katsuta S, Kato H, Yokoi M, et al. Retinal angiography and optical coherence tomography disclose focal optic disc vascular leakage and lipid-rich fluid accumulation within the retina in a patient with leber idiopathic stellate neuroretinitis. J Neuroophthalmol. 2009;29(3):203–7.PubMedGoogle Scholar
  5. 5.
    Maitland CG, Miller NR. Neuroretinitis. Arch Ophthalmol. 1984;102(8):1146–50.PubMedGoogle Scholar
  6. 6.
    Celiker H, Kazokoglu H, Eraslan M, Cerman E, Karabas L. Bartonella henselae neuroretinitis in patients without cat scratch. Jpn J Infect Dis. 2018;71(6):397–401.PubMedGoogle Scholar
  7. 7.
    Narayan SK, Kaliaperumal S, Srinivasan R. Neuroretinitis, a great mimicker. Ann Indian Acad Neurol. 2008;11(2):109–13.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Vaphiades MS. Rocky Mountain Spotted Fever as a cause of macular star figure. J Neuroophthalmol. 2003;23(4):276–8.PubMedGoogle Scholar
  9. 9.
    Reche-Sainz JA, Gracia Garcia-Miguel MT, Perez-Jacoiste MA. Papillitis and neuroretinitis of tuberculous etiology. Arch Soc Esp Oftalmol. 2019.Google Scholar
  10. 10.
    Fusco R, Magli A, Guacci P. Stellate maculopathy due to Salmonella typhi. A case report. Ophthalmologica. 1986;192(3):154–8.PubMedGoogle Scholar
  11. 11.
    Guliani BP, Kumar S, Chawla N, Mehta A. Neuroretinitis as presenting and the only presentation of Lyme disease: diagnosis and management. Indian J Ophthalmol. 2017;65(3):250–2.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Shoeibi N, Hosseini SM, Bayani R. Toxoplasmosis neuroretinitis: a case report. Iran Red Crescent Med J. 2016;18(4):e33115.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Basumatary LJ, Das S, Das M, Goswami M, Kayal AK. Leptospirosis presenting as neuroretinitis. J Neurosci Rural Pract. 2012;3(2):224–6.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Besirli CG, Elner SG. Retinal vasculitis in Toxocara canis neuroretinitis. J Ophthalmic Inflamm Infect. 2013;3(1):5.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Choi RY, Lauer A, Rosenbaum JT. Molecular diagnosis and ocular imaging of varicella zoster virus associated neuroretinitis. Am J Ophthalmol Case Rep. 2018;11:146–8.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Hsia YC, Chin-Hong PV, Levin MH. Epstein-Barr virus neuroretinitis in a lung transplant patient. J Neuroophthalmol. 2017;37(1):43–7.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Johnson BL, Wisotzkey HM. Neuroretinitis associated with herpes simplex encephalitis in an adult. Am J Ophthalmol. 1977;83(4):481–9.PubMedGoogle Scholar
  18. 18.
    Sivakumar RR, Prajna L, Arya LK, Muraly P, Shukla J, Saxena D, et al. Molecular diagnosis and ocular imaging of West Nile virus retinitis and neuroretinitis. Ophthalmology. 2013;120(9):1820–6.PubMedGoogle Scholar
  19. 19.
    Panday A, Sandy S, King D, Ramdeen S. A case of suspected symptomatic Zika Neuroretinitis. IDCases. 2017;9:104–5.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Davila PJ, Toledo A, Ulloa-Padilla JP, Izquierdo NJ, Emanuelli A. Unilateral neuroretinitis as a late-onset manifestation of the chikungunya fever: a case series. Retin Cases Brief Rep. 2017:1.Google Scholar
  21. 21.
    Ray S, Gragoudas E. Neuroretinitis. Int Ophthalmol Clin. 2001;41(1):83–102.PubMedGoogle Scholar
  22. 22.
    Fine M, Flocks M. Bilateral acute neuroretinitis with sarcoidosis treated with corticotropin and cortisone. AMA Arch Ophthalmol. 1953;50(3):358–62.PubMedGoogle Scholar
  23. 23.
