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Ortiz, V. Galvis, A. Tello, J.J. Miro-Quesada, R. Barrera, M. Ochoa" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Ortiz" "email" => array:1 [ 0 => "docaortizoft@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "V." "apellidos" => "Galvis" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Tello" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "J.J." "apellidos" => "Miro-Quesada" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "R." "apellidos" => "Barrera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Ochoa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento de Oftalmología, Fundación Oftalmológica de Santander (FOSCAL), Bucaramanga, Santander, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro Oftalmológico Virgilio Galvis, Floridablanca, Santander, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Universidad Autónoma de Bucaramanga (UNAB), Bucaramanga, Santander, Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Clorpromazina retrobulbar en el manejo del ojo doloroso ciego o con baja visión" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1469 "Ancho" => 1667 "Tamanyo" => 105008 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">IOP pre and post-application of retrobulbar chlorpromazine according to etiology of patients with painful blind eye FOSCAL 2015.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Painful blind or poor vision eye has a significant impact on the quality of life of patients. Frequently, it is the final outcome of many severe ocular diseases (ocular trauma, absolutely glaucoma, etc.).<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1–33</span></a> This is a relatively frequent issue for ophthalmologists and, despite available therapeutic options, sometimes said pain cannot be adequately controlled only with medical management. Before adopting a radical or surgical approach such as evisceration or enucleation,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">1</span></a> it is necessary to try measures that respect the ocular anatomy. These less invasive therapeutic options include retrobulbar application of different substances in order to interrupt nervous impulses in the sensitive fibers of the ciliary ganglion.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2–32</span></a> One of the techniques utilized for nearly a century was the application of absolute alcohol in various concentrations (from 33% to 95%).<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2–13</span></a> Subsequently, in the early 50s, an alternative technique appeared, consisting in a retrobulbar injection of chlorpromazine, a neuroleptic with antiemetic action the action mechanism of which is not fully understood but it has been related with membrane stabilization in the ciliary ganglion, produced significant analgesia with good tolerance and apparently less collateral effects.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">13–32</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The utilization of retrobulbar chlorpromazin as a therapeutic alternative in these cases is not very well known. The present study assessed the results of retrobulbar chlorpromazin injection in standard concentration (25<span class="elsevierStyleHsp" style=""></span>mg/2<span class="elsevierStyleHsp" style=""></span>ml) for the treatment of painful eye, either blind or with poor vision, evaluating its effect on pain, intraocular pressure (IOP) and associated complications.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Subjects, materials and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">After obtaining the approval of the local Ethics Committee, a longitudinal and retrospective study was carried out in the Virgilio Galvis Ophthalmology Center in the city of Bucaramanga (Colombia), from May 2009 up to March 2015. The study included 33 eyes of 33 patients with painful blind eye of diverse etiology.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Variables included the etiology of painful blind eye, topical or systemic medicaments previously applied, pain severity, pre-and post-application visual acuity, pre-and post-application intraocular pressure (taken with Goldmann tonometer [KAT Goldmann Tonometer, Keeler, Windsor, United Kingdom] or Schiötz [Schiötz Tonometer, Riester, Jungingen, Germany], in the case of irregularities in the ocular surface) and the complications that arose during application of subsequently. The pain was measured with an Analog Pain Scale (APS) from 1 to 10, with zero being in the absence of pain, increasing up to 10 for very severe pain. The results were grouped in the following categories: 0<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>no pain, 1–3<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>slight pain, 4–6<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>moderate pain, 7–9<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>severe pain, 10<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>very severe pain. These variables were evaluated 24<span class="elsevierStyleHsp" style=""></span>h postop, 3 months and subsequently once a year.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical technique</span><p id="par0025" class="elsevierStylePara elsevierViewall">The technique for the application of retrobulbar chlorpromazine initially consisted in a retrobulbar injection of anesthetic with a 5<span class="elsevierStyleHsp" style=""></span>cc syringe (1–4<span class="elsevierStyleHsp" style=""></span>ml lidocaine without epinephrine), utilizing a 40<span class="elsevierStyleHsp" style=""></span>mm 25<span class="elsevierStyleHsp" style=""></span>G needle. The syringe was withdrawn while the handle of the needle was held with tweezers, keeping it in the same position. Subsequently, a 3<span class="elsevierStyleHsp" style=""></span>cc syringe was coupled to the same needle for applying 2<span class="elsevierStyleHsp" style=""></span>ml (25<span class="elsevierStyleHsp" style=""></span>mg) of chlorpromazine chlorhydrate (generic, Laboratorios Biosano S.A., Santiago, Chile) at the retrobulbar level during one minute. Subsequently, ocular globe compression was applied (utilizing a weight full of mercury) during 5<span class="elsevierStyleHsp" style=""></span>min.