Adenoviral keratoconjunctivitis: An update | Archivos de la Sociedad Española de Oftalmología (English Edition)

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González-López, R. Morcillo-Laiz, F.J. Muñoz-Negrete" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J.J." "apellidos" => "González-López" "email" => array:1 [ 0 => "juliojose.gonzalez@live.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "Morcillo-Laiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "F.J." "apellidos" => "Muñoz-Negrete" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirugía, Facultad de Medicina, Universidad de Alcalá, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Queratoconjuntivitis adenovíricas: actualización" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Photography courtesy of Dr. Mateos Sánchez." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 776 "Ancho" => 1333 "Tamanyo" => 153473 ] ] "descripcion" => array:1 [ "en" => "Pseudomembranes in superior tharsal conjunctiva in patients with epidemic keratoconjunctivitis." ] ] ] "textoCompleto" => "IntroductionInfectious keratoconjunctivitis due to adenovirus is an extremely frequent ophthalmological disease produced by various serological subtypes of human adenovirus (HAV) which can present with various symptoms and signs. As there is no exact correlation between the HAV serotypes and the clinical expressions they produce, adenoviral keratoconjunctivitis (AKC) is the term used to define ocular surface infections produced by any of the known HAV serotypes.AKC comprises 2 clearly differentiated clinical syndromes, i.e., epidemic keratoconjunctivitis (EKC) and pharyngoconjunctival fever (PCF).The objective of this review is to summarize the clinical and epidemiological characteristics of AKC and to present a practical update on the diagnosis, treatment and prevention of said ocular infections.MicrobiologyAdenovirus were first described in 1953 by Rowe et al.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> who observed that the human lymphoid tissue suffered a characteristic spontaneous degeneration when maintained in culture several weeks after surgical extraction. In 1955, Jawetz et al.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> were the first to attribute the etiology of EKC to the infection of ocular surface tissue caused by HAV.Since their discovery, 51 different types of adenovirus have been described.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Among them, 7 have high affinity with the conjunctival epithelium and can produce AKC (serotypes 3,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> 4,<a class="elsevierStyleCrossRef" href="#bib0025">5</a> 7, 8,<a class="elsevierStyleCrossRefs" href="#bib0010">2,6</a> 11, 19,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> 37<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a>).Adenovirus are virus with double-stranded DNA having 90–100nm diameter, without cover and with icosahedral capsid having 20 sides and 12 vertices, made up of 252 subunits called capsomeres. DNA has a molecular weight of 23×106Da, and represents 10–15% of the virus mass.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>HAV are able to interact with human cells in 3 ways:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Lytic infection, involving epithelial cells. The virus completes its multiplication cycle, producing cellular death and releasing between 104 and 106 new viruses, of which between 1% and 5% are infectious.</li><li class="elsevierStyleListItem" id="lsti0010">-Latent infection, involving lymphoid cells such as those in which the virus was first isolated.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Only small amounts of virus are released and the cellular death rate is offset by normal multiplication.</li><li class="elsevierStyleListItem" id="lsti0015">-Oncogenic transformation. The viral DNA is included in the cellular genetic material and replicates inside it without producing a new infectious virus.</li></ul>HAV are very stable against chemical and physical agents as well as in adverse pH conditions. This allows them to survive for long periods of time outside the body and water. Studies have demonstrated that they are able to remain feasible maintaining infectious concentrations even after 28 days on a metal or plastic surface.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a>EpidemiologyAKC is one of the most frequent ocular diseases, exhibiting ubiquitous distribution. Due to its high frequency and that many of the cases do not obtain medical help it is impossible to develop precise statistics about its incidence. In addition, there are no reliable data about the social and health costs caused by this disease.HAV can give rise to epidemic outbreaks both in the general population and in hospital environments. In fact, AKC is the most frequent hospital ophthalmological disease.<a class="elsevierStyleCrossRefs" href="#bib0035">7,12</a> The incidence of AKC, particularly the one related to serotypes 3, 4 and 37, increases in summer when temperature rises.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> EKC outbreaks have been mainly associated to serotypes 8, 19 and 37, while PCF cases have been related more with serotypes 3, 7 and 11.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>The most frequent transmission of HAV is direct from person to person through the respiratory or fecal-oral pathways, although transmission can also occur through fomites. The virus can be easily isolated from ocular secretions of patients for at least 9 days since the onset of symptoms.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> In the ophthalmology practice there is a risk of transmission through contact tonometry, use of eyedrops and through the hands of health professionals.<a class="elsevierStyleCrossRefs" href="#bib0035">7,10,16</a> In the general population the risk of contagion from the patients to domestic contacts is of approximately 10%, with the risk increasing in cases of prolonged disease.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Clinical syndromesHAV infections can produce 2 different clinical syndromes with ocular involvement: EKC and PCF.Epidemic keratoconjunctivitisEKC is a form of conjunctivitis that produces epidemic outbreaks in hospitals,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> swimming pools,<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a> barracks, schools and other communities. The incubation period varies between 4 and 24 days and, even though it is likely that the disease is no longer contagious during this period, Kimura et al.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> did not find virus through the polymerase chain reaction (PCR) in conjunctival exudates obtained previously at the onset of symptoms. EKC is a slow onset and predominantly unilateral condition, although it can become bilateral in up to 70% of cases.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The most frequent symptoms are tearing, foreign body feeling and photophobia. The most frequent signs are predominantly bulbar conjunctival reddening (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) and in tharsal conjunctivitis the appearance of follicular reaction (more importantly in inferior tharsal conjunctivitis, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B and C), conjunctival chemosis, petechiae and even full subconjunctival hemorrhages. The duration of the inflammation varies between 1 and 4 weeks.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The appearance of pseudomembranes (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) is a frequent complication in patients with EKC, above all if the infection is caused by serotypes 8, 19 and 37.<a class="elsevierStyleCrossRefs" href="#bib0040">8,14</a> Pseudomembranes are clots of exudates firmly adhered to the upper and lower tharsal conjunctivae. It is possible to separate them from the underlying conjunctiva without damaging the epithelium by means of peeling, producing minor bleeding, if any.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The appearance of subepithelial infiltrates (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) is an additional frequent EKC complication which can be observed in up to 50% of cases. Said infiltrates a particularly frequent in serotype 8 infections.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> In addition, they are considered to be pathognomic of adenoviral infection and generally appear when the conjunctivitis begins to resolve. It is believed that these infiltrates are due to a cellular immune response against HAV antigens which remained trapped in the corneal stroma under Bowman's membrane.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> If the infiltrates involve the visual axis, photophobia and visual acuity loss can occur and, if untreated, they resolve within a period that can vary between weeks and months. Even though said infiltrates are sensitive to the use of topical corticosteroids, the improvement seems to be temporary and does not affect the long-term length of the process.<a class="elsevierStyleCrossRef" href="#bib0095">19</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Bacterian overinfection is not frequent but it could occur. The most frequently involved passive genes are gram-positive cocci such as Streptococcus pyogenes. Overinfection is particularly severe in children and could go as far as causing amblyopia.