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Posterior microphthalmos, retinitis pigmentosa and optic disc drusen with white dots. A case report
Síndrome del microftalmos posterior-drusas papilares-retinosis pigmentaria asociado a puntos blancos. Caso clínico
P. Plaza
, O. Iturralde, C. Abascal
Corresponding author
Servicio de Oftalmología, Complejo Hospitalario de Navarra, Pamplona (Navarra), Spain
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LE exhibits small navicular hemorrhage with a white central spot (Roth spot) in the superotemporal vascular arcade, and a 0.5<span class="elsevierStyleHsp" style=""></span>mm diameter solitary whitish infiltrates in the inferior temporal arcade with well defined edges.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Hernández Pardines, J.C. Molina Martín, L. Fernández Montalvo, A. Juárez Marroquí" "autores" => array:4 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Hernández Pardines" ] 1 => array:2 [ "nombre" => "J.C." "apellidos" => "Molina Martín" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Fernández Montalvo" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Juárez Marroquí" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S036566911730031X" "doi" => "10.1016/j.oftal.2017.01.007" "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/S036566911730031X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579417301639?idApp=UINPBA00004N" "url" => "/21735794/0000009200000011/v1_201710301214/S2173579417301639/v1_201710301214/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Short communication</span>" "titulo" => "Posterior microphthalmos, retinitis pigmentosa and optic disc drusen with white dots. A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "555" "paginaFinal" => "558" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Plaza, O. Iturralde, C. Abascal" "autores" => array:3 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Plaza" "email" => array:1 [ 0 => "pablo.plaza.ramos@navarra.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "O." "apellidos" => "Iturralde" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Abascal" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmología, Complejo Hospitalario de Navarra, Pamplona (Navarra), Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome del microftalmos posterior-drusas papilares-retinosis pigmentaria asociado a puntos blancos. Caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1754 "Ancho" => 3000 "Tamanyo" => 387515 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Right eye OCT, showing hyperfluorescent depositions in the retina pigment epithelium. Left eye OCT was similar to the opposite eye.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The posterior microphthalmos, retinitis pigmentosa and optic disc drusen syndrome was first described by Buys and Pavlin in 1999.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Since then it has been reported 4 times. Patients with said syndrome require close follow-up because visual acuity could diminish due to the 3 syndrome components. To this we must add possible foveoschisis, which has been associated to the same syndrome by several authors.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The case of a 37-year-old male exhibiting the 3 characteristics that define said syndrome is presented. In addition, said patient exhibited white dots in the posterior pole, which is submitted as a possible new characteristic of the syndrome. The present case is scientifically relevant due to the rarity of said syndrome and because it is the first to be reported in association with white dots in the posterior pole.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Clinical case</span><p id="par0015" class="elsevierStylePara elsevierViewall">Male, 37, operated for convergent strabismus in childhood and in follow-up due to high hypermetropia. The patient did not refer relevant family history and had no systemic diseases.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Examination revealed 15° endotropia in primary gaze position with a visual acuity of 20/40 with (+14) in right eye and 20/25 with (+13.50; −0.75 at 90°) in left eye. Biomicroscopy examination was normal. Ocular fundus revealed papillary drusen that blurred the papillary contour, whitish dots in posterior pole, apparently anodyne macula and clear vitreous (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The periphery exhibited bone spicules beyond the vascular arcades. The pattern was bilateral and symmetrical.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In autofluorescence, the posterior pole white dots matched hyperfluorescent material depositions in the retina pigment epithelium (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Optical coherence tomography (Cirrus, Heidelberg, Zeiss, Jena, Germany) showed bilateral foveal thickening with a central thickness of 398<span class="elsevierStyleHsp" style=""></span>μm in right eye and 417<span class="elsevierStyleHsp" style=""></span>μm in the left eye. The right eye exhibited parafoveal spongelike pattern (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Angiography showed a broad window effect that remained stable in time (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Biometry revealed an axial diameter of 16.54<span class="elsevierStyleHsp" style=""></span>mm in right eye and 16.63<span class="elsevierStyleHsp" style=""></span>mm in left eye. Corneal diameters were 11.0<span class="elsevierStyleHsp" style=""></span>mm in the right eye and 11.9<span class="elsevierStyleHsp" style=""></span>mm in the contralateral eye. The right eye anterior chamber had a depth of 2.75<span class="elsevierStyleHsp" style=""></span>mm and the left eye depth was 2.83<span class="elsevierStyleHsp" style=""></span>mm. Sita-Fast 24-2 campimetry (Humphrey, Humphrey 3, Zeiss, Jena, Germany) revealed increased bilateral blind spot, with arc-shaped scotoma in the right eye and superior arc-shaped scotoma in the left eye.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Visual evoked potentials were requested, which evidenced compromise of evoked response with significantly enlarged latency and notably diminished amplitude in both eyes, with greater involvement of the right eye. In turn, electroretinogram displayed acute reduction both in rod and cone response, the latter to a lesser extent, as well as in the response to standard flash evidenced in scotopic conditions. Under photopic conditions, response was normal.</p><p id="par0040" class="elsevierStylePara elsevierViewall">After completing the study, it was decided to closely follow up the patient.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The posterior microphthalmos, retinitis pigmentosa and optic disc drusen syndrome was first described by Buys and Pavlin from the Toronto Hospital in 1999.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> After this first article, Zenteno et al. presented 2 Mexican families affected by said 3 alterations and defined it as a syndrome. The genetic study revealed mutations in 2 genes of chromosomes 11 and 14. In addition, association with foveoschisis or foveolar thickening was verified in some of these patients. In 2012, an article published by Paun et al. confirmed said syndrome and found a new mutation in gene CRB1 in chromosome 1q31.3.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The literature comprises numerous mentions and case series associating pigment retinosis with papillary drusen. Likewise, the association of pigmented retinitis with nanophthalmos or microphthalmos can be found, although the latter association is less frequent than the former.