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Analysis of the vitreoretinal surgery learning curve
Análisis de la curva de aprendizaje en cirugía vitreorretiniana
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Respuesta anatómica y funcional de los pacientes con hemangioma coroideo tratados con terapia fotodinámica" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 2646 "Ancho" => 1211 "Tamanyo" => 414052 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Evolution of patient number 7 in images. (A) retinography, showing orange lesion in upper temporal arch. (B) Autofluorescence, showing enhancement of lesion with hyper-and hypo-autofluorescent granulated pattern. (C) Mode B echography, showing hyperintense and homogeneous solid mass 1.6<span class="elsevierStyleHsp" style=""></span>mm height and 10.31<span class="elsevierStyleHsp" style=""></span>mm base, without posterior acoustic shadow. (D) ssOCT over the tumor, showing slightly over-elevated lesion that produces undulations of Bruch's membrane and retina pigment epithelium (arrow). Typical choroidal vasculature pattern loss can be observed (*). (E) macular OCT before treatment, showing subfoveal NSD (*). (F) retinography with retinal thicknesses graph prior to treatment: central foveal thickness 475<span class="elsevierStyleHsp" style=""></span>μm. (G) Macular OCT 20 months after a single PDT session, showing complete absence of NSD. (H) Retinography with retinal thicknesses chart after treatment, showing central foveal thickness of 249<span class="elsevierStyleHsp" style=""></span>μm.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "O. Subirà, H. Brosa, D. 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"apellidos" => "Caminal-Mitjana" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669116302428" "doi" => "10.1016/j.oftal.2016.11.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669116302428?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579417300439?idApp=UINPBA00004N" "url" => "/21735794/0000009200000006/v1_201705310014/S2173579417300439/v1_201705310014/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173579417300713" "issn" => "21735794" "doi" => "10.1016/j.oftale.2017.02.011" "estado" => "S300" "fechaPublicacion" => "2017-06-01" "aid" => "1165" "copyright" => "Sociedad Española de Oftalmología" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Arch Soc Esp Oftalmol. 2017;92:249-50" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 41 "formatos" => array:3 [ "EPUB" => 2 "HTML" => 31 "PDF" => 8 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "3D vitrectomy. 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Martín-Avià, P. Romero-Aroca" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Martín-Avià" "email" => array:1 [ 0 => "drjmartin@drjmartin.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" => "P." "apellidos" => "Romero-Aroca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Xarxa Sanitària i Social de Santa Tecla, Tarragona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitari Sant Joan, Institut d’Investigació Sanitària Pere Virgili [IISPV], Universitat Rovira i Virgili, Reus, Tarragona, 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" => "Análisis de la curva de aprendizaje en cirugía vitreorretiniana" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1193 "Ancho" => 2477 "Tamanyo" => 286082 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Evolution in time of post-surgery complications percentages based on main diagnostic. (a) Primary retina detachment (PRD). (b) Repeated retina detachment (ReRD). (c) Vitreomacular interface pathology (VMP). (d) Vitreous hemorrhage (VH).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In ophthalmology, vitreoretinal surgery is characterized by making contact with highly sensitive structures that may produce irreversible consequences for vision.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> In addition, on many occasions intra-surgery maneuvers are improvised on the basis of what is being observed, with many complications that the surgeon must foresee and know how to resolve. Accordingly, vitreoretinal surgery is regarded as having one of the longest learning curves, despite the fact that there is no standardization about the meaning of this term.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The “learning curve” concept was originally introduced in 1936 in the aircraft industry by TP Wright, who described a theory for evaluating repetitive assembly production of aircraft.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> The hypothesis was that the man-hours required for completing a production unit decrease in a constant percentage every time production doubled. In said industry, the “learning curve” is applied to production time and cost.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In surgery, a “learning curve” is defined as the time and number of procedures that a surgeon requires to perform a new procedure with a reasonable result.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In ophthalmology, the only recommended surgeries to be considered as learning curve are those carried out in some fellowships at internationally renowned hospitals. According to the program of the Luis Sánchez Bulnes hospital of the Association for Preventing Blindness in Mexico, the number of proposed surgeries is of 75 in one year<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> and, according to the Fellowship of the European School for Advanced Studies in Ophthalmology (ESASO), the number increases to 150 surgeries although without differentiating between head surgeon or assistant.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">There is no standard for measuring learning curves in surgery with the exception of robotic urology surgery performed with the DaVinci system which mainly takes into account the study of complications.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The objective of the present paper is to describe the evolution of intra-and post-surgery complications as well as the evolution of surgical techniques in the first 4 years of practice of a retina surgeon, enabling an evaluation of the approximate time required to reduce the number of complications and identify pathologies that should be referred to other hospitals in order to increase surgical experience.