Computer-aided identification of novel ophthalmic artery waveform parameters in healthy subjects and glaucoma patients

Purpose: Arterial waveform parameters (WPs) are commonly used to monitor and diagnose systemic diseases. Color Doppler Imaging (CDI) is a consolidated technique to measure blood velocity profile in some of the major ocular vessels. This study proposes a computer-aided manipulation process of ophthalmic artery (OA) CDI images to classify and quantify WPs that might be significant in the assessment of glaucoma.Methods: Fifty CDI images acquired by four different operators on nine healthy individuals and 38 CDI images of 38 open-angle glaucoma (OAG) patients were considered. An ad-hoc semi-automated image processing code was implemented to detect the digitalized OA velocity waveform and to extract the WPs. Concordance correlation coefficient (CCC), two-sample t-test and Pearson’s correlation coefficient were used to test for similarities, differences and associations among variables.Results: The OA-CDI images manipulation proposed showed a higher concordance between measured peak systolic velocity (PSV) data and extracted PSV data (0.80≤CCC≤0.98) than on end diastolic velocity (EDV) (0.45≤CCC≤0.63) and resistive index (RI) (0.30≤CCC≤0.58) data. In OAG patients, EDV, RI, subendocardial viability ratio (SEVR), period (T), area ratio (f) and normalized distance between ascending and descending limb (DAD/T) were found statistically correlated to at least one of the following factors: gender, age, ocular medications and year of diagnosis. When compared to healthy individuals, OAG patients OA-CDI profiles showed statistically higher values of f (p < 0.001) and DAD/T (p = 0.002) (p-values corrected by age and gender).Conclusion: The proposed computer-aided manipulation of OA-CDI images allowed to identify DAD/T as a novel WP that vary significantly among healthy individuals and OAG patients, and among female and male OAG patients. Future studies on longitudinal OAG data are suggested to investigate the potential of DAD/T to predict severity and progression of the disease.

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Correlation of progression of diabetic retinopathy with the alterations in retrobulbar circulation

Nepalese Journal of Ophthalmology ◽

10.3126/nepjoph.v5i2.8705 ◽

2013 ◽

Vol 5 (2) ◽

pp. 147-153 ◽

Cited By ~ 2

Author(s):

S Sood ◽

Subina Narang ◽

S Kocchhar ◽

S Sarda ◽

S Aggarwal ◽

...

Keyword(s):

Diabetic Retinopathy ◽

Normal Population ◽

Color Doppler ◽

Case Series ◽

Peak Systolic Velocity ◽

Resistive Index ◽

Doppler Imaging ◽

Arterial Circulation ◽

Diastolic Velocity ◽

Group I

Introduction: Color Doppler Imaging (CDI) is used widely to study retrobulbar circulation. Objectives: To determine the association between progression of diabetic retinopathy (DR) and alterations in retrobulbar arterial circulation using CDI studies. Materials and methods: Prospective observational case series. It is single institutional study of 50eyes of nonproliferative diabetic retinopathy in 50 patients with type II diabetes mellitus. DR was graded according to ETDRS system. Retrobulbar circulation was studied in patients for Peak systolic velocity (PSV), End diastolic velocity (EDV) and Resistive index (RI) in Central retinal artery (CRA), Ophthalmic artery (OA) and Posterior ciliary artery (PCA) using CDI initially and reevaluated after 6 months or later for any change in retinopathy grade and arterial circulation parameters. The patients were grouped as Group I not showing progression of DR and Group II showing progression. The two groups were compared for any significant change in CDI parameters. Results: The baseline resistive indices were higher than normal population. There was significant increase in RI in PCA and CRA in all patients after 6 months. 14 patients (28%) showed progression of DR and 36 (72%) did not show progression of DR. There was no significant association with progression of retinopathy and CDI findings. (p=>0.05). Conclusion: The retrobulbar arterial circulation seems to be affected in all diabetics with DR. The changes appear to be progressive. The CDI findings in arterial circulation however lack predictive power for progression of diabetic retinopathy in non proliferative DR. Nepal J Ophthalmol 2013; 5(10): 147-153 DOI: http://dx.doi.org/10.3126/nepjoph.v5i2.8705

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The Impact of Intraocular Pressure Reduction on Retrobulbar Hemodynamic Parameters in Patients with Open-Angle Glaucoma

