Age-related distance esotropia: Clinical features and therapeutic outcomes | Archivos de la Sociedad Española de Oftalmología (English Edition)

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Gómez de Liaño Sánchez, G. Olavarri González, P. Merino Sanz, J.C. Escribano Villafruela" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Gómez de Liaño Sánchez" ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Olavarri González" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Merino Sanz" ] 3 => array:2 [ "nombre" => "J.C." 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The measurement (wider white line) is the distance between the lateral rectus insertion (wide arrow) to the limbus (arrow tip). The posterior limbus is identified in the external visor of the eye (red asterisk) which, when being marked, shows a vertical line (red star), which is the reference point for making the measurement. The white asterisk identifies the iris, inverted due to image artifact. (B) Direct intraoperative measurement with compass. (C) Trans-conjunctival intraoperative measurement with compass." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. de-Pablo-Gómez-de-Liaño, J.I. Fernández-Vigo, N. Ventura-Abreu, L. Morales-Fernández, J. García-Feijóo, R. Gómez-de-Liaño" "autores" => array:6 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "de-Pablo-Gómez-de-Liaño" ] 1 => array:2 [ "nombre" => "J.I." "apellidos" => "Fernández-Vigo" ] 2 => array:2 [ "nombre" => "N." "apellidos" => "Ventura-Abreu" ] 3 => array:2 [ "nombre" => "L." 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Gómez de Liaño Sánchez, G. Olavarri González, P. Merino Sanz, J.C. Escribano Villafruela" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Gómez de Liaño Sánchez" ] 1 => array:4 [ "nombre" => "G." "apellidos" => "Olavarri González" "email" => array:1 [ 0 => "gloria.olavarri@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Merino Sanz" ] 3 => array:2 [ "nombre" => "J.C." "apellidos" => "Escribano Villafruela" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sección Estrabismo y Motilidad Ocular, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Esotropia asociada a la edad: manifestaciones clínicas y resultados terapéuticos" ] ] "textoCompleto" => "IntroductionAge-related distance esotropia (ARDE) is a benign acquired condition that expresses in patients over 60 without previous strabismus or associated neurological disease. In 2006, Mittleman<a class="elsevierStyleCrossRef" href="#bib0055">1</a> defined ARDE as an individual entity and described it as “adult onset age-related distance esotropia” to differentiate it from other forms of comitant esotropia (ET) such as divergence insufficiency or palsy. Since then, ARDE has been given different names such as “endotropia of the elderly”, “esotropia of the aging”, or “sagging eye syndrome”.<a class="elsevierStyleCrossRef" href="#bib0060">2</a>The clinical condition of ARDE is characterized by acquired comitant ET that causes intermittent of constant horizontal diplopia, mainly in distance vision. In near vision, diplopia does not usually occur and patients can present eso/exophoria without alterations in fusion. In some cases, minor vertical deviations have been observed. Duction is normal and saccadic speed in abduction is also normal. ARDE can also associate periocular tissue alterations in the form of blepharoptosis, increased upper palpebral ciliary sulcus or elasticity loss in the lower eyelid.<a class="elsevierStyleCrossRef" href="#bib0060">2</a> Even though ARDE is a benign condition, it exhibits a tendency toward progression.<a class="elsevierStyleCrossRef" href="#bib0065">3</a>Diagnostic time is highly variable, ranging between a few months and several years. In the early stages of the disease, patients frequently refer blurred vision instead of diplopia. Clinic exploration is not always definitive as in some cases it is difficult to make a diagnostic differential with other entities such as VI cranial nerve palsy, divergence insufficiency or palsy.The most recent etiopathogenic hypothesis establishes that the orbital connective tissue and inter-muscular strip degeneration, as well as the displacement of extraocular muscles demonstrated through magnetic resonance (NMR) are in the last case the true causes of said deviation.<a class="elsevierStyleCrossRefs" href="#bib0060">2,4</a> In addition to said positional and degenerative alterations, other factors can coexist such as progressive deterioration of convergence, fusion and binocular vision.Very few publications analyze the results of medical or surgical treatment of said entity. The objective of this study is to analyze the clinic characteristics and therapeutic results obtained in patients with ARDE.Subjects, material and methodThe present study was approved by the Ethics Committee of the Gregorio Marañón General University Hospital and carried out in accordance with the principles of the Helsinki Declaration. After being adequately informed, all the subjects signed an informed consent in accordance with said principles.The records of patients visiting the Gregorio Marañón General University Hospital (GMGUH) with clinically suspected ARDE between 2008 and 2015 were retrospectively analyzed. Inclusion criteria comprised patients with sub-acute onset comitant ET that was greater in distance than in near vision, with reserved duction and version, with ages over 60. The exclusion criteria comprised the presence of high refractive myopia with increased axial length in biometry, history of previous strabismus or other ophthalmological diseases (excepting uncomplicated cataract surgery), thyroid disease, recent traumatism, VI cranial nerve paresis or paralysis or any neurological disease. In pseudophakic patients, ET symptoms should have started at least one year after cataract surgery.Clinical records data included basic ophthalmological examination (visual acuity, biomicroscopy and funduscopy) as well as diplopia study, which included cover test measurement and deviation prisms in distance position at 33cm and in lateroversions, Lancaster screen and sensory examination with Worth tests and TNO. Fusion amplitude was not obtained.All patients underwent magnetic resonance with Orbit NMR 1.5Tesla Philips Medical System, Intera model (Best, Netherlands) utilizing a Fast Field Echo 3D sequence (FFD 3D) enhanced in T1, without fatty saturation and in coronal orientation. The images were processed with the Multi Modality Works Station application (MMWS) (Imaging Lab, Gregorio Marañón General University Hospital, Madrid, Spain). The analysis section was made in the quasi-coronal plane between 3 and 7mm in front of the junction of the optic nerve with the ocular globe. As for cases who underwent surgery, a good result was defined as the disappearance of diplopia in all gaze positions.Statistical analysis was performed with IBM SPSS Statistics for Windows, Version 21.0 (Armonk, NY: IBM Corp.). Frequency analysis performed for quantitative and qualitative variables of interest.ResultsThe retrospective study included 16 patients with a mean age of 78.19±6.77 years (between 67 and 90 years), 5 males (31.3%) and 11 females (68.8%).The mean visual acuity of each eye was 0.75±0.15 (between 0.5 and 1) in the decimal scale (Snellen fraction: mean 20/25 with a range between 20/40 