Optimization of an Implantable Collamer Lens Sizing
Method Using High-Frequency Ultrasound
Biomicroscopy
TAKASHI KOJIMA, SHO YOKOYAMA, MAYUKA ITO, RIE HORAI, SHUYA HARA, TOMOAKI NAKAMURA,
AND KAZUO ICHIKAWA
● PURPOSE: To develop and evaluate a new implantable
collamer lens (ICL) sizing method that uses high-fre-
quency ultrasound biomicroscopy (UBM).
● DESIGN: Interventional case series.
● METHODS: ICL were implanted in 47 eyes of 25
patients (8 male, 17 female, mean age 34.7 ⴞ 6.8 years).
At 3 months after ICL surgery, the vault (distance
between ICL and crystalline lens) was measured using
anterior optical coherence tomography (OCT). Stepwise
multiple regression analysis was performed in order to
determine the optimal ICL size that will be expected to
achieve a 0.5-mm vault, and the regression equation was
calculated. Mean keratometric power, axial length, anterior
chamber depth, sulcus-to-sulcus (STS) diameter, and dis-
tance between STS plane and crystalline lens were applied
as candidates for explanatory variables. Subsequently, the
equation was applied to a new group of patients (81 eyes of
43 patients, 20 male and 23 female, mean age 35.6 ⴞ 7.2
years) in order to decide the ICL size. Postoperative vault
was evaluated at 3 months after surgery. Main outcome
measures were mean postoperative vault and percentages of
eyes that achieved moderate vault.
● RESULTS: The regression equation was determined
using 3 explanatory variables: anterior chamber depth
(ACD), STS diameter, and distance between STS plane
and anterior crystalline lens surface (STSL). The mean
vault error (postoperative vault – predicted vault) was
ⴚ0.06 ⴞ 0.29 mm. Of the total number of eyes, 88.9%
had a vault between 0.15 and 1.0 mm. None of the eyes had
a low vault (<0.15 mm). Nine eyes (11.1%) had a high
vault (>1.0 mm).
● CONCLUSION: A novel ICL sizing equation was devel-
oped and shown to be an effective method for calculation
of the optimal ICL size in order to achieve an appropriate
vault. (Am J Ophthalmol 2012;153:632– 637.
© 2012 by Elsevier Inc. All rights reserved.)
Accepted for publication Jun 24, 2011.
From Nagoya Eye Clinic, Nagoya, Japan (T.K., M.I., R.H., S.H., T.N.);
Department of Ophthalmology, Keio University School of Medicine,
Tokyo, Japan (T.K.); and Department of Ophthalmology, Social Insur-
ance Chukyo Hospital, Aichi, Japan (S.Y., S.H., K.I.).
Inquiries to Takashi Kojima, Department of Ophthalmology, Keio
University School of Medicine, Shinanomachi 35, Shinjuku-ku, Tokyo
160-8582, Japan; e-mail: tkojkoj@mac.com
632 © 2012 BY ELSEVIER INC. ALL
A
N IMPLANTABLE COLLAMER LENS (ICL; STAAR SUR-
gical, Monrovia, California, USA) is a posterior
chamber–type phakic intraocular lens that is de-
signed to be implanted in the ciliary sulcus. Determination
of ICL size is crucial in order to achieve a successful result.
A too-large ICL will result in shallowness of the anterior
chamber and an increased risk of angle-closure or pupillary
block glaucoma.1,2 On the other hand, a too-small ICL will
result in a decreased distance between the ICL and
crystalline lens and in an increasing risk of cataract
formation.3–5 Conventionally, ICL size has been deter-
