Gian Paolo Giuliari

Unidad Oftalmologica de Caracas, El Cafetal, Estado Miranda, Venezuela

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Publications (40)103.42 Total impact

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    ABSTRACT: To describe the appearance of acute syphilitic posterior placoid chorioretinitis, a rare ocular manifestation of syphilis, on spectral domain optical coherence tomography (SD OCT) both before and after treatment. Ophthalmic examination and imaging studies of 30 eyes of 19 confirmed cases were analyzed both at the time of presentation and at each follow-up visit. Patients with SD OCT and fluorescein angiography at the time of presentation, and at least three documented follow-up visits after initiation of therapy, were included in the study. Standard treatment of neurosyphilis was given to each patient, including 4 million units of penicillin G administered intravenously every 4 hours for 14 days. Fundus examination and imaging studies were consistent with previous reports and confirmed the diagnosis of acute syphilitic posterior placoid chorioretinitis. In 13 eyes (43.3%), baseline SD OCT scans were performed within 1 to 2 days of presentation and revealed a small amount of subretinal fluid, disruption of the inner segment/outer segment junction, and hyperreflective thickening of the retinal pigment epithelium (RPE). All 30 eyes were again scanned between Days 7 and 9 after presentation and revealed loss of the inner segment/outer segment and OS/RPE bands, and irregular hyperreflectivity of the RPE with prominent nodular elevations but without subretinal fluid. Early disruption of the external limiting membrane and punctate choroidal hyperreflectivity were seen in 1 of the 30 eyes (3.3%) and 14 of the 30 eyes (46.6%), respectively. Vision improved and the outer retinal abnormalities normalized in 28 of the 30 eyes (93.3%) after the treatment of neurosyphilis. The external limiting membrane, inner segment/outer segment band, and/or linear outer segment/RPE junction remained substantially abnormal despite treatment in 2 eyes left with 20/200 vision. Patients with acute syphilitic posterior placoid chorioretinitis show characteristic outer retinal abnormalities on SD OCT imaging, including disruption of the inner segment/outer segment band, nodular thickening of the RPE with loss of the linear outer segment/RPE junction, and, in some cases, loss of the external limiting membrane, accumulation of subretinal fluid, and punctate hyperreflectivity in the choroid. Vision improved and these abnormalities reversed after treatment of neurosyphilis in most of the patients. Persistently, poor vision despite treatment was associated with long-term loss or disruption of outer retinal anatomy on SD OCT.
    Retina (Philadelphia, Pa.) 07/2013; 34(2). DOI:10.1097/IAE.0b013e3182993f11 · 3.24 Impact Factor
  • Gian Paolo Giuliari · Ama Sadaka · David M Hinkle ·
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    ABSTRACT: Experimental uveitis models were developed in an effort to elucidate the pathogenesis of human uveitis. The therapeutic effects of numerous anti-inflammatory agents including corticosteroids and immunomodulatory agents including biologic response modifiers have been investigated in both experimental and human uveitis. Monoclonal antibodies to tumor necrosis factor alpha and anti-interleukins, among others, demonstrate efficacy and are employed in the treatment of uveitis refractory to conventional immunomodulatory agents.
    International Ophthalmology 03/2013; 34(1). DOI:10.1007/s10792-013-9756-0 · 0.55 Impact Factor

  • Journal of American Association for Pediatric Ophthalmology and Strabismus 02/2013; 17(1):e27. DOI:10.1016/j.jaapos.2012.12.101 · 1.00 Impact Factor
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    Archives of ophthalmology 09/2012; 130(9):1229-31. DOI:10.1001/archophthalmol.2012.1677 · 4.40 Impact Factor
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    Ama Sadaka · Gian Paolo Giuliari ·
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    ABSTRACT: Proliferative vitreoretinopathy is a disease process that follows the proliferation of ectopic cell sheets in the vitreous and/or periretinal area, causing periretinal membrane formation and traction, in patients with rhegmatogenous retinal detachments. Currently, vitreous surgery is the standard treatment; however, the results aren't satisfactory given the vision loss that ensues and that redetachment is relatively common. It is becoming clearer that there exists an interplay between various cytokines/growth factors, matrix proteins, and the different cell types that drive the undesirable formation of periretinal membranes. This fundamental understanding is aiding in identifying different adjunct agents that can block the cellular events intrinsic to proliferative vitreoretinopathy. In this review, we describe the current understanding on the pathogenesis and discuss how the fundamental understanding of the biochemical/molecular events is instrumental in developing the novel treatment strategies that are also highlighted.