and 20/20). None of the patients exhibited a refractive defect exceeding 3 positive or negative spherical diopters or a cylinder above 1.50. Overall, 56.25% of patients exhibited correct bilateral pseudophakia without complicated surgery histories.Deviation at 33cm varied between −4 prismatic diopters (pd) of exotropia up to 8pd ET with a mean deviation of 2.25±3.08pd ET. In distance vision, the ET range was 2–18pd with mean deviation of 9.75±4.18pd ET. Mean deviation in dextro- and levoversion were 5.44±3.06pd and 5.81±4.65pd ET, respectively (with ranges of 0 to 12 and 0 to 14 respectively). Only one patient exhibited a vertical deviation of 4pd with right eye hypertrophia (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>None of the patients exhibited duction or version alterations. In all cases, the Lancaster screen showed comitant deviation, discarding muscular palsy. In addition, onset was insidious in all cases.As can be expected of patients in this age range, according to clinic records 5 patients were in treatment for arterial hypertension, 6 for dyslipidemia, 6 in anti-aggregation treatment due to heart problems, while one presented systemic erythematosus lupus.In addition, 5 patients did not require any type of treatment because the symptoms were intermittent or they exhibited good tolerance to diplopia. One patient exhibited full diplopia correction with an external base 2-diopter prism. A second patient was treated with botulinum toxin injection without clinic improvement. Subsequently, surgery was proposed but the patient declined, remaining with a residual deviation of 2pd ET in near vision and 8pd ET in distance vision.Overall, muscle surgery was proposed to 9 of 16 patients. One patient was operated for 4mm unilateral middle rectus (MR) resection and 7 patients for unilateral reinforcement (or folding) of lateral rectus (LR) (mean reinforcement: 5.13±0.83mm, range between 4 and 6mm). The most deviated or non-dominant eye was selected, or that in which NMR revealed alterations (either muscle displacement or inter-muscular strip degeneration). One patient declined surgery despite constant distance vision diplopia.After a mean 16.5 months follow-up, none of the patients who underwent surgery exhibited diplopia in any gaze position. Near and far post-surgery deviation was 0.4±1.26pd ET (range between 0 and 4) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>DiscussionARDE is a chronic and benign acquired entity that can limit daily activities. Patients frequently refer high propensity to fall, which produces significant repercussions and comorbidities in the elderly.In 2006, Mittelman<a class="elsevierStyleCrossRef" href="#bib0055">1</a> introduced the term “age-related distance esotropia or ARDE” to define a group of patients over 60 with horizontal diplopia in far vision without or with minor near vision alteration. This condition seems to be caused by age-related orbital tissue degeneration without neurological disease. Since then, different authors have utilized a range of nomenclatures,<a class="elsevierStyleCrossRefs" href="#bib0075">5–7</a> until it was finally concluded that the most adequate term for this disease is ARDE or “age-related distance esotropia”. This enables differentiating this entity from classic paralysis divergence which is related to often severe neurological alterations that occur suddenly in patients of any age.<a class="elsevierStyleCrossRefs" href="#bib0055">1,3</a> In addition, ARDE must be differentiated from divergence insufficiency, a benign and subacute condition that occurs in moderately myopic younger patients in the absence of neurological alterations.<a class="elsevierStyleCrossRefs" href="#bib0065">3,8</a> The 2 latter conditions exhibit similarities with comitant ET only in far vision, without or with very slight alteration in near vision.In subsequent studies, Chaudari et al.<a class="elsevierStyleCrossRef" href="#bib0060">2</a> added a relationship between clinical strabismus and age-related anatomic changes such as orbital connective tissue degeneration, which led to the introduction of the “sagging eye syndrome”, differentiating it from the “heavy eye syndrome” presented by magnus myopia patients. Even so, in many cases it is still difficult to carry out a differential diagnostic (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). For instance, slight VI cranial nerve palsy can be very difficult to differentiate from ARDE. One of the first cases was diagnosed as ARDE, but the disappearance of diplopia several months later led the authors to exclude said case from the analyzed group.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>On the other hand, it is not adequate to oversize the condition. Caution must be taken before diagnosing ARDE to any patients with slight endotropia or a vertical strabismus occurring after lens surgery because it could be due to said operation. In the present series, at least one year should elapse after phacoemulsification in patients who underwent cataract surgery.One of the differences found in the present study is the small number of diagnosed patients in comparison to other publications. This could be due to the stringent inclusion and exclusion criteria which discarded all cases with doubtful oculomotor VI cranial nerve palsy as well as high myopics with small horizontal deviations, patients with a history of any neurological disease, thyroid patients and those under 60 years of age.Some characteristics are useful for orienting diagnostic toward ARDE such as insidious acquired onset, absence of near gaze diplopia, small deviation (in the present study up to 18pd) in far vision, the absence of incomitance (both in clinic exploration and Lancaster screen) and finally NMR orbit alterations (rectus muscle displacement, pulley anomalies or intramuscular strip degeneration).In general, diagnostic is made as of 60 years of age even though insidious symptoms are described earlier when patients refer blurred vision in many cases, which delays the diagnostic several months or years. As in other studies,<a class="elsevierStyleCrossRef" href="#bib0065">3</a> a slow natural progression of the deviation angle in this entity has been observed. Out of the 16 analyzed patients, 2 exhibited slow deterioration in 6–8 years.As in other studies, this study found more females with ARDE (68.8% of cases). These differences could depend on the orbital structure, which is different in each sex.The presence of rectus muscle displacement as well as degeneration of the strip between the superior and lateral rectus is evident in patients with ARDE.