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>Pharyngoconjunctival feverPCF is a well-described syndrome attributed to HAV sub-gender B, particularly serotype 3<a class="elsevierStyleCrossRef" href="#bib0105">21</a> which causes small outbreaks, mainly among children. Outbreaks are frequent in schools, kindergartens and summer camps.PCF courses with an acute onset comprising fever, pharyngitis, rinitis, cervical adenopathies and bulbar and palpebral conjunctivitis with slight-moderate follicular reaction. The duration of the condition is of 3–5 days. Ocular inflammation also begins in one eye and generally becomes bilateral in the course of the disease. Bacterian overinfection and ocular complications are much less frequent than in EKC.The main sources of infection associated to PCF are contaminated waters of swimming pools and water reservoirs.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>DiagnosticThe diagnosis of these diseases is made usually on the basis of anamnesis and on the patient clinical findings. Differential diagnosis should include the following pathological processes:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">-Allergic conjunctivitis. Symptoms are generally similar in the early stages. However, allergic conjunctivitis is more frequently bilateral and symmetrical in addition to subacute or chronic course. These patients generally exhibit papillary conjunctival reactions which is more intense in the upper tharsal conjunctiva. Itching is the most characteristic symptoms of allergic conjunctivitis,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> whereas the foreign body feeling would indicate adenoviral origin.</li><li class="elsevierStyleListItem" id="lsti0025">-Herpetic conjunctivitis. These patients exhibit typically unilateral symptoms and complain more frequently about pain. Occasionally, the characteristic blisters can be seen in the conjunctiva and mainly in the skin of the eyelids. Herpetic conjunctivitis could include bacterian overinfection with greater frequency than adenoviral conjunctivitis. Herpetic conjunctivitis has a self-limited course of 8–9 days.<a class="elsevierStyleCrossRef" href="#bib0070">14</a></li><li class="elsevierStyleListItem" id="lsti0030">-Chlamydia inclusion conjunctivitis. This disease exhibits larger follicle sizes, mainly in the inferior sac fundus. In addition, these patients may refer Chlamydia genital-urinary infection history in themselves or their sexual partners.</li></ul>A severity evaluation could be necessary to perform clinical studies or essays. The heterogeneous nature of the evaluation of conjunctivitis severity is a significant problem when comparing studies on this disease or preparing meta-analysis. For this reason, it is proposed that future studies apply the symptoms and signs scales proposed by the International Ocular Inflammation Society (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>).<a class="elsevierStyleCrossRef" href="#bib0115">23</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Even though the diagnosis of AKC continues to be mainly clinical, tests are available in the market to confirm the adenoviral etiology of conjunctivitis. RPS (rapid pathogen screening) Adeno Detector is approved by the FDA for use in ophthalmology practices.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> This test is based on the principles of lateral flow immunochromatography which detects a region of the virus which is very well preserved among the various serotypes<a class="elsevierStyleCrossRef" href="#bib0125">25</a> and provides results in only 10min. In addition it has demonstrated a sensitivity of 88% and a specificity of 91% vis-à-vis adenovirus cell cultures as well as a sensitivity of 89% and specificity of 94% vis-à-vis PCR.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Its use has been recommended in primary health care so that a positive result could justify conservative management of conjunctivitis by primary health care physicians.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Udeh et al. found that the systematic use of this test could reduce costs derived from the inadequate use of antibiotics in patients with EKC in 71.30 US dollars per patient.<a class="elsevierStyleCrossRef" href="#bib0135">27</a>For epidemiological studies, the tests considered as gold standard continued to be cell cultures and PCR. HAV cell cultures, traditionally considered as gold standard for diagnosis, are laborious and take 3 weeks to produce results. In addition, culture results may vary depending on how the sample and the seeding are performed as well as on the identification of the cytopathic effects by technicians.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> For this reason, the use of HAV cell cultures is being substituted by new PCR techniques which are able to amplify small amounts of a viral DNA with great sensitivity and without losing specificity, to the extent that nowadays said techniques are considered to be the new gold standard.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> PCR-RFLP (restriction fragment length polymorphism) detects HAV serotypes in 24–48h, and RT PCR (real time PCR) provides information about the rate of virus proliferation and the number of copies present at a given point in time.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>TreatmentTo this date there is no specific drug against HAV replication. There is a search for molecules active against HAV replication without adverse effects.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> Some candidates that have exhibited benefits in these areas are zalcitabine,<a class="elsevierStyleCrossRef" href="#bib0150">30</a> sanilbudine,<a class="elsevierStyleCrossRef" href="#bib0145">29</a> cidofovir,<a class="elsevierStyleCrossRef" href="#bib0155">31</a> interferon beta,<a class="elsevierStyleCrossRefs" href="#bib0145">29,32,33</a> antiosteopontine peptide<a class="elsevierStyleCrossRef" href="#bib0145">29</a> and N-chlorotaurine,<a class="elsevierStyleCrossRef" href="#bib0170">34</a> although randomized clinical trials must be carried out to confirm the efficacy and safety of these molecules in the treatment of AKC.AKC is a self-limited disease that exhibits complete resolution within 3 weeks in most cases. At this time, AKC treatment is focused on managing patient symptoms and avoiding the appearance of complications while the patient immune system resolves the infection. To this end, the following treatments are available.Conservative measuresEven though there are no trials confirming the usefulness of these measures, the use of cold packs and artificial tears could provide efficient symptom relief with hardly any risk of adverse effects.Topical corticosteroidsRabbit studies have demonstrated that the use of topical corticosteroids could increase the replication rate of adenovirus in the conjunctiva and extend the duration of infection.<a class="elsevierStyleCrossRefs" href="#bib0175">35–37</a> On the other hand, the use of topical corticosteroids could worsen conjunctivitis if its etiology is herpetic<a class="elsevierStyleCrossRef" href="#bib0190">38</a> and could increase the risk of bacterian overinfection.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> Accordingly, the use of topical corticosteroids should be restricted.In accordance with the above, the use of topical corticosteroids should be restricted to complicated cases with pseudomembranes or subepithelial infiltrates<a class="elsevierStyleCrossRefs" href="#bib0175">35,40</a> where it appears to be efficient. In what concerns infiltrates, the use of corticosteroids seems to significantly diminish its incidence during treatment although infiltrates can reappear when treatment is discontinued. However, the reestablishment of topical corticoid therapy is useful to achieve the elimination of infiltrates. Taking into account the adverse effects of topical corticoid therapy, treatment of subepithelial infiltrates should be reserved for cases where visual acuity is significantly impaired.Topical nonsteroid anti-inflammatoriesRabbit studies have demonstrated that the use of topical ketorolac or diclofenac does not increase adenovirus replication in the conjunctiva or extend the infection duration and therefore could be a safe alternative for treating the symptoms of these patients.<a class="elsevierStyleCrossRef" href="#bib0205">41</a>Topical antihistaminic and vasoconstrictorsA randomized clinical trial carried out in Pakistan<a class="elsevierStyleCrossRef" href="#bib0210">42</a> reported the usefulness of associating topical antihistaminics such as nafiracine with topical vasoconstrictors such as feniracine to shorten EKC duration and improve symptoms in a statistically significant manner. However, due to the risk of local toxicity and hypersensitivity, the use thereof should not be considered safe in the presence of severe itching because the risks could offset said benefits.Topical cyclosporine ARabbit studies have demonstrated that the use of 0.5% topical cyclosporine A in artificial tears and 2% in corn oil reduces the incidence of post adenoviral subepithelial infiltrates, extending at the same time the duration of the infection.<a class="elsevierStyleCrossRef" href="#bib0215">43</a> A retrospective nonrandomized study in humans demonstrated that the use of topical cyclosporine A does not increase the visual acuity in a statistically significant manner in patients with subepithelial infiltrates, although it did improve objective signs.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> A randomized clinical trial in humans demonstrated that the use of cyclosporine A in combination with cidofovir did not significantly diminish the incidence of subepithelial infiltrates in comparison with cidofovir on its own.