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array:24 [ "pii" => "S2173579422000548" "issn" => "21735794" "doi" => "10.1016/j.oftale.2022.03.008" "estado" => "S300" "fechaPublicacion" => "2022-07-01" "aid" => "1987" "copyright" => "Sociedad Española de Oftalmología" "copyrightAnyo" => "2022" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Arch Soc Esp Oftalmol. 2022;97:376-80" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0365669122000156" "issn" => "03656691" "doi" => "10.1016/j.oftal.2021.10.005" "estado" => "S300" "fechaPublicacion" => "2022-07-01" "aid" => "1987" "copyright" => "Sociedad Española de Oftalmología" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Arch Soc Esp Oftalmol. 2022;97:376-80" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artículo original</span>" "titulo" => "Epiteliopatía en limpiaparabrisas en pacientes con blefaroespasmo o espasmo hemifacial" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "376" "paginaFinal" => "380" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Lid wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 578 "Ancho" => 905 "Tamanyo" => 78485 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Graduación de la epiteliopatía del limpiaparabrisas. Afectación horizontal<span class="elsevierStyleHsp" style=""></span>> 10<span class="elsevierStyleHsp" style=""></span>mm (grado 3), afectación sagital<span class="elsevierStyleHsp" style=""></span>> 75% de la zona correspondiente al limpiaparabrisas (grado 3). Puntuación total es la media aritmética, en este ejemplo: grado 3 o grave.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.D. Romero-Caballero, M.P. Salmerón Ato, A. Palazón-Cabanes, A. Caravaca-Alegría" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M.D." "apellidos" => "Romero-Caballero" ] 1 => array:2 [ "nombre" => "M.P." "apellidos" => "Salmerón Ato" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Palazón-Cabanes" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Caravaca-Alegría" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173579422000548" "doi" => "10.1016/j.oftale.2022.03.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579422000548?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669122000156?idApp=UINPBA00004N" "url" => "/03656691/0000009700000007/v1_202207010747/S0365669122000156/v1_202207010747/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173579422000275" "issn" => "21735794" "doi" => "10.1016/j.oftale.2022.02.007" "estado" => "S300" "fechaPublicacion" => "2022-07-01" "aid" => "1986" "copyright" => "Sociedad Española de Oftalmología" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Arch Soc Esp Oftalmol. 2022;97:381-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Validation of the color graduation scale in the optical nerve photograph, an alternative for qualitative classification" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "381" "paginaFinal" => "385" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Validación de la escala de graduación del color en la fotografía del nervio óptico, una alternativa para la clasificación cualitativa" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 568 "Ancho" => 2341 "Tamanyo" => 107798 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Subjective rating of evaluators.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Morales Domínguez, Ó.L. Teherán Forero, M.M. Ochoa-Díaz, E.C. Ramos Clason" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Morales Domínguez" ] 1 => array:2 [ "nombre" => "Ó.L." "apellidos" => "Teherán Forero" ] 2 => array:2 [ "nombre" => "M.M." "apellidos" => "Ochoa-Díaz" ] 3 => array:2 [ "nombre" => "E.C." "apellidos" => "Ramos Clason" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669122000144" "doi" => "10.1016/j.oftal.2021.10.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669122000144?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579422000275?idApp=UINPBA00004N" "url" => "/21735794/0000009700000007/v1_202206300612/S2173579422000275/v1_202206300612/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173579422000767" "issn" => "21735794" "doi" => "10.1016/j.oftale.2021.11.002" "estado" => "S300" "fechaPublicacion" => "2022-07-01" "aid" => "1996" "copyright" => "Sociedad Española de Oftalmología" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Arch Soc Esp Oftalmol. 2022;97:370-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Limits of the precision in refractive results after cataract surgery" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "370" "paginaFinal" => "375" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Límites de la precisión en el resultado refractivo tras la cirugía de cataratas" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1264 "Ancho" => 1507 "Tamanyo" => 83462 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Percentage of eyes in each error range for the ideal situation and the situation described by Melles et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> with the Barrett Universal-II. In the ideal situation the percentage of eyes between ±0.50D of the refractive target was 91.93% while for the situation described by Melles et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> it was 78.55%.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Romero Valero, J. Escolano Serrano, C.E. Monera Lucas, G. Castilla Martínez, J.J. Martínez Toldos" "autores" => array:5 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Romero Valero" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Escolano Serrano" ] 2 => array:2 [ "nombre" => "C.E." "apellidos" => "Monera Lucas" ] 3 => array:2 [ "nombre" => "G." "apellidos" => "Castilla Martínez" ] 4 => array:2 [ "nombre" => "J.J." "apellidos" => "Martínez Toldos" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669122000399" "doi" => "10.1016/j.oftal.2021.11.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669122000399?