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">At this point in time, due to the infrequent incidents of said syndrome, there are no studies on inheritance pattern or diagnostic criteria. However, a group of researchers led by Doctor Zenteno has defined it as a syndrome that must exhibit the following characteristics:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Posterior microphthalmos with anteroposterior diameter between 13 and 18.5<span class="elsevierStyleHsp" style=""></span>mm.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">corneal and anterior chamber diameters within normal size.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">High hypermetropia, between +8 and +25 diopters.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Papillary drusen with campimetric defects similar to those caused by simple chronic glaucoma.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">Retinal dystrophy compatible with pigment retinosis confirmed by electroretinogram study.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Association with foveoschisis, cystoid macular edema or foveolar thickening.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">Each newly diagnosed patient exhibits different genetic variants. Some cases have been diagnosed with sporadic mutations in chromosomes 11q23, 14q24.3 and 1q31.3, formerly linked to various forms of nanophthalmos and isolated segments retinosis.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2–4</span></a> The present patient fulfilled the above criteria and in addition exhibited white dots in the posterior pole.</p><p id="par0095" class="elsevierStylePara elsevierViewall">In what concerns the follow-up of said patients, we must be aware that, even though papillary drusen and microphthalmos are alterations that remain stable in time, drusen could produce ischemia episodes due to central retinal artery occlusion. Similarly, it is necessary to closely follow up pigment retinosis due to the fact that it is a progressive disease. In the present case, the patient remains in half-yearly follow-up and the condition remains stable for the time being. The same occurs with the white dots in the posterior pole of both eyes.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The present case aims at reporting a possible new clinical variant undescribed as yet in the literature of the posterior microphthalmos, retinitis pigmentosa and optic disc drusen syndrome, in this case associated to white dots in the posterior pole.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0105" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres933130" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec907509" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres933131" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Discusión" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec907510" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-11-21" "fechaAceptado" => "2017-01-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec907509" "palabras" => array:5 [ 0 => "Retinitis pigmentosa" 1 => "Microphthalmia" 2 => "Optic nerve drusen" 3 => "Foveoschisis" 4 => "White dots" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec907510" "palabras" => array:5 [ 0 => "Retinitis pigmentaria" 1 => "Microftalmos" 2 => "Drusas del nervio óptico" 3 => "Foveosquisis" 4 => "Puntos blancos" ] ] ] ] "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 present the case of a patient with a posterior microphthalmos-optic disc drusen-retinitis pigmentosa syndrome associated, for the first time, with white dots in the posterior pole.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methodology</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The posterior microphthalmos, retinitis pigmentosa and optic disc drusen syndrome was described for the first time in literature in 1991. Later, it was associated with a pattern of foveal thickening and/or foveoschisis. Different forms of mutations on chromosomes 11 and 14 have been identified as being responsible for the appearance of this syndrome, but the inheritance pattern is unknown.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The case is reported of a 37 year-old man, with no personal or family history of interest, diagnosed with this syndrome in association with white dots in the posterior pole. Such a morphological association has never been published before in literature.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The posterior microphthalmos, retinitis pigmentosa and optic disc drusen syndrome is a very rare entity, and has never been described associated with white dots in the posterior pole. More case reports are needed to establish clear patterns of both the disease and inheritance.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "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">Presentar el caso de un paciente con un síndrome del microftalmos posterior-drusas papilares-retinosis pigmentaria asociado por primera vez a puntos blancos en el polo posterior.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El síndrome del microftalmos posterior-drusas papilares-retinosis pigmentaria fue descrito por primera vez en la literatura en 1991. Posteriormente se asoció a un patrón de engrosamiento foveolar o foveosquisis. Distintas formas de mutaciones en los cromosomas 11 y 14 han sido identificadas como responsables de la aparición de este síndrome, sin que se haya podido esclarecer, hasta el momento, un patrón de herencia determinado.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discusión</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un varón de 37 años, sin antecedentes personales ni familiares de interés, con este síndrome asociado a puntos blancos en el polo posterior. Esta asociación morfológica nunca ha sido descrita en la literatura.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El síndrome del microftalmos posterior-drusas papilares-retinosis pigmentaria es una entidad muy poco común y nunca ha sido descrita asociada a puntos blancos en el polo posterior. Es necesaria más casuística para establecer patrones claros tanto de la enfermedad como en su herencia.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Discusión" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Plaza P, Iturralde O, Abascal C. Síndrome del microftalmos posterior-drusas papilares-retinosis pigmentaria asociado a puntos blancos. Caso clínico. Arch Soc Esp Oftalmol. 2017;92:555–558.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This study was presented as a paper in the 37th Congress of the Northern Ophthalmological Association held in Bilbao on November 27–28, 2015.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 747 "Ancho" => 995 "Tamanyo" => 136477 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Right eye retinograph, showing drusen in the optic nerve and whitish dots in posterior pole. Left eye retinograph exhibited the same pattern.</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" => 1754 "Ancho" => 3000 "Tamanyo" => 387515 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Right eye OCT, showing hyperfluorescent depositions in the retina pigment epithelium. Left eye OCT was similar to the opposite eye.</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" => 788 "Ancho" => 1600 "Tamanyo" => 234110 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Right eye optical coherence tomography, showing para foveal sponge-like pattern which could not be observed in the left eye.</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" => 747 "Ancho" => 995 "Tamanyo" => 110549 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Right eye angiography, showing window effect caused by retina pigment epithelium atrophy. Same pattern can be appreciated in the left eye of the patient.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Retinitis pigmentosa, nanophthalmos, and optic disc drusen: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Y.M. Buys" 1 => "C.J. 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