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>Considering the above results, topical cyclosporine A should be used only in patients with subepithelial infiltrates that produce significant visual acuity loss and do not respond to topical corticoid therapy.Povidone-iodinePovidone-iodine is a broad spectrum antiseptic. A phase 2 clinical trial with 6 patients found that the use of 0.4% topical povidone iodine in combination with 0.1% topical dexamethasone eradicated the secretion of virus in 5 patients on the fifth day of follow-up.<a class="elsevierStyleCrossRef" href="#bib0225">45</a> However, a clinical trial carried out in children did not find differences in the rate of healing between those treated with 1.25% povidone iodine or with antibiotic.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> New randomized clinical trials are necessary to determine the actual efficacy and safety of povidone iodine treatments in patients with AKC.Topical antibiotic therapyThe use of topical antibiotics to prevent bacterian overinfection should be reserved for high risk patients such as children.Excimer laserA recent series of cases has reported the usefulness of Excimer laser phototherapeutic keratectomy to improve best corrected visual acuity in patients with persistent subepithelial infiltrates secondary to AKC.<a class="elsevierStyleCrossRef" href="#bib0235">47</a>ProphylaxisAs there is no efficient antiviral treatment against HAV, prophylaxis is essential to control the infections caused by this pathogen. Washing of hands and disinfection of instruments do not appear to be sufficient to control the propagation of AKC outbreaks.<a class="elsevierStyleCrossRefs" href="#bib0035">7,11,48</a> A prospective study demonstrated that the application of a hospital infection control protocol against adenovirus can diminish the incidence of epidemic outbreaks and isolated adenoviral conjunctivitis cases through a four-year period.<a class="elsevierStyleCrossRef" href="#bib0245">49</a> Recently, Dart et al.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> demonstrated again that the application of an AKC identification and control protocol diminishes the incidence of hospital contagion.The measures that have demonstrated to diminish the incidence of AKC contagion<a class="elsevierStyleCrossRefs" href="#bib0060">12,49</a> are summarized in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>ConclusionsAKC is an ocular surface infection produced by multiple HAV serotypes, a DNA virus without envelope highly resistant to physical and chemical agents that is contaged through direct contact or fomites. The most frequent clinical syndromes are EKC and PCF. EKC gives rise to severe ocular surface inflammation which can be complicated with the formation of pseudomembranes or subepithelial infiltrates caused by cellular immune reaction against virus antigen remains trapped below Bowman's membrane. The diagnosis is mainly clinic although the etiology can be confirmed by tests such as RPS Adeno Detector, cell culture or PCR. There is no efficient antiviral drug against HAV. Therefore, symptomatic treatment is recommended with conservative measures and topical nonsteroid anti-inflammatory drugs. If complications arise the use of topical corticoid therapy could be indicated. Prevention is crucial to control the propagation of this infection.Conflict of interestNo conflict of interest has been declared by the authors." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres190830" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec178294" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres190831" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec178293" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Microbiology" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Epidemiology" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Clinical syndromes" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Epidemic keratoconjunctivitis" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Pharyngoconjunctival fever" ] ] ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Diagnostic" ] 9 => array:3 [ "identificador" => "sec0040" "titulo" => "Treatment" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Conservative measures" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Topical corticosteroids" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Topical nonsteroid anti-inflammatories" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Topical antihistaminic and vasoconstrictors" ] 4 => array:2 [ "identificador" => "sec0065" "titulo" => "Topical cyclosporine A" ] 5 => array:2 [ "identificador" => "sec0070" "titulo" => "Povidone-iodine" ] 6 => array:2 [ "identificador" => "sec0075" "titulo" => "Topical antibiotic therapy" ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Excimer laser" ] ] ] 10 => array:2 [ "identificador" => "sec0085" "titulo" => "Prophylaxis" ] 11 => array:2 [ "identificador" => "sec0090" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0095" "titulo" => "Conflict of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-12-29" "fechaAceptado" => "2012-07-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec178294" "palabras" => array:5 [ 0 => "Adenovirus" 1 => "Conjunctivitis" 2 => "Viral conjunctivitis" 3 => "Keratitis nummularis" 4 => "Keratoconjunctivitis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec178293" "palabras" => array:5 [ 0 => "Adenovirus" 1 => "Conjuntivitis" 2 => "Conjuntivitis vírica" 3 => "Queratitis nummularis" 4 => "Queratoconjuntivitis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The objective of this review is to describe the clinical and epidemiological characteristics of adenoviral conjunctivitis, as well as to present a practical update on its diagnosis, treatment and prophylaxis.There are two well-defined adenoviral keratoconjunctivitis clinical syndromes: epidemic keratoconjunctivitis and pharyngoconjunctival fever, which are caused by different adenovirus serotypes. The exact incidence of adenoviral conjunctivitis is unknown. However, cases are more frequent during warmer months. Contagion is possible through direct contact or fomites and the virus is extremely resistant to different physical and chemical agents. The symptomatology of conjunctival infection is similar to any other conjunctivitis, with a higher incidence of pseudomembranes. In the cornea, adenoviral infection may lead to keratitis nummularis. Diagnosis is mainly clinical, but its etiology can be confirmed using cell cultures, polymerase chain reaction or immunochromatography. Multiple treatments have been tried for this disease, but none of them seems to be completely effective. Prevention is the most reliable way to control this contagious infection." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El objetivo de esta revisión es resumir las características clínicas y epidemiológicas de las queratoconjuntivitis adenovíricas (QCA), así como presentar una actualización práctica sobre el diagnóstico, tratamiento y prevención de estas infecciones oculares.Dentro de las QCA, existen dos síndromes clínicos claramente diferenciados, la queratoconjuntivitis epidémica y la fiebre faringoconjuntival, que están causados por diferentes serotipos de adenovirus. Su incidencia exacta es desconocida, y los casos son más frecuentes durante los meses cálidos. El contagio se produce mediante contacto directo y por fómites, y los virus son extremadamente resistentes a diferentes agentes físicos y químicos. La sintomatología conjuntival es semejante a la de otras conjuntivitis, con una mayor predilección por la formación de seudomembranas. En la córnea, la infección adenovírica puede producir infiltrados subepiteliales. El diagnóstico es fundamentalmente clínico, aunque el diagnóstico etiológico puede confirmarse mediante cultivos celulares, reacción en cadena de la polimerasa o inmunocromatografía. Se han probado múltiples tratamientos para esta enfermedad, aunque ninguno parece ser completamente eficaz. El método más eficaz para controlar esta infección es la prevención del contagio." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: González-López JJ, et al. Queratoconjuntivitis adenovíricas: actualización. Arch Soc Esp Oftalmol. 2013;88:108–15." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2400 "Ancho" => 1067 "Tamanyo" => 224764 ] ] "descripcion" => array:1 [ "en" => "Bulbar conjunctival hyperemia (A) and follicle-petechial reaction in the upper (B) and lower (C) bulbar conjunctiva in a patient with epidemic keratoconjunctivitis." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Photography courtesy of Dr. Mateos Sánchez." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 776 "Ancho" => 1333 "Tamanyo" => 153473 ] ] "descripcion" => array:1 [ "en" => "Pseudomembranes in superior tharsal conjunctiva in patients with epidemic keratoconjunctivitis." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 745 "Ancho" => 996 "Tamanyo" => 68297 ] ] "descripcion" => array:1 [ "en" => "Subepithelial infiltrates which appeared 2 weeks after the resolution of epidemic keratoconjunctivitis." ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "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=""><tbody title="tbody"><tr title="table-row"><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">Foreign body feeling \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">From 0 (without symptoms) to 10 (unbearable) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Photophobia \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">From 0 (without photophobia) to 10 (cannot open eyes) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Tearing \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">From 0 (without tearing) to 10 (abundant and continuous) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Itching \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">From 0 (without itching) to 10 (permanent and unbearable) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab326367.