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A database was designed and utilized in Excel 2011, United States, to register obtained variables which were subsequently exported to the statistical application for analysis (Statcal 7.1, Atlanta, United States). The demographic variables were analyzed with descriptive statistics utilizing quartiles, percentages, histograms and frequency distributions to characterize the scores given by the sample of the study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">The study included 33 eyes of 33 patients with painful blind eye diagnostic secondary to different etiologies (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) who visited the Virgilio Galvis Ophthalmological Center. The mean age of patients was 67.9 years (12–83 years); 66.7% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>22) were females and 33.3% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11) were males, 45.5% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>15) of eyes were right side and 54.6% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>18) were left eyes. The mean follow-up was 25 months (between 3 and 67 months).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In the first assessment, 50% of patients referred ocular pain above 8 in APS. Nine were administered topical management with cycloplegics (atropine) and 12 with cycloplegics (atropine) plus topical steroids. Pre-application visual acuity ranged between finger counting, bulk vision light perception and projection (LPP) and no perception of light (NPL). Of the 12 patients with residual vision prior to the application of chlorpromazine, 7 exhibited some degree of visual acuity impairment, 4 went from LP to NPL, one eye went from LPP to NPL, 2 eyes went from LPP to LP and one eye went up from finger counting to bulk vision (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">IOP went from a pre-application mean of 30.74<span class="elsevierStyleHsp" style=""></span>mmHg to a mean 22.45<span class="elsevierStyleHsp" style=""></span>mmHg in the latest checkup (27% reduction) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.003), with greater reduction in patients with neovascular and absolute glaucoma (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Out of the 33 eyes, 2 could not submit to IOP measurement due to marked ocular surface alterations, while 30% maintained high IOP and 70% exhibited diminished IOP.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In what concerns presurgery pain, 50% of patients expressed ocular pain above 8 in APS, with an interquartile range (IQR) between 5 and 10; the remaining 50% referred less pain (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). After the application, 29 of the 33 patients (87.9%) referred significant pain reduction in statistically significant proportions (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001), ranging from complete absence of pain up to moderate pain. Two patients with neovascular glaucoma and one with absolute glaucoma maintained severe pain. One of these was treated with retrobulbar application of absolute alcohol with slight improvement, another was treated with evisceration and the other was treated with supplementary cryotherapy with nearly complete pain remission.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The complications evidenced during the study (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) included 7 patients with some degree of diminished vision, 5 patients with slight complications comprising temporary palpebral ptosis (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3) and one of these cases remained unchanged up to the latest checkup and 2 patients exhibited slight palpebral edema associated to chemosis that resolved spontaneously. None of the patients exhibited systemic symptoms after the application.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Retrobulbar application of neurolytic substances (alcohol or chlorpromazine) has been useful for managing painful blind eyes for a long time due to the easy application of various substances close to the ciliary ganglion that produce degeneration, stabilization or blockage.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2–31</span></a> Systemic as well as local effects have been described as inherent to the administration of these substances, including direct optic nerve injury,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> injection of the substance in the meninges surrounding the optic nerve (with severe potential consequences including risk of death) and hematogenous distribution of the substance reaching dangerous concentrations at the systemic level. In a published case, the anesthetic applied prior to the alcohol injection produced a nearly complete blockage of the trigeminal nerve in a patient with a history of maxillary antrum radiotherapy.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> To ensure the adequate location of the needle in the retrobulbar space in the muscular cone it is essential to previously inject local anesthetic, although imaging tests such as radiography<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> or ecography<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">25,26</span></a> have been utilized as additional support techniques.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Retrobulbar injection of ethyl alcohol has been a therapeutic practice for nearly a century in painful blind eye cases, with variable results in diminishing pain intensity and duration.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2–12</span></a> In addition, side effects have been documented such as optical atrophy, palpebral ptosis, severe palpebral edema and chemosis, external ophthalmoplegia, cellulite, inflammatory orbital disease and neurotrophic keratopathy.