    Clinical Ophthalmology 08/2012; 6(1):1325-33. DOI:10.2147/OPTH.S27896 · 0.76 Impact Factor
  • Peter Y Chang · Rola Hamam · Gian Paolo Giuliari · C Stephen Foster ·

    Canadian Journal of Ophthalmology 08/2012; 47(4):e12-3. DOI:10.1016/j.jcjo.2012.03.011 · 1.33 Impact Factor
  • G Paolo Giuliari · Ama Sadaka · Ralph Eagle · Victor H Gonzalez ·
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    ABSTRACT: Purpose: To describe a case of an immunosuppressed patient with history of renal transplant that presented with sudden unilateral loss of vision. Methods: Case report. Review of medical records. Results: A 49-year-old man with history of renal transplantation presenting with visual symptoms without initial systemic manifestations. Because of the rarity of ocular involvement, the patient's diagnosis of Nocardia asteroides endophthalmitis was delayed culminating in systemic involvement and necessitating enucleation of the eye. Conclusion: Nocardiosis is a serious life-threatening complication in immunosuppressed patients. Visual symptoms and endophthalmitis in this population should raise the suspicion of a possible serious systemic infection like nocardia.
    Retinal Cases & Brief Reports 06/2012; 6(3):245-8. DOI:10.1097/ICB.0b013e31822477c4
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    Gian Paolo Giuliari · Ama Sadaka · Maria Angelica Cortez · Antonina Paniagua ·
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    ABSTRACT: Objective. To present the case of an aggressive orbital Burkitt's lymphoma. Methods. Chart review. Case Presentation. A 24-year-old Haitian man came to our clinic complaining of rapidly progressive right eye proptosis. On examination, a large friable exophytic mass with necrotic areas and exudative/hemorrhagic secretions was noted protruding from his right orbit. A biopsy revealed the characteristic “starry-sky” appearance of a Burkitt lymphoma. The patient died shortly after due to complications from systemic involvement. Discussion. This case is meant to raise physicians' awareness on the healthcare situation in some underdeveloped countries, emphasizing the importance of education in preventive medicine.
    03/2012; 2012:354043. DOI:10.1155/2012/354043
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    Gian Paolo Giuliari · Ama Sadaka · Maria Angelica Cortez · Adalgisa Corona ·
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    ABSTRACT: Purpose. To report an untypical presentation of a presumed Sturge-Weber Syndrome (SWS), and to highlight the indispensable value of thorough clinical examination as primary means for proper diagnosis and management. Methods. Chart review. Results. A 7 year-old boy, with a long history of ocular symptoms and an unspecified ocular surgery, presents with a painful blind left eye. Based on clinical examination, the suspicion of SWS was raised. The presentation was not typical in the sense that no evident port-wine stain was observed on the face. However, facial asymmetry and gum discoloration were guiding clinical clues to pursue further investigations. Unfortunately, due to poor treatment response, the patient underwent enucleation. Tissue pathology revealed diffuse choroidal hemangiomas, consistent with the diagnosis of SWS. Conclusion. SWS presents with hamartomatous malformations and venous dilation affecting the skin, central nervous system and eye. The ocular involvement may vary, with the most common complications being glaucoma, buphthalmos and diffuse choroidal hemangiomas. This case report helps remind physicians of the importance of a thorough clinical examination, and highlights the ophthalmologists' responsibility of examining beyond the eye.
