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Agreement between intraoperative measurements and optical coherence tomography of the limbus-insertion distance of the extraocular muscles
Concordancia de la distancia desde la inserción hasta el limbo de los músculos rectos entre la medida intraoperatoria y con tomografía de coherencia óptica
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A) Tomografía de coherencia óptica que muestra el limbo posterior y el recto lateral del ojo derecho. La medida (línea blanca más ancha) es la distancia desde la inserción del recto lateral (flecha ancha) al limbo (punta de flecha). El limbo posterior se identifica en el visor externo del ojo (asterisco rojo) y, al marcarlo, se muestra una línea vertical (estrella roja) que lo señala, el cual es el punto de referencia para realizar la medida. El asterisco blanco identifica el iris invertido por un artefacto de la imagen. B) Medida intraoperatoria directa mediante compás. C) Medida intraoperatoria transconjuntival mediante compás.</p>" ] ] ] "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." 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Fernández-Vigo, N. Ventura-Abreu, L. Morales-Fernández, J. García-Feijóo, R. Gómez-de-Liaño" "autores" => array:6 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "de-Pablo-Gómez-de-Liaño" "email" => array:2 [ 0 => "depablo.lucia@gmail.com" 1 => "kinga84@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.I." "apellidos" => "Fernández-Vigo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "N." "apellidos" => "Ventura-Abreu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Morales-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "García-Feijóo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "R." "apellidos" => "Gómez-de-Liaño" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Oftalmología, Complejo Asistencial de Ávila, Ávila, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Oftalmología, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria (IdISSC), Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Concordancia de la distancia desde la inserción hasta el limbo de los músculos rectos entre la medida intraoperatoria y con tomografía de coherencia óptica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1462 "Ancho" => 2667 "Tamanyo" => 440501 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Measuring the distance from muscle insertion to limbus with 3 methods: (A) optical coherence tomography, showing right eye posterior limbus and lateral rectus. 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.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Extraocular rectus muscles insert in the sclera along the Tillaux spiral.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> The distance of these muscles to the limbus varies between individuals and their importance has been studied for many years in strabology surgery.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2,3</span></a> In specific cases such as muscular fibrosis or in previously intervened patients, the insertion-limbus distance acquires greater relevance.</p><p id="par0010" class="elsevierStylePara elsevierViewall">To date, different imaging technologies have been used for visualizing extraocular muscles such as nuclear magnetic resonance and computerized axial tomography.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4–6</span></a> Unfortunately, said devices lack precision and cannot be utilized for establishing the exact location of muscles insertions or to measure the distance to the limbus. In addition, they involve several disadvantages such as lack of availability in daily practice and high costs. In addition, computerized axial tomography is limited due to the radiation it involves. Other imaging technologies include echography which offers low resolution of the insertion<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">7,8</span></a> and ultrasound biomicroscopy which provides higher resolution but is an invasive and uncomfortable procedure for patients, making it difficult to utilize in children without sedation or general anesthesia.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">9–12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In recent years, optical coherence tomography (OCT) has become an efficient alternative for identifying ocular rectus muscles, with the added benefit of being noninvasive and comfortable for patients, making it easy to use with children.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">13–17</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The first published paper on the use of OCT for analyzing the distance of extraocular rectus muscle insertions was by Liu et al.,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> which reported good matches with intraoperative measurements. In turn, Ngo et al.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> also obtained good matches between OCT and intraoperative measurements for the insertion of horizontal and vertical rectus muscles, comprising patients with and without previous surgery. Recently, OCT has evolved from the time domain utilized by said authors to spectral domain, which has been applied in this study as it provides higher acquisition rates which translate into improved image resolution.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Accordingly, the purpose of the present study is to demonstrate that spectral domain OCT is an efficient technology for preoperative measurement of the insertion-limbus distance and evaluating matches between this technique and the measurements taken intraoperatively.