Original Article

Influence of Donor Thickness on Visual Acuity in
Descemet’s Stripping Automated Endothelial

Keratoplasty

Tomislav Kuzman, MD, PhD; Ana Meter, MD, PhD; Miro Kalauz, MD, PhD; Sanja Masnec, MD, PhD; Ivan Škegro,
MD, PhD; Ivana Jonjić, MD

Department of Ophthalmology, University Hospital Center Zagreb, Zagreb, Croatia

ORCID:
Tomislav Kuzman: https://orcid.org/0000-0002-7137-5059

Ivana Jonjic: https://orcid.org/0000-0003-1740-9198

Abstract

Purpose: Conventional Descemet’s Stripping Automated Endothelial
Keratoplasty (DSAEK) is a corneal transplantation procedure where the patient’s
inner dysfunctional layer is replaced with donor lamella. The data currently
present in the literature about the correlation between lamellar thickness and
visual acuity is sometimes contradictory and lacks clarity.
Methods: Study included 55 eyes that underwent the conventional DSAEK
procedure. Patients had no other comorbidities that could affect visual acuity.
Data about lamellar thickness and visual acuity were measured six months after
surgery with anterior segment optical coherent tomography (A5-OCT).
Results: The results show that visual acuity before surgery improved from 0.82 to
0.25 logMAR after surgery. Better visual acuity of 0.20 logMAR was achieved with
postoperative lamellas thinner than 124 μm, while statistically significantly lower
visual acuity of 0.29 logMAR was gained with postoperative lamellas thicker than
124 μm.
Conclusion: Our results suggest that the goal after conventional DSAEK is to
have postoperative lamellas thinner than 124 μm in the eye, as this will result in
better postoperative visual acuity. This value represents the optimal thickness for
conventional DSAEK surgery that could minimize tissue loss for eye banks and
surgeons may experience fewer problems during surgery, while obtaining good
final visual acuity.

Keywords: Cornea; Corneal Transplantation; Descemet Stripping Endothelial Keratoplasty;
Fuchs’s Endothelial Dystrophy

J Ophthalmic Vis Res 2022; 17 (4): 462–469

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Donor Thickness and VA in DSAEK ; Kuzman et al

INTRODUCTION

The first contact with the outside world through
light transition begins in the cornea which also acts
as the first barrier against infection. Thus, millions
of people around the world who suffer from corneal
scarring may experience total or partial vision loss
if remain untreated.[1]

Cornea is a multilayered organ composed of the
epithelium, stroma, and endothelium. The corneal
epithelium is the most anterior nonkeratinized, five
to six cells thick layer.[1] The stroma is resilient,
collagenous tissue arranged in sheets of fibrils
called lamellae. The corneal endothelium is the last
but not the least barrier comprising one layer of the
cells incapable to regenerate after damage.

The most common diseases causing endothelial
damage are Fuchs’s endothelial dystrophy and
pseudophakic bullous keratopathy. Fuchs’s
endothelial dystrophy is a slowly progressive
disease that usually affects both eyes; more
common in women in later life. The key
pathophysiological moment is the decay of
the endothelial cells that causes increased
accumulation of fluid and subsequently edematous
stroma leading to cloudy cornea.

The pathophysiological mechanism responsible
for bullous keratopathy is the inability of the corneal
endothelium to maintain a normally dehydrated
cornea. The corneal endothelium trauma can occur
after cataract surgery, excessive flow of fluid during
surgery, high dissipated ultrasound energy during
emulsification of hard cataracts or after applying
intracameral agents.[2–4] The term pseudophakic
bullous keratopathy is used in the occurrence
of bullous keratopathy in patients who have had
intraocular lens insertion after phacoemulsification
(PHACO) surgery. The innovative improvements in
corneal transplant surgery has made it possible
today to replace the diseased layers of the
recipient cornea.