    03/2012; 2012:509693. DOI:10.1155/2012/509693
  • Gian Paolo Giuliari · Hatem Krema · Hugh D McGowan · Charles J Pavlin · E Rand Simpson ·
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    ABSTRACT: To determine the clinical and ultrasound biomicroscopy (UBM) features associated with growth in iris melanocytic lesions. Retrospective case series analysis. We included all iris melanocytic lesions that were monitored between January 2005 and November 2009. At the end of the analysis, 44 eyes of 44 patients were included in the final analysis. The clinical features analyzed were: iris color, largest base diameter, radial location of the lesion epicenter, circumferential location of the lesion epicenter, lesion configuration, lesion pigmentation, intrinsic vascularity within the lesion, presence of associated pigmentation, the impact on the pupil, presence of iris atrophy, and lesion-induced localized cataracts. The UBM features included lesion thickness, presence of corneal touch, presence of surface plaque, internal structure, and internal reflectivity. Regression analysis was performed to define the features associated with growth. Twenty-three percent of the lesions showed documented growth. Mean follow-up was 21.4 months (range: 10-48). Clinical features associated with growth were a large basal diameter at baseline (P = .004) and inferior location (P = .004). UBM features associated with growth were: a greater baseline thickness (P = .01), presence of corneal touch (P = .007), an irregular internal structure (P = .0001), and the presence of dots and linear streaks (P < .0001). Clinical features that were not associated with growth were the radial location of the lesion in the iris (P > .999), lesion configuration (P > .999), lesion pigmentation (P > .999), the presence of pigment dispersion (P = .70), iris freckles (P = .15), corectopia (P > .999), ectropion (P > .999), and intrinsic vascularity (P = .70). UBM features not associated with growth were the presence of a surface plaque (P = .07) and the internal reflectivity (P = .77). Substantial growth in iris melanocytic lesions is associated with original larger basal diameter and inferior lesion location. On UBM growth is associated with greater original thickness, presence of corneal touch, and an irregular internal structure. Presence of these features could modify the frequency of observation of those lesions.
    American Journal of Ophthalmology 02/2012; 153(6):1043-9. DOI:10.1016/j.ajo.2011.11.004 · 3.87 Impact Factor
  • Gian P Giuliari ·
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    ABSTRACT: Diabetes mellitus has become a major health concern worldwide and its incidence is projected to increase. Diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) are considered the most sight-threatening ocular complications in these patients. Pivotal studies, such as the Early Treatment Diabetic Retinopathy Study (ETDRS) and the Diabetic Retinopathy Study (DRS), have established macular and pan-retinal laser as the gold-standard of treatment for these complications. The recent discovery of the vascular endothelial growth factor (VEGF) and its role in the development of proliferative disease, has led to a movement towards treating PDR and DME with anti-angiogenic medications alone or in conjunction with the gold-standard of care. Due to the severity of the diabetic ocular complications and the rising incidence of diabetes worldwide, it is important for the non-ophthalmologist care provider to be informed of the new treatments available for these conditions in an effort to better guide their patients. In this review, I will discuss the importance of these new methods of treatment as well as the significance of systemic glucose control, vitreous surgery and laser photocoagulation.
    Current diabetes reviews 01/2012; 8(1):32-41. DOI:10.2174/157339912798829188
  • Gian Paolo Giuliari · Peter Y Chang · Rafael Muci-Mendoza · Rafael T Cortez ·
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    ABSTRACT: Purpose: To describe a patient with sudden unilateral loss of vision associated with white inner retinal lesions and a history of a nonspecific viral infection. Methods: Case report. We reviewed the medical record and retinal angiogram of one patient. Results: The patient presented with a sudden loss of visual acuity in the left eye. Fundus examination revealed multiple white inner retinal lesions and hyperemic optic disks in both eyes. Spontaneous improvement of visual acuity and resolution of the retinal lesions were noted over the ensuing weeks. Conclusion: Retinitis can present as a nonspecific response to various infectious agents. We herein report a case of acute multifocal inner retinitis associated with a nonspecific viral illness.