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Symptoms scale of the International Ocular Inflammation Society." ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "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=""><tbody title="tbody"><tr title="table-row"><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">Conjunctival hyperemia (bulbar/palpebral) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: none \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: slight vascular congestion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">2: moderate vascular congestion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">3: intense vascular congestion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Conjunctival edema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: without edema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: slight (edema in one segment of the bulbar conjunctiva) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">2: moderate (uniform and diffuse edema throughout the bulbar conjunctiva) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">3: severe (conjunctival chemosis with profusion of conjunctiva outside of the palpebral slit) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Palpebral edema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: without edema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: slight (discrete swelling of the upper or lower eyelid without changes in the palpebral slit) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">2: moderate (upper and/or lower eyelid swelling with diminished palpebral slit) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">3: severe (swelling of both eyes it's that causes partial or total closure of the palpebral slit) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Secretion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: no secretion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: slight (discrete sticky secretion limited to sac fundus, only visible with slit lamp) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">2: moderate (secretion visible without slit lamp) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">3: severe (abundant secretion which can produce adherence of both eyelids) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Palpebral conjunctiva \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: smooth and uniform appearance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: slight (localized formation of papillas or follicles under 1mm diameter, without fluorescein staining at the peak) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">2: moderate (diffuse formation of papillas or follicles under 1mm diameter, with or without fluorescein staining at the peak) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">3: severe (abundant papilla or follicles over 1mm diameter, with or without fluorescein staining at the peak) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Type of staining (rose Bengala or lissamine green) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: none \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: micro- or macro-dots \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">2: filliform \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">3: patch shapes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Extension of staining (rose Bengal or lissamine green) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: none \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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:under 25% of conjunctival surface \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">2: between 25% and 50% of conjunctival surface \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">3: over 50% of conjunctival surface \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Depth of erosion/ulceration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: none \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: superficial epithelium \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">2: deep epithelium \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">3: tenon and/or sclera \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Characteristics of membranes and pseudomembranes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: none \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: present in one sac fundus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">2: present in both sac fundus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">3: present beyond the sac fundus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Extension of membranes and pseudomembranes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: under 25% of conjunctival surface \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">2: between 25% and 50% of conjunctival surface \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">3: over 50% of conjunctival surface \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Secondary corneal involvement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: none \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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: under 25% of corneal surface \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">2: between 25% and 50% of corneal surface \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">3: over 50% of corneal surface \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab326366.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Signs scale of the International Ocular Inflammation Society." ] ] 5 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "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=""><tbody title="tbody"><tr title="table-row"><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">Measures for infected health professionals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Off duty for 2 weeks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Quarantine measures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Identification of suspects patients when entering hospital \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Independent waiting room for suspect patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Independent consulting room for suspect patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Minimize patient stay at the hospital \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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><tr title="table-row"><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">Measures for evaluating patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Wash hands with water and soap or antiseptic solution before and after seeing each patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Clean surfaces and slit lamp with 70% isopropyl alcohol before and after seeing each patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Use single-dose eyedrops \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Avoid the use of contact tonometers or diagnostic and therapeutic contact lenses in suspect patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Use disposable tonometry cones or cleaned with sterile water and 70% isopropyl alcohol during 5–10min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Sterilize diagnostic and therapeutic contact lenses with hydrogen peroxide plasma devices or clean with sterile water and bleach or 10% hydrogen peroxide during 10min \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab326368.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Measures for preventing the contagion of adenoviral keratoconjunctivitis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:49 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Isolation of a cytopathogenic agent from human adenoids undergoing spontaneous degeneration in tissue culture" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "W.P. Rowe" 1 => "R.J. Huebner" 2 => "L.K. Gilmore" 3 => "R.H. Parrot" 4 => "T.G. Ward" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Proc Soc Exp Biol Med" "fecha" => "1953" "volumen" => "84" "paginaInicial" => "570" "paginaFinal" => "573" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13134217" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New type of APC virus from epidemic keratoconjunctivitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "E. Jawetz" 1 => "S. Kimura" 2 => "A.N. Nicholas" 3 => "P. Thygeson" 4 => "L. Hanna" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Science" "fecha" => "1955" "volumen" => "122" "paginaInicial" => "1190" "paginaFinal" => "1191" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13274081" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adenoviruses from human immunodeficiency virus-infected individuals, including two strains that represent new candidate serotypes Ad50 and Ad51 of species B1 and D, respectively" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.C. De Jong" 1 => "A.G. Wermenbol" 2 => "M.W. Verweij-Uijterwaal" 3 => "K.W. Slaterus" 4 => "P. Wertheim-Van Dillen" 5 => "G.J. 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Adenoviral keratoconjunctivitis: An update

Queratoconjuntivitis adenovíricas: actualización

J.J. González-Lópeza,b,

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juliojose.gonzalez@live.com

Corresponding author.