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Subjects, materials and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A review of all patients who underwent retinal surgery performed by the same surgeon at the Ophthalmology Dept. of the <span class="elsevierStyleItalic">Xarxa Sanitaria i Social</span> of Santa Tecla, Tarragona (Spain) between October 23, 2007 and December 31, 2011. The Retina Unit was started up with an entirely new team. The only previous experience of the head surgeon in vitreoretinal surgery was that of an assistant. In turn, assistant surgeons and nurses had experience in scleral surgery but no previous contact with vitrectomy.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the beginning, the <span class="elsevierStyleItalic">technical means</span> available to the unit consisted in a 20G vitrectomy system, endocular laser, SF6, liquid perfluorocarbon (LPFC) and a set of Landers contact lenses. In December 2008, a broad field contact visualization system was acquired, Photon lighting system (Synergetics, Inc., St. Louis, USA), with a Chandelier probe (Synergetics, Inc., St. Louis, USA), Eckardt and Tano intra-ocular tweezers (Synergetics, Inc., St. Louis, USA), brilliant blue, C3F8 and silicon oil, all of the above for 20 and 23G. In July 2009 the intraocular laser equipment was renewed due to highly suspected malfunction.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">surgical technique</span> was as follows: for macular pathology, a 3-way pars plana approach was performed with 20 or 23G, central and peripheral vitrectomy under scleral indentation, posterior hyaloids dissection with triamcinolone staining. The technique continued with epiretinal membrane (ERM) peeling under negative staining with brilliant blue, associating internal limiting membrane peeling up to arches according to each case.</p><p id="par0050" class="elsevierStylePara elsevierViewall">As for retina detachments, scleral surgery, vitrectomy or combined surgery was performed depending on each case. Vitrectomy consisted in a 3-way pars plana approach with 20 or 23G, central and peripheral vitrectomy under indentation, identification of ruptures, injection of perfluorocarbon, exchange with air, 3-barrier endolaser around ruptures, dissection of existing vitreoretinal proliferations (VRP) or ERM, LPFC aspiration and exchange with tamponade depending on each case (air, 20% SF6, 14% C3F8, 1000 or 5700 cst silicon oil). At closure time, sutures were made in planes with Vycril 7/0 in the 20G approach. In 23G surgery, trocars were withdrawn adding transconjunctival suture with Vycril 7/0 in cases with clear leak.</p><p id="par0055" class="elsevierStylePara elsevierViewall">All surgical procedures were preceded by standard ocular surgical asepsis with cutaneous ocular 50% iodine povidone during 3<span class="elsevierStyleHsp" style=""></span>min, repeated upon completion of surgery.</p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Data collection</span> comprised the following fields: patient age and sex, main diagnostic, learning time, vitrectomy approach, intra-and post-surgery complications and follow-up time in weeks. Learning time was measured in quarters (13 weeks) in order to have sufficiently large timeframe for grouping cases without losing an excess of wealth of data that would occur in linear time variables. The descriptive statistical analysis was performed with the SPSS Statistics application (IBM Inc, New York, USA).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">During the period comprised between October 2007 and December 2011, 247 retina surgeries were performed with a mean follow-up time of 68.57 weeks. Retina detachment (RD) surgery comprised 43% of cases, differentiating between primary detachment (PRD), with 30%, and repeated retina detachments (ReRD), with 13%. The latter cases exhibited the highest incidence in the beginning between quarters 6 and 8, subsequently diminishing to between zero and 2 cases per quarter.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Overall, 36.4% of surgeries were due to vitreomacular interface pathologies (VMP) such as epimacular membranes, vitreomacular tractions and macular holes. In addition, 17% were vitreous hemorrhages (VH) due to proliferative diabetic retinopathy or venous thrombosis, while 3.6% were due to other causes (uveitis, endophthalmitis and traumatisms).</p><p id="par0075" class="elsevierStylePara elsevierViewall">The percentage between 20G and 23G illustrates the change toward transconjunctival surgery that began between quarters 9 and 10 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Assessing the timeline for gauge type utilized per diagnostic, a trend toward 23G is observed in PRD as of quarter 15, and of VH as of quarter 11. ReRD remained in 20G and VMP did not vary as it was carried out with 23G from the beginning (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> show absolute values and percentages of the described intra-surgery complications (IC) and post-surgery complications (PC). In what concerns the former, iatrogenic retinotomy and corneal edema were most relevant whereas PC had intraocular hypertension (IOH) and ReRD as the most relevant complications. The percentage of cases with some IC was of 16.1%, which increased to 23.27% in PC. An assessment of the complications timeline shows a progressive reduction in both types of complications, above all as of quarter 12, with a previous peak between quarter 9 and 11 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Stratifying IC on the basis of main diagnostic (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) it can be seen that it diminishes in PRD as of quarter 7, with a peak between quarter 10 and 13, subsequently diminishing again. ReRD exhibited a marked reduction as of quarter 6, whereas VMP exhibited a sustained peak between quarters 9 and 13 and subsequently diminishing. In turn, VH exhibited a highly heterogeneous graph.