    Retinal Cases & Brief Reports 12/2011; 6(1):40-42. DOI:10.1097/ICB.0b013e3182051d06
  • Gian Paolo Giuliari · Ama Sadaka ·
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    ABSTRACT: Choroidal metastasis represents the most common form of intraocular malignancies. It may occur in up to 10% of patients with systemic metastasis with almost half of the patients developing central nervous system disease. The most common primary sites of ocular metastasis are breast cancer in women and lung cancer in men. In most cases, these lesions tend to be asymptomatic and are not evaluated by an ophthalmologist. The diagnosis is generally made by the history of present or prior malignancies and an ophthalmological examination with slit-lamp biomicroscopy and indirect ophthalmoscopy. As with other malignancies, management may vary with each patient. Small tumors, that do not compromise the vision and that have responded previously to systemic treatment, may be closely observed. For larger lesions and for symptomatic ones, external beam radiation offers an excellent alternative to save the eye and stabilize vision. Bevacizumab (Avastin), a potent monoclonal antibody that has also been employed for the treatment of ocular vaso-proliferative diseases, has been used in the treatment of choroidal metastasis and has shown promising results.
    Oncology Reports 11/2011; 27(3):603-7. DOI:10.3892/or.2011.1563 · 2.30 Impact Factor
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    ABSTRACT: To collaborate with multiple centers to identify representative epidemiological, clinical, and pathologic characteristics of melanoma of the iris. This international, multicenter, Internet-assisted study in ophthalmic oncology demonstrates the collaboration among eye cancer specialists to stage and describe the clinical and pathologic characteristics of biopsy-proven melanoma of the iris. A computer program was created to allow for Internet-assisted multicenter, privacy-protected, online data entry. Eight eye cancer centers in 6 countries performed retrospective chart reviews. Statistical analysis included patient and tumor characteristics, ocular and angle abnormalities, management, histopathology, and outcomes. A total of 131 patients with iris melanoma (mean age, 64 years [range, 20-100 years]) were found to have blue-gray (62.2%), green-hazel (29.1%), or brown (8.7%) irides. Iris melanoma color was brown (65.6%), amelanotic (9.9%), and multicolored (6.9%). A mean of 2.5 clock hours of iris was visibly involved with melanoma, typically centered at the 6-o'clock meridian. Presentations included iritis, glaucoma, hyphema, and sector cataract. High-frequency ultrasonography revealed a largest mean tumor diameter of 4.9 mm, a mean maximum tumor thickness of 1.9 mm, angle blunting (52%), iris root disinsertion (9%), and posterior iris pigment epithelium displacement (9%). Using the American Joint Commission on Cancer-International Union Against Cancer classification, we identified 56% of tumors as T1, 34% of tumors as T2, 2% of tumors as T3, and 1% of tumors as T4. Histopathologic grades were G1-spindle (54%), G2-mixed (28%), G3-epithelioid (5%), and undetermined (13%) cell types. Primary treatment involved radiation (26%) and surgery (64%). Kaplan-Meier analysis found a 10.7% risk of metastatic melanoma at 5 years. Iris melanomas were most likely to be brown and found in the inferior quadrants of patients with light irides. Typically small and unifocal, melanomas are commonly associated with angle blunting and spindle cell histopathology. This multicenter, Internet-based, international study successfully pooled data and extracted information on biopsy-proven melanoma of the iris.
    Archives of ophthalmology 09/2011; 130(1):57-64. DOI:10.1001/archophthalmol.2011.286 · 4.40 Impact Factor
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    ABSTRACT: To demonstrate the correlation of ultrasound biomicroscopy (UBM) features of iris melanoma with histopathology. Retrospective analysis of medical records. The medical records of patients that underwent surgery for iris melanoma at the Princess Margaret Hospital, University of Toronto, from June 1990 to October 1998 were reviewed. The clinical features, as well as the UBM findings prior to surgical intervention, were evaluated. The anatomic features noted on UBM were correlated with histopathologic features seen in the surgical specimens. Fourteen cases met the inclusion criteria and were included in the final analysis. The ultrasound acoustic characteristics showed a broad spectrum of findings among iris melanomas. Tumor acoustic parameters correlated well with histologic features, including tumor vascularity, surface plaque, extrascleral extension, ciliary body involvement, and integrity of iris pigment epithelium. UBM is a useful imaging technique for the in vivo assessment of primary iris melanoma and can provide detailed imaging of the tumor's interface with the angle structures. The preoperative assessment of these tumors by UBM may aid the surgeon in choosing the most appropriate technique to ensure total removal.