Correspondence to:

Ivana Jonjić, MD. Department of Ophthalmology,
University Hospital Center Zagreb, Kišpatićeva St., 12,
10000, Zagreb, Croatia.
Email: ivanajonjic91@gmail.com
Received: 04-03-2021 Accepted: 21-03-2022

Access this article online

Website: https://knepublishing.com/index.php/JOVR

DOI: 10.18502/jovr.v17i4.12296

Lamellar endothelial keratoplasty has replaced
penetrating keratoplasty (PK) as the standard
for treating endothelial corneal diseases. The
most common surgical technique is Descemet
stripping automated endothelial keratoplasty
(DSEAK) which has rapidly become the preferred
alternative to PK because of its smaller incision
size, faster rehabilitation, and minimal induction
of astigmatism and refractive shift.[5–7] DSAEK
employs mechanical stripping of the host
endothelium and replaces it with a healthy
homograft of posterior corneal lenticule harvested
using an automated microkeratome.[6] Advantage
of DSAEK over PK includes preservation of
biomechanical corneal properties because there
is no need for corneal stitches.[8]

Further development in DSAEK graft preparation
encouraged toward more delicate and thinner
lamellas, so surgeons could use nano-thin (< 50
μm), ultra-thin (< 100 μm), or conventional (> 100
μm) grafts.[9] Surgeons’ special requests to eye
banks for thin and ultra-thin graft thickness have
led to real implications including: increased risks
of tissue loss during graft processing, and during
the logistics of tissue distribution with increased
associated costs and pricing for special tissue
processing.[10] Over time, there has been a change
in the definition of subtypes of the DSAEK method
depending on the thickness of the lamella. As
confirmed by a recent study, the conventional and
ultra-thin DSAEK methods’ definitions have been
confirmed by 56% of experienced surgeons who
defined donor lamellar thickness <100 μm as ultra-
thin DSAEK and lamellar thickness >100 μm as the
conventional DSAEK method. Conventional DSAEK
is the most used keratoplasty procedure in the
United States.[11]

The data currently present in the literature
about the correlation between lamellar thickness
and the visual acuity is sometimes contradictory
and lacks clarity [Table 1]. Many authors found that

This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

How to cite this article: Kuzman T, Meter A, Kalauz M, Masnec
S, Škegro I. Influence of Donor Thickness on Visual Acuity
in Descemet’s Stripping Automated Endothelial Keratoplasty . J
Ophthalmic Vis Res 2022;17:462–469.

JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 17, Issue 4, October-December 2022 463

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Donor Thickness and VA in DSAEK ; Kuzman et al

there is correlation between final visual acuity
and thickness of donor lamella, concluding that
transplanting thinner donor lamellas result in
better visual acuity.[6, 8, 10, 12–14] On the other hand,
there are also many authors whose results found
no correlation between postoperative lamellar
thickness and visual acuity after DSEAK surgery,
suggesting that donor graft thickness did not
influence final visual acuity.[15–20] Some authors, for
example, Tourabaly et al in recent papers suggest
that there were no significant differences in final
visual acuity between all investigated groups with
varied postoperative lamellar thickness which
includes lamellas from nano-thin grafts (15–49 μm)
all through to very thick group of grafts (150–250
μm).[20] Such significant inconsistencies inspired
this research. This research would encourage more
accurate and explicit definitions of prospective
criteria when selecting the conventional DSEAK
method. In addition, when performing DSEAK
operations, more consideration would be paid
toward frame design and focusing on establishing
clearer lamellae thickness criteria which would
encourage improved tissue safety, technical
concerns, and result in better surgical outcomes
such as enhanced visual acuity improvement.
However, preparation and handling of thinner
grafts would not be without challenges;[8] such
as determining whether the surgeons in an
effort to easily perform surgical procedures while
achieving optimal visual outcomes for their patients
should insist on creating thinner graft tissue, or
determining how thin the donor lamellas should
be in order to avoid tissue loss during preparation.

METHODS

The study was approved by the Ethics Committee
of University Hospital Centre Zagreb (approved
19.09.2017.; Reference number: 02/21 AG). All
patients signed the informed consent form to
take part in the study. The study was performed
according to the ICMJE recommendations for
protection of research participants and adhering to
the newest revision of the Helsinki Declaration.