, R. Morcillo-Laiza, F.J. Muñoz-Negretea,b

a Servicio de Oftalmología, Hospital Universitario Ramón y Cajal, Madrid, Spain

b Departamento de Cirugía, Facultad de Medicina, Universidad de Alcalá, Madrid, Spain

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treatment and prevention of said ocular infections&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Microbiology</span><p id="par0020" class="elsevierStylePara elsevierViewall">Adenovirus were first described in 1953 by Rowe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> who observed that the human lymphoid tissue suffered a characteristic spontaneous degeneration when maintained in culture several weeks after surgical extraction&#46; In 1955&#44; Jawetz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> were the first to attribute the etiology of EKC to the infection of ocular surface tissue caused by HAV&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Since their discovery&#44; 51 different types of adenovirus have been described&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Among them&#44; 7 have high affinity with the conjunctival epithelium and can produce AKC &#40;serotypes 3&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> 4&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> 7&#44; 8&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6</span></a> 11&#44; 19&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> 37<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Adenovirus are virus with double-stranded DNA having 90&#8211;100<span class="elsevierStyleHsp" style=""></span>nm diameter&#44; without cover and with icosahedral capsid having 20 sides and 12 vertices&#44; made up of 252 subunits called capsomeres&#46; DNA has a molecular weight of 23<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span><span class="elsevierStyleHsp" style=""></span>Da&#44; and represents 10&#8211;15&#37; of the virus mass&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">HAV are able to interact with human cells in 3 ways&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Lytic infection</span>&#44; involving epithelial cells&#46; The virus completes its multiplication cycle&#44; producing cellular death and releasing between 10<span class="elsevierStyleSup">4</span> and 10<span class="elsevierStyleSup">6</span> new viruses&#44; of which between 1&#37; and 5&#37; are infectious&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Latent infection</span>&#44; involving lymphoid cells such as those in which the virus was first isolated&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Only small amounts of virus are released and the cellular death rate is offset by normal multiplication&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Oncogenic transformation&#46;</span> The viral DNA is included in the cellular genetic material and replicates inside it without producing a new infectious virus&#46;</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">HAV are very stable against chemical and physical agents as well as in adverse pH conditions&#46; This allows them to survive for long periods of time outside the body and water&#46; Studies have demonstrated that they are able to remain feasible maintaining infectious concentrations even after 28 days on a metal or plastic surface&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Epidemiology</span><p id="par0060" class="elsevierStylePara elsevierViewall">AKC is one of the most frequent ocular diseases&#44; exhibiting ubiquitous distribution&#46; Due to its high frequency and that many of the cases do not obtain medical help it is impossible to develop precise statistics about its incidence&#46; In addition&#44; there are no reliable data about the social and health costs caused by this disease&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">HAV can give rise to epidemic outbreaks both in the general population and in hospital environments&#46; In fact&#44; AKC is the most frequent hospital ophthalmological disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;12</span></a> The incidence of AKC&#44; particularly the one related to serotypes 3&#44; 4 and 37&#44; increases in summer when temperature rises&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> EKC outbreaks have been mainly associated to serotypes 8&#44; 19 and 37&#44; while PCF cases have been related more with serotypes 3&#44; 7 and 11&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The most frequent transmission of HAV is direct from person to person through the respiratory or fecal-oral pathways&#44; although transmission can also occur through fomites&#46; The virus can be easily isolated from ocular secretions of patients for at least 9 days since the onset of symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In the ophthalmology practice there is a risk of transmission through contact tonometry&#44; use of eyedrops and through the hands of health professionals&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;10&#44;16</span></a> In the general population the risk of contagion from the patients to domestic contacts is of approximately 10&#37;&#44; with the risk increasing in cases of prolonged disease&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical syndromes</span><p id="par0075" class="elsevierStylePara elsevierViewall">HAV infections can produce 2 different clinical syndromes with ocular involvement&#58; EKC and PCF&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Epidemic keratoconjunctivitis</span><p id="par0080" class="elsevierStylePara elsevierViewall">EKC is a form of conjunctivitis that produces epidemic outbreaks in hospitals&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> swimming pools&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> barracks&#44; schools and other communities&#46; The incubation period varies between 4 and 24 days and&#44; even though it is likely that the disease is no longer contagious during this period&#44; Kimura et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> did not find virus through the polymerase chain reaction &#40;PCR&#41; in conjunctival exudates obtained previously at the onset of symptoms&#46; EKC is a slow onset and predominantly unilateral condition&#44; although it can become bilateral in up to 70&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The most frequent symptoms are tearing&#44; foreign body feeling and photophobia&#46; The most frequent signs are predominantly bulbar conjunctival reddening &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41; and in tharsal conjunctivitis the appearance of follicular reaction &#40;more importantly in inferior tharsal conjunctivitis&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B and C&#41;&#44; conjunctival chemosis&#44; petechiae and even full subconjunctival hemorrhages&#46; The duration of the inflammation varies between 1 and 4 weeks&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The appearance of pseudomembranes &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; is a frequent complication in patients with EKC&#44; 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It is believed that these infiltrates are due to a cellular immune response against HAV antigens which remained trapped in the corneal stroma under Bowman&#39;s membrane&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> If the infiltrates involve the visual axis&#44; photophobia and visual acuity loss can occur and&#44; if untreated&#44; they resolve within a period that can vary between weeks and months&#46; Even though said infiltrates are sensitive to the use of topical corticosteroids&#44; the improvement seems to be temporary and does not affect the long-term length of the process&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Bacterian overinfection is not frequent but it could occur&#46; The most frequently involved passive genes are gram-positive cocci such as <span class="elsevierStyleItalic">Streptococcus pyogenes</span>&#46; Overinfection is particularly severe in children and could go as far as causing amblyopia&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pharyngoconjunctival fever</span><p id="par0100" class="elsevierStylePara elsevierViewall">PCF is a well-described syndrome attributed to HAV sub-gender B&#44; particularly serotype 3<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> which causes small outbreaks&#44; mainly among children&#46; Outbreaks are frequent in schools&#44; kindergartens and summer camps&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">PCF courses with an acute onset comprising fever&#44; pharyngitis&#44; rinitis&#44; cervical adenopathies and bulbar and palpebral conjunctivitis with slight-moderate follicular reaction&#46; The duration of the condition is of 3&#8211;5 days&#46; Ocular inflammation also begins in one eye and generally becomes bilateral in the course of the disease&#46; Bacterian overinfection and ocular complications are much less frequent than in EKC&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The main sources of infection associated to PCF are contaminated waters of swimming pools and water reservoirs&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnostic</span><p id="par0115" class="elsevierStylePara elsevierViewall">The diagnosis of these diseases is made usually on the basis of anamnesis and on the patient clinical findings&#46; Differential diagnosis should include the following pathological processes&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Allergic conjunctivitis&#46;</span> Symptoms are generally similar in the early stages&#46; However&#44; allergic conjunctivitis is more frequently bilateral and symmetrical in addition to subacute or chronic course&#46; These patients generally exhibit papillary conjunctival reactions which is more intense in the upper tharsal conjunctiva&#46; Itching is the most characteristic symptoms of allergic conjunctivitis&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> whereas the foreign body feeling would indicate adenoviral origin&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Herpetic conjunctivitis&#46;</span> These patients exhibit typically unilateral symptoms and complain more frequently about pain&#46; Occasionally&#44; the characteristic blisters can be seen in the conjunctiva and mainly in the skin of the eyelids&#46; Herpetic conjunctivitis could include bacterian overinfection with greater frequency than adenoviral conjunctivitis&#46; Herpetic conjunctivitis has a self-limited course of 8&#8211;9 days&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Chlamydia inclusion conjunctivitis</span>&#46; This disease exhibits larger follicle sizes&#44; mainly in the inferior sac fundus&#46; In addition&#44; these patients may refer Chlamydia genital-urinary infection history in themselves or their sexual partners&#46;</p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">A severity evaluation could be necessary to perform clinical studies or essays&#46; The heterogeneous nature of the evaluation of conjunctivitis severity is a significant problem when comparing studies on this disease or preparing meta-analysis&#46; For this reason&#44; it is proposed that future studies apply the symptoms