    American Journal of Ophthalmology 04/2011; 151(4):579-585.e1. DOI:10.1016/j.ajo.2010.09.024 · 3.87 Impact Factor
  • Gian P Giuliari · Ama Sadaka · Peter Y Chang · Rafael T Cortez ·
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    ABSTRACT: Diabetes mellitus is a growing global epidemic. Patients with this disease present with a variety of health conditions, including a number of ocular complications that threaten vision, such as proliferative diabetic retinopathy and macular edema. Diabetic papillopathy, another potential ocular complication from diabetes, is a self-limiting, sometimes bilateral disease that may affect both type 1 and type 2 diabetics. It is characterized by optic disc swelling caused by vascular leakage and axonal edema in and around the optic nerve head. Occasionally, it may be accompanied by intraretinal hemorrhages and hard exudates. Diabetic papillopathy tends to be mild and is usually associated with good visual prognosis; however, there are some cases in which permanent visual impairment can develop. The pathogenesis remains largely unknown, but there has been evidence suggestive of its associations with a small cup/disc ratio and rapid reduction in glycemia. There is no validated therapy for diabetic papillopathy; however, current case reports have shown promising results after local injections of corticosteroids as well as bevacizumab (Avastin), a potent monoclonal antibody that has been employed for the treatment of ocular vaso-proliferative diseases such as choroidal neovascular membranes associated with age-related macular degeneration and proliferative diabetic retinopathy.
    Current diabetes reviews 03/2011; 7(3):171-5. DOI:10.2174/157339911795843122
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    P Y Chang · G P Giuliari · M Shaikh · P Thakuria · D Makhoul · C S Foster ·
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    ABSTRACT: To evaluate effectiveness and safety of mycophenolate mofetil (MMF) monotherapy in paediatric autoimmune uveitis. We reviewed medical records of patients, 18 years of age or younger, with autoimmune uveitis treated with MMF at our practice from 2005 to 2009. The dose and duration of MMF therapy, inflammation status, visual acuity, previous immunomodulatory therapies, and adverse effects were recorded. In addition, the following subgroups were defined: (1) Durable Disease Control: patients whose uveitis remained quiescent for at least 2 years on MMF monotherapy, with no more than two flare-ups successfully treated with an increase in MMF dosage and/or a short course (<1 month) of corticosteroids; (2) Short-term Inflammation Control: patients whose uveitis remained quiescent for less than 2 years, with no more than one flare-up successfully treated with an increase in MMF dosage and/or a short course of corticosteroids, or who initially achieved inflammation control but discontinued MMF because of significant adverse effects. A total of 38 out of 52 patients (73.1%) obtained inflammation control following 2 months of MMF monotherapy, achieving ≤ 0.5+ grading in anterior chamber cell/flare and vitreous haze. In the cross-sectional analysis, 25 patients (48.1%) met the criteria for Durable Disease Control, and 13 others (25.0%) qualified for Short-term Inflammation Control. Visual acuity remained stable or improved in 94.2% of the study population. Six patients (11.5%) discontinued MMF because of significant adverse effects, the most common of which was gastrointestinal disturbances. MMF monotherapy appears to be an effective and safe treatment in paediatric autoimmune uveitis.