mined based on the horizontal corneal diameter (white-
to-white, WTW) and anterior chamber depth (ACD).
However, accumulated reports have revealed that there is
a poor correlation between ciliary sulcus-to-sulcus (STS)
diameter and WTW measurement.6 –10 Choi and associ-
ates determined ICL size using conventional 50-MHz
ultrasound biomicroscopy (UBM).11 Even though only a
small number of cases were evaluated, the UBM method
was superior to conventional methods for achieving a
moderate vault. The emergence of high-frequency UBM
with a wide scanning field has enabled direct measurement
of STS diameter.
Vault changes according to the difference between ICL
size and STS diameter. Gonvers and associates reported
that there was no contact between the ICL and crystalline
lens in cases with the central vaulting equal to or greater
than 0.15 mm.3 They concluded that 0.15 mm of central
vaulting should be the minimum target for ICL implanta-
tion. Therefore, in the present report, the lower limit of
vaulting was set at 0.15 mm.
Recently, Dougherty and associates conducted a multi-
center study that reported a regression equation to calcu-
late optimal ICL size.12 They used STS and ICL power as
explanatory variables. Since the distance between the
fixed position of the ICL and crystalline lenses can affect
ICL vault, a new parameter was created in the present
study: the distance between STS plane and anterior
crystalline lens surface (STSL).
The purpose of this study was to develop an equation using
stepwise multiple regression analysis for determination of
appropriate ICL size, and then to validate the efficacy of the
equation by investigating postoperative vault.
RIGHTS RESERVED. 0002-9394/$36.00
doi:10.1016/j.ajo.2011.06.031
 TABLE 1. Patient Information in Relation to the Manifest
Refraction, Ocular Parameters, and Implanted Implantable
Collamer Lens Power in the Study for Developing the Size
Calculation Equation
Mean ⫾ Standard Deviation (Range)
Number of patients (eyes) 24 (45)
Age (years) 34.3 ⫾ 6.6 (22 to 45)
Sex (female, male) 12, 12
Manifest refractive sphere (D) ⫺9.22 ⫾ 3.08 (⫺3.75 to ⫺15.5)
Manifest refractive cylinder (D) ⫺0.95 ⫾ 0.78 (0 to -2.75)
Axial length (mm) 27.9 ⫾ 1.3 (25.8 to 31.3)
Anterior chamber depth (mm) 3.25 ⫾ 0.27 (2.77 to 3.81)
Ciliary sulcus-to-sulcus 11.79 ⫾ 0.44 (11.17 to 12.95)
diameter (mm)
STS to anterior lens surface 0.31 ⫾ 0.18 (-0.04 to 0.69)
distance (STSL) (mm)
Implanted ICL power (D) ⫺14.17 ⫾ 3.77 (-6.0 to -22.5)
D ⫽ diopter; ICL ⫽ implantable collamer lens; STS ⫽
sulcus-to-sulcus.
METHODS
● SUBJECTS IN THE IMPLANTABLE COLLAMER LENS SIZ-
ING EQUATION STUDY: A total of 45 eyes of 24 con-
secutive patients (12 male, 12 female, mean age 34.3 ⫾
6.6 years) who underwent ICL surgery at Nagoya Eye
Clinic were enrolled in the study. Patient demographics
are shown in Table 1. Patients were excluded if they had
other ocular diseases except for refractive error. The
mean manifest refractive sphere and cylinder of these
subjects were ⫺9.22 ⫾ 3.08 diopters (D; range ⫺3.75 to
⫺24.0 D) and ⫺0.95 ⫾ 0.78 D (range 0 to ⫺2.75 D),
respectively. The ICL size was determined with a
conventional STAAR sizing nomogram that calculated