and signs scales proposed by the <span class="elsevierStyleItalic">International Ocular Inflammation Society</span> &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">Even though the diagnosis of AKC continues to be mainly clinical&#44; tests are available in the market to confirm the adenoviral etiology of conjunctivitis&#46; <span class="elsevierStyleItalic">RPS &#40;rapid pathogen screening&#41; Adeno Detector</span> is approved by the FDA for use in ophthalmology practices&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> This test is based on the principles of lateral flow immunochromatography which detects a region of the virus which is very well preserved among the various serotypes<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and provides results in only 10<span class="elsevierStyleHsp" style=""></span>min&#46; In addition it has demonstrated a sensitivity of 88&#37; and a specificity of 91&#37; vis-&#224;-vis adenovirus cell cultures as well as a sensitivity of 89&#37; and specificity of 94&#37; vis-&#224;-vis PCR&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Its use has been recommended in primary health care so that a positive result could justify conservative management of conjunctivitis by primary health care physicians&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Udeh et al&#46; found that the systematic use of this test could reduce costs derived from the inadequate use of antibiotics in patients with EKC in 71&#46;30 US dollars per patient&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">For epidemiological studies&#44; the tests considered as gold standard continued to be cell cultures and PCR&#46; HAV cell cultures&#44; traditionally considered as gold standard for diagnosis&#44; are laborious and take 3 weeks to produce results&#46; In addition&#44; culture results may vary depending on how the sample and the seeding are performed as well as on the identification of the cytopathic effects by technicians&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> For this reason&#44; the use of HAV cell cultures is being substituted by new PCR techniques which are able to amplify small amounts of a viral DNA with great sensitivity and without losing specificity&#44; to the extent that nowadays said techniques are considered to be the new <span class="elsevierStyleItalic">gold standard</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> PCR-RFLP &#40;<span class="elsevierStyleItalic">restriction fragment length polymorphism</span>&#41; detects HAV serotypes in 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#44; and RT PCR &#40;<span class="elsevierStyleItalic">real time PCR</span>&#41; provides information about the rate of virus proliferation and the number of copies present at a given point in time&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Treatment</span><p id="par0150" class="elsevierStylePara elsevierViewall">To this date there is no specific drug against HAV replication&#46; There is a search for molecules active against HAV replication without adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Some candidates that have exhibited benefits in these areas are zalcitabine&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> sanilbudine&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> cidofovir&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> interferon beta&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;32&#44;33</span></a> antiosteopontine peptide<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> and N-chlorotaurine&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> although randomized clinical trials must be carried out to confirm the efficacy and safety of these molecules in the treatment of AKC&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">AKC is a self-limited disease that exhibits complete resolution within 3 weeks in most cases&#46; At this time&#44; AKC treatment is focused on managing patient symptoms and avoiding the appearance of complications while the patient immune system resolves the infection&#46; To this end&#44; the following treatments are available&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conservative measures</span><p id="par0160" class="elsevierStylePara elsevierViewall">Even though there are no trials confirming the usefulness of these measures&#44; the use of cold packs and artificial tears could provide efficient symptom relief with hardly any risk of adverse effects&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Topical corticosteroids</span><p id="par0165" class="elsevierStylePara elsevierViewall">Rabbit studies have demonstrated that the use of topical corticosteroids could increase the replication rate of adenovirus in the conjunctiva and extend the duration of infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#8211;37</span></a> On the other hand&#44; the use of topical corticosteroids could worsen conjunctivitis if its etiology is herpetic<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> and could increase the risk of bacterian overinfection&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Accordingly&#44; the use of topical corticosteroids should be restricted&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In accordance with the above&#44; the use of topical corticosteroids should be restricted to complicated cases with pseudomembranes or subepithelial infiltrates<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;40</span></a> where it appears to be efficient&#46; In what concerns infiltrates&#44; the use of corticosteroids seems to significantly diminish its incidence during treatment although infiltrates can reappear when treatment is discontinued&#46; However&#44; the reestablishment of topical corticoid therapy is useful to achieve the elimination of infiltrates&#46; Taking into account the adverse effects of topical corticoid therapy&#44; treatment of subepithelial infiltrates should be reserved for cases where visual acuity is significantly impaired&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Topical nonsteroid anti-inflammatories</span><p id="par0175" class="elsevierStylePara elsevierViewall">Rabbit studies have demonstrated that the use of topical ketorolac or diclofenac does not increase adenovirus replication in the conjunctiva or extend the infection duration and therefore could be a safe alternative for treating the symptoms of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Topical antihistaminic and vasoconstrictors</span><p id="par0180" class="elsevierStylePara elsevierViewall">A randomized clinical trial carried out in Pakistan<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> reported the usefulness of associating topical antihistaminics such as nafiracine with topical vasoconstrictors such as feniracine to shorten EKC duration and improve symptoms in a statistically significant manner&#46; However&#44; due to the risk of local toxicity and hypersensitivity&#44; the use thereof should not be considered safe in the presence of severe itching because the risks could offset said benefits&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Topical cyclosporine A</span><p id="par0185" class="elsevierStylePara elsevierViewall">Rabbit studies have demonstrated that the use of 0&#46;5&#37; topical cyclosporine A in artificial tears and 2&#37; in corn oil reduces the incidence of post adenoviral subepithelial infiltrates&#44; extending at the same time the duration of the infection&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> A retrospective nonrandomized study in humans demonstrated that the use of topical cyclosporine A does not increase the visual acuity in a statistically significant manner in patients with subepithelial infiltrates&#44; although it did improve objective signs&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> A randomized clinical trial in humans demonstrated that the use of cyclosporine A in combination with cidofovir did not significantly diminish the incidence of subepithelial infiltrates in comparison with cidofovir on its own&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Considering the above results&#44; topical cyclosporine A should be used only in patients with subepithelial infiltrates that produce significant visual acuity loss and do not respond to topical corticoid therapy&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Povidone-iodine</span><p id="par0195" class="elsevierStylePara elsevierViewall">Povidone-iodine is a broad spectrum antiseptic&#46; A phase 2 clinical trial with 6 patients found that the use of 0&#46;4&#37; topical povidone iodine in combination with 0&#46;1&#37; topical dexamethasone eradicated the secretion of virus in 5 patients on the fifth day of follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> However&#44; a clinical trial carried out in children did not find differences in the rate of healing between those treated with 1&#46;25&#37; povidone iodine or with antibiotic&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> New randomized clinical trials are necessary to determine the actual efficacy and safety of povidone iodine treatments in patients with AKC&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Topical antibiotic therapy</span><p id="par0200" class="elsevierStylePara elsevierViewall">The use of topical antibiotics to prevent bacterian overinfection should be reserved for high risk patients such as children&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Excimer laser</span><p id="par0205" class="elsevierStylePara elsevierViewall">A recent series of cases has reported the usefulness of Excimer laser phototherapeutic keratectomy to improve best corrected visual acuity in patients with persistent subepithelial infiltrates secondary to AKC&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prophylaxis</span><p id="par0210" class="elsevierStylePara elsevierViewall">As there is no efficient antiviral treatment against HAV&#44; prophylaxis is essential to control the infections caused by this pathogen&#46; Washing of hands and disinfection of instruments do not appear to be sufficient to control the propagation of AKC outbreaks&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;11&#44;48</span></a> A prospective study demonstrated that the application of a hospital infection control protocol against adenovirus can diminish the incidence of epidemic outbreaks and isolated adenoviral conjunctivitis cases through a four-year period&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> Recently&#44; Dart et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> demonstrated again that the application of an AKC identification and control protocol diminishes the incidence of hospital contagion&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The measures that have demonstrated to diminish the incidence of AKC contagion<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;49</span></a> are summarized in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0220" class="elsevierStylePara elsevierViewall">AKC is an ocular surface infection produced by multiple HAV serotypes&#44; a DNA virus without envelope highly resistant to physical and chemical agents that is contaged through direct contact or fomites&#46; The most frequent clinical syndromes are EKC and PCF&#46; EKC gives rise to severe ocular surface inflammation which can be complicated with the formation of pseudomembranes or subepithelial infiltrates caused by cellular immune reaction against virus antigen remains trapped below Bowman&#39;s membrane&#46; The diagnosis is mainly clinic although the etiology can be confirmed by tests such as <span class="elsevierStyleItalic">RPS Adeno Detector</span>&#44; cell culture or PCR&#46; There is no efficient antiviral drug against HAV&#46; Therefore&#44; symptomatic treatment is recommended with conservative measures and topical nonsteroid anti-inflammatory drugs&#46; If complications arise the use of topical corticoid therapy could be indicated&#46; Prevention is crucial to control the propagation of this infection&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">No conflict of interest has been declared by the authors&#46;</p></span></span>"