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Stratifying PC on the basis of the main diagnostic (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>), its percentage diminishes in VMP from the beginning. In PRD it diminishes as of quarter 7, while ReRD appeared to maintain the PC percentage. As in IC, VH again exhibited a highly heterogeneous graph.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">The learning curve gradient depends not only on the nature of the procedure but on the manual dexterity of the surgeon and the assisting surgical team.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">10,11</span></a> Accordingly, the fact that in the present case the entire team was made up of beginners means that the study of these of 4 years is not influenced by previous experiences.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The minimum number of surgeries proposed in a fellowship is of 75 in one year.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> In the present review, said number was reached at the end of quarter 8. In retina surgery, the 23G approach involves a number of improvements in exchange for greater difficulty in controlling and maneuvering instruments. In any surgical area, greater experience allows surgeons to make the most of minimally invasive surgery without its drawbacks entailing surgical problems such as increased complication rates. Accordingly, in the present case the learning curve was studied assessing the tendency to changing from the 20G to the 23G approach in vitrectomies and the variations of intra-and post-surgery complications.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Stratifying the evolution in time of the gauge-based approach per diagnostic, said trend toward 23G in PRD and VH can be seen. VMP was initiated with 23G and ReRD remained in 20G. The change occurs as of quarter 11 in VH and quarter 15 in PRD, which hypothetically means that more complicated surgeries have longer adoption periods. ReRD remained in 20G because it associates a higher number of scleral surgeries in which the conjunctiva must be desiccated, thus losing the advantages of transconjunctival surgery as well as more use of silicon oil to be administered through the 20G at that time.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Accordingly, if the trend from 20G to 23G in some pathologies is analyzed, it can be concluded that the surgeon experienced greater confidence to diminish the gauge as of quarter 10, which is approximately 98 surgeries. Taking into account that when all the material for vitrectomy is introduced in quarter 6, the number of surgeries was 20, and it could be stated that trend changed at about 78 surgeries.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In what concerns IC, the most frequent was intrasurgery corneal edema which mainly appeared in RD surgeries. This could be explained by the initial tendency to work with higher intraocular pressures due to the greater difficulty in maintaining watertightness of the vitreous cavity during surgery due to the absence of valvulated trocars at that time, together with longer surgical times required by said pathology. The following pathology in order of frequency was iatrogenic retinotomy, mainly in VMP and VH. In the former it was due to the initial difficulty for controlling the intraocular tweezers for peeling the epimacular membrane of the internal limiting membrane. In the case of VH, due to the high risk of retinal rupture while peeling the fibrovascular proliferations in proliferative diabetic retinopathy cases.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Within the most frequent PC a high index in IOH and ReRD was observed, mainly in RD surgery, which was concomitant in the same case on many occasions. The cause of IOH in RD surgery could be due to poorly controlled gas dilution due to lack of experience of nurses or to excessive intraocular pressure while suturing sclerotomies due to lack of experience by the surgeon regarding the amount of gas to be introduced, probably caused by respect for hypotony.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Assessing the presence of complications along the timeline exhibits a progressive reduction both during and after surgery, mainly as of quarter 11–12, which represents approximately 130 operations (or 110 if the first 20 interventions performed without all the material are discarded). The high number of complications in the first 6 quarters was due to the lack of full technical equipment.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Stratifying results on the basis of the main diagnostic, the presence of IC varies considerably (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). In PRD it diminishes as of quarter 7, at which time the team had been using all the available surgical material for 3 months. However, a subsequent peak appeared between quarter 10 and 14. In ReRD the incidence diminished suddenly in the same quarter probably due to the same reason as PRD. VMP exhibited high incidence between quarter 9 and 13 and subsequently diminished. VH showed a heterogeneous graph which could be due to the high variability in baseline pathologies as well as the smaller number of cases when compared to the rest of pathologies.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The trend change from 20G to 23G (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) appeared around quarter 9–10 and could indicate increased surgeon confidence, which would involve higher intra-surgery risk and more complex cases, which could explain the IC peak described both in PRD and in VMP in the following quarters.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In what concerns PC (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>), a clear downward tendency was observed, mainly in VMP, whereas in RD it diminished and then remained stable due to the complexity of the pathology that maintains a “minimum” amount of complications. VH exhibited a highly heterogeneous graph that can be explained with the same reasons given for IC.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">The surgery learning curve is generally considered as the number of cases with which a surgeon with feel the same confidence carrying out a new procedure as with a previous technique. Generally, the surgeon decides when he has obtained sufficient experience, and this is a subjective impression in the vast majority of cases. Said confidence gives rise to a false feeling of safety that leads to an increase in complications, so that the learning curve is longer than what the surgeon believed.