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Subjects, material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">An observational and transversal study carried out on 67 muscles of 21 patients to compare the distance between the insertion of the horizontal rectus muscles to the sclerocorneal limbus. Preoperatively, measurements were taking utilized in anterior segment OCT which were subsequently compared with measurements taken intraoperatively with a Castroviejo compass under topical anesthesia. Overall, 12 patients exhibited endotropia and 9 exotropia.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study protocol complied with the Helsinki declaration norms and was approved by the Clinic Research Ethical Committee of the San Carlos Clinic Hospital. Informed consents were obtained of all patients who participated in the study. Inclusion criteria comprised: Caucasian ethnicity, with strabismus, scheduled for extraocular muscle surgery or botulinum toxin injection. Patients with anterior segment compromise preventing adequate identification of the sclerocorneal limbus were excluded.</p><p id="par0040" class="elsevierStylePara elsevierViewall">All the OCT examinations were carried out by the same technician (JIFV), measurements were taken by the same examiner (LDPGL) and intraoperative measurements were made by a single surgeon (RGL). Intraoperative examination was masked, i.e., the surgeon was not aware of the preoperative OCT measurements.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Examination with optical coherence tomography</span><p id="par0045" class="elsevierStylePara elsevierViewall">The horizontal rectus muscles were examined utilizing OCT Spectralis (Heidelberg Engineering Inc., Heidelberg, Germany). The anterior segment module and lens were utilized in the sclera software mode. This OCT device carries out 40,000 scans per second with an axial resolution of 7<span class="elsevierStyleHsp" style=""></span>μm. The examination protocol consisted of 21 parallel scans with a length of 16.7<span class="elsevierStyleHsp" style=""></span>mm and a height of 5.7<span class="elsevierStyleHsp" style=""></span>mm, with a space of 278<span class="elsevierStyleHsp" style=""></span>μm between scans (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). This protocol enables the analysis of the entire quadrant; accordingly, the entire extension of the muscle insertion is included in the images. After capturing the images, the most central scan (11° of 21°) was selected as a reference for measurement at 3 and 9 o’clock to visualize the horizontal rectus muscles (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). In the case that the muscle could not be identified in the specific central scan, the clearest image closest to 11°<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2 was systematically selected, which means that the measurements were always taken between the 9° and 13° scans. The examination was guided by external light fixation and patients carried out a maximum temporal gaze that facilitated the examination of the median rectus muscle (MR), and maximum nasal gaze for examining the lateral rectus muscle (LR). Both muscles were identified as a hypo-reflective structure between a hyper-reflective strip corresponding to the sclera below the muscle and the overlying Tenon's capsule and conjunctiva (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The posterior limbus was easily identified and marked in the external viewer of the eye (red asterisk, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). When making the mark, the software displays a vertical line (red star, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) that marks the limbus, which is the reference point for making the measurement. The distance from the muscle insertion (from the end of the tendon) to the posterior sclerocorneal limbus was measured utilizing the device software.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Intraoperative measurements</span><p id="par0050" class="elsevierStylePara elsevierViewall">Intraoperative measurements were made in 2 ways: the first was a direct measurement, exposing the muscle with a strabismus hook after the incision and conjunctival opening in patients to be operated on, measuring the distance to the limbus with a Castroviejo compass from the central part of the muscle insertion over the hook up to the posterior limbus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). This measurement was adopted as <span class="elsevierStyleItalic">gold standard</span>. The second measurement was taken in patients to be treated with botulinum toxin or in muscles that were not going to be operated on and therefore did not require conjunctival opening. In these, the muscle insertion distance was measured transconjunctivally utilizing Moody tweezers to locate the muscle insertion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C).<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">SPSS (Statistical Package for Social Sciences, v18.0; SPSS Inc., Chicago, IL, USA) was utilized for calculating the intraclass correlation coefficient (ICC) with a confidence interval of 95% (CI 95%), carrying out a Bland–Altman analysis to assess the match between OCT and intraoperative measurements. A difference of 1<span class="elsevierStyleHsp" style=""></span>mm between both measurements was taken as clinically acceptable.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">13,15</span></a><span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 was regarded as clinically significant.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">The mean age of patients was 45.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>20.9 years (range 16–85), with 52% being females. Of the 67 muscles of 21 patients included in the study, 8 muscles of 5 patients had previously undergone surgery. Twenty-three additional muscles were included in the direct intraoperative and OCT measurements group, while the remaining 44 muscles were measured with OCT and transconjunctival intraoperatively.