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579422000767?idApp=UINPBA00004N" "url" => "/21735794/0000009700000007/v1_202206300612/S2173579422000767/v1_202206300612/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Lid wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "376" "paginaFinal" => "380" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M.D. Romero-Caballero, M.P. Salmerón Ato, A. Palazón-Cabanes, A. Caravaca-Alegría" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M.D." "apellidos" => "Romero-Caballero" "email" => array:1 [ 0 => "mdromero@um.es" ] "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.P." "apellidos" => "Salmerón Ato" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Palazón-Cabanes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Caravaca-Alegría" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital General Universitario Reina Sofía, Murcia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neurología, Hospital General Universitario Reina Sofía, Murcia, 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" => "Epiteliopatía en limpiaparabrisas en pacientes con blefaroespasmo o espasmo hemifacial" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 574 "Ancho" => 905 "Tamanyo" => 59087 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Epitheliopathy in the palpebral wiper area stained with lissamine green. The arrows delimit the vertical involvement between the Marx line or mucocutaneous junction (upper arrow) and the subtarsal fold (lower arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The palpebral wiper is a small conjunctival area that is in close contact with the ocular surface during blinking. Its main function is to provide an adequate distribution of the tear film on the ocular surface and its corresponding cleaning.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This region extends sagittally from the mucocutaneous junction line or line of Marx to the subtarsal fold and longitudinally from the lacrimal point to the external canthus.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Macroscopically it is very small, but microscopically it is lined by various transitional epithelia. The line of Marx represents the change from keratinised stratified squamous epithelium (typical of the palpebral skin) to non-keratinised squamous epithelium. This, in turn, evolves into a proper conjunctival epithelium, which is stratified columnar, with the presence of accessory lacrimal glands and mucin-producing caliciform cells.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This tarsal conjunctiva receives sensory innervation from the trigeminal nerve and, like the cornea, is very uncomfortable in the face of aggression or inflammatory processes.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">LWE (<span class="elsevierStyleItalic">lid wiper epitheliopathy</span>) is an inflammatory disease compromising the epithelium of said conjunctiva. The underlying pathophysiological mechanism that triggers LWE is twofold: on the one hand, the existence of a lubricant film of poor quality or insufficient thickness to separate the surfaces and, on the other hand, an increased coefficient of friction between the surfaces.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> The involvement of the epithelium of this dynamic surface produces in affected patients symptoms similar to other inflammatory diseases of the ocular surface such as dry eye, but without the associated clinical signs.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Currently, there is no study reflecting the presence of LWE in patients with increased blink frequency. The aim of this study was to demonstrate and grade the presence of wiper epitheliopathy in patients with hemifacial spasm or essential blepharospasm before and 4 weeks after infiltration with periocular botulinum toxin A.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">A longitudinal and prospective study was designed including 31 eyes corresponding to 20 patients (15 females and 5 males) with a previous neurological diagnosis of hemifacial spasm (9 eyes of 9 patients) and essential blepharospasm (22 eyes of 11 patients), who were undergoing routine treatment with botulinum toxin type A in this hospital.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Inclusion and exclusion criteria</span><p id="par0025" class="elsevierStylePara elsevierViewall">Patients over 18 years of age with a diagnosis of hemifacial spasm or essential blepharospasm under treatment with botulinum toxin A, but untreated for at least 6 months were included.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Exclusion criteria were being a contact lens wearer, having undergone any eyelid disease, corneal refractive surgery or intraocular surgery in the 6 months prior to the study. All patients were duly informed and freely consented to participate in this study. The research protocol followed the principles of the Helsinki declaration. In addition, the study was approved by the Ethics and Clinical Research Committee.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Toxin infiltration technique</span><p id="par0035" class="elsevierStylePara elsevierViewall">Allergan® Botox® 100 units (U) (Irvine, USA) was used. Each vial was reconstituted with 2 ml of preservative-free sterile saline just prior to infiltration, so that each 0.1 ml of the resulting product had 5 U of active toxin. The medication was applied by a single expert, by injection into the orbicular muscle at 4 points of the eyelids and also into the corrugator and procerus muscles between the eyebrows with a 30 G needle. For the treatment of hemifacial spasm, infiltrations were also performed in the involved facial muscles (zygomaticus major and buccal orbicularis oris, among others).