the size from the 2 parameters of WTW and anterior
chamber depth.13
● REGRESSION EQUATION VALIDATION STUDY SUB-
JECTS: A total of 81 eyes of 43 patients (21 male, 22
female, mean age 35.6 ⫾ 7.2 years) who underwent ICL
implantation surgery were enrolled in the study. Patient
demographics are shown in Table 2. The mean manifest
refractive sphere and cylinder of these subjects were
⫺9.21 ⫾ 3.34 D (range ⫺3.25 to ⫺24.0 D) and ⫺1.12 ⫾
0.95 D (range 0 to ⫺3.75 D), respectively.
● MULTIPLE REGRESSION ANALYSIS: Before ICL im-
plantation surgery, mean keratometric value (ARK-530A;
Nidek, Gamagori, Japan), axial length (IOL Master; Carl
Zeiss Meditec, Jena, Germany), anterior chamber depth
(IOL Master; Carl Zeiss Meditec), and STS (VumaxII;
SONOMED Inc, Lake Success, New York, USA) and
STSL (VumaxII) were measured. At 3 months after
surgery, vault was measured using anterior OCT (Visante;
VOL. 153, NO. 4 OPTIMIZATION OF IMPLANTABLE
TABLE 2. Patient Information in Relation to the Manifest
Refraction, Ocular Parameters, and Implanted Implantable
Collamer Lens Size in the Evaluation Study of the
Implantable Collamer Lens Sizing Equation
Mean ⫾ Standard Deviation (Range)
Number of patients (eyes) 43 (81)
Age (years) 35.6 ⫾ 7.2 (25 to 48)
Sex (female, male) 23, 20
Manifest refractive sphere (D) ⫺9.21 ⫾ 3.34 (-3.25 to -24.0)
Manifest refractive cylinder (D) ⫺1.12 ⫾ 0.95 (0 to -3.75)
Anterior chamber depth (mm) 3.08 ⫾ 0.26 (2.63 to 3.61)
Ciliary sulcus-to-sulcus 11.74 ⫾ 0.57 (11.17 to 12.95)
diameter (mm)
STS to anterior lens surface 0.35 ⫾ 0.20 (0 to 0.82)
distance (mm)
Implanted ICL size 12.7 ⫾ 0.37 (12.1 to 13.2)
D ⫽ diopter; ICL ⫽ implantable collamer lens; STS ⫽
sulcus-to-sulcus.
Carl Zeiss Meditec). From the observation that ICL vault
increases 1.1 times higher along the compression length in
a balanced salt solution (BSS) (STAAR proprietary data),
optimal ICL size to achieve 0.5-mm vault was estimated
with the following equation:
Optimal ICL size ⫽ Implanted ICL size ⫹ (0.5
⫺ Postoperative vault) ⁄ 1.1.
Then, stepwise multiple regression analysis was per-
formed in order to evaluate the correlation between
optimal ICL size and other ocular parameters. The
dependent variable was optimal ICL size. The candi-
dates of an explanatory variable included mean kerato-
metric value, axial length, STS, STSL, and ICL
spherical power. In the regression analysis, a variance
inflation factor was calculated and the amount of
multicollinearity was assessed.
● ULTRASOUND BIOMICROSCOPY SCANNING SYSTEM: A
high-frequency B-scan diagnostic ultrasound biomicros-
copy imaging system (VumaxII) was employed in the
present study. The system has a scanning field depth of
18.5 ⫻ 14 mm, and can capture the entire anterior
segment in a single scan. The sampling rate was 22
frames/s. A headpiece with a 35-MHz transducer was
used for STS and STSL measurement. The axial and
lateral resolution in the anterior segment with a 12-mm
height were 0.022 mm and 0.38 mm, respectively. The
repeatability of STS measurements has been previously
evaluated, and the coefficient of variation was 0.62%.14
A single, experienced examiner carried out all UBM
measurements.
COLLAMER LENS SIZING 633