Subjects

This prospective case series study enrolled
55 eyes of patients. Criteria for eligibility were
Fuchs endothelial dystrophy (26 patients) and

pseudophakic bullous keratopathy (29 patients),
that underwent DSAEK. The average patient age
was 70.9 +/– 9.4 years. The study excluded patients
with other illnesses that might have affected visual
acuity, such as macular degeneration, macular
edema, diabetic retinopathy, visual nerve damage,
postoperative complications and glaucoma. Eyes
with preoperative lamellar thickness of <100 μm
were also not considered for the study because
tissue processing for ultra-thin or nano-thin DSAEK
is not performed in our eye bank as it requires a
more intricate procedure which is different from
what is utilized in conventional standard DSAEK
procedure.

Patient follow-up was six months with the
100% enrollment all through the study. Informed
consents were obtained from all patients enrolled
in the study.

Each patient underwent a complete
ophthalmology examination preoperatively and at
six months post treatment which included: best-
corrected visual acuity (BCVA; Early Treatment
Diabetic Retinopathy Study [ETDRS] chart –
logMAR table), Goldmann aplanation tonometry,
Slit-lamp examination and fundus evaluation.
Information about the thickness of cornea and
lamella were examined by anterior segment OCT
Visante (Carl Zeiss Meditec, Jena, Germany).

The corneas were stored in the University
Hospital Centre Zagreb Eye Bank in either
hypothermic storage or tissue culture media.
Corneas in a hypothermic storage medium were
stored at a temperature of 4ºC for a maximum
of seven days, and were then prepared for
lamellar keratoplasty immediately before planned
operation. The other corneas were kept in a
tissue culture media at a temperature of 31ºC for
a maximum of 28 days. During storage in tissue
culture, the media was microbiologically controlled.
At the end of storage, the endothelial cell viability
and morphology were determined. Corneas during
storage in tissue culture becomes much thicker.[21]
To return to the physiological thickness, it must be
stored in a transport media containing dextran, for
at least for 24 hr before the preparation for lamellar
keratoplasty. Due to the short corneal validity in the
transport media (depending on the manufacturer,
Alchemy five days, Eurobio four days), the cornea
were placed in the transport medium only when
assigned to patient. The transport medium was
kept until the third microbiological control that
was taken in the incubator at 31ºC. After taking

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Donor Thickness and VA in DSAEK ; Kuzman et al

Table 1. Influence of lamella thickness on visual acuity with data regarding to the author, number of patients, method of
measurement, and lamellar thickness.

Author N Method Avg lamella preop
(µm)

Avg lamella postop
(µm)

Influence of lamella
thickness on visual acuity

Pogorelov et al[6] 15 Postop slit-lamp,
AS OCT

191 100 Yes

Maier et al[10] 65 AS OCT 169 153 Yes

Neff et al[12] 33 AS OCT / 131 Yes

Dickmann et al[8] 79 AS OCT / 97 Yes

Busin et al[13] 279 AS OCT Intraop / 78 Yes

Roberts et al[14] 130 Preop US Post AS
OCT

95 90 Yes

Cleyenenbreugel et
al[19]

37 Preop US 175 / No

Woodward et al[16] 64 Post AS OCT 199 165 No

Terry et al[15] 418 Preop US Post AS
OCT

162 / No

Phillips et al[17] 144 Preop US Post AS
OCT

145 / No

Ivarsen et al[18] 125 Post AS OCT / 149 (n = 11) 183 (n = 19) No

Tourabaly et al[20] 150 Post AS OCT / 74 No

N, number of patients; US, ultrasound pachymetry; AS OCT, anterior segment optical coherence tomography; Avg lamella
preop, average lamellar thickness preoperative; Avg lamella postop, average lamellar thickness postoperative

Table 2. Arithmetic mean and associated standard deviation, median and total range of at least to the highest value for variables
of best-corrected visual acuity (BCVA) before and after surgery (six months follow-up) *P < 0.05.