    Eye (London, England) 03/2011; 25(4):427-35. DOI:10.1038/eye.2011.23 · 2.08 Impact Factor
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    L M Vasquez · G P Giuliari · W Halliday · C J Pavlin · B L Gallie · E Héon ·
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    ABSTRACT: To determine the role of ultrasound biomicroscopy (UBM) in the management of children affected with retinoblastoma. A review of clinical records of children with the diagnosis of retinoblastoma at the Hospital for Sick Children from January 1995 to December 2007, for whom UBM was used to determine the extent of intraocular tumor. Clinical characteristics were compared with UBM. Pathological correlation was performed for enucleated eyes. In total, 101 eyes of 75 patients were included in the final analysis. Only 11 eyes were diagnosed on UBM to have extension of the tumor anterior to the ora serrata, and were enucleated. Histopathological examination confirmed the anterior extension in all the 11 eyes. In total, 50 eyes were enucleated because of various reasons, such as poor visual prognosis (12 eyes), unilateral group D or E (23 eyes), recurrences (8 eyes), and treatment failure (7 eyes). None of those patients were found to have anterior extension of the disease on histopathological examination. UBM did not yield any false negative (0/50) or any false positives (0/11). The UBM provided a sensitive and reproducible visualization of the anterior retina, ciliary region, and anterior segment allowing a better staging of the advanced disease process. Primary assessment of the true extent of retinoblastoma is critical for the selection of an optimal management approach.
    Eye (London, England) 02/2011; 25(2):141-7. DOI:10.1038/eye.2010.193 · 2.08 Impact Factor
  • Gian Paolo Giuliari · Allan Connor · E Rand Simpson ·

    The Lancet 02/2011; 377(9768):848. DOI:10.1016/S0140-6736(10)60815-X · 45.22 Impact Factor
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    Gian Paolo Giuliari · Ama Sadaka · David M Hinkle · E Rand Simpson ·
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    ABSTRACT: to review the currently available therapeutic modalities for radiation retinopathy (RR), including newer investigational interventions directed towards specific aspects of the pathophysiology of this refractory complication. a review of the literature encompassing the pathogenesis of RR and the current therapeutic modalities available was performed. RR is a chronic and progressive condition that results from exposure to any source of radiation. It might be secondary to radiation treatment of intraocular tumors such as choroidal melanomas, retinoblastomas, and choroidal metastasis, or from unavoidable exposure to excessive radiation from the treatment of extraocular tumors like cephalic, nasopharyngeal, orbital, and paranasal malignancies. After the results of the Collaborative Ocular Melanoma Study, most of the choroidal melanomas are being treated with plaque brachytherapy increasing by that the incidence of this radiation complication. RR has been reported to occur in as many as 60% of eyes treated with plaque radiation, with higher rates associated with larger tumors. Initially, the condition manifests as a radiation vasculopathy clinically seen as microaneurysms and telangiectases, with posterior development of retinal hard exudates and hemorrhages, macular edema, neovascularization and tractional retinal detachment. Regrettably, the management of these eyes remains limited. Photodynamic therapy, laser photocoagulation, oral pentoxyphylline and hyperbaric oxygen have been attempted as treatment modalities with inconclusive results. Intravitreal injections of anti-vascular endothelial growth factor such as bevacizumab, ranibizumab and pegaptanib sodium have been recently used, also with variable results. RR is a common vision threatening complication following radiation therapy. The available therapeutic options are limited and show unsatisfactory results. Further large investigative studies are required for developing better therapeutic as well as preventive treatment strategies.
    Acta oncologica (Stockholm, Sweden) 01/2011; 50(1):6-13. DOI:10.3109/0284186X.2010.500299 · 3.00 Impact Factor

Publication Stats

272 Citations
103.42 Total Impact Points


  • 2012-2013
    • Unidad Oftalmologica de Caracas
      El Cafetal, Estado Miranda, Venezuela
  • 2011-2012
    • The Princess Margaret Hospital
      Toronto, Ontario, Canada
  • 2010-2012
    • University of Toronto
      • Department of Ophthalmology and Vision Sciences
      Toronto, Ontario, Canada
    • Central University of Venezuela
      Caracas, Distrito Federal, Venezuela
  • 2009-2012
    • Massachusetts Eye Research and Surgery Institution
      Cambridge, Massachusetts, United States
  • 2008
    • Centro Médico de Caracas
      Caracas, Distrito Federal, Venezuela
  • 2007
    • Denver Health and Hospital Authority
      Denver, Colorado, United States