European Journal of Ophthalmology ◽

10.5301/ejo.2011.8311 ◽

2011 ◽

Vol 22 (1) ◽

pp. 77-82 ◽

Cited By ~ 3

Author(s):

Ivan Marjanovic ◽

Natasa Milic ◽

Antonio Martinez

Keyword(s):

Intraocular Pressure ◽

Open Angle Glaucoma ◽

Color Doppler ◽

Statistical Significance ◽

Peak Systolic Velocity ◽

Doppler Imaging ◽

Hemodynamic Parameters ◽

Open Angle ◽

Diastolic Velocity ◽

The Impact

Purpose To assess the retrobulbar hemodynamic parameters in the ophthalmic artery (OA), central retinal artery (CRA), and short posterior ciliary arteries (PCA) after decreasing elevated intraocular pressure (IOP) in patients with open-angle glaucoma (OAG) by using color Doppler imaging. Methods A total of 46 eyes from 46 patients with OAG, with elevated IOP, were consecutively included in this prospective study. Peak-systolic velocity, end-diastolic velocity, and Pourcelot resistivity index were assessed in the OA, CRA, and PCA. The IOP was measured with Goldmann applanation tonometer (GAT) and the dynamic contour tonometer (DCT), 3 times respectively. Ocular pulse amplitude (OPA) appeared during the DCT measurement. Results After decreasing the elevated IOP, measured with both GAT and DCT, the retrobulbar parameters showed no differences as compared with baseline measurements. After Bonferroni correction (p≤0.0042, alpha/12), statistical significance appeared in retrobulbar hemodynamics only in DCT (29.3±6.4 vs 15.5±4.2 mmHg), GAT (33.0±8.3 vs 15.8±7.0 mmHg), and OPA measurements (4.1±1.3 vs 2.7±1.4 mmHg), in comparison to baseline. There was no correlation between the changes in IOP measured with either DCT or GAT and the changes in the retrobulbar hemodynamic parameters (p>0.05 for all). Conclusions The results of our study suggested a lack of correlation between the changes in IOP, measured with either DCT or GAT, and the changes in the retrobulbar hemodynamic parameters. The results of our study might suggest that the blood flow disturbances found in glaucoma patients are independent of the IOP.

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Waveform parameters of retrobulbar vessels in glaucoma patients with different demographics and disease severity

European Journal of Ophthalmology ◽

10.1177/1120672119848259 ◽

2019 ◽

Vol 30 (5) ◽

pp. 1019-1027

Author(s):

Lucia Carichino ◽

Alon Harris ◽

Sergey Lapin ◽

Giovanna Guidoboni ◽

Simone Cassani ◽

...

Keyword(s):

Image Processing ◽

Correlation Coefficient ◽

Disease Severity ◽

Ophthalmic Artery ◽

Open Angle Glaucoma ◽

Peak Systolic Velocity ◽

Central Retinal Artery ◽

Open Angle ◽

Computer Aided ◽

Retinal Artery

Introduction: To identify novel velocity waveform parameters of the ophthalmic artery and central retinal artery by computer-aided image processing of Doppler ultrasonography measurements, and to evaluate correlations between the waveform parameters and different demographics and disease severity of open-angle glaucoma patients. Methods: Thirty-six images of 36 open-angle glaucoma patients were considered. A semiautomated image processing code was used to detect the digitalized ophthalmic artery and central retinal artery velocity waveforms and to extract the waveform parameters. Concordance correlation coefficient, two-sample t-test, and Pearson’s correlation coefficient were used to test for similarities, differences, and associations among variables. Results: Female glaucoma patients showed a statistically higher ophthalmic artery normalized distance between ascending and descending limb (p = 0.004), hypertensive glaucoma patients a statistically higher ophthalmic artery peak systolic velocity time (p = 0.025), glaucoma patients with hyperlipidemia a statistically higher ophthalmic artery resistivity index (p = 0.023) and a statistically higher ophthalmic artery peak systolic velocity acceleration (p = 0.025), glaucoma patients with cardiovascular diseases a statistically lower central retinal artery normalized distance between ascending and descending limb of the wave (p = 0.033) and a statistically higher central retinal artery period (p = 0.028), and patients with different body mass index a statistically different central retinal artery normalized distance between ascending and descending limb of the wave (p = 0.016). Groups with different disease severity, classified following the Brusini glaucoma staging system 2, showed statistically different central retinal artery normalized distance between ascending and descending limb of the wave (p < 0.001) and central retinal artery period (p = 0.016). No statistical differences were found in regard to race, diabetes status, glaucoma family history, and smoking. Discussion: Ophthalmic artery and central retinal artery computer-aided analysis of velocity waveforms could identify novel waveform parameters capable of differentiating among different demographics and disease severity of open-angle glaucoma patients.