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In what concerns the identification percentage and measurements of the insertion-limbus distance of muscles, the direct intraoperative measurement was accomplished in 95.6% (22/23), through the transconjunctival intraoperative approach in 90.9% (40/44) and by means of OCT in 85% of muscles, globally (57/67). However, said OCT percentage was significantly higher when analyzing muscles which had not previously undergone surgery, reaching 91.5% (54/59) against those with previous surgery, which amounted to 37.5% (3/8).</p><p id="par0070" class="elsevierStylePara elsevierViewall">In the group analyzed with direct intraoperative and OCT measurements, one muscle was excluded because it was displaced and could not be identified with either technique. Finally, this group comprised 22 muscles. As regards the trans-conjunctival intraoperative and OCT measurements, 9 muscles were excluded from the analysis because they could not be identified with both techniques (4 due to previous surgery and 5 muscles of 2 patients due to who were image quality derived from lack of cooperation). Finally, this group comprised the study of 35 muscles.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The mean distance at which all the MR and LR muscles were observed with direct intraoperative measurements (i.e., muscles with and without previous surgery) was 6.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.9 and 7.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.8<span class="elsevierStyleHsp" style=""></span>mm, respectively, finding OCT measurements of 6.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.9 and 6.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.9<span class="elsevierStyleHsp" style=""></span>mm in the same group. In what concerns the mean distance of MR and LR measured with the transconjunctival intraoperative approach the distances were 5.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.4 and 7.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.8<span class="elsevierStyleHsp" style=""></span>mm, whereas the OCT measurement was 5.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.6 and 7.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.7<span class="elsevierStyleHsp" style=""></span>mm, respectively (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">ICC demonstrated adequate reliability of OCT measurements vis-à-vis direct intraoperative measurements, reaching 0.931 (CI 95%: 0.839–0.972; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). It also exhibited good matches between trans-conjunctival intraoperative and OCT measurements, reaching ICC<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.889 (CI 95%: 0.790–0.942; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). In over 94% of intraoperative measurements, both through the direct (95.4%; 21/22) and trans conjunctival approach (94.2%; 33/35) versus OCT, a difference predefined as acceptable was observed between both methods (difference of <1<span class="elsevierStyleHsp" style=""></span>mm, the same value established by other authors).<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">13,15</span></a> The Bland–Altman analysis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) illustrates the differences between intraoperative and OCT measurements against the mean average of measurements made with both techniques. It can be seen that the variation between measurements was homogeneous through the entire range of the variables, i.e., no major differences arose in short as well as long insertion-limbus distances.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The present study found an excellent match between the insertion-limbus measured with OCT and intraoperatively, which was higher when measured with the direct intraoperative approach (ICC<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.931) when compared with the trans-conjunctival measurement (ICC<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.889). Other authors obtained similar results: Liu et al.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> obtained an ICC<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.85 between the intraoperative and OCT measurements of horizontal rectus muscles in adult patients with strabismus who has not previously undergone surgery. Ngo et al.,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> obtained a slightly lower ICC of 0.73 (CI 95%: 0.53–0.85) in children, although said author also included vertical rectus muscles (with 91% identification) and muscles with previous surgery, obtaining 77.8% identification. In addition, said author utilized time domain OCT which produced lower image resolution compared to spectral domain OCT devices such as that used in the present study.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In the population of the study, the OCT measurements seem to be slightly lower than direct intraoperative measurements, considered as the gold standard, and this could be because the measurement points is not exactly the same in both cases. In OCT, the measurement is taken from the point of insertion of the posterior edge of the tendon in the sclera, whereas the intraoperative measurement takes the anterior edge of the tendon just above the strabismus hook and not exactly at the end of the sclera insertion. In contrast, Liu and Ngo observed that time domain OCT overestimates the insertion-limbus distance vis-à-vis the intraoperative measurement.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">13,15</span></a> However, this could be due to the fact that they carried out indirect measurements and, as said authors indicated, this could lead to systematic measurement errors as both measure the distance from the insertion to the angled recess and not up to the sclerocorneal limbus, which adds 1<span class="elsevierStyleHsp" style=""></span>mm to the result. In a previous study utilizing the same spectral domain OCT device utilized in the present study, de-Pablo-Gómez-de-Liaño et al. demonstrated that this is an efficient technique for measuring from the insertion to the limbus in healthy subjects with ages between 6 and 85, said measurements being highly reproducible.