<a class="elsevierStyleCrossRefs" href="#bib0060">2,4</a> However, these alterations were also found in some healthy subjects. Accordingly, the authors consider that said alterations do not exclusively account for deviation. Possibly, additional factors are at play such as progressive deterioration of binocular vision in elderly patients, diminished convergence, fusion and fusion amplitude, or phoria decompensation due to lens opacity which could give rise to the development of said entity.The majority of patients with ARDE also exhibit alterations due to orbital connective tissue degeneration such as upper sulcus deformity, aponeurosis ptosis or even enophthalmia due to orbital fat atrophy.ARDE diagnostic is performed on the basis of clinic exploration. NMR provides additional information for suspected ARDE cases. Evidently, NMR is increasingly requested as it assists in understanding the etiology of some as yet unknown forms of strabismus. However, it remains an expensive supplementary test that can be difficult to obtain in some hospital environments. Each specialist should apply common sense to identify cases in which the information provided by NMR could be crucial.Diplopia is expressed almost exclusively in distance vision, with tolerance being variable and therefore not all cases will require surgery. In the experience of the authors, even when slight diplopia is frequently corrected with therapeutic prisms, patients do not use it possibly to the diminished vision it involves.The use of botulinum toxin is not recommended because, apart from not being effective, the risk of diffusion to a vertical muscle could produce limitations far beyond the baseline horizontal diplopia.Accordingly, surgery was performed with topical anesthesia on 8 of the 16 patients (50%). Muscle surgery was unilateral, either with MR weakening (in one case) or LR folding (in 7 cases). The authors deemed it necessary to use provisional prism treatment prior to surgery in the presence of significant discomfort. All the cases exhibited excellent post-surgery results, with disappearance of diplopia in the 9 gaze directions.In what concerns surgery type (MR weakening or LR reinforcement), the decision was also determined by clinic exploration. As the results reported in the literature are similar,<a class="elsevierStyleCrossRefs" href="#bib0075">5,8–10</a> it is preferable to reinforce the LR in order to diminish the risk of ischemia (which, in any case, is quite small) and avoid convergence deterioration.Extraocular muscle degeneration, which seems to be the cause of ARDE, may continue to evolve. For this reason, symptoms may reappear sometime after surgery.<a class="elsevierStyleCrossRef" href="#bib0065">3</a>Tolerance to diplopia is highly variable in patients with ARDE, which means that not all cases require surgery. Muscle weakening or reinforcement enables diplopia correction in patients with ARDE. Differential diagnostic with VI cranial nerve palsy and divergence insufficiency or palsy is not simple.Conflict of interestsNo conflict of interests was declared by the authors." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres764824" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec766254" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres764825" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec766255" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Subjects, material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-03-01" "fechaAceptado" => "2016-04-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec766254" "palabras" => array:7 [ 0 => "Age-related esotropia" 1 => "Aging" 2 => "Diplopia" 3 => "Strabismus surgery" 4 => "Rectus muscles" 5 => "Recession" 6 => "Plication" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec766255" "palabras" => array:7 [ 0 => "Cirugía del estrabismo" 1 => "Diplopía" 2 => "Envejecimiento" 3 => "Esotropia asociada a la edad" 4 => "Músculos rectos" 5 => "Retroinserción" 6 => "Plegamiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo describe the clinical characteristics and surgical outcomes of a group of patients with age-related distance esotropia (ARDE). MethodsA retrospective study was conducted on a consecutive case series of 16 adult patients diagnosed with ARDE between 2008 and 2015. The clinical features evaluated included mean age and gender, primary position deviations at distance and near, measured in prism dioptres (pd), treatment offered in each case, and post-surgical deviations. Ductions and versions were full, with no evidence of lateral rectus paresis. None of these patients had any obvious underlying neurological disorder, such as, high myopia or thyroid disease. A good result is considered to be the disappearance of diplopia in all positions of gaze. ResultsA total of 16 patients (11 females [68.8%]) were identified. The mean age at diagnosis was 78.19±6.77 years. The mean initial esodeviation was 2.25±3.08pd at near (−4 to +8pd) and 9.5±4.18pd at distance (2–18pd). Treatment was not necessary in 5 cases because the symptoms were intermittent or well-tolerated. Of the 11 patients with symptoms, one was corrected with an external base therapeutic prism. Botulinum toxin was administered in another patient, without satisfactory results. Unilateral medial rectus muscle recession was performed on one patient, and unilateral lateral rectus plication on 7 patients, indicating prisms before surgery. One patient refused surgery despite continuous diplopia in far vision. After a mean follow-up of 16.5 months, all operated patients were asymptomatic. ConclusionsNot all patients with ARDE require treatment, as the tolerance to diplopia varies from one subject to another. Both medial rectus weakening and lateral rectus strengthening provides excellent results." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoAnalizar las características clínicas de la esotropia asociada a la edad (ETAE), su tratamiento y los resultados terapéuticos obtenidos. MétodosSe analizaron retrospectivamente expedientes de pacientes diagnosticados de ETAE entre los años 2008 y 2015. Se evaluaron edad media y sexo, desviación en posición primaria de lejos y de cerca medida en dioptrías prismáticas (dp), tratamiento realizado y desviación posquirúrgica. Ducciones y versiones eran normales, sin sospecha de limitación en la abducción. Se excluyó a pacientes con enfermedad neurológica o tiroidea y miopía magna. Se consideró un buen resultado la desaparición de la diplopía en todas las posiciones de la mirada. ResultadosUn total de 16 expedientes fueron analizados (11 mujeres [68,8%]). La edad media al diagnóstico fue de 78,19±6,77 años. La desviación a 33cm variaba desde −4 dp de exotropia hasta 8 dp de esotropia con una desviación media de 2,25±3,08 dp de esotropia. En la mirada lejana, el rango de esotropia era de 2 a 18 dp con una desviación media de 9,75±4,18 dp. En 5 casos no fue necesario tratamiento por ser la sintomatología intermitente y bien tolerada. De 11 pacientes sintomáticos, uno fue corregido con prisma. Se administró toxina botulínica en otro paciente sin resultado satisfactorio. Otros 7 fueron intervenidos mediante plegamiento de recto lateral y uno mediante retroinserción de recto medio, al que se le indicaron prismas antes de la intervención. Un paciente rechazó la cirugía a pesar de la diplopía constante en visión lejana. A los 16,5 meses de media de evolución, todos los pacientes intervenidos quirúrgicamente se encontraban asintomáticos. ConclusionesNo todos los pacientes con ETAE requieren tratamiento, pues la tolerancia a la diplopía es variable de unos sujetos a otros. El debilitamiento del recto medial o el refuerzo del recto lateral proporcionan excelentes resultados." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gómez de Liaño Sánchez P, Olavarri González G, Merino Sanz P, Escribano Villafruela JC. Esotropia asociada a la edad: manifestaciones clínicas y resultados terapéuticos. Arch Soc Esp Oftalmol. 2016;91:561–566." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "pd: prism diopters; ET: endotropia; M: male; ORTHO: orthotropia; F: female; Pat: patient; XT: exotropia." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pat \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Course \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Clinic \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Deviation near (pd) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Deviation far (pd) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Deviation right (pd) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Deviation left (pd) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Progressive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Continuous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Progressive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Continuous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermittent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermittent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermittent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Progressive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermittent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Progressive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Continuous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Progressive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermittent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Progressive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Continuous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermittent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Progressive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Continuous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Progressive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermittent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Progressive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermittent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermittent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Progressive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Continuous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−4 XT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermittent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1264171.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Age, sex, course, clinic and desviaciones near and far." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "pd: prism diopters; ET: endotropia; ORTHO: orthotropia." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pat \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Result \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Near posqx deviation (pd) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Far posqx deviation (pd) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral rectus folding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral rectus folding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Botulin toxin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Residual diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 ET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral rectus folding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No surgery required \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medial rectus retroinsertion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral rectus folding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgery rejected \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral rectus folding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No surgery required \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">lateral rectus folding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 ET \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No surgery required \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral rectus folding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Therapeutic prism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral rectus folding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ORTHO \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No surgery required \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1264172.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Treatment in each case and results." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ARDE: age-related distance esotropia." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VI pair palsy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Divergence palsy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Divergence insufficiency \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">ARDE \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Onset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brusque \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brusque \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Subacute \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Insidious \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abduction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limited \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not limited \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not limited \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not limited \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diplopia far \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diplopia near \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; 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entry_with_role_rowhead " align="left" valign="top">Mean age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Indifferent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Indifferent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Young \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>60 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nistagmus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">May appear \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">May appear \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fusion amplitude \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diminished \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diminished \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diminished \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Orbital magnetic resonance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No alteration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not studied \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not studied \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Muscular displacement \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1264173.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Differential diagnostic between VI cranial nerve palsy, divergence palsy, divergence insufficiency and age-related esotropia." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Age-related distance esotropia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. 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Age-related distance esotropia: Clinical features and therapeutic outcomes

Esotropia asociada a la edad: manifestaciones clínicas y resultados terapéuticos

P. Gómez de Liaño Sánchez, G. Olavarri González

Corresponding author

gloria.olavarri@gmail.com

Corresponding author.