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ophthalmological examination</span><p id="par0040" class="elsevierStylePara elsevierViewall">Patients were evaluated before toxin injection and 4 weeks after toxin injection. Said evaluation comprised the <span class="elsevierStyleItalic">Ocular surface disease index</span> (OSDI) questionnaire, to grade symptomatology into normal-mild (score < 22) and moderate-severe (score > 23); visual acuity corrected with Snellen optotypes and decimal scale measurement; Schirmer's test without anesthesia (normal > 10 mm) and a biomicroscopic examination including tear break-up time (normal BUT > 10 s) and vital staining with 1% single-dose fluorescein and 1% lissamine green in magistral formula. The drops were instilled sequentially 5 min apart and, after 2 min, the entire ocular surface was assessed for conjunctival and corneal staining using the Oxford scale. After everting the upper eyelid, the wiper area was observed with a slit lamp and cobalt blue light (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) to assess horizontal and vertical staining using the scale published by Korb.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The amount of horizontal staining was categorised into 4 grades: grade 0, staining 2 < mm; grade 1 or mild, staining between 2 and 4 mm; grade 2 or moderate, staining between 5 and 9 mm and grade 3 or severe, if >10 mm. Similarly, vertical staining was assessed as grade 0 if staining affected an area of the total wiper blade <25%; grade 1 or mild if it occupied between 25% and <50%; grade 2 or moderate if staining between 50 and <75% and grade 3 or severe if >75%. The total score for each eye was calculated using the arithmetic mean of horizontal and vertical involvement (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Descriptive statistics were calculated for the parameters under study, and the t for Student test for paired data was used to compare quantitative variables. The Wilcoxon signed ranks test for paired data was used to compare semi-quantitative variables. Statistically significant differences were found when <span class="elsevierStyleItalic">p <</span> 0.05. The statistical package Stata version 14 (StataCorp. 2015. <span class="elsevierStyleItalic">Stata Statistical Software: Release 14.</span> College Station, TX: StataCorp LP).</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The mean age of the participants was 54.8 ± 5.8 years. Of the 20 patients included, 15 were female (75%) and 5 were male (25%); a total of 31 eyes were part of the study, 9 eyes of 9 patients with hemifacial spasm and 22 eyes of 11 patients with essential blepharospasm.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Corrected visual acuity before infiltration with botulinum toxin was 0.7 ± 0.2 and 4 weeks later it was 0.8 ± 0.1, a parameter with statistical significance (<span class="elsevierStyleItalic">p <</span> 0.01) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Before infiltration with periocular toxin, OSDI was scored as normal-mild in 15 patients (75%) and moderate-severe in 5 patients (25%). After 4 weeks of infiltration, 16 patients (80%) had a normal-mild OSDI score, while 4 patients (20%) were moderate-severe, without statistical significance (<span class="elsevierStyleItalic">p =</span> 0.07).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The mean Schirmer’s test before infiltration was 11.4 ± 5.5 mm and 4 weeks later 12.5 ± 4.5 mm. The mean BUT obtained before infiltration was 7,2 ± 1.6 s and after toxin was 7.5 ± 0.7 s. No significant differences were found for these parameters (<span class="elsevierStyleItalic">p =</span> 0.578 and <span class="elsevierStyleItalic">p =</span> 0.288, respectively).</p><p id="par0065" class="elsevierStylePara elsevierViewall">Dye staining assessed with the Oxford scale was normal in 30.7%, grade 1 in 61.5% and grade 2 in 7.8% at initial examination and after infiltration 46% of cases were normal, while 54% were grade 1 for this test. Wiper involvement was present in 100% of the patients before toxin treatment and was scored as mild in 30% of the eyes and moderate in 70%. After 4 weeks of treatment, wiper impairment was mild in 100% of the eyes under study. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the mean values and standard deviation of the parameters under study before and after application of periocular toxin.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Blinking is an involuntary reflex action that occurs between 10 and 20 times per minute; therefore, physiologically, humans blink between 3,000 and 15,000 times a day.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> There are special situations that increase the frequency of blinking both physiologically (in the face of danger or stress) and pathologically (in facial dystonia). Essential blepharospasm and hemifacial spasm are facial dystonia that affect the quality of life of patients, as they can lead to permanent closure of the eyelids and cause functional blindness. In addition, increased blink rate can trigger mechanical trauma to the wiper epithelium (LWE) and the ocular surface in these patients and lead to chronic inflammation of the ocular surface.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Visual acuity in patients with blepharospasm and hemifacial spasm improves significantly after toxin treatment. This improvement is probably secondary to changes in the corneal curvature which is, together with the tear, the primary refractive surface of the eye. It is known that the mechanical action exerted by the eyelid on the corneal surface can mould the anterior surface of the cornea. This capacity for corneal remodelling by palpebral pressure has been widely reported in patients with lagophthalmos and palpebral weights,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> blepharoptosis,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> palpebral<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> massage, vernal<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> conjunctivitis or palpebral tumours, among other causes.