FIGURE 1. Representative image of ultrasound biomicroscopy
showing the ciliary sulcus-to-sulcus plane (STS) and the
distance between ciliary sulcus-to-sulcus plane and anterior
crystalline lens surface (STSL) measurements.
● MEASUREMENTS OF CILIARY SULCUS-TO-SULCUS DI-
AMETER AND DISTANCE BETWEEN CILIARY SULCUS-
TO-SULCUS PLANE AND ANTERIOR CRYSTALLINE LENS
SURFACE USING HIGH-FREQUENCY ULTRASOUND BIO-
MICROSCOPY: Topical anesthesia consisting of oxybupro-
caine hydrochloride 0.4% (Benoxil ophthalmic solution;
Santen, Osaka, Japan) was administered, and an appropri-
ately sized eyecup (18.0, 20.0, 22.0, or 24.0 mm diameter)
was used depending on interpalpebral size. The eyecup was
filled with sterile normal saline, and the subject was asked
to fixate a target on the ceiling with the fellow eye in order
to maintain fixation. The probe was immersed to the water
surface vertically, and sectional images were taken on the
horizontal meridian. The probe was moved horizontally
along the superior-inferior axis and images were recorded
as a movie. The examiner captured the images according
to the following 3 conditions. First, corneal, posterior, and
anterior lens capsule references were in 1 image, and these
structures were located at a position symmetrical to a
central vertical line in the scanned area. Second, the
ciliary sulcus was kept at a depth of 12 mm in order to
achieve the best resolution. Third, the examiner kept the
largest pupil size during consecutive scans. After 6 still
images were chosen from recording video frames in
which the STS was captured clearly, the end of the high
reflective line on the back surface of the iris was defined
as the ciliary sulcus. Subsequently, STS was measured
manually using a digital caliper. After excluding maxi-
mum and minimum values of 6 measurements, the mean
STS value was calculated. Similarly, the distance be-
tween the STS line and the anterior surface of the
crystalline lens was measured. STS and STSL in the
representative UBM image are shown in Figure 1. When
the STS plane was posterior to the anterior crystalline
lens surface, STSL was defined as a positive value.
● IMPLANTABLE COLLAMER LENS IMPLANTATION SUR-
GERY: Two weeks before ICL implantation, 2 peripheral
laser iridotomies using neodymium:YAG and an argon
laser were performed at the 10:30 and 1:30 clock-hour
634 AMERICAN JOURNAL
positions. Details of the ICL implantation procedure have
been described previously.15 Briefly, topical anesthesia was
administered. Paracentesis was then performed with the
aqueous humor replaced by a viscoelastic material (Ope-
gan; Santen Pharmaceuticals, Osaka, Japan). Subse-
quently, an injector cartridge (STAAR Surgical) was
used to insert the ICL through a sutureless 2.9-mm
temporal clear corneal incision. After initially placing
the ICL on the iris, a specially designed manipulator was
used to place 4 haptics behind the iris. Once correct ICL
positioning in the center of the pupillary zone was
confirmed, an intraocular mitotic was applied, followed
by irrigation of the anterior chamber with a balanced
salt solution. Postoperatively, 250 mg acetazolamide was
taken orally in order to decrease intraocular pressure.
Intraocular pressure was measured 2 hours after surgery.
Topical moxifloxacin was administered locally 4 times
daily for 4 weeks.
● CALCULATION OF PREDICTED VAULT: Since ICL was
manufactured with 0.5-mm length increments, ICL with
exact length as calculated from the equation cannot be
implanted. Therefore, predicted vault was calculated as
follows to validate the equation:
Predicted vault
⫽ (Postoperative vault in the present study)
⫹ 1.1 (ICL size calculated from the
each equation ⁄ nomogram
⫺ implanted ICL size)
● STATISTICAL ANALYSIS: The means, standard devia-
tions, and coefficients of variation were calculated using
Microsoft Excel 2007 (Microsoft, Redmond, Washington,
USA). The difference in distribution of postoperative
vault between the present equation and a previously
reported nomogram were analyzed with ␹2 analysis. ␹2
analysis and stepwise multiple regression analysis were
evaluated using IBM SPSS Statistics (IBM, Armonk, New
York, USA) for a Macintosh OS X (Apple, Cuppertino,
California, USA). A P value of less than .05 was consid-
ered statistically significant.
RESULTS
● REGRESSION EQUATION DEVELOPED TO DETERMINE
OPTIMAL IMPLANTABLE COLLAMER LENS SIZE: The re-
gression equation was determined with 3 explanatory
variables including ACD, STS, and STSL, as follows:
Optimal ICL size (mm, in BSS)
⫽ 3.75 ⫹ 0.46 ⫻ (STS) ⫹ 0.95 ⫻ (ACD)
⫹ 1.25 ⫻ (STSL)
OF OPHTHALMOLOGY APRIL 2012
 TABLE 3. Result of Stepwise Multiple Regression Analysis for Prediction of Implantable