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          "titulo" => "Abstract"
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          "titulo" => "Keywords"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Microbiology"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Epidemiology"
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          "identificador" => "sec0020"
          "titulo" => "Clinical syndromes"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Epidemic keratoconjunctivitis"
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            1 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Pharyngoconjunctival fever"
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          "identificador" => "sec0035"
          "titulo" => "Diagnostic"
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          "titulo" => "Treatment"
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            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Conservative measures"
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            1 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Topical corticosteroids"
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            2 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Topical nonsteroid anti-inflammatories"
            ]
            3 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Topical antihistaminic and vasoconstrictors"
            ]
            4 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Topical cyclosporine A"
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            5 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Povidone-iodine"
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            6 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Topical antibiotic therapy"
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            7 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "Excimer laser"
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          ]
        ]
        10 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Prophylaxis"
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        11 => array:2 [
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          "titulo" => "Conclusions"
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        12 => array:2 [
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          "titulo" => "Conflict of interest"
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    "fechaRecibido" => "2011-12-29"
    "fechaAceptado" => "2012-07-06"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:5 [
            0 => "Adenovirus"
            1 => "Conjunctivitis"
            2 => "Viral conjunctivitis"
            3 => "Keratitis nummularis"
            4 => "Keratoconjunctivitis"
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          "palabras" => array:5 [
            0 => "Adenovirus"
            1 => "Conjuntivitis"
            2 => "Conjuntivitis v&#237;rica"
            3 => "Queratitis <span class="elsevierStyleItalic">nummularis</span>"
            4 => "Queratoconjuntivitis"
          ]
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objective of this review is to describe the clinical and epidemiological characteristics of adenoviral conjunctivitis&#44; as well as to present a practical update on its diagnosis&#44; treatment and prophylaxis&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">There are two well-defined adenoviral keratoconjunctivitis clinical syndromes&#58; epidemic keratoconjunctivitis and pharyngoconjunctival fever&#44; which are caused by different adenovirus serotypes&#46; The exact incidence of adenoviral conjunctivitis is unknown&#46; However&#44; cases are more frequent during warmer months&#46; Contagion is possible through direct contact or fomites and the virus is extremely resistant to different physical and chemical agents&#46; The symptomatology of conjunctival infection is similar to any other conjunctivitis&#44; with a higher incidence of pseudomembranes&#46; In the cornea&#44; adenoviral infection may lead to keratitis nummularis&#46; Diagnosis is mainly clinical&#44; but its etiology can be confirmed using cell cultures&#44; polymerase chain reaction or immunochromatography&#46; Multiple treatments have been tried for this disease&#44; but none of them seems to be completely effective&#46; Prevention is the most reliable way to control this contagious infection&#46;</p>"
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        "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El objetivo de esta revisi&#243;n es resumir las caracter&#237;sticas cl&#237;nicas y epidemiol&#243;gicas de las queratoconjuntivitis adenov&#237;ricas &#40;QCA&#41;&#44; as&#237; como presentar una actualizaci&#243;n pr&#225;ctica sobre el diagn&#243;stico&#44; tratamiento y prevenci&#243;n de estas infecciones oculares&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dentro de las QCA&#44; existen dos s&#237;ndromes cl&#237;nicos claramente diferenciados&#44; la queratoconjuntivitis epid&#233;mica y la fiebre faringoconjuntival&#44; que est&#225;n causados por diferentes serotipos de adenovirus&#46; Su incidencia exacta es desconocida&#44; y los casos son m&#225;s frecuentes durante los meses c&#225;lidos&#46; El contagio se produce mediante contacto directo y por f&#243;mites&#44; y los virus son extremadamente resistentes a diferentes agentes f&#237;sicos y qu&#237;micos&#46; La sintomatolog&#237;a conjuntival es semejante a la de otras conjuntivitis&#44; con una mayor predilecci&#243;n por la formaci&#243;n de seudomembranas&#46; En la c&#243;rnea&#44; la infecci&#243;n adenov&#237;rica puede producir infiltrados subepiteliales&#46; El diagn&#243;stico es fundamentalmente cl&#237;nico&#44; aunque el diagn&#243;stico etiol&#243;gico puede confirmarse mediante cultivos celulares&#44; reacci&#243;n en cadena de la polimerasa o inmunocromatograf&#237;a&#46; Se han probado m&#250;ltiples tratamientos para esta enfermedad&#44; aunque ninguno parece ser completamente eficaz&#46; El m&#233;todo m&#225;s eficaz para controlar esta infecci&#243;n es la prevenci&#243;n del contagio&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Gonz&#225;lez-L&#243;pez JJ&#44; et al&#46; Queratoconjuntivitis adenov&#237;ricas&#58; actualizaci&#243;n&#46; Arch Soc Esp Oftalmol&#46; 2013&#59;88&#58;108&#8211;15&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Bulbar conjunctival hyperemia &#40;A&#41; and follicle-petechial reaction in the upper &#40;B&#41; and lower &#40;C&#41; bulbar conjunctiva in a patient with epidemic keratoconjunctivitis&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Pseudomembranes in superior tharsal conjunctiva in patients with epidemic keratoconjunctivitis&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Subepithelial infiltrates which appeared 2 weeks after the resolution of epidemic keratoconjunctivitis&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "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=""><tbody title="tbody"><tr title="table-row"><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">Foreign body feeling&nbsp;\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">From 0 &#40;without symptoms&#41; to 10 &#40;unbearable&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Photophobia&nbsp;\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">From 0 &#40;without photophobia&#41; to 10 &#40;cannot open eyes&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Tearing&nbsp;\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">From 0 &#40;without tearing&#41; to 10 &#40;abundant and continuous&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Itching&nbsp;\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">From 0 &#40;without itching&#41; to 10 &#40;permanent and unbearable&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab326367.png"
              ]
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          ]
        ]
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Symptoms scale of the International Ocular Inflammation Society&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "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=""><tbody title="tbody"><tr title="table-row"><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"><span class="elsevierStyleItalic">Conjunctival hyperemia &#40;bulbar&#47;palpebral&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>0&#58; none&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>1&#58; slight vascular congestion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate vascular congestion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>3&#58; intense vascular congestion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Conjunctival edema</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>0&#58; without edema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>1&#58; slight &#40;edema in one segment of the bulbar conjunctiva&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate &#40;uniform and diffuse edema throughout the bulbar conjunctiva&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>3&#58; severe &#40;conjunctival chemosis with profusion of conjunctiva outside of the palpebral slit&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Palpebral edema</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>0&#58; without edema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>1&#58; slight &#40;discrete swelling of the upper or lower eyelid without changes in the palpebral slit&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate &#40;upper and&#47;or lower eyelid swelling with diminished palpebral slit&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>3&#58; severe &#40;swelling of both eyes it&#39;s that causes partial or total closure of the palpebral slit&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Secretion</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>0&#58; no secretion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>1&#58; slight &#40;discrete sticky secretion limited to sac fundus&#44; only visible with slit lamp&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate &#40;secretion visible without slit