</p><p id="par0080" class="elsevierStylePara elsevierViewall">While in the general population the prevalence of ocular surface disease is estimated at 5–30%, in patients with blepharospasm or hemifacial spasm it is higher: 25% exhibit moderate to severe symptomatology assessed with the OSDI questionnaire. Only one patient (20%) improved after blink relaxation with the toxin. The poor improvement in symptomatology is probably due to the short time elapsed after application of the toxin and, therefore, the limited regenerative capacity of the wiper conjunctiva in this short period of time. The prophylactic use of thicker artificial tears in these patients would provide greater relief of their symptomatology. In addition, initiating short- or long-term anti-inflammatory treatment with corticosteroids or cyclosporine may be indicated in some patients.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The amount or volume of tears assessed by the Schirmer test is hardly modified after the cessation of blinking due to the action of the toxin: in more than 80% of the eyes an adequate amount is observed, as well as the BUT. Although previous studies report that there are no alterations in the tear film after the application of toxin in these patients,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> other studies carried out with confocal microscopy show that in patients with blepharospasm the sustained spasmodic contraction of the orbicularis muscle causes morphological alterations in the structure of the Meibomian glands, reducing the acinar area and producing irregularity in the glandular acini, among other anomalies.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> These changes in the acinar structure of the glands together with the decrease in glandular expression actively carried out by the orbicularis muscle must be taken into account, as they could worsen the clinical situation of these patients in the long term, causing Meibomian gland dysfunction and alterations in tear stability.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Korb et al. described a new inflammatory ocular surface disease affecting the epithelium of the marginal portion of the tarsal conjunctiva of the upper eyelid as wiper epitheliopathy (LWE)<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and, although initially described in contact lens wearers, it has been found to be present in other ocular surface diseases such as dry eye.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The prevalence of this disease in contact lens wearers is 67–80% in symptomatic patients and 13–32% in asymptomatic patients.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> In patients with dry eye, the prevalence is also high: 88% in symptomatic patients and 16% in asymptomatic patients. In patients with essential blepharospasm or hemifacial spasm, palpebral wiper impairment affects 100% of patients both at baseline and after toxin treatment, although there is a significant improvement in the degree of impairment. This study also found significant differences between the staining of the ocular surface as assessed by the Oxford scale before and after application of periocular toxin. It should be taken into account that in these patients the coefficient of friction is very high and therefore there is a greater possibility of erosion of the ocular surface and the wiper area. Although this study presents short-term results (4 weeks after treatment) and accordingly the possibilities of conjunctival epithelium regeneration in such a short time are scarce, it reveals the importance of reducing the friction coefficient to improve the condition of the ocular surface in these patients.</p><p id="par0095" class="elsevierStylePara elsevierViewall">It can be concluded that the most important pathophysiological mechanism in the production of wiper epitheliopathy in patients with blepharospasm or hemifacial spasm is the increase in the friction coefficient since, as in other studies, our results reveal a tear film of normal volume and quality. Accordingly, tt is therefore necessary in these patients to continue chronic treatment with botulinum toxin and it is advisable to add a thicker tear gel, whether or not they show symptoms, in order to avoid or delay the possible aggression in this small area of the ocular surface.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0100" class="elsevierStylePara elsevierViewall">This research has not received specific support from public sector agencies, the commercial sector or non-profit organisations.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">No conflicts of interest were declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1740874" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1535374" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1740873" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1535373" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Inclusion and exclusion criteria" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Toxin infiltration technique" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Ophthalmological examination" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-05-24" "fechaAceptado" => "2021-10-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1535374" "palabras" => array:4 [ 0 => "Blepharospasm" 1 => "Hemifacial spasm" 2 => "Lid wiper epitheliopathy" 3 => "Ocular surface" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1535373" "palabras" => array:4 [ 0 => "Blefaroespasmo" 1 => "Espasmo hemifacial" 2 => "Epiteliopatía en limpiaparabrisas" 3 => "Superficie ocular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To evaluate the presence of wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm before and 4 weeks after routine treatment with botulinum toxin.