    Matsuda A, Chin S, Ohashi T. A case of neuroretinitis associated with long-standing polyarteritis nodosa. Ophthalmologica. 1994;208(3):168–71.PubMedGoogle Scholar
  24. 24.
    Aigbe N, Bennouk Y, Madzou M, El Asri F, Chergui K, Brahime F, et al. Bilateral neuroretinitis secondary to Takayasu’s arteritis in a young girl. J Fr Ophtalmol. 2015;38(5):e89.PubMedGoogle Scholar
  25. 25.
    Santra G, Das I. Systemic lupus erythematosus presenting as neuroretinitis. J Assoc Physicians India. 2015;63(10):77–8.PubMedGoogle Scholar
  26. 26.
    Pellegrini F, Interlandi E, Prosdocimo G. Vogt-Koyanagi-Harada disease presenting as unilateral neuroretinits. Neuroophthalmology. 2018;42(1):11–6.PubMedGoogle Scholar
  27. 27.
    Purvin V, Sundaram S, Kawasaki A. Neuroretinitis: review of the literature and new observations. J Neuroophthalmol. 2011;31(1):58–68.PubMedGoogle Scholar
  28. 28.
    Saito M, Saito W, Kanda A, Ohguro H, Ishida S. A case of paraneoplastic optic neuropathy and outer retinitis positive for autoantibodies against collapsin response mediator protein-5, recoverin, and alpha-enolase. BMC Ophthalmol. 2014;14:5.PubMedPubMedCentralGoogle Scholar
  29. 29.
    • Lee AR, El-Dairi MA. Anti-myelin oligodendrocyte glycoprotein optic neuritis or neuroretinitis? JAMA Ophthalmol. 2018;136(10):e182928. This case report highlights a patient with neuroretinitis who was discovered to have anti-MOG antibodies, indicating that anti-MOG ought to be excluded before labeling patients with idiopathic disease.PubMedGoogle Scholar
  30. 30.
    • Dalvin LA, Shields CL, Orloff M, Sato T, Shields JA. CHECKPOINT INHIBITOR IMMUNE THERAPY: systemic indications and ophthalmic side effects. Retina. 2018;38(6):1063–78 In this review, the authors highlight the ophthalmic complications of the newer chemotherapy agents, checkpoint inhibitors, including neuroretinitis.PubMedGoogle Scholar
  31. 31.
    Hahn L, Pepple KL. Bilateral neuroretinitis and anterior uveitis following ipilimumab treatment for metastatic melanoma. J Ophthalmic Inflamm Infect. 2016;6(1):14.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Bajgai P, Katoch D, Dogra MR, Singh R. Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome: clinical perspectives. Clin Ophthalmol. 2017;11:1805–17.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Purvin V, Ranson N, Kawasaki A. Idiopathic recurrent neuroretinitis: effects of long-term immunosuppression. Arch Ophthalmol. 2003;121(1):65–7.PubMedGoogle Scholar
  34. 34.
    Purvin VA, Chioran G. Recurrent neuroretinitis. Arch Ophthalmol. 1994;112(3):365–71.PubMedGoogle Scholar
  35. 35.
    Sundaram SV, Purvin VA, Kawasaki A. Recurrent idiopathic neuroretinitis: natural history and effect of treatment. Clin Exp Ophthalmol. 2010;38(6):591–6.PubMedGoogle Scholar
  36. 36.
    Habot-Wilner Z, Zur D, Goldstein M, Goldenberg D, Shulman S, Kesler A, et al. Macular findings on optical coherence tomography in cat-scratch disease neuroretinitis. Eye (Lond). 2011;25(8):1064–8.Google Scholar
  37. 37.
    Stewart MW, Brazis PW, Barrett KM, Eidelman BH, Mendez JC. Optical coherence tomography in a case of bilateral neuroretinitis. J Neuroophthalmol. 2005;25(2):131–3.PubMedGoogle Scholar
  38. 38.
    Zatreanu L, Sibony PA, Kupersmith MJ. Optical coherence tomography in neuroretinitis: epipapillary infiltrates and retinal folds. J Neuroophthalmol. 2017;37(2):176–8.PubMedGoogle Scholar
  39. 39.