Surgery M (SD) C TR (Min–Max)

BCVA Before 0.15 (0.107) (0.82 logMAR) 0.10* 0.50 (0.10–0.60)

After six months follow-up 0.57 (0.202) (0.25 logMAR) 0.60* 0.75 (0.10–0.60)

BCVA, best-corrected visual acuity; M, arithmetic mean; SD, standard deviation; C, central value; TR, total range; *P < 0.05

the last microbiological control, it was kept in the
thermostat at 22ºC until release. The procedure
for preparing corneas for lamellar keratoplasty
was performed by specially trained employees
using the automatic microkeratome (Gebauer Slc
Original, Neuhausen, Germany). Each cornea was
placed on the artificial eye chamber filled with
corneal storage media to preserve the endothelial
cell viability. The epithelium of each cornea was
removed to make the cut as precise as possible.
The permissible variation of the knife, which was
30 μm, should be considered. The cornea was
carefully removed from the artificial eye chamber
and stored in a transport media for delivery to
transplantation center.

All patients underwent DSAEK and were
operated in University Hospital Centre Zagreb,
Croatia. The DSAEK was performed by one
surgeon using a standardized operative technique.
All surgeries were performed under general
anesthesia. The patients with Fuchs dystrophy and
cataract underwent combined phacoemulsification
and DSAEK surgery. Descemet stripping was
performed under air bubble or with use of
viscoelastic during combined procedures.
Implantation of lamella was performed with
use of Busin glider to minimize tissue trauma. The
lamella was attached with air bubble.

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Donor Thickness and VA in DSAEK ; Kuzman et al

Table 3. T-test for differentiated lamellar thickness between preoperative and postoperative determined according to the
lamellar thickness.

Lamellar thickness (µm) N M (SD) t-test

BCVA ≤124 28 (50.9%) 0.63 (0.162) (0.2 logMAR)
>124 27 (49.1%) 0.51 (0.221) (0.29 logMAR) 2.390*

*P < 0.01

t-test, test for paired samples; M, arithmetic mean; SD, standard deviation; BCVA, best-corrected visual acuity

Statistics

Microsoft SPSS statistical package for Windows
was used. Results were expressed as mean
value and standard deviation (SD). Differences
between the groups were tested by Student’s t-
test. A P-value of<0.05 was considered statistically
significant.

RESULTS

The current study included a total of 55 eyes of
55 patients (34 female, 61.8%) aged 48 to 73 years.
The average age was 70.9 years.

Table 2 shows the data of descriptive statistics
(arithmetic mean and associated standard
deviation, median and total range of at least to the
highest value) for variables of visual acuity before
and six months after surgery. The preoperative
BCVA ranged from a minimum of 1.00 logMAR to
a maximum of 0.22 logMAR and postoperatively
from 1.00 logMAR to 0.07 logMAR. The average
BCVA before surgery was 0.82 logMAR while
after surgery improved to 0.25 logMAR which was
statistically significant (P < 0.05 t-test for pair
samples).

Subjects were divided in two groups: above or
under the donor lamella thickness median after
surgery (C = 124 μm) in order to determine whether
the visual acuity was statistically significant to the
lamellar thickness. We observe them as a group of
50% of the subjects below and the group of 50% of
the subjects above the central value (C = 124 μm).
Table 3 shows 28 subjects (50.9%) had a lamella
thickness of 124 μm or less, while for the remaining
27 subjects the lamella was above 124 μm. There
was a statistically significant difference in the mean
values of these two groups (t = 2.390 P < 0.01).
Better visual acuity of 0.20 logMAR was achieved
with lamellas thinner than 124 μm, while statistically
significant lower visual acuity was 0.29 logMAR for
lamellas thicker than 124 μm.