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> Every surgeon that ventures into a new surgical field should regularly review complications in order to determine whether the “learning curve” has been acquired in an objective manner.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">It is absolutely essential to have a complete equipment from the beginning in order to avoid unnecessary complications. Attending practical courses on animal or even virtual models will increase the responsiveness of the entire team when facing intra-surgery complications.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0155" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres845211" "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" => "xpalclavsec840093" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres845210" "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" => "xpalclavsec840092" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Subjects, materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-04-24" "fechaAceptado" => "2016-07-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec840093" "palabras" => array:7 [ 0 => "Learning curve" 1 => "Vitreoretinal surgery" 2 => "Vitrectomy" 3 => "Retinal detachment" 4 => "Vitreous hemorrhage" 5 => "Epiretinal membrane" 6 => "Surgical skills" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec840092" "palabras" => array:7 [ 0 => "Curva de aprendizaje" 1 => "Cirugía vitreorretiniana" 2 => "Vitrectomía" 3 => "Desprendimiento de retina" 4 => "Hemorragia vítrea" 5 => "Membrana epirretiniana" 6 => "Habilidades quirúrgicas" ] ] ] ] "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 describe intra- and post-operative complications, as well as the evolution of the surgical technique in first 4<span class="elsevierStyleHsp" style=""></span>years of work of a novice retina surgeon, and evaluate minimal learning time required to reduce its complications, deciding which pathologies should still be referred to higher level hospitals, until further experience may be achieved.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A study was conducted on patients that had undergone vitreoretinal surgery by a novice surgeon in Tarragona between 23rd October 2007 and 31st December 2011. The primary diagnosis, surgeon learning time, surgical technique, intra-operative and post-operative complications were recorded.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 247 surgeries were studied. The percentage of use of 20G and 23G calibers during the time, marks a change toward trans-conjunctival surgery from the ninth trimester (98 surgeries). Surgical complications decreased toward twelfth trimester (130 surgeries) with an increase in the previous months.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The shift toward 23G technique around 100 surgeries is interpreted as greater comfort and safety by the surgeon. Increased surgical complications during the following months until its decline around 130 surgeries can be interpreted as an ‘overconfidence’. It is arguable that the learning curve is slower than what the surgeon believes. An individual analysis of the complications and surgical outcomes is recommended to ascertain the status of the learning curve.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir la evolución de las complicaciones intraoperatorias y postoperatorias, así como la evolución en la técnica quirúrgica, en los 4 primeros años de un cirujano de retina y poder evaluar el tiempo de aprendizaje necesario para reducir el número de complicaciones, objetivando aquellas patologías que debieran seguir derivándose a otros centros hasta conseguir una mayor experiencia quirúrgica.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se revisaron los pacientes intervenidos de cirugía retiniana por un cirujano novel en Tarragona, entre el 23 de octubre de 2007 y el 31 de diciembre de 2011. Se evaluaron el diagnóstico principal, el tiempo de aprendizaje del cirujano, la técnica quirúrgica, las complicaciones intraoperatorias y las postoperatorias.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se revisaron 247 cirugías. El porcentaje de uso de los calibers 20G y 23G durante el tiempo denota un cambio hacia la cirugía transconjuntival a partir del noveno trimestre (98 cirugías realizadas). Las complicaciones descienden a partir del trimestre 12 (130 cirugías), con un incremento en los meses anteriores.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El cambio de tendencia hacia la técnica 23G alrededor de las 100 cirugías se interpreta como una mayor comodidad y seguridad en la cirugía. El aumento de complicaciones quirúrgicas durante los meses siguientes hasta el descenso a partir de las 130 cirugías se puede interpretar como un «exceso de confianza». Puede afirmarse que la curva de aprendizaje es más lenta de lo que el cirujano cree, siendo recomendable el análisis individual de las propias complicaciones y de la evolución quirúrgica para poder determinar en qué situación de la curva de aprendizaje se encuentra.</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: Martín-Avià J, Romero-Aroca P. Análisis de la curva de aprendizaje en cirugía vitreorretiniana. Arch Soc Esp Oftalmol. 2017;92:251–256.</p>" ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 515 "Ancho" => 1532 "Tamanyo" => 85047 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Evolution of vitrectomy gauge in time.</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" => 1253 "Ancho" => 2484 "Tamanyo" => 254989 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Evolution of vitrectomy gauge in time based on diagnostic: (a) primary retina detachment (PRD). (b) Repeated retina detachment (ReRD). (c) vitreomacular interface pathology (VMP). (d) Vitreous hemorrhage (VH).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 465 "Ancho" => 1553 "Tamanyo" => 86643 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Evolution in time of complication percentages.