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2–12</span></a> On the other hand, since 1953 researchers in Italy and Russia<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">14–16</span></a> started using retrobulbar chlorpromazine for managing painful blind eye. As from 1970, it was utilized in France<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">17</span></a> and since the 80s in the United States.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a> Its mechanism of action is not entirely clear but it is believed that, as chlorpromazine is a derivate of phenothiazine with neuroleptic and antipsychotic action and has a stabilizing effect on the post-synaptic membrane, it is able to stabilize the membrane inducing irreversible damage in the ciliary ganglion. However, other theories focus on toxic and lytic injury of retro-ocular sensitive fibers.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">13–32</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Retrobulbar chlorpromazine injection at the standard dose (25<span class="elsevierStyleHsp" style=""></span>mg in 1 or 2<span class="elsevierStyleHsp" style=""></span>ml)<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">13–32</span></a> has demonstrated to be an effective treatment for pain in patients with blind eyes of different etiology, with effects similar to those of alcohol according to a recently published control study by Galindo-Ferreiro et al. that compared the retrobulbar application of absolute alcohol versus chlorpromazine.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> Other authors have pointed out that it could have a higher rate of success in comparison with alcohol.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">19–22</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The results of the present study demonstrate effective pain control in 90% of the 33 cases, above the effectiveness generally reported for absolute alcohol (which in the literature varies between 20% and 87%).<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> The high percentage achieved in the present series is similar to other studies with chlorpromazine such as Fiore et al., who reported pain control in 82.5% of 63 cases with a mean follow-up of 2.6 years,<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a> and Bastrikov who reported pain control in 83.8% with even lower dosages of between 10 and 25<span class="elsevierStyleHsp" style=""></span>mg, in 56 patients with terminal glaucoma, avoiding enucleation.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">17</span></a> A multicenter study of 20 eyes published in 2002 that included cases in the United States and the Philippines with 18 amaurotic eyes and 2 maintaining perception of light that received 25<span class="elsevierStyleHsp" style=""></span>mg/ml of chlorpromazine reported that 80% of patients referred pain reduction which lasted over one year in 50%. As for the 2 patients that maintained some previous visual acuity, one patient maintained vision while the other one lost it after the procedure. In addition, a mean IOP reduction of 56.2–38.7<span class="elsevierStyleHsp" style=""></span>mmHg was reported the first day post-injection (31% reduction).<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">21</span></a> Other series reported similar studies in what concerns pain control.<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">24,27,28</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">However, other researchers have found lower effectiveness with chlorpromazine. In a series published in 2000 comprising 9 eyes, Estafanous et al. reported pain control in only 44% of cases.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a> In a recently published clinical trial comprising 32 cases, Galindo-Ferreiro et al. compared the retrobulbar application of 1.5<span class="elsevierStyleHsp" style=""></span>ml of absolute alcohol (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16) versus 1.5<span class="elsevierStyleHsp" style=""></span>ml of chlorpromazine chlorhydrate (25<span class="elsevierStyleHsp" style=""></span>mg) (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16) in patients with painful blind eye of various ideologies. Said authors found that only 6 out of 16 eyes (43.7%) treated with a retrobulbar chlorpromazine injection achieved complete control of said pain, although 10 of the 16 eyes (62.5%) achieved at least partial control.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> The numbers for retrobulbar alcohol injection were similar (43.7 and 68.8%, respectively).</p><p id="par0085" class="elsevierStylePara elsevierViewall">In 2014, Martínez et al. published their experience in the application of retrobulbar chlorpromazine at a dose of 25<span class="elsevierStyleHsp" style=""></span>mg in patients with absolute glaucoma and a five-year follow-up (43 casos). Said authors reported pain reduction from 9.3 to 2.7 out of 10 according to EVA, as well as IOP (in 35.9%) and also indicated that complications were few and not severe.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a> Previously, in 2009, the same authors had reported results with 3 months follow-up in a smaller series of patients (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>27) with similar results but a higher rate of severe complications, notably orbital cellulite in 5 patients (18.5%), 3 cases of lipothymia (11.1%), 2 cases of sphincter relaxation (7.4%) and one case of mental confusion. Milder complications such as palpebral edema and chemosis were reported in 8 (29.6%) and 4 cases (14.8%), respectively.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">24</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">AT the ARVO meeting in 2009, Sahr et al. reported a series of cases with 17 eyes who were administered lower concentrations (5<span class="elsevierStyleHsp" style=""></span>mg/ml) with 2% lidocaine, obtaining satisfactory results in 16 patients (94.12%). None referred pain during the applications. The complications included corneal ulcer in one case, with another patient referring several hours of sleepiness and one case of weakness, headaches, paleness, nausea and vomiting during a few minutes. Even though one patient required the second injection, in none of the cases it was necessary to perform more aggressive procedures.