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Alió" "autores" => array:1 [ 0 => array:2 [ "nombre" => "J.L." 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Alañón Fernández, M. Alañón Fernández, F. Alañón Cárdenas, B. Marín González, V. Cueva-López" "autores" => array:5 [ 0 => array:4 [ "nombre" => "F.J." "apellidos" => "Alañón Fernández" "email" => array:1 [ 0 => "fealfe1@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Alañón Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Alañón Cárdenas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "B." "apellidos" => "Marín González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "V." "apellidos" => "Cueva-López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Instituto Lacrimal Internacional, Jaén, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidad de Jaén, Jaén, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mejora de la planificación de las cirugías lagrimales a partir de imágenes tridimensionales con el visualizador DICOM Horos®" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1135 "Ancho" => 1583 "Tamanyo" => 239069 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Acute dacryocystitis secondary to maxillary tumour.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">One of the pillars of lacrimal surgery is its structural knowledge. Managing anatomical individuality is fundamental to increase safety and obtain a good result.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The application of intraoperative X-rays began in the 1960s with two-dimensional (2D) equipment, which was not suitable for planning lacrimal surgery and its complex anatomical relationships with the facial skeleton due to overlapping images.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Up to now, images obtained by dacryocystography and two-dimensional computed tomography (DCG-CT) require a mental recreation and subjective interpretation by surgeons of the pathology to be operated on and its relationship to the surrounding tissue.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Improvements in the acquisition of images and their analysis with specific software have made it possible to study these variables and interactively plan the surgical intervention, enabling knowledge of the conformation and disposition of the anatomical structures of the lacrimal duct prior to surgery with the greatest possible orientation and precision. Its objective is to mark the specific reference structures in the surgical field that allow us to access the lacrimal sac in a precise manner, anticipating foreseeable difficulties during the surgical act, dispensing with trial and error manoeuvres, increasing surgical success, avoiding iatrogenic collateral damage and reinterventions.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Intraoperative surgical navigators provide a multiplanar view, but require these tasks to be performed in the operating theatre, which entails high material and time costs.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">New technologies allow clinicians to access the complete archive of images in digital imaging and communication in medicine (DICOM) format with the. dcm extension from their personal computers.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In 2015, the Horos® (Horos project) appeared, an open source programme that transforms an Apple Macintosh® computer into a DICOM workstation to process and visualise medical images<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> from multiple sources (MRI, CT, PET, PET-CT, SPECT-CT, ultrasound, etc.). The program is distributed under a GNU-type licence, and its code is openly available, completely free of charge and without advertising (adware). Horos® is more stable than its predecessors, with fewer unexpected crashes. It is 64-bit, so it is faster in image processing. It offers high reliability, allowing a maximum accuracy error of 0.3 mm. The surgeon can interactively view all slices by moving the axis crossing point in the surgical site. It performs linear area and volumetric measurements, establishes coordinates and trajectories, and performs the three-dimensional and multiplanar reconstructions with surface and volume simulation that it deems most convenient, avoiding the loss of valuable information generated in the process of image selection and printing by the radiology staff,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> which may not be the most useful for the surgeon. The aim of this paper is to present the use of Horos® software, through volumetric fusion of Dacryo-CT images: its 3D reconstruction performs a pre-surgical approach that can assist surgery quickly and safely, and provides a thorough post-operative follow-up in necessary cases.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material</span><p id="par0040" class="elsevierStylePara elsevierViewall">The surgical planning process with Horos® was evaluated in 174 consecutive complex lacrimal surgery procedures from March 2016 to March 2020 with the diagnoses of epiphora grade III–V on the Munk scale (n = 44), chronic dacryocystitis (n = 70) and acute dacryocystitis (n = 60) both first intention (n = 148) and reinterventions (n = 26).