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Prospective study comprising 31 eyes of 20 patients with neurological diagnosis of hemifacial spasm (9 eyes of 9 patients) and essential blepharospasm (22 eyes of 11 patients). Various ocular surface parameters were assessed before and 4 weeks after infiltration with botulinum toxin using the OSDI questionnaire, Schirmer's test, tear break-up time (BUT), fluorescein and lissamine green staining assessed with the Oxford test and the degree of involvement of the palpebral wiper.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">100% of the patients had palpebral wiper involvement before (30% mild and 70% moderate) and after toxin treatment (100% mild). 75% of patients had mild-normal OSDI before treatment, after treatment it was 80%. The BUT was 7.2 ± 0.2 sg before and 7.5 ± 0.7 sg after treatment. Schirmer’s test was 11.4 ± 5.5 and 12.5 ± 5.5 mm before and after treatment. The Oxford test was initially pathological in 69.3% of patients, after 4 weeks it was pathological in only 54%.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Wiper epitheliopathy is present in 100% of patients with blepharospasm and/or hemifacial spasm. The main pathophysiological mechanism that triggers it in these patients is the increase in the coefficient of friction, as tear volume and stability are normal.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Evaluar la presencia de epiteliopatía en limpiaparabrisas en pacientes con blefaroespasmo y/o espasmo hemifacial antes y 4 semanas después del tratamiento habitual con toxina botulínica.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo compuesto por 31 ojos de 20 pacientes con diagnóstico neurológico de espasmo hemifacial (9 ojos de 9 pacientes) y blefaroespasmo esencial (22 ojos de 11 pacientes). Se evaluaron antes y 4 semanas después de la infiltración con toxina botulínica diversos parámetros de superficie ocular con el cuestionario OSDI, test de Schirmer, tiempo de ruptura lagrimal (BUT) y tinciones de fluoresceína y verde lisamina valoradas con el test de Oxford y el grado de afectación del limpiaparabrisas palpebral.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El 100% de los pacientes presentaron afectación del limpiaparabrisas palpebral antes (30% grado leve y 70% moderado) y después del tratamiento con toxina (100% grado leve). El 75% de pacientes presentaron un OSDI normal-leve antes del tratamiento, después del tratamiento fue del 80%. El BUT fue de 7,2 ± 0,2 sg antes y de 7,5 ± 0,7 sg después del tratamiento. El test de Schirmer fue de 11,4 ± 5,5 y 12,5 ± 5,5 mm antes y después del tratamiento. El test de Oxford resultó patológico inicialmente en el 69,3% de los pacientes, tras 4 semanas solo fue patológico en el 54%.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La epiteliopatía en limpiaparabrisas está presente en el 100% de los pacientes con blefaroespasmo y/o espasmo hemifacial. El principal mecanismo fisiopatológico que la desencadena en estos pacientes es el aumento en el coeficiente de fricción, ya que el volumen y estabilidad lagrimal son normales.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Romero-Caballero MD, Salmerón Ato MP, Palazón-Cabanes A, Caravaca-Alegría A. Epiteliopatía en limpiaparabrisas en pacientes con blefaroespasmo o espasmo hemifacial. Arch Soc Esp Oftalmol. 2022;97:376–380.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 574 "Ancho" => 905 "Tamanyo" => 59087 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Epitheliopathy in the palpebral wiper area stained with lissamine green. The arrows delimit the vertical involvement between the Marx line or mucocutaneous junction (upper arrow) and the subtarsal fold (lower arrow).</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" => 578 "Ancho" => 905 "Tamanyo" => 81166 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Grading of wiper epitheliopathy. Horizontal involvement >10 mm (grade 3), sagittal involvement >75% of the wiper area (grade 3). Total score is the arithmetic mean, in this example: grade 3 or severe.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">AVCSC: visual acuity with correction; BUT: tear break-up time; LWE: wiper epitheliopathy; OSDI: ocular surface disease index; SD: Standard deviation.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Before treatment (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">After treatment (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Significance level (<span class="elsevierStyleItalic">p <</span> 0.05) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AVCSC (decimal scale) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.7 ± 0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 ± 0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BUT (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.2 ± 1.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.5 ± 0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.288 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Schirmer test (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.4 ± 5.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.5 ± 4.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.578 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">OSDI score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.3 ± 10.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.2 ± 8.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.071 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oxford stain score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.7 ± 0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 ± 0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.008 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 ± 0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.7 ± 0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LWE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Comparison of parameters under study before and 4 weeks after botulinum toxin application.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "TFOS DEWS II pathophysiology report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.J. 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