, P. Merino Sanz, J.C. Escribano Villafruela

Sección Estrabismo y Motilidad Ocular, Hospital General Universitario Gregorio Marañón, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Age-related distance esotropia &#40;ARDE&#41; is a benign acquired condition that expresses in patients over 60 without previous strabismus or associated neurological disease&#46; In 2006&#44; Mittleman<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> defined ARDE as an individual entity and described it as &#8220;adult onset age-related distance esotropia&#8221; to differentiate it from other forms of comitant esotropia &#40;ET&#41; such as divergence insufficiency or palsy&#46; Since then&#44; ARDE has been given different names such as &#8220;endotropia of the elderly&#8221;&#44; &#8220;esotropia of the aging&#8221;&#44; or &#8220;sagging eye syndrome&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical condition of ARDE is characterized by acquired comitant ET that causes intermittent of constant horizontal diplopia&#44; mainly in distance vision&#46; In near vision&#44; diplopia does not usually occur and patients can present eso&#47;exophoria without alterations in fusion&#46; In some cases&#44; minor vertical deviations have been observed&#46; Duction is normal and saccadic speed in abduction is also normal&#46; ARDE can also associate periocular tissue alterations in the form of blepharoptosis&#44; increased upper palpebral ciliary sulcus or elasticity loss in the lower eyelid&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Even though ARDE is a benign condition&#44; it exhibits a tendency toward progression&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Diagnostic time is highly variable&#44; ranging between a few months and several years&#46; In the early stages of the disease&#44; patients frequently refer blurred vision instead of diplopia&#46; Clinic exploration is not always definitive as in some cases it is difficult to make a diagnostic differential with other entities such as VI cranial nerve palsy&#44; divergence insufficiency or palsy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The most recent etiopathogenic hypothesis establishes that the orbital connective tissue and inter-muscular strip degeneration&#44; as well as the displacement of extraocular muscles demonstrated through magnetic resonance &#40;NMR&#41; are in the last case the true causes of said deviation&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4</span></a> In addition to said positional and degenerative alterations&#44; other factors can coexist such as progressive deterioration of convergence&#44; fusion and binocular vision&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Very few publications analyze the results of medical or surgical treatment of said entity&#46; The objective of this study is to analyze the clinic characteristics and therapeutic results obtained in patients with ARDE&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Subjects&#44; material and method</span><p id="par0030" class="elsevierStylePara elsevierViewall">The present study was approved by the Ethics Committee of the Gregorio Mara&#241;&#243;n General University Hospital and carried out in accordance with the principles of the Helsinki Declaration&#46; After being adequately informed&#44; all the subjects signed an informed consent in accordance with said principles&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The records of patients visiting the Gregorio Mara&#241;&#243;n General University Hospital &#40;GMGUH&#41; with clinically suspected ARDE between 2008 and 2015 were retrospectively analyzed&#46; Inclusion criteria comprised patients with sub-acute onset comitant ET that was greater in distance than in near vision&#44; with reserved duction and version&#44; with ages over 60&#46; The exclusion criteria comprised the presence of high refractive myopia with increased axial length in biometry&#44; history of previous strabismus or other ophthalmological diseases &#40;excepting uncomplicated cataract surgery&#41;&#44; thyroid disease&#44; recent traumatism&#44; VI cranial nerve paresis or paralysis or any neurological disease&#46; In pseudophakic patients&#44; ET symptoms should have started at least one year after cataract surgery&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Clinical records data included basic ophthalmological examination &#40;visual acuity&#44; biomicroscopy and funduscopy&#41; as well as diplopia study&#44; which included cover test measurement and deviation prisms in distance position at 33<span class="elsevierStyleHsp" style=""></span>cm and in lateroversions&#44; Lancaster screen and sensory examination with Worth tests and TNO&#46; Fusion amplitude was not obtained&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">All patients underwent magnetic resonance with Orbit NMR 1&#46;5<span class="elsevierStyleHsp" style=""></span>Tesla Philips Medical System&#44; Intera model &#40;Best&#44; Netherlands&#41; utilizing a Fast Field Echo 3D sequence &#40;FFD 3D&#41; enhanced in T1&#44; without fatty saturation and in coronal orientation&#46; The images were processed with the Multi Modality Works Station application &#40;MMWS&#41; &#40;Imaging Lab&#44; Gregorio Mara&#241;&#243;n General University Hospital&#44; Madrid&#44; Spain&#41;&#46; The analysis section was made in the quasi-coronal plane between 3 and 7<span class="elsevierStyleHsp" style=""></span>mm in front of the junction of the optic nerve with the ocular globe&#46; As for cases who underwent surgery&#44; a good result was defined as the disappearance of diplopia in all gaze positions&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Statistical analysis was performed with IBM SPSS Statistics for Windows&#44; Version 21&#46;0 &#40;Armonk&#44; NY&#58; IBM Corp&#46;&#41;&#46; Frequency analysis performed for quantitative and qualitative variables of interest&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">The retrospective study included 16 patients with a mean age of 78&#46;19<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;77 years &#40;between 67 and 90 years&#41;&#44; 5 males &#40;31&#46;3&#37;&#41; and 11 females &#40;68&#46;8&#37;&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The mean visual acuity of each eye was 0&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;15 &#40;between 0&#46;5 and 1&#41; in the decimal scale &#40;Snellen fraction&#58; mean 20&#47;25 with a range between 20&#47;40 and 20&#47;20&#41;&#46; None of the patients exhibited a refractive defect exceeding 3 positive or negative spherical diopters or a cylinder above 1&#46;50&#46; Overall&#44; 56&#46;25&#37; of patients exhibited correct bilateral pseudophakia without complicated surgery histories&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Deviation at 33<span class="elsevierStyleHsp" style=""></span>cm varied between &#8722;4 prismatic diopters &#40;pd&#41; of exotropia up to 8<span class="elsevierStyleHsp" style=""></span>pd ET with a mean deviation of 2&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;08<span class="elsevierStyleHsp" style=""></span>pd ET&#46; In distance vision&#44; the ET range was 2&#8211;18<span class="elsevierStyleHsp" style=""></span>pd with mean deviation of 9&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;18<span class="elsevierStyleHsp" style=""></span>pd ET&#46; Mean deviation in dextro- and levoversion were 5&#46;44<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;06<span class="elsevierStyleHsp" style=""></span>pd and 5&#46;81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;65<span class="elsevierStyleHsp" style=""></span>pd ET&#44; respectively &#40;with ranges of 0 to 12 and 0 to 14 respectively&#41;&#46; Only one patient exhibited a vertical deviation of 4<span class="elsevierStyleHsp" style=""></span>pd with right eye hypertrophia &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">None of the patients exhibited duction or version alterations&#46; In all cases&#44; the Lancaster screen showed comitant deviation&#44; discarding muscular palsy&#46; In addition&#44; onset was insidious in all cases&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As can be expected of patients in this age range&#44; according to clinic records 5 patients were in treatment for arterial hypertension&#44; 6 for dyslipidemia&#44; 6 in anti-aggregation treatment due to heart problems&#44; while one presented systemic erythematosus lupus&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In addition&#44; 5 patients did not require any type of treatment because the symptoms were intermittent or they exhibited