Collamer Lens Optimal Size to Achieve a 0.5-mm Vault (Distance Between Crystalline Lens
and Implantable Collamer Lens)
Nonstandardized Partial
Predictive Variable Regression Coefficient
ACD 0.947
STS 0.460
STSL 1.246
R2 ⫽ 0.91, Adjusted R2 ⫽ 0.829
ACD ⫽ anterior chamber depth; STS ⫽ sulcus-to-sulcus diameter; STSL ⫽ STS to anterior lens
surface distance; VIF ⫽ variance inflation factor.
R2 of the multiple regression was 0.83. Variance inflation
factor for 3 parameters showed that 3 parameters were not
correlated with each other (Table 3).
● DISTRIBUTION OF DISTANCE BETWEEN CILIARY SUL-
CUS-TO-SULCUS PLANE AND ANTERIOR CRYSTALLINE
LENS SURFACE: The mean STSL was 0.31 ⫾ 0.18 mm.
The maximum and minimum values were 0.68 and -0.04
mm, respectively. The distribution of STSL values is
shown in Figure 2.
● VALIDATION OF REGRESSION EQUATION: Patient de-
mographics are shown in Table 3, and postoperative vaults
are summarized in Table 4. The mean postoperative vault
was 0.64 ⫾ 0.25 mm. The maximum and minimum vaults
were 0.19 and 1.33 mm, respectively. The mean vault error
(postoperative vault ⫺ predicted vault) was -0.06 ⫾ 0.29
mm. The minimum and maximum vault errors were -0.7
and 0.57 mm, respectively. Seventy-two of 81 eyes
(88.9%) had a vault in the range from 0.15 to 1.0 mm.
Sixty of the 81 eyes (74.1%) had a vault in the range
from 0.25 to 0.75 mm.
● COMPARISON WITH PREVIOUSLY REPORTED NOMO-
GRAM (STAAR AND DOUGHERTY’S NOMOGRAM): The
postoperative vault in the current study was compared with
the predicted vault if STAAR sizing nomogram or Dough-
erty’s nomogram were applied to determine ICL size. A
summary of the analysis is shown in Table 4. The distri-
bution of vault in the current study differed significantly
from the distribution of predicted vault if STAAR or
Dougherty’s nomogram was applied (vs STAAR: P ⬍ .001;
vs Dougherty’s nomogram: P ⫽ .036).
● COMPLICATIONS: No eyes showed crystalline lens
opacity or pupillary block during the follow-up period
after ICL implantation surgery. At 3 months after
surgery, gonioscopic observation showed no peripheral
anterior synechia or pigment dispersion even in high-
vault cases.
VOL. 153, NO. 4 OPTIMIZATION OF IMPLANTABLE
Standardized Partial
Regression Coefficient P Value VIF
0.599 ⬍.001 2.727
0.477 ⬍.001 1.873
0.530 ⬍.001 1.807
DISCUSSION
IN THE PRESENT STUDY, STSL WAS MEASURED AS A NEW
parameter. The mean STSL was 0.31 ⫾ 0.18 mm. The
minimum and maximum STSL values were -0.04 and 0.69
mm, respectively. Judging from these values, STSL was not
a clinically ignorable parameter. In fact, stepwise regres-
sion analysis determined that STSL was one of the
explanatory variables to predict optimal ICL size. Varia-
tion in STSL values was observed in the present cases. To
further optimize the ICL sizing equation, it is worth
investigating what kinds of factors determine the STSL
value in future studies.
In the present study, multiple regression analysis re-
vealed that ACD, STS, and STSL were explanatory
variables for optimal ICL size prediction. Dougherty and
associates reported a different equation that used STS and
ICL power as explanatory variables.12 This conflict with
the present study can be explained as follows: in the
present study, most patients were highly myopic, and
myopia less than 8 D was seen in only 1 case. In our clinic,
ICL surgery is chosen if patients are not suitable for laser in
situ keratomileusis (LASIK) surgery. Therefore, most can-
didates for ICL surgery are highly myopic or have thin
corneas. There are more and more patients with low
myopia undergoing ICL surgery, and a previous study has
shown that ICL is safer and more effective than LASIK,
even in patients with low myopia.16 If patients with a wide
range of refractive errors were enrolled in the present
study, ICL power might have been an explanatory variable.
Future studies with larger numbers of patients and includ-
ing eyes with a wider range of refractive errors will optimize
the newly developed regression equation.
In relation to the formation of a moderate postoperative
vault, the newly developed equation was superior to
previously reported nomograms (STAAR and Dougherty’s
nomogram). However, 9 of 81 eyes (11.1%) still showed a
high vault. Even if gonioscopic observation shows no
peripheral synechia and pigment dispersion, long-term
follow-up is needed. In the current study, mean keratometric
COLLAMER LENS SIZING 635
FIGURE 2. Distribution of the distance between the ciliary sulcus-to-sulcus plane and the anterior crystalline lens surface (STSL)
measured by high-frequency ultrasound biomicroscopy. The mean distance between the ciliary sulcus-to-sulcus plane and anterior
crystalline lens surface was 0.31 ⴞ 0.18 mm (maximum, 0.69 mm; minimum, -0.04 mm).