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Retrobulbar hemodynamic parameters in men and women with open angle glaucoma

Vojnosanitetski pregled ◽

10.2298/vsp1412128m ◽

2014 ◽

Vol 71 (12) ◽

pp. 1128-1131 ◽

Cited By ~ 1

Author(s):

Ivan Marjanovic ◽

Marija Marjanovic ◽

Ranko Gvozdenovic ◽

Dusica Risovic

Keyword(s):

Intraocular Pressure ◽

Open Angle Glaucoma ◽

Color Doppler ◽

Peak Systolic Velocity ◽

Doppler Imaging ◽

Hemodynamic Parameters ◽

Open Angle ◽

Cross Sectional ◽

Diastolic Velocity ◽

Elevated Intraocular Pressure

Background/Aim. Several factors may have influence on systemic circulation. Additionally, peripheral circulation also demonstrates sex differences, in young women presenting significantly lower finger blood flow in comparison to men of the same age, a finding that disappears in women after menopause. The aim of this study was to compare the retrobulbar hemodynamic parameters measured by means of color Doppler imaging in women and men with open-angle glaucoma and elevated intraocular pressure. Methods. A total of 52 eyes from 52 open-angle glaucoma (OAG) patients, with elevated intraocular pressure (IOP), were included in this cross-sectional study. Peak-systolic velocity (PSV), end-diastolic velocity (EDV), and Pourcelot resistivity index (RI) were assessed in the ophtalmic artery (OA), central retinal artery (CRA), and posterior cilliary arteries (PCA). IOP was measured both with Goldmann Applanation tonometer (GAT) and with the dynamic contour tonometer (DCT), three times respectively. Ocular pulse amplitude (OPA) appeared during the DCT measurement. Results. The retrobulbar hemodynamic parameters did not show any difference between men and post-menopausal women. Conclusion. The results of our study did not find any difference between sexes in patients with open-angle glaucoma and elevated intraocular pressure.

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Ocular doppler imaging: opening a new window in decoding glaucoma

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20193923 ◽

2019 ◽

Vol 7 (9) ◽

pp. 3417

Author(s):

K. P. S. Senger ◽

A. K. Anand ◽

Ankita Singh ◽

Vivek Sharma ◽

S. Patiyal

Keyword(s):

Open Angle Glaucoma ◽

Peak Systolic Velocity ◽

Resistive Index ◽

Ocular Blood Flow ◽

Doppler Imaging ◽

Diastolic Velocity ◽

Progression Of Disease ◽

Promising Application ◽

Retinal Artery

Background: In the aetiopathogenesis of multifactorial glaucoma autoregulation of ocular blood flow plays an important role as failure of autoregulation may lead to progression of disease. Aim of this study to understand this better this study was designed to investigate the quantum of these abnormalities and their likely role in pathogenesis and prognosis of primary open angle glaucoma(POAG).Methods: This is a case control study design which involved 67 POAG patients and 67 matched controls. The parameters assessed includes peak systolic velocity(PSV), end diastolic velocity(EDV) and resistive index(RI) of ophthalmic artery(OA) and central retinal artery(CRA) of patients having POAG with age and sex matched healthy subjects. The data obtained was statistically analysed using IBM SPSS 21.Results: The study showed decreased PSV of 31.7 cm/s vs 42.7 cm/s(p=0.0001) and EDV11.7 cm/s vs 19.8 cm/s(p=0.002) with increased RI 0.63 vs 0.53(p=0.000) in OA and PSV of 15.2 cm/s vs 21.4 cm/s(p=0.001) and EDV4.7 cm/s vs 11.7 cm/s(p=0.003) with increased RI 0.69 vs 0.45(p=0.000) in CRA in both eyes in POAG patients as compared to healthy controls.Conclusion: The study has shown the promising application of ocular Doppler in evaluating POAG patients. However, more such studies are needed with larger study sample and on follow up basis for better understanding glaucoma hemodynamics and applicability of ocular Doppler in management of glaucoma.