good tolerance to diplopia&#46; One patient exhibited full diplopia correction with an external base 2-diopter prism&#46; A second patient was treated with botulinum toxin injection without clinic improvement&#46; Subsequently&#44; surgery was proposed but the patient declined&#44; remaining with a residual deviation of 2<span class="elsevierStyleHsp" style=""></span>pd ET in near vision and 8<span class="elsevierStyleHsp" style=""></span>pd ET in distance vision&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Overall&#44; muscle surgery was proposed to 9 of 16 patients&#46; One patient was operated for 4<span class="elsevierStyleHsp" style=""></span>mm unilateral middle rectus &#40;MR&#41; resection and 7 patients for unilateral reinforcement &#40;or folding&#41; of lateral rectus &#40;LR&#41; &#40;mean reinforcement&#58; 5&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;83<span class="elsevierStyleHsp" style=""></span>mm&#44; range between 4 and 6<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; The most deviated or non-dominant eye was selected&#44; or that in which NMR revealed alterations &#40;either muscle displacement or inter-muscular strip degeneration&#41;&#46; One patient declined surgery despite constant distance vision diplopia&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">After a mean 16&#46;5 months follow-up&#44; none of the patients who underwent surgery exhibited diplopia in any gaze position&#46; Near and far post-surgery deviation was 0&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;26<span class="elsevierStyleHsp" style=""></span>pd ET &#40;range between 0 and 4&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">ARDE is a chronic and benign acquired entity that can limit daily activities&#46; Patients frequently refer high propensity to fall&#44; which produces significant repercussions and comorbidities in the elderly&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In 2006&#44; Mittelman<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> introduced the term &#8220;age-related distance esotropia or ARDE&#8221; to define a group of patients over 60 with horizontal diplopia in far vision without or with minor near vision alteration&#46; This condition seems to be caused by age-related orbital tissue degeneration without neurological disease&#46; Since then&#44; different authors have utilized a range of nomenclatures&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#8211;7</span></a> until it was finally concluded that the most adequate term for this disease is ARDE or &#8220;age-related distance esotropia&#8221;&#46; This enables differentiating this entity from classic paralysis divergence which is related to often severe neurological alterations that occur suddenly in patients of any age&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3</span></a> In addition&#44; ARDE must be differentiated from divergence insufficiency&#44; a benign and subacute condition that occurs in moderately myopic younger patients in the absence of neurological alterations&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;8</span></a> The 2 latter conditions exhibit similarities with comitant ET only in far vision&#44; without or with very slight alteration in near vision&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In subsequent studies&#44; Chaudari et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> added a relationship between clinical strabismus and age-related anatomic changes such as orbital connective tissue degeneration&#44; which led to the introduction of the &#8220;sagging eye syndrome&#8221;&#44; differentiating it from the &#8220;heavy eye syndrome&#8221; presented by magnus myopia patients&#46; Even so&#44; in many cases it is still difficult to carry out a differential diagnostic &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; For instance&#44; slight VI cranial nerve palsy can be very difficult to differentiate from ARDE&#46; One of the first cases was diagnosed as ARDE&#44; but the disappearance of diplopia several months later led the authors to exclude said case from the analyzed group&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">On the other hand&#44; it is not adequate to oversize the condition&#46; Caution must be taken before diagnosing ARDE to any patients with slight endotropia or a vertical strabismus occurring after lens surgery because it could be due to said operation&#46; In the present series&#44; at least one year should elapse after phacoemulsification in patients who underwent cataract surgery&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">One of the differences found in the present study is the small number of diagnosed patients in comparison to other publications&#46; This could be due to the stringent inclusion and exclusion criteria which discarded all cases with doubtful oculomotor VI cranial nerve palsy as well as high myopics with small horizontal deviations&#44; patients with a history of any neurological disease&#44; thyroid patients and those under 60 years of age&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Some characteristics are useful for orienting diagnostic toward ARDE such as insidious acquired onset&#44; absence of near gaze diplopia&#44; small deviation &#40;in the present study up to 18<span class="elsevierStyleHsp" style=""></span>pd&#41; in far vision&#44; the absence of incomitance &#40;both in clinic exploration and Lancaster screen&#41; and finally NMR orbit alterations &#40;rectus muscle displacement&#44; pulley anomalies or intramuscular strip degeneration&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In general&#44; diagnostic is made as of 60 years of age even though insidious symptoms are described earlier when patients refer blurred vision in many cases&#44; which delays the diagnostic several months or years&#46; As in other studies&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> a slow natural progression of the deviation angle in this entity has been observed&#46; Out of the 16 analyzed patients&#44; 2 exhibited slow deterioration in 6&#8211;8 years&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">As in other studies&#44; this study found more females with ARDE &#40;68&#46;8&#37; of cases&#41;&#46; These differences could depend on the orbital structure&#44; which is different in each sex&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The presence of rectus muscle displacement as well as degeneration of the strip between the superior and lateral rectus is evident in patients with ARDE&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4</span></a> However&#44; these alterations were also found in some healthy subjects&#46; Accordingly&#44; the authors consider that said alterations do not exclusively account for deviation&#46; Possibly&#44; additional factors are at play such as progressive deterioration of binocular vision in elderly patients&#44; diminished convergence&#44; fusion and fusion amplitude&#44; or phoria decompensation due to lens opacity which could give rise to the development of said entity&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The majority of patients with ARDE also exhibit alterations due to orbital connective tissue degeneration such as upper sulcus deformity&#44; aponeurosis ptosis or even enophthalmia due to orbital fat atrophy&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">ARDE diagnostic is performed on the basis of clinic exploration&#46; NMR provides additional information for suspected ARDE cases&#46; Evidently&#44; NMR is increasingly requested as it assists in understanding the etiology of some as yet unknown forms of strabismus&#46; However&#44; it remains an expensive supplementary test that can be difficult to obtain in some hospital environments&#46; Each specialist should apply common sense to identify cases in which the information provided by NMR could be crucial&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Diplopia is expressed almost exclusively in distance vision&#44; with tolerance being variable and therefore not all cases will require surgery&#46; In the experience of the authors&#44; even when slight diplopia is frequently corrected with therapeutic prisms&#44; patients do not use it possibly to the diminished vision it involves&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The use of botulinum toxin is not recommended because&#44; apart from not being effective&#44; the risk of diffusion to a vertical muscle could produce limitations far beyond the baseline horizontal diplopia&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Accordingly&#44; surgery was