TABLE 4. Comparison of Postoperative Vault in the Current Study With Predicted Vault if STAAR Sizing Nomogram or
Dougherty’s Nomogram Is Applied to Determine Implantable Collamer Lens Size

Low Vault Vault Moderate Vault 0.15 mm High Vault 1.0

⬍ 0.15 mm ⱕ vault ⱕ 1.0 mm mm ⬍ vault P Value

Distribution of 3-month postoperative vault in the current 0 (0%) 72 (88.9%) 9 (11.1%) Current equation vs STAAR
study, number of eyes (percentage) nomogram: P ⬍ .001
Distribution of predicted vault when ICL size was 13 (16.0%) 54 (66.7%) 14 (17.3%) Current equation vs
calculated by STAAR nomogram, number of eyes Dougherty’s nomogram:
(percentage) P ⫽ .036 STAAR
Distribution of predicted vault when ICL size was 6 (7.4%) 69 (85.2%) 6 (7.4%) nomogram vs
calculated by Dougherty’s nomogram, number of eyes Dougherty’s nomogram:
(percentage) P ⫽ .022

ICL ⫽ implantable collamer lens.

value, axial length, STS, STSL, and ICL spherical power
were considered explanatory variable candidates for predic-
tion of optimal ICL size. There are other possible explanatory
variable candidates, such as iridocorneal angle, crystalline
lens thickness, crystalline lens radius, and detailed design of
ICL. Further validation of the equation is needed with
inclusion of other ocular and ICL parameters in the future.
In the present study, it was assumed that ICL was fixed in
the ciliary sulcus. A previous study by García-Feijoó and
associates, using UBM, showed that haptics were folded and
impacted in the ciliary body in some cases.17 If ICL was not
fixed in the sulcus, the present equation could not achieve an
optimal ICL vault. Future investigations to improve the
fixation method of ICL should be performed.
There are limitations to the present study. The regres-
sion equation was developed from a relatively small num-
ber of cases. Even if the R2 of the regression was high, a
larger number of cases is needed to optimize the equation.
Moreover, all of the patients in the present study were
Japanese. It is possible that there is variation in terms of
anatomic features of the ciliary sulcus between ethnic
groups, and the present regression equation should be
carefully applied with this in mind in different patient
populations. Previous studies also have shown that inter-
examiner variation of STS measurements by UBM was
relatively high while intra-examiner variation was low.14 If
STS measurements are carried out by several examiners,
inter-examiner variation should be validated before mea-
surement values are applied to select ICL size.
Although the lower limit of vault was reported by
Gonvers3 to be 0.15 mm, there is no evidence on how high
a vault is acceptable. Since a high vault can cause angle
closure, the association between ICL vault and iridocor-
neal angle also should be evaluated in future studies.
The ICL is manufactured with 0.5-mm increments in
length. This means, then, that if an ICL with 0.5 mm

636 AMERICAN JOURNAL OF OPHTHALMOLOGY APRIL 2012

longer size is chosen, the vault can theoretically become In conclusion, the present study developed and evalu-
0.55 mm (0.5 ⫻ 1.1) higher. To achieve optimal vault, ated a novel regression equation for choosing ICL size.
ICL lengths with 0.25-mm increments are preferable to This equation is a promising tool that can be used to
those with 0.5-mm increments. achieve appropriate vault after ICL implantation surgery.

THE AUTHORS INDICATE NO FUNDING SUPPORT OR FINANCIAL CONFLICTS OF INTEREST. INVOLVED IN DESIGN AND
conduct of the study (T.K., T.N., K.I.); collection, management, analysis, and interpretation of the data (T.K., S.Y., M.I., R.H., S.H.); and preparation,
review, or approval of manuscript (T.K., S.Y., M.I., R.H., S.H., T.N., K.I.). The protocol of this study was approved by the Institutional Review Board
of the Nagoya Eye Clinic and the study procedures conformed to the ethical principles for research involving human subjects as outlined in the
Declaration of Helsinki. Informed consent was obtained from all subjects after receiving an explanation of the nature and possible consequences of taking
part in the study.

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 Biosketch
Takashi Kojima received his medical degree at Nagoya University School of Medicine. He completed a research fellowship
with Prof. Dimitri Azar at Massachusetts Eye and Ear Infirmary, Harvard University and Department of Ophthalmology,
University of Illinois at Chicago. Dr Kojima focused on basic and clinical research in relation to the dry eye diseases,
contact lens and refractive surgery.

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