</p><p id="par0045" class="elsevierStylePara elsevierViewall">We define complex interventions<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> as cases with a history of facial trauma, absence of canaliculi, presence of diverticula, fistulas, dacryoliths, suspected tumours and intrasacral foreign bodies, lacrimal bone thicker than 1,500 μm, septal deviation, synechiae, polyposis, concomitant cysts and surgical reinterventions.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In this study, a comparison was made between three-dimensional and two-dimensional images of the following variables: ascending maxillary branch, agger nasi cells, uncinate process and middle turbinate insertion. The size of the lacrimal sacs and the thickness of the lacrimal bones were also quantified, in addition to identifying concomitant pathology adjacent to the excretory pathway.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The process begins with the transfer of the images from the CT equipment in DICOM files to the computer where the planning is to be carried out. The image is processed by selecting the region on which the intervention will be carried out, segmenting the bone on which the osteotomy will be performed, identifying the different anatomical references as is done in the surgical act, with the advantage that it allows the surgeon to perform it in the different planes of space.</p><p id="par0060" class="elsevierStylePara elsevierViewall">High resolution images are obtained that provide great information and visualisation of the surgical and post-surgical changes of the lacrimal duct, as well as the positioning and functionality of the different prostheses used in the same.</p><p id="par0065" class="elsevierStylePara elsevierViewall">This method allows the surgeon to analyse the complex lacrimal, maxillary and nasal anatomy by showing the relationships between bone and soft tissues<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In this way, customised surgical models can be produced.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The software is essential for measuring coordinates, distances, interpreting and relating angles of the surgical trajectories to be performed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), and contrasting tissues in high resolution. The surgeon reviews all the radiological slices and carries out the simulations as appropriate.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">All cases were evaluated by our team in a specific session prior to laser dacryocystorhinostomy (DCR) by completing a radiological imaging checklist. This session lasted an average of 10 min (range 8−16 min).</p><p id="par0080" class="elsevierStylePara elsevierViewall">Multiplanar (simultaneous axial, coronal and sagittal) and three-dimensional reconstruction was performed at different angles to plan surgery quickly and non-invasively. Distances to risk areas were measured and a meticulous surgical map was constructed, essential for successful surgery.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The evaluation of the potential improvements of 3D image-based surgical planning with Horos® was measured through the variables of clinical-radiological correlation and operative difficulties.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The surgical procedures were performed using images obtained with the ophthalmic microscope, optics and endoscopic instrumentation. The key anatomical points, the different phases of the technique and the usefulness of the crucial steps were noted preoperatively.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The clinical-radiological correlation was assessed by comparing the identifications made with SPSS version 26 (IBM SPSS Statistics®) according to the radiological checklist on conventional 2D plates with the pre-surgical identifications with Horos® and the microscopic and endoscopic findings intraoperatively.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In order to determine whether the Horos® viewer is better than the printed 2D images based on endoscopic and microscopic findings, the χ<span class="elsevierStyleSup">2</span> test was performed and the results studied. The PHI coefficient of association was used to calculate the correlation between the classic plates printed by the radiodiagnostic service and the three-dimensional reconstruction performed by the surgeons with a total of 0.239 (23.9%), a weak association, as the values are maximum at 1, with 0 being the minimum. In other words, there is not a very high direct dependence.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The surgeons (FAF and MAF) had to identify: canaliculi, lacrimal sac, lacrimal bone, nasolacrimal duct, size of the osteotomy and synechiae in the case of reinterventions, assess the nasal septum, agger nasi and its relationship with the lacrimal sac, the ethmoid ampulla, the ascending branch of the maxilla and its intersection with the unciform process (most frequent level of drainage at the level of the common canaliculus), the base of the skull and its relationship with the ethmoidal arteries, all of which are crucial anatomical structures.