performed with topical anesthesia on 8 of the 16 patients &#40;50&#37;&#41;&#46; Muscle surgery was unilateral&#44; either with MR weakening &#40;in one case&#41; or LR folding &#40;in 7 cases&#41;&#46; The authors deemed it necessary to use provisional prism treatment prior to surgery in the presence of significant discomfort&#46; All the cases exhibited excellent post-surgery results&#44; with disappearance of diplopia in the 9 gaze directions&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In what concerns surgery type &#40;MR weakening or LR reinforcement&#41;&#44; the decision was also determined by clinic exploration&#46; As the results reported in the literature are similar&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;8&#8211;10</span></a> it is preferable to reinforce the LR in order to diminish the risk of ischemia &#40;which&#44; in any case&#44; is quite small&#41; and avoid convergence deterioration&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Extraocular muscle degeneration&#44; which seems to be the cause of ARDE&#44; may continue to evolve&#46; For this reason&#44; symptoms may reappear sometime after surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Tolerance to diplopia is highly variable in patients with ARDE&#44; which means that not all cases require surgery&#46; Muscle weakening or reinforcement enables diplopia correction in patients with ARDE&#46; Differential diagnostic with VI cranial nerve palsy and divergence insufficiency or palsy is not simple&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0180" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "identificador" => "xres764824"
          "titulo" => "Abstract"
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              "identificador" => "abst0005"
              "titulo" => "Objective"
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          "titulo" => "Resumen"
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          "titulo" => "Introduction"
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          "titulo" => "Subjects&#44; material and method"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-03-01"
    "fechaAceptado" => "2016-04-12"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec766254"
          "palabras" => array:7 [
            0 => "Age-related esotropia"
            1 => "Aging"
            2 => "Diplopia"
            3 => "Strabismus surgery"
            4 => "Rectus muscles"
            5 => "Recession"
            6 => "Plication"
          ]
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      ]
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec766255"
          "palabras" => array:7 [
            0 => "Cirug&#237;a del estrabismo"
            1 => "Diplop&#237;a"
            2 => "Envejecimiento"
            3 => "Esotropia asociada a la edad"
            4 => "M&#250;sculos rectos"
            5 => "Retroinserci&#243;n"
            6 => "Plegamiento"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the clinical characteristics and surgical outcomes of a group of patients with age-related distance esotropia &#40;ARDE&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was conducted on a consecutive case series of 16 adult patients diagnosed with ARDE between 2008 and 2015&#46; The clinical features evaluated included mean age and gender&#44; primary position deviations at distance and near&#44; measured in prism dioptres &#40;pd&#41;&#44; treatment offered in each case&#44; and post-surgical deviations&#46; Ductions and versions were full&#44; with no evidence of lateral rectus paresis&#46; None of these patients had any obvious underlying neurological disorder&#44; such as&#44; high myopia or thyroid disease&#46; A good result is considered to be the disappearance of diplopia in all positions of gaze&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 16 patients &#40;11 females &#91;68&#46;8&#37;&#93;&#41; were identified&#46; The mean age at diagnosis was 78&#46;19<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;77 years&#46; The mean initial esodeviation was 2&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;08<span class="elsevierStyleHsp" style=""></span>pd at near &#40;&#8722;4 to &#43;8<span class="elsevierStyleHsp" style=""></span>pd&#41; and 9&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;18<span class="elsevierStyleHsp" style=""></span>pd at distance &#40;2&#8211;18<span class="elsevierStyleHsp" style=""></span>pd&#41;&#46; Treatment was not necessary in 5 cases because the symptoms were intermittent or well-tolerated&#46; Of the 11 patients with symptoms&#44; one was corrected with an external base therapeutic prism&#46; Botulinum toxin was administered in another patient&#44; without satisfactory results&#46; Unilateral medial rectus muscle recession was performed on one patient&#44; and unilateral lateral rectus plication on 7 patients&#44; indicating prisms before surgery&#46; One patient refused surgery despite continuous diplopia in far vision&#46; After a mean follow-up of 16&#46;5 months&#44; all operated patients were asymptomatic&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Not all patients with ARDE require treatment&#44; as the tolerance to diplopia varies from one subject to another&#46; Both medial rectus weakening and lateral rectus strengthening provides excellent results&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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            "titulo" => "Conclusions"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar las caracter&#237;sticas cl&#237;nicas de la esotropia asociada a la edad &#40;ETAE&#41;&#44; su tratamiento y los resultados terap&#233;uticos obtenidos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se analizaron retrospectivamente expedientes de pacientes diagnosticados de ETAE entre los a&#241;os 2008 y 2015&#46; Se evaluaron edad media y sexo&#44; desviaci&#243;n en posici&#243;n primaria de lejos y de cerca medida en dioptr&#237;as prism&#225;ticas &#40;dp&#41;&#44; tratamiento realizado y desviaci&#243;n posquir&#250;rgica&#46; Ducciones y versiones eran normales&#44; sin sospecha de limitaci&#243;n en la abducci&#243;n&#46; Se excluy&#243; a pacientes con enfermedad neurol&#243;gica o tiroidea y miop&#237;a magna&#46; Se consider&#243; un buen resultado la desaparici&#243;n de la diplop&#237;a en todas las posiciones de la mirada&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Un total de 16 expedientes fueron analizados &#40;11 mujeres &#91;68&#44;8&#37;&#93;&#41;&#46; La edad media al diagn&#243;stico fue de 78&#44;19<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;77 a&#241;os&#46; La desviaci&#243;n a 33<span class="elsevierStyleHsp" style=""></span>cm variaba desde &#8722;4 dp de exotropia hasta 8 dp de esotropia con una desviaci&#243;n media de 2&#44;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;08 dp de esotropia&#46; En la mirada lejana&#44; el rango de esotropia era de 2 a 18 dp con una desviaci&#243;n media de 9&#44;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;18 dp&#46; En 5 casos no fue necesario tratamiento por ser la sintomatolog&#237;a intermitente y bien tolerada&#46; De 11 pacientes sintom&#225;ticos&#44; uno fue corregido con prisma&#46; Se administr&#243; toxina botul&#237;nica en otro paciente sin resultado satisfactorio&#46; Otros 7 fueron intervenidos mediante plegamiento de recto lateral y uno mediante retroinserci&#243;n de recto medio&#44; al que se le indicaron prismas antes de la intervenci&#243;n&#46; Un paciente rechaz&#243; la cirug&#237;a a pesar de la diplop&#237;a constante en visi&#243;n lejana&#46; A los 16&#44;5 meses de media de evoluci&#243;n&#44; todos los pacientes intervenidos quir&#250;rgicamente se encontraban asintom&#225;ticos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">No todos los pacientes con ETAE requieren tratamiento&#44; pues la tolerancia a la diplop&#237;a es variable de unos sujetos a otros&#46; El debilitamiento del recto medial o el refuerzo del recto lateral proporcionan excelentes resultados&#46;</p></span>"
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            "titulo" => "Resultados"
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            "titulo" => "Conclusiones"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez de Lia&#241;o S&#225;nchez P&#44; Olavarri Gonz&#225;lez G&#44; Merino Sanz P&#44; Escribano Villafruela JC&#46; Esotropia asociada a la edad&#58; manifestaciones cl&#237;nicas y resultados terap&#233;uticos&#46; Arch Soc Esp Oftalmol&#46; 2016&#59;91&#58;561&#8211;566&#46;</p>"