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Role of Color Doppler Imaging in Early Diagnosis and Prediction of Progression in Glaucoma

BioMed Research International ◽

10.1155/2013/871689 ◽

2013 ◽

Vol 2013 ◽

pp. 1-11 ◽

Cited By ~ 14

Author(s):

Fatima Jimenez-Aragon ◽

Elena Garcia-Martin ◽

Raquel Larrosa-Lopez ◽

Jose M. Artigas-Martín ◽

Pilar Seral-Moral ◽

...

Keyword(s):

Risk Factors ◽

Early Diagnosis ◽

Color Doppler ◽

Resistive Index ◽

Color Doppler Imaging ◽

Roc Curves ◽

Doppler Imaging ◽

Operating Characteristics ◽

Diastolic Velocity ◽

Retinal Artery

This longitudinal and prospective study analyzes the ability of orbital blood flow measured by color Doppler imaging (CDI) to predict glaucoma progression in patients with glaucoma risk factors. Patients with normal perimetry but having glaucoma risk factors and patients in the initial phase of glaucoma were prospectively included in the study and divided, after a five-year follow-up, into two groups: “Progression” and “No Progression” based on the changes in the Moorfields regression analysis (MRA) classification of Heidelberg retina tomograph (HRT). An orbital CDI was performed in all patients and the parameters obtained were correlated with changes in HRT. A logistic discrimination function (LDF) was calculated for ophthalmic artery (OA) and central retinal artery (CRA) parameters. Receiver operating characteristics curves (ROC) were used to assess the usefulness of LDFs to predict glaucomatous progression. A total of 71 eyes were included. End-diastolic velocity, time-averaged velocity, and resistive index in the OA and CRA were significantly different (P<0.05) between the Progression and No Progression groups. The area under the ROC curves calculated for both LDFs was of 0.695 (OA) and 0.624 (CRA). More studies are needed to evaluate the ability of CDI to perform early diagnosis and to predict progression in glaucoma in eyes.

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Role of Duplex Color Doppler Study of Uterine Artery in the Early Diagnosis of Preeclampsia in Pregnant Women

Journal of Medicine ◽

10.3329/jom.v20i2.42008 ◽

2019 ◽

Vol 20 (2) ◽

pp. 87-91

Author(s):

Sohely Sultana ◽

Tarana Yasmin ◽

Md Nazir Uddin Mollah ◽

Shyamal Kumar Roy ◽

Mohammad Sazzad Hossain ◽

...

Keyword(s):

Complex Disease ◽

Color Doppler ◽

Peak Systolic Velocity ◽

Resistive Index ◽

Wave Form ◽

College Hospital ◽

Doppler Study ◽

Diastolic Velocity ◽

Significant Difference ◽

Doppler Indices

Background: Duplex Colour Doppler Sonography is gaining increasing popularity for assessment of blood vessels in various disease processes around the world as well as for the surveillance of fetus compromised by intra uterine growth retardation (IUGR) and to assess foetal structural abnormalities and complex disease processes. Materials & methods: This cross sectional study was carried out to observe Doppler wave form in subjects with preeclampsia enrolling 40 subjects with preeclampsia, in the Department of Radiology and Imaging, Dhaka Medical College Hospital, Dhaka, over a period of six months from 20th May 2012 to 19th November 2012. A total number of 40 normal pregnancies were also included for comparison. Peak systolic velocity (PSV), end diastolic velocity (EDV), Resistive index (RI), Pulsatility index (PI) in different groups of study subjects from 24th to 37th weeks were observed and compared for any significant differences. Results: Majority (35% in normal and 37.5% in preeclampsia) of the respondents were found in the age group of 21-30 years. Unpaired t-test revealed no significant difference between mean age between two groups. Among normal group, mean±SD PSV, EDV, PI and RI were 43.94±15.41 cm/sec and 15.51 (±4.93) cm/sec, 1.12±0.0846 and 0.571 (±0.058) respectively. Mean PSV, EDV, PI and RI were 83.19±18.44 cm/sec, 11.86±5.19 cm/sec, 2.497±0.369 and 0.8255±0.087 in preeclampsia group. There was statistically significant (By unpaired ttest) difference in mean Doppler indices between these two groups. It was observed that early diastolic notch was found in 90% subjects with preeclampsia. Early diastolic notch was observed in Doppler wave form in 5% subject with normal pregnancy. Chi-square test showed that there was statistically significant difference in presence of early diastolic notch between normal subjects and subjects with preeclampsia. Conclusions: From the study result it was concluded that Doppler indices with presence of early diastolic notch are reliable indicators for early detection of preeclampsia. J MEDICINE JUL 2019; 20 (2) : 87-91