lamp&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>3&#58; severe &#40;abundant secretion which can produce adherence of both eyelids&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Palpebral conjunctiva</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>0&#58; smooth and uniform appearance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>1&#58; slight &#40;localized formation of papillas or follicles under 1<span class="elsevierStyleHsp" style=""></span>mm diameter&#44; without fluorescein staining at the peak&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate &#40;diffuse formation of papillas or follicles under 1<span class="elsevierStyleHsp" style=""></span>mm diameter&#44; with or without fluorescein staining at the peak&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>3&#58; severe &#40;abundant papilla or follicles over 1<span class="elsevierStyleHsp" style=""></span>mm diameter&#44; with or without fluorescein staining at the peak&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Type of staining &#40;rose Bengala or lissamine green&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>0&#58; none&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>1&#58; micro- or macro-dots&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>2&#58; filliform&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>3&#58; patch shapes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Extension of staining &#40;rose Bengal or lissamine green&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>0&#58; none&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>1&#58;under 25&#37; of conjunctival surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>2&#58; between 25&#37; and 50&#37; of conjunctival surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>3&#58; over 50&#37; of conjunctival surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Depth of erosion&#47;ulceration</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>0&#58; none&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>1&#58; superficial epithelium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>2&#58; deep epithelium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>3&#58; tenon and&#47;or sclera&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Characteristics of membranes and pseudomembranes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>0&#58; none&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>1&#58; present in one sac fundus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>2&#58; present in both sac fundus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>3&#58; present beyond the sac fundus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Extension of membranes and pseudomembranes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>1&#58; under 25&#37; of conjunctival surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>2&#58; between 25&#37; and 50&#37; of conjunctival surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>3&#58; over 50&#37; of conjunctival surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Secondary corneal involvement</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>0&#58; none&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>1&#58; under 25&#37; of corneal surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>2&#58; between 25&#37; and 50&#37; of corneal surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>3&#58; over 50&#37; of corneal surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab326366.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Signs scale of the International Ocular Inflammation Society&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "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=""><tbody title="tbody"><tr title="table-row"><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"><span class="elsevierStyleItalic">Measures for infected health professionals</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Off duty for 2 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Quarantine measures</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Identification of suspects patients when entering hospital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Independent waiting room for suspect patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Independent consulting room for suspect patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Minimize patient stay at the hospital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">Measures for evaluating patients</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Wash hands with water and soap or antiseptic solution before and after seeing each patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Clean surfaces and slit lamp with 70&#37; isopropyl alcohol before and after seeing each patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Use single-dose eyedrops&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Avoid the use of contact tonometers or diagnostic and therapeutic contact lenses in suspect patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Use disposable tonometry cones or cleaned with sterile water and 70&#37; isopropyl alcohol during 5&#8211;10<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Sterilize diagnostic and therapeutic contact lenses with hydrogen peroxide plasma devices or clean with sterile water and bleach or 10&#37; hydrogen peroxide during 10<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Measures for preventing the contagion of adenoviral keratoconjunctivitis&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:49 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                        0 => array:2 [
                          "etal" => false
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                            0 => "W&#46;P&#46; Rowe"
                            1 => "R&#46;J&#46; Huebner"
                            2 => "L&#46;K&#46; Gilmore"
                            3 => "R&#46;H&#46; Parrot"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
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              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "E&#46; Jawetz"
                            1 => "S&#46; Kimura"
                            2 => "A&#46;N&#46; Nicholas"
                            3 => "P&#46; Thygeson"
                            4 => "L&#46; Hanna"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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                      "Revista" => array:6 [
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            ]
            2 => array:3 [
              "identificador" => "bib0015"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adenoviruses from human immunodeficiency virus-infected individuals&#44; including two strains that represent new candidate serotypes Ad50 and Ad51 of species B1 and D&#44; respectively"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;C&#46; De Jong"
                            1 => "A&#46;G&#46; Wermenbol"
                            2 => "M&#46;W&#46; Verweij-Uijterwaal"
                            3 => "K&#46;W&#46; Slaterus"
                            4 => "P&#46; Wertheim-Van Dillen"
                            5 => "G&#46;J&#46; Van Doornum"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An outbreak of adenovirus type 3 disease at a private recreation center swimming pool"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "W&#46;J&#46; Martone"
                            1 => "J&#46;C&#46; Hierholzer"
                            2 => "R&#46;A&#46; Keenlyside"
                            3 => "D&#46;W&#46; Fraser"
                            4 => "L&#46;J&#46; D&#8217;Angelo"
                            5 => "K&#46;G&#46; Winkler"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Epidemiol"
                        "fecha" => "1980"
                        "volumen" => "111"
                        "paginaInicial" => "229"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6243855"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pharyngoconjunctival fever caused by adenovirus type 4&#58; Report of a swimming pool-related outbreak with recovery of virus from pool water"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "L&#46;J&#46; D&#8217;Angelo"
                            1 => "J&#46;C&#46; Hierholzer"
                            2 => "R&#46;A&#46; Keenlyside"
                            3 => "L&#46;J&#46; Anderson"
                            4 => "W&#46;J&#46; Martone"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Infect Dis"
                        "fecha" => "1979"
                        "volumen" => "140"
                        "paginaInicial" => "42"
                        "paginaFinal" => "47"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/222852"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemic keratoconjunctivitis&#58; a community outbreak of mixed adenovirus type 8 and type 19 infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "B&#46; Guyer"
                            1 => "D&#46;M&#46; O&#8217;Day"
                            2 => "J&#46;C&#46; Hierholzer"
                            3 => "W&#46; Schaffner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Infect Dis"
                        "fecha" => "1975"
                        "volumen" => "132"
                        "paginaInicial" => "142"
                        "paginaFinal" => "150"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1159321"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Keratoconjunctivitis associated with adenovirus type 37&#58; an extended outbreak in an ophthalmologist office"
                      "autores" => array:1 [
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Article information

ISSN: 21735794
Original language: English

DOI:10.1016/j.oftale.2012.07.002

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Year/Month	Html	Pdf	Total

2023 March	5	0	5
2022 January	1	2	3
2018 February	34	7	41
2018 January	44	6	50
2017 December	32	4	36
2017 November	27	11	38
2017 October	34	11	45
2017 September	52	11	63
2017 August	47	11	58
2017 July	37	17	54
2017 June	61	15	76
2017 May	61	25	86
2017 April	57	8	65
2017 March	64	22	86
2017 February	110	11	121
2017 January	45	9	54
2016 December	61	13	74
2016 November	103	24	127
2016 October	121	20	141
2016 September	118	13	131
2016 August	52	10	62
2016 July	63	8	71
2016 June	61	27	88
2016 May	74	45	119
2016 April	53	32	85
2016 March	54	26	80
2016 February	75	38	113
2016 January	49	29	78
2015 December	55	28	83
2015 November	54	32	86
2015 October	65	40	105
2015 September	41	30	71
2015 August	64	26	90
2015 July	63	21	84
2015 June	36	23	59
2015 May	74	33	107
2015 April	59	27	86
2015 March	60	33	93
2015 February	44	28	72
2015 January	51	23	74
2014 December	91	25	116
2014 November	66	25	91
2014 October	82	36	118
2014 September	74	39	113
2014 August	75	26	101
2014 July	87	19	106
2014 June	81	17	98
2014 May	83	31	114
2014 April	66	27	93
2014 March	93	20	113
2014 February	56	29	85
2014 January	62	29	91
2013 December	70	32	102
2013 November	67	30	97
2013 October	206	44	250
2013 September	34	26	60
2013 August	2	0	2
2013 July	0	1	1
2013 June	2	1	3

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