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Said surgeons were initially presented with the original 2D images printed on radiological plates. Subsequently, they viewed and processed them freely with Horos®. The percentage of correctly identified structures was measured for each of the two options.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0115" class="elsevierStylePara elsevierViewall">The CT study indicates that in most cases the axilla and uncinate cover part of the lacrimal fossa, while the lower and anterior parts are free for a surgical approach.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Optimal access to the maxillolacrimal suture line should involve incision of the uncinate process and its excision, opening access to the posterior border of the frontal process of the maxilla.</p><p id="par0125" class="elsevierStylePara elsevierViewall">It was found that 93% of the ostia formed with the laser were located at the vertex formed by the intersection of two structures: the ascending process of the maxilla and the unciform process, very close to both, 3% inside the maxillary line and 3% below this vertex, between the maxillary line and the unciform process, in no case inside the unciform process. Partial unciformectomy was required in 97% of cases to expose the sac.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The DICOM format improves the findings compared to conventional radiographs. There are significant differences in the symmetry of both techniques: χ<span class="elsevierStyleSup">2</span>exp = 18.207; p < 0.0001.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In the ascending maxillary branch, accuracy was superior with the three-dimensional imaging system: χ<span class="elsevierStyleSup">2</span>exp = 18.207; p < 0.0001.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In the agger nasi cells their definition was also superior with the virtual surgical planning system χ<span class="elsevierStyleSup">2</span>exp = 16.203; p < 0.0001.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The different positions of the uncinate apophysis were superiorly objectified with the Horos® programme χ<span class="elsevierStyleSup">2</span>exp = 21.247; p < 0.0001.</p><p id="par0150" class="elsevierStylePara elsevierViewall">At the middle turbinate insertion, the reference area, was best studied with volumetric image fusion χ<span class="elsevierStyleSup">2</span>exp = 21.989; p < 0.0001.</p><p id="par0155" class="elsevierStylePara elsevierViewall">The correlation between the two imaging tests was calculated and the PHI coefficient of association was used: for the maxillary ascending process: 0.239 (23.9%); for the agger nasi: 0.226 (22.6%); for the unciform process: 0.258 (25.8%), and for the middle turbinate: 0.262 (26.2%). According to the scale of their values, these variables obtained an agreement strength of excellent category in all comparisons.</p><p id="par0160" class="elsevierStylePara elsevierViewall">The mean lacrimal bone thickness in our patients was 1.3 mm (range 0.7–7.7), much higher than that described in previous studies without this diagnostic test and specific software.</p><p id="par0165" class="elsevierStylePara elsevierViewall">The lacrimal sac was measured craniocaudally (mean 8.78 mm [range 5.9–11]) and transverse (mean 4.4 mm [range 2.7–7]).</p><p id="par0170" class="elsevierStylePara elsevierViewall">Sinusitis coexisted in 28% of patients: 10% had maxillary sinusitis and 18% had occupancy of the ethmoid cells. Polyposis was found in 19% and turbinate pathology in the form of hypertrophy and atrophy in another 18%. In addition, mucous cysts in the nasal fossa were found in 9% of cases (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Dacryocystitis secondary to maxillary tumour was diagnosed in one patient (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">The surgical findings coincided in 98.27% of cases with the programme images in the reoperations, where the perilacrimal anatomy may be altered.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0180" class="elsevierStylePara elsevierViewall">The most important complications occur when the surgeon loses references during surgery, with consequent iatrogenic effects on surrounding tissues.</p><p id="par0185" class="elsevierStylePara elsevierViewall">CT is useful to study the bony and soft tissue configuration of the facial mass, and dacryocystography is the best test to study the lumen of the lacrimal duct; therefore, the combination of Dacryo-CT adds the advantages of both separately and provides information on the anatomical relationship of the excretory lacrimal duct with nearby structures, the functionality of the lacrimal duct and the level of obstruction.</p><p id="par0190" class="elsevierStylePara elsevierViewall">This mixed technique is indicated for the study of complex lacrimal problems.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13–15</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The proximity between tomographic slices for the study of the lacrimal duct sometimes generates very extensive studies, which are usually reviewed and summarised by the radiology staff in order to send only the slices that, according to their evaluation, suggest lesions. In this process, useful information for the pre-surgical study of the patient may be lost. Ideally, the surgeon should review the entire examination and create reconstructions in coronal, sagittal and three-dimensional projections according to each case.