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1056 "Ancho" => 2633 "Tamanyo" => 223447 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Evolution in time of intra-surgery complication percentages based on main diagnostic. (a) Primary retina detachment (PRD). (b) Repeated retina detachment (ReRD). (c) Vitreomacular interface pathology (VMP). (d) Vitreous hemorrhage (VH).</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1193 "Ancho" => 2477 "Tamanyo" => 286082 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Evolution in time of post-surgery complications percentages based on main diagnostic. (a) Primary retina detachment (PRD). (b) Repeated retina detachment (ReRD). (c) Vitreomacular interface pathology (VMP). (d) Vitreous hemorrhage (VH).</p>" ] ] 5 => 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="spar0075" class="elsevierStyleSimplePara elsevierViewall">AC, anterior chamber; ERM, epimacular membrane.</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"> \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">Value \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">% \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">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">206 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82.7 \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">Cataract \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2 \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">Corneal edema \t\t\t\t\t\t\n \t\t\t\t</td><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">4.4 \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">Retinal detachment \t\t\t\t\t\t\n \t\t\t\t</td><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">2.4 \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">Retinotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.6 \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">Hemorrhage in AC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \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">Incomplete ERM peeling \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \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">Trans-scleral puncture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \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">Choroidal detachment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">249 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1427458.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Intra-surgery complications.</p>" ] ] 6 => 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" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">AC, anterior chamber; CD, choroidal detachment; RD, retina detachment; IOH, intraocular hypertension; VH, vitreous hemorrhage; IOL, intraocular lens; ERM, epimacular membrane; NVM, neovascular membrane; LPFC, liquid perfluorocarbon; ReRD, retina redetachment; SIO, silicon oil.</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"> \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">Value \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">% \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">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">139 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Corneal edema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phthisis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8 \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">LPFC in AC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \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">ERM relapse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NVM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Endophthalmitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Submacular fibrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \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">Hyphema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \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">Hypotony \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4 \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">Explant rejection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute glaucoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \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">ReRD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.7 \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">IOL dislocation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \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">RD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8 \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">LPFC in posterior pole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \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 cellulite \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \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">SIO in AC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \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">No reapplication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5 \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">ERM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5 \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">VH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.8 \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">IOH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.5 \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">Cataract \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.6 \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">CD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Corneal erosion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">283 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1427459.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Post-surgery complications.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vitrectomía primaria en desprendimiento regmatógeno de retina" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H. 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|---|---|---|---|
| 2023 July | 1 | 0 | 1 |
| 2023 March | 3 | 0 | 3 |
| 2022 October | 1 | 2 | 3 |
| 2020 September | 0 | 1 | 1 |
| 2018 April | 1 | 0 | 1 |
| 2018 February | 17 | 5 | 22 |
| 2018 January | 15 | 0 | 15 |
| 2017 December | 29 | 5 | 34 |