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In the 80s a publication reported a case of retrobulbar application of chlorpromazine in a patient with angle closure glaucoma and cataracts, achieving control of pain, and after removing the cataracts the patient achieved a visual acuity of 20/30.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a> However, these visual acuity levels were not reported in any other publication, among other reasons because at present in a painful eye with that visual potential said procedure is contraindicated due to the high risk of visual loss secondary to optic nerve compromise as well as to the risk of other complications. Other reports have documented diminished residual vision after chlorpromazine injection in percentages ranging between 40<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a> and 50% of cases.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">21</span></a> In the present study, 12 of the 33 patients had some remaining vision prior to the chlorpromazine injection (2 eyes had movement of hands, 2 had bulk vision, 4 had light perception and projection and a further 4 had perception of light). In the last checkup, 7 out of 12 patients (21%) has lost some visual acuity, while 4 lost perception of light, which matches the above-mentioned reports.</p><p id="par0100" class="elsevierStylePara elsevierViewall">As regards IOP, the present study found a reduction of approximately 27% in 30 of the 33 cases. This was slightly lower in comparison with similar studies.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> The 3 patients who did not exhibit diminished IOP (one of which had absolute glaucoma) required retrobulbar application of absolute alcohol, whereas the 2 remaining cases with neovascular glaucoma required supplementary treatment, one a cycle-destructive procedure and the other evisceration.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Nearly all series reported minor complications such as palpebral edema and chemosis, expressing in between 10 and 50% of cases.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">13–32</span></a> These are generally temporary conditions with slight-moderate severity, although some cases were severe enough to require tarsorraphy.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">23</span></a> Other series have reported neurotrophic corneal ulcers secondary to the compromise of nerve branches that innervate the cornea, leading to corneal anesthesia both for alcohol<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> and chlorpromazine.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">31</span></a> One reported complication of absolute alcohol injection was slight orbital inflammatory disease that was not evidenced with the use of chlorpromazine.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">30</span></a> In the present series, 54% of patients exhibited some complication, mainly slight and temporary palpebral edema and chemosis not requiring management, whereas 6% were significant although also temporary. In addition, 27% evidenced some degree of temporary palpebral ptosis except one case that remained unchanged up to the last checkup. As mentioned above, 21% exhibited some degree of reduction in their remaining vision.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In the present series, none of the patients exhibited post-application systemic symptoms. However, several cases series have reported symptoms such as lipothymia, nausea, palpitation and loss of sphincter control, possibly due to arteriolar infiltration or extravasation through the dural perioptical sheath.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">20,24,28,32</span></a> It is recommendable for all patients to undergo evaluations by cardiologists or anesthesiologists and for staff and patients to be aware that said events may arise.</p><p id="par0115" class="elsevierStylePara elsevierViewall">On the other hand, new alternatives have been implemented for treating painful blind eye, including the stellate ganglion blocking (6 weekly dosis of 4<span class="elsevierStyleHsp" style=""></span>ml 0.5% bupivacaine without vasoconstrictor and 1<span class="elsevierStyleHsp" style=""></span>mcg/kg clonidine). However, the results one year after application in 6 patients showed that only 2 remained asymptomatic.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion, retrobulbar chlorpromazine is a valid therapeutic alternative for managing painful blind eyes with very good success rates in pain control (equal to or better than absolute alcohol) and with a low rate of side effects. In addition, chlorpromazine exhibits the additional effect of diminishing IOP. For this reason, its use should be considered as part of a therapeutic options for said patients. However, the risk of local complications (including loss of residual vision, permanent ptosis) and systemic complications including lipothymia and nausea should be taken into account.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare the absence of any commercial conflict of interests and that they have not received financial support.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres818597" "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" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec815646" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres818596" "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" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec815645" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Subjects, materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Statistical methods" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusion" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-08-18" "fechaAceptado" => "2016-10-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec815646" "palabras" => array:5 [ 0 => "Chlorpromazine" 1 => "Blindness" 2 => "Eye pain" 3 => "Low visión" 4 => "Intractable pain" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec815645" "palabras" => array:5 [ 0 => "Clorpromazina" 1 => "Ceguera" 2 => "Dolor ocular" 3 => "Baja visión" 4 => "Dolor intratable" ] ] ] ] "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="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the results of applying retrobulbar chlorpromazine in the management of patients with painful blind eyes or with very poor vision.