    Yamanuha JJYMM. Bartonella neuroretinitis: a case report with new insights from fundus autofluorescence. J Clin Exp Ophthalmol. 2014:445.Google Scholar
  40. 40.
    Williams KE, Johnson LN. Neuroretinitis in patients with multiple sclerosis. Ophthalmology. 2004;111(2):335–40. discussion 40-1.PubMedGoogle Scholar
  41. 41.
    Parmley VC, Schiffman JS, Maitland CG, Miller NR, Dreyer RF, Hoyt WF. Does neuroretinitis rule out multiple sclerosis? Arch Neurol. 1987;44(10):1045–8.PubMedGoogle Scholar
  42. 42.
    Reddy AK, Morriss MC, Ostrow GI, Stass-Isern M, Olitsky SE, Lowe LH. Utility of MR imaging in cat-scratch neuroretinitis. Pediatr Radiol. 2007;37(8):840–3.PubMedGoogle Scholar
  43. 43.
    Schmalfuss IM, Dean CW, Sistrom C, Bhatti MT. Optic neuropathy secondary to cat scratch disease: distinguishing MR imaging features from other types of optic neuropathies. AJNR Am J Neuroradiol. 2005;26(6):1310–6.PubMedGoogle Scholar
  44. 44.
    Breitschwerdt EB. Bartonellosis: one health perspectives for an emerging infectious disease. ILAR J. 2014;55(1):46–58.PubMedGoogle Scholar
  45. 45.
    • Habot-Wilner Z, Trivizki O, Goldstein M, Kesler A, Shulman S, Horowitz J, et al. Cat-scratch disease: ocular manifestations and treatment outcome. Acta Ophthalmol. 2018;96(4):e524–e32 Multicenter review of over 100 eyes that highlights the common ophthalmic manifestations of CSD. Additionally, the authors suggest antibiotics plus steriods improved acuity better than antibiotics alone.PubMedGoogle Scholar
  46. 46.
    Suhler EB, Lauer AK, Rosenbaum JT. Prevalence of serologic evidence of cat scratch disease in patients with neuroretinitis. Ophthalmology. 2000;107(5):871–6.PubMedGoogle Scholar
  47. 47.
    Reed JB, Scales DK, Wong MT, Lattuada CP Jr, Dolan MJ, Schwab IR. Bartonella henselae neuroretinitis in cat scratch disease. Diagnosis, management, and sequelae. Ophthalmology. 1998;105(3):459–66.PubMedGoogle Scholar
  48. 48.
    Gulati A, Yalamanchili S, Golnik KC, Lee AG. Cat scratch neuroretinitis: the role of acute and convalescent titers for diagnosis. J Neuroophthalmol. 2012;32(3):243–5.PubMedGoogle Scholar
  49. 49.
    Hage CA, Azar MM, Bahr N, Loyd J, Wheat LJ. Histoplasmosis: up-to-date evidence-based approach to diagnosis and management. Semin Respir Crit Care Med. 2015;36(5):729–45.PubMedGoogle Scholar
  50. 50.
    Bass JW, Freitas BC, Freitas AD, Sisler CL, Chan DS, Vincent JM, et al. Prospective randomized double blind placebo-controlled evaluation of azithromycin for treatment of cat-scratch disease. Pediatr Infect Dis J. 1998;17(6):447–52.PubMedGoogle Scholar
  51. 51.
    Margileth AM. Antibiotic therapy for cat-scratch disease: clinical study of therapeutic outcome in 268 patients and a review of the literature. Pediatr Infect Dis J. 1992;11(6):474–8.PubMedGoogle Scholar
  52. 52.
    Pitassi LH, Magalhaes RF, Barjas-Castro ML, de Paula EV, Ferreira MR, Velho PE. Bartonella henselae infects human erythrocytes. Ultrastruct Pathol. 2007;31(6):369–72.PubMedGoogle Scholar
  53. 53.