</p><p id="par0200" class="elsevierStylePara elsevierViewall">With Horos®, the visualisation and processing of DICOM images takes on a particularly relevant dimension for learning, teaching<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and non-invasive planning of lacrimal surgery, highlighting difficulties where additional surgical manoeuvres are required.</p><p id="par0205" class="elsevierStylePara elsevierViewall">It provides additional information on the degree of stenosis, the level of obstruction and the relationship with adjacent anatomical structures, regardless of the route used, i.e., external, endonasal or endocanalicular. With this programme, the rest of the structures not visible according to the approach route can be observed, and in cases with possible complexity, previously identified in the history and clinical examination, warning us of the anomalies and difficulties that we are going to find.</p><p id="par0210" class="elsevierStylePara elsevierViewall">The possibility of intraoperative consultation of the images processed with Horos® can in itself reduce the surgical time due to its precision, the high clinical-radiological correlation and the visualisation of the complete conformation of the anatomical structures on which we are going to act. Trial manipulations during surgery are avoided and the surgeon is assured.</p><p id="par0215" class="elsevierStylePara elsevierViewall">The time and effort invested in the preoperative evaluation of DICOM images with Horos® is less than the time and effort required to analyse 2D images or plates, and better results are obtained. It is evident that even specialists who are experts in producing three-dimensional mental reconstructions from 2D images benefit significantly from technological tools that facilitate this process, such as Horos®, especially with the rapid availability of tangible models that simulate real surgery.</p><p id="par0220" class="elsevierStylePara elsevierViewall">In the preoperative study, a study by Karlo et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> analysed the time and accuracy of CT and MRI image fusion with such software, performed by a neurosurgeon and radiologist, and found no clinically significant differences between the two.</p><p id="par0225" class="elsevierStylePara elsevierViewall">The average time required for fusion was less than 16 min in all cases.</p><p id="par0230" class="elsevierStylePara elsevierViewall">We have not compared the reinterventions with any control group, as the cases are complex or have been operated on previously by different surgeons, so there would be a bias.</p><p id="par0235" class="elsevierStylePara elsevierViewall">The bone thickness of our population was superior to previously published studies, perhaps due to better measurements on higher quality images. The extreme case of lacrimal bone of 7.7 mm corresponded to a patient with fibrous dysplasia.</p><p id="par0240" class="elsevierStylePara elsevierViewall">The resolution of a high-resolution dacryo-CT scan is between 1 and 2.5 mm between slices, and in the DICOM format, 0.3 mm. To be reliable, static slice vision processes require images no more than 2 mm apart. This would require a minimum of 100 to 200 frames per area and its entirety, which so far do not reach the ophthalmologist.</p><p id="par0245" class="elsevierStylePara elsevierViewall">The surgeon uses these images to establish surgical strategies in highly complex surgeries.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0250" class="elsevierStylePara elsevierViewall">Systematic use of Horos® for stand-alone viewing and processing of 3D tear images from DICOM files is straightforward and allows surgeons to perform procedures with significantly better perception in all three planes of space. It can provide greater accuracy and safety than using 2D images, thereby reducing trauma and surgical morbidity. In complex cases its use is probably the best cost-effective technique for diagnosis and surgical assessment.</p><p id="par0255" class="elsevierStylePara elsevierViewall">It represents an example of collaboration between surgeons, radiologists and engineers.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1583661" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1425289" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1583660" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1425288" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Material" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-10-24" "fechaAceptado" => "2020-12-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1425289" "palabras" => array:6 [ 0 => "Virtual reality" 1 => "Guided images" 2 => "DICOM viewer" 3 => "Navigation" 4 => "Lacrimal surgery" 5 => "Horos®" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1425288" "palabras" => array:6 [ 0 => "Realidad virtual" 1 => "Imágenes guiadas" 2 => "Visor DICOM" 3 => "Navegación" 4 => "Cirugía lagrimal" 5 => "Horos®" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The individual anatomic variation of the course of the lacrimal duct and surrounding structures requires the thorough knowledge of its three-dimensional configuration in order to perform the surgery in the safest and most efficient way. The aim of this study was to consider virtual surgical planning in order to improve dacryocystorhinostomies.