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In addition, the present study also aimed at measuring the insertion-limbus distance through the transconjunctival approach as a noninvasive option to assess said distance in muscles which were not scheduled for surgery. This could be useful to postoperatively assess the location of muscles in the case of hypo- or hyper-corrections due to be treated with toxin or for planning subsequent surgery.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The present study gave a high identification percentage of horizontal rectus muscles through OCT, notably higher in muscles without previous surgery when compared to those who had undergone surgery. This was due to 2 main reasons, i.e. conjunctival cicatricial and Tenon changes that hindered their visualization and to the fact that broad retro-insertions place the muscle beyond the field that at present OCT is able to explore. In the present study, the longest distance of a muscle from the limbus was 11<span class="elsevierStyleHsp" style=""></span>mm; however, this is not always possible because patient cooperation plays a role. Also utilizing OCT, Ngo was able to measure at a distance of 13.5<span class="elsevierStyleHsp" style=""></span>mm. These distances are exceeded by ultrasound biomicroscopy, that is able to measure up to 18<span class="elsevierStyleHsp" style=""></span>mm.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">9,15</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The present study exhibits limitations: firstly and as commented above, OCT does not enable the exploration of an area located beyond 11–12<span class="elsevierStyleHsp" style=""></span>mm of the limbus due to the limited exploration length of the device. In addition, only the horizontal rectus muscles were assessed because eyelid manipulation is required for measuring vertical muscles and this could produce artifacts. For the development of this study, said limitation was not relevant because the most frequent strabismus being studied were endotropia and exotropia. In what concerns the subjects included in the study, it should be noted that all were Caucasian and therefore additional studies should be made to determine whether the same results are obtained with other ethnicities. As regards the limitations of the technique, it must be added that some conjunctival disorders or limbus alterations, as well as chemosis due to recent surgery, could produce artifacts on the images. Lastly, a limitation of the intraoperative measurements technique must be pointed out, i.e., that the compass can only measure in multiples of 0.5<span class="elsevierStyleHsp" style=""></span>mm. In addition, distances were measured in a single central insertion point.</p><p id="par0110" class="elsevierStylePara elsevierViewall">As far as the authors are aware, this is the first study that measures the distance from the muscle insertion to the limbus intraoperatively and with spectral domain in a Caucasian population.</p><p id="par0115" class="elsevierStylePara elsevierViewall">It can be expected that the development of OCT technology will enable the attention of images with higher exploration ranges and higher resolution, which may facilitate improvements in surgical planning, particularly for muscles in which previous surgery cannot be determined, or lost or displaced muscles, or those in which insertion alterations are suspected.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion, spectral domain OCT enables efficient measurements of the distance between the insertion of horizontal rectus muscles up to the sclerocorneal limbus, exhibiting high matches with intraoperative measurements.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0125" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres764827" "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" => "xpalclavsec766256" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres764826" "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" => "xpalclavsec766257" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Subjects, material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Examination with optical coherence tomography" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Intraoperative measurements" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-04-02" "fechaAceptado" => "2016-05-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec766256" "palabras" => array:5 [ 0 => "Optical coherence tomography" 1 => "Extraocular muscles" 2 => "Strabismus" 3 => "Horizontal rectus muscles insertion" 4 => "Limbus-insertion distance" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec766257" "palabras" => array:5 [ 0 => "Tomografía de coherencia óptica" 1 => "Músculos extraoculares" 2 => "Estrabismo" 3 => "Inserción de rectos horizontales" 4 => "Distancia inserción-limbo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the agreement between intraoperative measurements of the limbus-insertion distance of the extraocular muscles with those measured by spectral domain optical coherence tomography.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An analysis was made of a total of 67 muscles of 21 patients with strabismus. The limbus-insertion distance of the horizontal rectus muscles were measured using pre-operative SD-OCT and intra-operatively in 2 ways: (1) direct, after a conjunctival dissection in patients who underwent surgery, or (2) transconjunctival in patients who were treated with botulinum toxin, or in those who were not going to be operated. The intraclass correlation coefficient and Bland–Altman plots were calculated to determine the concordance between the 2 methods.