    Golnik KC, Marotto ME, Fanous MM, Heitter D, King LP, Halpern JI, et al. Ophthalmic manifestations of Rochalimaea species. Am J Ophthalmol. 1994;118(2):145–51.PubMedGoogle Scholar
  54. 54.
    Curi AL, Machado D, Heringer G, Campos WR, Lamas C, Rozental T, et al. Cat-scratch disease: ocular manifestations and visual outcome. Int Ophthalmol. 2010;30(5):553–8.PubMedGoogle Scholar
  55. 55.
    Bhatti MT, Lee MS. Should patients with bartonella neuroretinitis receive treatment? J Neuroophthalmol. 2014;34(4):412–6.PubMedGoogle Scholar
  56. 56.
    Conrad DA. Treatment of cat-scratch disease. Curr Opin Pediatr. 2001;13(1):56–9.PubMedGoogle Scholar
  57. 57.
    Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of Bartonellosis. Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. 2017 [updated 05/07/2017. 1-5]. Available from: https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/329/bartonellosis. Accessed 1 May 2019.
  58. 58.
    Rosen BS, Barry CJ, Nicoll AM, Constable IJ. Conservative management of documented neuroretinitis in cat scratch disease associated with Bartonella henselae infection. Aust N Z J Ophthalmol. 1999;27(2):153–6.PubMedGoogle Scholar
  59. 59.
    Solley WA, Martin DF, Newman NJ, King R, Callanan DG, Zacchei T, et al. Cat scratch disease: posterior segment manifestations. Ophthalmology. 1999;106(8):1546–53.PubMedGoogle Scholar
  60. 60.
    Chi SL, Stinnett S, Eggenberger E, Foroozan R, Golnik K, Lee MS, et al. Clinical characteristics in 53 patients with cat scratch optic neuropathy. Ophthalmology. 2012;119(1):183–7.PubMedGoogle Scholar
  61. 61.
    Centers for Disease Control and Prevention - Bartonella infection (cat scratch disease, trench fever, and Carrión’s disease) 2014 [updated 12/14/2015]. Available from: https://www.cdc.gov/bartonella/clinicians/index.html. Accessed 1 May 2019.
  62. 62.
    Attawan A, Pepper IM, Hickman SJ. The natural history of idiopathic neuroretinitis. Pract Neurol. 2015;15(5):387–8.PubMedGoogle Scholar
  63. 63.
    Sanchez E, Vannier E, Wormser GP, Hu LT. Diagnosis, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: a review. JAMA. 2016;315(16):1767–77.PubMedGoogle Scholar
  64. 64.
    Centers for Disease Control and Prevention - Lyme disease 2018 [updated 12/21/2018. Available from: https://www.cdc.gov/lyme/treatment/index.html. Accessed 1 May 2019.
  65. 65.
    Hu LT. Lyme disease. Ann Intern Med. 2016;164(9):ITC65–80.PubMedGoogle Scholar
  66. 66.
    Ljostad U, Skogvoll E, Eikeland R, Midgard R, Skarpaas T, Berg A, et al. Oral doxycycline versus intravenous ceftriaxone for European Lyme neuroborreliosis: a multicentre, non-inferiority, double-blind, randomised trial. Lancet Neurol. 2008;7(8):690–5.PubMedGoogle Scholar
  67. 67.
    The diagnosis, management and prevention of syphilis: an update and review – a clinical guidance document for use in the diagnosis and management of syphilis. Based on content from the 2015 CDC STD treatment guidelines, and developed by the NYC Department of Health and Mental Hygiene Bureau of Sexually Transmitted Infections and the NYC STD Prevention Training Center. March 2019.Google Scholar
  68. 68.
    Centers for Disease Control and Prevention - 2015 Sexually transmitted diseases treatment guidelines: Syphilis.2015.Google Scholar
  69. 69.
    Arruga J, Valentines J, Mauri F, Roca G, Salom R, Rufi G. Neuroretinitis in acquired syphilis. Ophthalmology. 1985;92(2):262–70.PubMedGoogle Scholar
  70. 70.
    Clement ME, Okeke NL, Hicks CB. Treatment of syphilis: a systematic review. JAMA. 2014;312(18):1905–17.PubMedGoogle Scholar
  71. 71.
    Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis. 2016;63(7):e147–e95.PubMedPubMedCentralGoogle Scholar
  72. 72.
    American Thoracic S, Cdc, Infectious Diseases Society of America. Treatment of tuberculosis. MMWR Recomm Rep. 2003;52(RR-11):1–77.Google Scholar
  73. 73.
    Cutrufello NJ, Karakousis PC, Fishler J, Albini TA. Intraocular tuberculosis. Ocul Immunol Inflamm. 2010;18(4):281–91.PubMedGoogle Scholar
  74. 74.
    Biggs HM, Behravesh CB, Bradley KK, Dahlgren FS, Drexler NA, Dumler JS, et al. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain Spotted Fever and other spotted fever group rickettsioses, ehrlichioses, and anaplasmosis - United States. MMWR Recomm Rep. 2016;65(2):1–44.PubMedGoogle Scholar
  75. 75.
    Brett-Major DM, Coldren R. Antibiotics for leptospirosis. Cochrane Database Syst Rev. 2012;(2):CD008264.Google Scholar
  76. 76.
    Todd SR, Dahlgren FS, Traeger MS, Beltran-Aguilar ED, Marianos DW, Hamilton C, et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever. J Pediatr. 2015;166(5):1246–51.PubMedGoogle Scholar
  77. 77.
    Gupta V, Gupta A, Rao NA. Intraocular tuberculosis--an update. Surv Ophthalmol. 2007;52(6):561–87.PubMedGoogle Scholar
  78. 78.
    Dreyer RF, Hopen G, Gass JD, Smith JL. Leber’s idiopathic stellate neuroretinitis. Arch Ophthalmol. 1984;102(8):1140–5.PubMedGoogle Scholar
  79. 79.
    Kirby JE. In vitro model of Bartonella henselae-induced angiogenesis. Infect Immun. 2004;72(12):7315–7.PubMedPubMedCentralGoogle Scholar
  80. 80.
    Cakir M, Cekic O, Bozkurt E, Pekel G, Yazici AT, Yilmaz OF. Combined intravitreal bevacizumab and triamcinolone acetonide injection for idiopathic neuroretinitis. Ocul Immunol Inflamm. 2009;17(3):221–3.PubMedGoogle Scholar
  81. 81.
    Empeslidis T, Banerjee S, Vardarinos A, Konstas AG. Dexamethasone intravitreal implant for idiopathic retinal vasculitis, aneurysms, and neuroretinitis. Eur J Ophthalmol. 2013;23(5):757–60.PubMedGoogle Scholar
  82. 82.
    Saatci AO, Ayhan Z, Takes O, Yaman A, Bajin FM. Single bilateral dexamethasone implant in addition to panretinal photocoagulation and oral azathioprine treatment in IRVAN syndrome. Case Rep Ophthalmol. 2015;6(1):56–62.PubMedPubMedCentralGoogle Scholar
  83. 83.
    Chong YJ, Logeswaran A, Sarmad A, Damato EM. Idiopathic retinal vasculitis, aneurysms and neuroretinitis (IRVAN): case series of three patients with multimodal imaging. Graefes Arch Clin Exp Ophthalmol. 2019;257(5):1013–8.PubMedGoogle Scholar
  84. 84.
    Cheema RA, Al-Askar E, Cheema HR. Infliximab therapy for idiopathic retinal vasculitis, aneurysm, and neuroretinitis syndrome. J Ocul Pharmacol Ther. 2011;27(4):407–10.PubMedGoogle Scholar
  85. 85.
    Fellner C. Ipilimumab (yervoy) prolongs survival in advanced melanoma: serious side effects and a hefty price tag may limit its use. P T. 2012;37(9):503–30.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Aaron M. Fairbanks
    • 1
  • Matthew R. Starr
    • 1
  • John J. Chen
    • 1
    • 2
  • M. Tariq Bhatti
    • 1
    • 2
    Email author
  1. 1.Department of OphthalmologyMayo ClinicRochesterUSA
  2. 2.Department of NeurologyMayo ClinicRochesterUSA

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