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Horos® was used as a viewer and manager of DICOM-format images for multiplanar, three-dimensional (3D) reconstruction when planning 148 first-time lacrimal operations and 26 reoperations by laser endonasal and endocanalicular DCRs.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The 3D images of the CT dacryocystography were much better identified than the 2D ones, Horos® showing a statistically significant correlation (P < .0001). Over 98.27% of the images match the programme reconstruction. Less than 1.73% of them showed some discordance due to study distortion. These cases were related to trauma. The intraopearative location of the lacrimal system was very accurate, avoiding complications.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Viewing and studying 3D images, Horos® is a very useful tool for diagnosis and preoperative planning. It is very helpful in complex conditions by marking surgical references, locating the lacrimal sac and controlling the post-operative permeability of the lacrimal system. The information loss produced by the image selection is also avoided.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Another great advantage is that the programme is free.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La variación anatómica individual del trayecto de la vía lagrimal y estructuras adyacentes requiere disponer del mejor conocimiento posible de su configuración tridimensional para afrontar una cirugía con mayor seguridad y eficacia. El objetivo del trabajo fue estudiar la utilidad de la planificación quirúrgica virtual para la mejora en la realización de las dacriocistorrinostomías (DCR).</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se usó el programa Horos® como visualizador y gestor de imágenes en formato DICOM para reconstrucción multiplanar y tridimensional (3D) en la planificación de 148 cirugías lagrimales complejas de primera intención y 26 reintervenciones mediante DCR endocanalicular y endonasal con láser.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se identificaron más rápidamente y con mayor precisión en las imágenes en 3D de la dacriocistografía-TAC que con placas visualizadas en 2D, con una correlación clínico-radiológica estadísticamente significativa (p < 0,0001) a favor de Horos®. Más del 98,27% de las imágenes coincidieron con las reconstrucciones del programa; menos del 1,73% presentaron algún grado de discordancia por distorsiones en el estudio; estos casos fueron los secundarios a traumatismos. La localización intraoperatoria del sistema lagrimal fue muy precisa por la buena orientación, evitando complicaciones.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La mejora en la planificación prequirúrgica con utilización sistemática de Horos® para visualización y tratamiento de imágenes en 3D es una herramienta muy útil para el diagnóstico y planificación preoperatoria, facilita una cirugía segura en las patologías complejas, ya que marca referencias quirúrgicas y localiza el saco lagrimal, así como el control postoperatorio de la permeabilidad del aparato lagrimal. Evita la pérdida de información que se produce en la selección de imágenes.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">El programa es gratuito y evita costosos sistemas de navegación.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Alañón Fernández FJ, Alañón Fernández M, Alañón Cárdenas F, Marín González B, Cueva-López V. Mejora de la planificación de las cirugías lagrimales a partir de imágenes tridimensionales con el visualizador DICOM Horos®. Arch Soc Esp Oftalmol. 2021;96:509–514.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1394 "Ancho" => 1583 "Tamanyo" => 212028 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acute dacryocystitis and its relation to facial structures.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 913 "Ancho" => 1625 "Tamanyo" => 293962 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Lacrimal surgery patency, osteotomy and angulation study in new pathway with goniotrans (tool courtesy of Dr. Soler).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 933 "Ancho" => 1583 "Tamanyo" => 191926 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Enlarged lacrimal sac (red arrow) and deviation of the nasal septum to the right side (blue arrow).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1135 "Ancho" => 1583 "Tamanyo" => 239069 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Acute dacryocystitis secondary to maxillary tumour.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "El futuro próximo de la exploración por la imagen en oftalmología" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. 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