DISCUSSION

The results of our study show that in conventional
DSAEK, donor lamella thickness correlates with
the BCVA, suggesting that thinner lamellae may
result in better visual acuity. All factors related to
visual acuity improvement are being intensively
investigated as endothelial keratoplasty has
become more widely used today than full
corneal PK when treating corneal endothelial
disease.[22, 23] DSAEK, unlike PK, provides faster
recovery, less postoperative eye irritation, less
postoperative refractive error, better visual acuity,
and less invasive eye surgery.[24] The method
of transplanting only the Descemet membrane
called DMEK (Descemet membrane endothelial
keratoplasty) was introduced as an improvement
to the technique of endothelial keratoplasty. In
DMEK, only Descemet’s endothelial membrane
without adjacent stroma is transplanted. DMEK
gives superior results of postoperative visual
acuity compared to DSAEK or PK.[25, 26] Through
experience, it became clear that the thin part
of the stroma transplanted in DSAEK affects the
poorer visual acuity compared to DMEK. Unlike
DSAEK, DMEK although a better method in terms
of final visual acuity is not still the most popular
due to the long learning curve and the complexity
of the operative technique.[25, 27, 28] As DSAEK
became the method of choice for the treatment
of endothelial diseases of majority of surgeons,
they tried to reduce the thickness of the lamella
to catch up with the visual acuity results achieved
with DMEK. Although many methods have been
developed to prepare extremely thin lamellas in a
nonstandard way, they have not yet entered into
wider application. Further developments in the
preparation of lamellas for DSAEK successfully
created thinner lamellas, resulting in lamellas
characterized as nano-thin lamellae thinner than
≤50 μm, then ultra-thin lamellae thinner than ≤100

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Donor Thickness and VA in DSAEK ; Kuzman et al

μm, and conventional lamellae thicker than ≥100
μm.[9] In addition to the special techniques required
in preparing ultra-thin lamellae, there are increased
risks of tissue loss in tissue processing, logistics,
and distribution with increased tissue processing
costs.[10] Our research dealt with the lamellae that
define the conventional DSAEK method, which
is implemented by most eye banks in the world.
However, even conventionally prepared lamellas
can vary in their thickness from 100 to 250 μm.
Although it is much safer for eye bank staff to cut a
thicker lamella because the possibility of damage
to the transplant is less and although it is easier
for the surgeon to manipulate the thicker lamella
during surgery, it is still debatable as to whether
transplanting thicker donor lamellas results in the
same visual acuity as the thin ones.

Studying the literature, we came across several
researchers who tried to determine whether there
was any correlation between postoperative visual
acuity and the thickness of the lamellae used
to perform the keratoplasty procedures [Table 1].
After processing our results, we concluded that
with conventional DSAEK, surgeons should strive
toward selecting lamellae thinner than 124 μm
because better visual acuity is achieved, potential
tissue loss during eye bank preparation is not
influenced, and is sufficient for safe manipulation
during surgery. In our study the improvement of
visual acuity was from an average of 0.82 logMAR
before surgery to 0.25 logMAR after surgery [Table
2]. However, patients with thinner lamellae below
124 µm achieved better visual acuity of 0.20
logMAR than those with lamellae thicker than 124
µm with an acuity of 0.29 logMAR [Table 3]. The
average postoperative visual acuity after DSAEK
in similar studies generally ranged from 0.45 to
0.15 logMAR and corroborates with our results
confirming the success of the procedure itself.[29]

Our results have been deemed comparable
with other studies that support the thesis that
thinner lamellae selected for DSAEK procedures
are better for achieving improved visual acuity.
Our conclusions were similar with Pogorelov’s
research which included 15 respondents with
deturgescence of donor lamellas from 191 to 100
μm six months after surgery.[6] Deturgescence
of donor lamella begins after implantation
in the eye and continues for several months.
Postoperative thickness of lamella stabilizes six
months after surgery, which is why we performed
final measurements at that time. Although the

study of Maier et al was retrospective, almost
identical results were obtained when compared
with our study. Their study was conducted on
65 eyes and showed that lamellar thickness of
<120 μm correlated with better visual acuity.[10]
Neff et al also obtained similar results in their
retrospective study on 33 eyes, and concluded
that donor lamellas below 131 μm resulted in
better visual acuity.[12] Dekaris et al conducted
a similar study and concluded in a 20 subjects
that lamellae thinner than 180 μm facilitates
better and faster visual recovery than thicker
grafts, although measurements were made on
the first postoperative day and postoperative
deturgescence was not taken into account.[30]