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean age was 45.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>20.9 years (range 16 to 85), with 52% being women.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The percentage of identification by direct intraoperative measurement was 95.6% (22/23), by transconjunctival intraoperative measurement 90.9% (40/44), and by OCT 85% (57/67), with 22 muscles finally being analyzed for the agreement study between direct intraoperative measurement and OCT measurements, and 35 muscles for the agreement between transconjuctival intraoperative measurement and OCT. The intraclass correlation coefficient showed good agreement with OCT and direct intraoperative measurements (0.931; 95% confidence interval (95% CI): 0.839–0.972; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001), and with transconjunctival intraoperative measurements (0.889; 95% CI: 0.790–0.942; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The SD-OCT is an effective technique to measure the distance from the insertion of the horizontal rectus muscles to the limbus, with a high agreement with intraoperative measurements being demonstrated.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Valorar la concordancia entre la medida intraoperatoria y mediante tomografía de coherencia óptica de dominio espectral (SD-OCT) de la distancia desde la inserción muscular de los rectos horizontales hasta el limbo.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 67 músculos de 21 pacientes con estrabismo. La distancia inserción-limbo de los músculos rectos horizontales fue medida mediante SD-OCT y de forma intraoperatoria de 2 maneras: 1) directa, tras la apertura de la conjuntiva en los pacientes en los que se realizó cirugía; 2) transconjuntival, en aquellos que fueron tratados con toxina o en músculos que no iban a ser intervenidos. Se calculó el coeficiente de correlación intraclase y se realizó un análisis de Bland-Altman para determinar la concordancia entre las medidas.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La edad media fue 45,9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>20,9 años (rango 16-85), con el 52% de mujeres. El porcentaje de identificación de manera intraoperatoria directa fue el 95,6% (22/23), mientras que transconjuntival fue el 90,9% (40/44) y mediante OCT fue de 85% (57/67). Fueron finalmente analizados para el estudio de concordancia 22 músculos mediante medida intraoperatoria directa y OCT y 35 mediante medida transconjuntival y OCT. El coeficiente de correlación intraclase mostró buena fiabilidad de la medida con OCT tanto con la medida intraoperatoria directa (0,931; intervalo de confianza al 95% (IC 95%): 0,839–0,972; p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001), como con la medida intraoperatoria transconjuntival (0,889; IC 95%: 0,790–0,942; p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La OCT de dominio espectral permite medir de una forma eficaz la distancia desde la inserción de los músculos rectos horizontales hasta el limbo esclerocorneal, con una elevada concordancia con la medida intraoperatoria.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: de-Pablo-Gómez-de-Liaño L, Fernández-Vigo JI, Ventura-Abreu N, Morales-Fernández L, García-Feijóo J, Gómez-de-Liaño R. Concordancia de la distancia desde la inserción hasta el limbo de los músculos rectos entre la medida intraoperatoria y con tomografía de coherencia óptica. Arch Soc Esp Oftalmol. 2016;91:567–572.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1462 "Ancho" => 2667 "Tamanyo" => 440501 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Measuring the distance from muscle insertion to limbus with 3 methods: (A) optical coherence tomography, showing right eye posterior limbus and lateral rectus. 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.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1161 "Ancho" => 2752 "Tamanyo" => 175435 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">(A) Bland–Altman analysis of the measurements from muscle insertion to the limbus through direct intraoperative approach and with OCT, and (B) through trans-conjunctival intraoperative approach and with OCT. It can be seen in both cases that measurement variations were homogeneous throughout the range of the variable.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ICC: intraclass correlation coefficient; CI 95%: confidence interval 95%; OCT: optical coherence tomography; LR: lateral rectus; MR: medial rectus.</p>" "tablatextoimagen" => array:2 [ 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">Parameter \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">OCT (mm) \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">Intraoperative, direct (mm) \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">ICC (CI 95%) \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">MR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">0.931 (0.839–0.972)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1264174.png" ] ] 1 => 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">Parameter \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">OCT (mm) \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">Intraoperative, trans-conjunctival (mm) \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">ICC (CI 95%) \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">MR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">0.889 (0.790–0.942)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1264175.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Measurement of distances (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation) from insertion to sclerocorneal limbus with optical coherence tomography and direct and trans-conjunctival intraoperative measurement.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "P.J. 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