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective, descriptive review was carried out on the medical records of 33 patients who were treated with a retrobulbar injection of chlorpromazine (25<span class="elsevierStyleHsp" style=""></span>mg) for the management of painful blind eyes in <span class="elsevierStyleItalic">Centro Oftalmológico Virgilio Galvis</span>.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pain control was achieved in 90% of cases (with mean follow-up of 2.1 years). The mean intraocular pressure decreased by 37%. In 7 out of 12 eyes that maintained residual vision, loss of some degree of vision was acknowledged. One patient required an additional cyclodestructive procedure, another one required an absolute alcohol injection, and in an additional case evisceration surgery was necessary to achieve pain control. No serious complications were noted with this therapy.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Retrobulbar injection of chlorpromazine is a valid option in painful, blind eye cases (or with very poor vision) with a poor visual prognosis.</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" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar los resultados de la aplicación de clorpromazina retrobulbar en el manejo del ojo doloroso ciego o con muy mala visión.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realizó una revisión descriptiva retrospectiva de las historias clínicas de 33 pacientes que fueron tratados con inyección retrobulbar de clorpromazina (25<span class="elsevierStyleHsp" style=""></span>mg) en el Centro Oftalmológico Virgilio Galvis.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se logró un control del dolor en el 90% de los casos (con un seguimiento promedio de 2,1 años). La presión intraocular promedio disminuyó en un 37%. En 7 de los 12 ojos que mantenían visión residual se perdió algún grado en la visión. Un paciente requirió un procedimiento ciclodestructivo adicional; otro, una inyección de alcohol absoluto y otro terminó en evisceración para lograr el control del dolor. No se presentaron complicaciones serias con la terapia.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El empleo de la inyección de clorpromazina retrobulbar es una opción válida en casos de ojos dolorosos, con mal pronóstico visual.</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" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ortiz A, Galvis V, Tello A, Miro-Quesada JJ, Barrera R, Ochoa M. Clorpromazina retrobulbar en el manejo del ojo doloroso ciego o con baja visión. Arch Soc Esp Oftalmol. 2017;92:154–159.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 976 "Ancho" => 1620 "Tamanyo" => 81556 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Etiology of patients with painful blind eye. FOSCAL 2015.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1292 "Ancho" => 1516 "Tamanyo" => 75458 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Visual acuity pre- and post-application of retrobulbar chlorpromazine in patients with painful blind eye in FOSCAL 2015.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1469 "Ancho" => 1667 "Tamanyo" => 105008 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">IOP pre and post-application of retrobulbar chlorpromazine according to etiology of patients with painful blind eye FOSCAL 2015.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 930 "Ancho" => 1612 "Tamanyo" => 74909 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Post-op complications after application of chlorpromazine in patients with painful blind eye.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">RD, full retina detachment; APS, Analog Pain Scale.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "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="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Etiology</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">total RD</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Absolute glaucoma</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Neovascular glaucoma</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Others</th></tr><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pain \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">APS \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pre \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Post \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pre \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Post \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pre \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Post \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pre \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Post \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Slight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4–6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7–9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Very severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Total</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1375918.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Pain before and after application of retrobulbar chlorpromazine according to etiology in patients with painful blind eye, FOSCAL 2015.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:33 [ 0 => array:3 [ "identificador" => "bib0170" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Enucleation of blind, painful eyes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.L. 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