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Short-Term Effects of Acupuncture on Open-Angle Glaucoma in Retrobulbar Circulation: Additional Therapy to Standard Medication

Evidence-based Complementary and Alternative Medicine ◽

10.1155/2011/157090 ◽

2011 ◽

Vol 2011 ◽

pp. 1-6 ◽

Cited By ~ 9

Author(s):

Shin Takayama ◽

Takashi Seki ◽

Toru Nakazawa ◽

Naoko Aizawa ◽

Seri Takahashi ◽

...

Keyword(s):

Open Angle Glaucoma ◽

Color Doppler ◽

Resistive Index ◽

Color Doppler Imaging ◽

Doppler Imaging ◽

Open Angle ◽

Before And After ◽

Standard Medication ◽

Ciliary Artery ◽

Additional Therapy

Background. The relation between glaucoma and retrobulbar circulation in the prognosis has been indicated.Purpose. To investigate the effects of acupuncture on retrobulbar circulation in open-angle glaucoma (OAG) patients.Methods. Eleven OAG patients (20 eyes with OAG) who were treated by topical antiglaucoma medications for at least 3 months were enrolled. Acupuncture was performed once at acupoints BL2, M-HN9, ST2, ST36, SP6, KI3, LR3, GB20, BL18, and BL23 bilaterally. Retrobulbar circulation was measured with color Doppler imaging, and intraocular pressure (IOP) was also measured at rest and one hour after rest or before and after acupuncture.Results. TheΔvalue of the resistive index in the short posterior ciliary artery (P<.01) and theΔvalue of IOP (P<.01) were decreased significantly by acupuncture compared with no acupuncture treatment.Conclusions. Acupuncture can improve the retrobulbar circulation and IOP, which may indicate the efficacy of acupuncture for OAG.

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OCT Angiography and Doppler Sonography in Normal-Tension Glaucoma

Czech and Slovak Ophthalmology ◽

10.31348/2020/20 ◽

2020 ◽

Vol 76 (3) ◽

pp. 120-123

Author(s):

Ján Lešták ◽

Martin Fůs ◽

Antonín Benda ◽

Klára Marešová

Keyword(s):

Visual Field ◽

Ophthalmic Artery ◽

Doppler Sonography ◽

Visual Fields ◽

Peak Systolic Velocity ◽

Resistive Index ◽

Normal Tension Glaucoma ◽

Vessel Density ◽

Diastolic Velocity ◽

Image Area

Aims: To investigate the dependence of blood vessel density and velocity in ophthalmic artery and arteria centralis retinae of the same eye in patients with normotensive glaucoma. Methods: The sample consisted of 20 patients with normotensive glaucoma (NTG). There were 17 women (mean age 56.1) and 3 men (mean age 60 years). Inclusion criteria for study: visual acuity 1.0 with correction up to ±3 dioptres, approximately equal changes in the visual field, whereby it was incipient NTG and diagnosis was confirmed by electrophysiological examination, without further ocular or neurological disease. Parameters of vessel density (VD) were evaluated by Avanti RTVue XR (Optovue). Perfusion parameters such as peak systolic velocity (PSV), end diastolic velocity (EDV) and resistive index (RI) were evaluated for ophthalmic artery (AO) and arteria centralis retinae (ACR) using Doppler sonography (Affinity 70G Philips, probe 5–12 MHz). Visual field (VF) was evaluated by automated perimeter (Medmont M700) using fast threshold glaucoma strategy test. The sum of sensitivity levels in apostilb (asb) were evaluated in range 0–22 degrees of visual field. Resulting values of VF were compared with VD and perfusion parameters in AO and ACR at the same eye. Results: Pearson’s correlation coefficient was used to evaluate the dependence. Data shows, that changes in visual fields are mainly caused by peripapillary VD of small and all vessels, and vessels throughout measured image area also. Correlation of small vessels throughout measured image area was weak (r = 0.23). Moderate negative correlation was found for PSV in AO and peripapillary small VD (r = -0.46), all peripapillary VD (r = -0.49), VD in whole area (r = -0.45), then between EDV in AO and VD in whole area (r = -0.42). Other correlations between VD and perfusion parameter were insignificant. Conclusions: Study confirms, that changes of visual field in NTG patients are mainly caused by VD rather than perfusion parameters, especially in AO. Perfusion parameters in ACR are not significantly correlated with changes of VF in NTG patients.