There are various studies that suggest that
where thinner donor lamellas, in most cases
ultra-thin lamellas, were utilized in performing
keratoplasty procedures the resultant visual acuity
was better as compared to those that utilized
thicker lamellas. Although comparative research
studies focused on using ultra-thin lamellas, it
still supports our thesis even though alternative
operative techniques were used. Busin conducted
research in 108 eyes and concluded that visual
acuity after UT-DSAEK was comparable to DMEK
but better than conventional DSAEK.[13] This
research is interesting because it showed that
visual acuity was better after the application of
thin lamellae. However, this research is related to
ultra-thin lamellae prepared by a special technique
of double-lamella cutting, which is currently not
performed in every eye bank. A similar study was
conducted by Roberts et al who developed a
special technique for preparing ultra-thin lamellae
by using the donor tissue dehydration method. This
prospective study of ultra-thin lamellae on a group
of 130 eyes concluded that thinner donor lamellae
transplantation achieve better visual acuity that is
close to the results of DMEK transplantation.[14]

Cleynenbreugel et al measured lamella
thickness in 37 eyes by ultrasound pachymetry
intraoperatively and concluded that lamella
thickness had no direct effect on visual acuity
or endothelial cell count.[19] This study does
not take into account postoperative lamella
deturgescence.[31] Woodward et al performed a
retrospective review on 64 eyes and concluded
that there was a poor correlation of BCVA at
the final visit with preoperative or postoperative
lamella thickness.[16] Possible reasons for this
conclusion can be found in the large postoperative

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Donor Thickness and VA in DSAEK ; Kuzman et al

range of lamellae from 88 to 335 μm, and various
postoperative thickness measurement time. Terry
et al conducted a retrospective study on 418 eyes
and obtained similar results to our study for a group
of lamellae with a range of 80 to 124 μm that had
better visual acuity, but eventually concluded that
in a large group of lamellae between 100 and 200
μm donor lamella thickness has a weak association
with postoperative visual acuity.[15] The mentioned
research was limited as preoperative thickness
was measured without taking deturgescence
into account. A study conducted by Phillips et
al on 144 eyes found no correlation between
lamella thickness and visual acuity, but the authors
compared preoperative thickness of the lamella
with postoperative visual acuity.[17] Tourabaly
et al in recent papers suggest that there were
no significant differences in final visual acuity
regardless of lamellar thickness from 15 to 250
μm.[20]

It can be concluded that there are studies that
confirm our research, while those that reflect
the opposite are usually comparing preoperative
lamella thickness with postoperative visual acuity.
These studies that don’t support our research
also do not take into account postoperative
deturgescence which may contribute toward
thinning of the lamella in the eye which stabilizes
from four to six months after surgery.[6, 32]

Some researchers are also focusing on
alternative factors that could affect visual acuity
in DSAEK. Ivarsen et al investigated the influence
of light scattering and total corneal thickness of
the recipient on the visual outcome after DSAEK.
This study conducted on 125 eyes focused more
on corneal densitometry after transplantation,
and the authors believe that changes in corneal
structure and potential unwanted light scattering at
the donor graft and cornea recipient interface are
more important for final vision quality than lamella
thickness alone.[18] Khakshour et al concluded in
a group of 16 eyes that there was a significant
correlation between lamellae and corneal interface
reflection and visual acuity, emphasizing that
higher order corneal aberrations have negative
influence on visual acuity.[33] Graffi et al evaluated
the relationship between graft thickness, regularity,
and visual acuity in 89 eyes and concluded that
DSAEK grafts thinner than 100 μm are also more
regular than thicker ones, and that in Fuchs
endothelial dystrophy thinner grafts result in better
visual acuity.[34]

Further research is recommended in
determining which qualities of the lamellae,
that is, either the thickness of the lamellae and
their respective architecture or the interface with
the recipient’s cornea are responsible for better
visual acuity postoperatively. Our results suggest
that the goal after conventional DSAEK is to have
postoperative lamellas thinner than 124 μm in the
eye, as this will result in better postoperative visual
acuity. This value can be the optimal thickness for
conventional DSAEK surgery that could minimize
tissue loss for eye banks and the surgeons
could have fewer problems during surgery, while
obtaining good final visual acuity.

Ethical Considerations

This study was approved by the Ethics Committee
of University Hospital Centre Zagreb (approved
19.09.2017.; Reference number: 02/21 AG). All
patients signed the informed consent form to
participate in the study.

Financial Support and Sponsorship

None.

Conflicts of Interest

There are no conflicts of interest.

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JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 17, Issue 4, October-December 2022 469