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">pd&#58; prism diopters&#59; ET&#58; endotropia&#59; M&#58; male&#59; ORTHO&#58; orthotropia&#59; F&#58; female&#59; Pat&#58; patient&#59; XT&#58; exotropia&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Course&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Clinic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Deviation near &#40;pd&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Deviation far &#40;pd&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Deviation right &#40;pd&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Deviation left &#40;pd&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progressive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continuous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progressive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continuous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Stable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Stable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Stable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progressive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progressive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continuous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progressive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progressive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continuous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Stable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progressive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continuous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progressive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progressive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Stable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Progressive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continuous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;4 XT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Stable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 ET&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="spar0045" class="elsevierStyleSimplePara elsevierViewall">Age&#44; sex&#44; course&#44; clinic and desviaciones near and far&#46;</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">pd&#58; prism diopters&#59; ET&#58; endotropia&#59; ORTHO&#58; orthotropia&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Result&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Near posqx deviation &#40;pd&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Far posqx deviation &#40;pd&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lateral rectus folding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lateral rectus folding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Botulin toxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Residual diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lateral rectus folding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No surgery required&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Medial rectus retroinsertion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lateral rectus folding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery rejected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lateral rectus folding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No surgery required&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">lateral rectus folding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No surgery required&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lateral rectus folding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Therapeutic prism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lateral rectus folding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ORTHO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No surgery required&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab1264172.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Treatment in each case and results&#46;</p>"
        ]
      ]
      2 => array:8 [
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">ARDE&#58; age-related distance esotropia&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleSmallCaps">VI</span> pair palsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Divergence palsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Divergence insufficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">ARDE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Brusque&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Brusque&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Subacute&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Insidious&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abduction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Limited&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not limited&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not limited&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not limited&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diplopia far&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diplopia near&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Comitance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">General clinic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurologic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurologic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Indifferent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Indifferent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Young&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;60 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nistagmus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">May appear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">May appear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fusion amplitude&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diminished&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diminished&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diminished&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Orbital magnetic resonance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No alteration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not studied&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not studied&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Muscular displacement&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="spar0065" class="elsevierStyleSimplePara elsevierViewall">Differential diagnostic between VI cranial nerve palsy&#44; divergence palsy&#44; divergence insufficiency and age-related esotropia&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:10 [
            0 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Age-related distance esotropia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "D&#46; Mittelman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaapos.2006.01.217"
                      "Revista" => array:6 [
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                        "fecha" => "2006"
                        "volumen" => "10"
                        "paginaInicial" => "212"
                        "paginaFinal" => "213"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16814172"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sagging eye syndrome&#58; connective tissue involution as a cause of horizontal and vertical strabismus in older patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Z&#46; Chaudhuri"
                            1 => "J&#46;L&#46; Demer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jamaophthalmol.2013.783"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA Ophthalmol"
                        "fecha" => "2013"
                        "volumen" => "131"
                        "paginaInicial" => "619"
                        "paginaFinal" => "625"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23471194"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Distance esotropia in the elderly"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46; Godts"
                            1 => "D&#46;G&#46; Mathysen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bjophthalmol-2013-303139"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Ophthalmol"
                        "fecha" => "2013"
                        "volumen" => "97"
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Article information

ISSN: 21735794
Original language: English

DOI:10.1016/j.oftale.2016.04.031

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