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Duplex Color Doppler Evaluation of Retinal Arterial Blood Flow in Type 2 Diabetic Subjects without Retinopathy

Journal of Enam Medical College ◽

10.3329/jemc.v4i3.20948 ◽

2014 ◽

Vol 4 (3) ◽

pp. 168-173

Author(s):

Mashah Binte Amin ◽

Farzana Shegufta ◽

Md Towhidur Rahman ◽

Tarana Yasmin ◽

Khaleda Parvin Rekha ◽

...

Keyword(s):

Healthy Subjects ◽

Color Doppler ◽

Peak Systolic Velocity ◽

Resistive Index ◽

Diabetic Patients ◽

Diastolic Velocity ◽

Healthy Control ◽

Retinal Artery ◽

Type 2 Diabetic

Background: Diabetic retinopathy is a vascular disorder affecting the microvasculature of retina. It is caused by changes in the blood vessels of retina. If untreated, it may lead to blindness which is usually preventable if retinopathy is diagnosed early and treated promptly. In ophthalmology, color Doppler imaging is a new method that enables us to assess the orbital vasculature. It allows for simultaneous two dimensional anatomical and Doppler evaluations of hemodynamic characteristics of retinal artery. Objective: To observe the difference between Doppler flow velocity indices (peak systolic velocity, end diastolic velocity and resistive index) of retinal artery in type 2 diabetic subjects without retinopathy and those of normal controls. Materials and Methods: This case-control study was carried out in the department of Radiology and Imaging, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) in collaboration with Ophthalmology Outpatient Department, BIRDEM, Dhaka from July 2011 to June 2013. Eighty diabetic patients without retinopathy aged 2768 years were enrolled as cases and age and sex matched 80 healthy subjects were selected as controls. Type 1 diabetic patients, type 2 diabetics with retinopathy, hypertensive and dyslipidemic subjects were excluded from the study. All the selected subjects underwent duplex Doppler ultrasonography of both eyes using 5 to 7.5 MHZ linear phase transducer. Duplex color Doppler findings including spectral analysis (PSV, EDV and RI) were recorded. Unpaired t test was done to compare blood flow velocity indices of retinal artery in type 2 diabetic patients without retinopathy and that of healthy control subjects. p value <0.05 was considered as significant. Results: Majority (42.5% and 47.5%) of subjects were in 4th decade of life in both groups with predominance of males. The mean duration of diabetes was 4.56 ± 2.1 years. Mean peak systolic velocity (PSV) in 80 diabetic patients without retinopathy was 10.70 ± 1.50 cm/sec ranging 5.3016.10 cm/sec and that of 80 healthy subjects was 11.27 ± 0.98 cm/sec ranging 9.013.10 cm/sec. Mean end diastolic velocity (EDV) in 80 diabetic patients without retinopathy was 2.58 ± 0.67 cm/sec ranging 1.00 5.10 cm/sec and that of 80 healthy subjects was 4.11 ± 2.7 cm/sec ranging 3.004.60 cm/sec. Mean resistive index (RI) in 80 diabetic patients without retinopathy was 0.75 ± 0.04 ranging 0.660.81 and that of 80 healthy subjects was 0.64 ± 0.02 ranging 0.600.70. Mean difference of retinal arterial RI of diabetic subjects without retinopathy and healthy control eyes was statistically significant (p<0.001). Conclusion: From the present study it can be concluded that, there is statistically significant difference between retinal arterial RI of type 2 diabetic patients without retinopathy and that of healthy control adult subjects. DOI: http://dx.doi.org/10.3329/jemc.v4i3.20948 J Enam Med Col 2014; 4(3): 168-173

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