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Amniotic membrane in the surgical treatment of post-blepharoplasty diplopia
Membrana amniótica en el tratamiento quirúrgico de diplopía posblefaroplastia
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Fernández Jiménez-Ortiz, R. Gómez de Liaño Sánchez, S. Navas Pérez, I. Genol Saavedra, N. Toledano Fernández" "autores" => array:5 [ 0 => array:4 [ "nombre" => "H." "apellidos" => "Fernández Jiménez-Ortiz" "email" => array:1 [ 0 => "hectorfjo@gmail.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" => "R." "apellidos" => "Gómez de Liaño Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Navas Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "I." "apellidos" => "Genol Saavedra" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "N." "apellidos" => "Toledano Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Clínico San Carlos, Departamento de Oftalmología, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Clínica Genol Cirugía y Medicina Estética, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Membrana amniótica en el tratamiento quirúrgico de diplopía posblefaroplastia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2198 "Ancho" => 2928 "Tamanyo" => 386753 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sagittal section of eyelid, ocular globe and inferior and anterior region of the orbit, showing the proximity of the medial fat package with the inferior oblique, inferior rectus muscles and the Lockwood ligament. Original illustration by Dr. Héctor Fernández Jiménez-Ortiz.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The most frequent complications of blepharoplasty include ectropion, lacrimal point eversion with epiphora, exposure keratitis and asymmetry between both eyes. Additional, less frequent but more severe complications include visual loss due to retrobulbar hemorrhage, infections, lacrimal canaliculi rupture, retrobulbar hematomae and diplopia.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Diplopia is infrequent: a comprehensive bibliographic search produced an incidence of 3 for every 1000.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, the invalidating nature of the disorder as well as its aesthetic repercussions make diplopia a reason of concern for patients and surgeons.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Causative factors<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> include tissue edema and hemorrhages (possible compressive effect), ischemia due to the use of electrocauterization needle, orbital septum rupture (upper blepharoplasty) with fat herniation and muscular restriction, fibrotic adherences to extraocular musculature as well as possible anesthetic toxicity.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The most frequently compromised muscles are the inferior oblique (IOb) and inferior rectus (IR), followed by the superior rectus. It has been suggested that the transconjunctival pathway increases the risk of diplopia.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This frequency of involvement suggests that the main risk factor would be the proximity of the IOb muscle and the Lockwood ligament to the surgical surface (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), as in the superior rectus is located more posteriorly than the anterior rectus.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The main hypotheses to explain the cause of post-blepharoplasty diplopia is restrictive strabismus caused by an adherence syndrome. The utilization of electrical cauterization would give rise to a cicatrization reaction in the perimuscular tissue (Tenon capsule and inter-muscular spindle or fascia). A contributing factor could be perimuscular hematoma, although it could resolve spontaneously in a few weeks.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Proposals to treat said adherence syndrome include adherence release as well as covering the muscular belly with amniotic membrane (AM) in order to avoid relapse. This has been utilized in ophthalmology to cover conjunctival and corneal defects, stopping leaks in glaucoma filtrating blebs as well as in the management of restrictive strabismus after multiple strabismus surgeries.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Surgical management of 2 vertical diplopia cases after inferior blepharoplasty is presented below.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">An observational, descriptive-type retrospective study involving 2, cases presented between January and May 2018. After releasing adherences, ultra-frozen human AM preserved in the eyes bank of the authors’ community was utilized. AM is preserved adhered by its stromal side to a cellulose substrate immersed, saline solution, a mixture of antibiotics, (vancomycin, imipenem, gentamicin, nystatin. Informed consents were obtained from patients for surgical examination, polymyxin B), use of AM in the same operation.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Both patients signed the informed consent and accepted publication of their data, worded according to the norms set by the Vancouver and Helsinki declarations.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">Both patients, aged 41 and 63, were followed up during 30 and 42 weeks, respectively.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 1</span><p id="par0055" class="elsevierStylePara elsevierViewall">Female, 41, who underwent inferior blepharoplasty in both eyes through transconjunctival pathway without intraoperative events. After 2 weeks she began to notice non-progressive binocular diplopia in supraversions.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Examination produced absence of limitations and the following diplopia chart: neutralization with 2 prismatic diopters (PD) with upper base in the left eye (LE) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Orbital magnetic resonance did not produce relevant findings. The patient was proposed strabismus surgery with local anesthesia and sedation to enable intra-surgery adjustments. The procedure was carried out 6 weeks later after blepharoplasty with the following technique:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0070" class="elsevierStylePara elsevierViewall">Forced ductions: slight supraduction restriction was found in the LE.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0075" class="elsevierStylePara elsevierViewall">Left IR examination without findings, dissection of inter-muscular partitions and Tenon capsule.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0080" class="elsevierStylePara elsevierViewall">Resolution of diplopia in primary gaze and intra-surgery supraduction.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0085" class="elsevierStylePara elsevierViewall">Covering the entire muscular belly of the exposed IR with AM.</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">At 12 weeks evolution, the patient did not exhibit torticollis or diplopia in any position.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case 2</span><p id="par0095" class="elsevierStylePara elsevierViewall">Female, 63, exhibiting progressive limitation and diplopia in upper days after bilateral inferior blepharoplasty performed 3 months earlier. Clinic examination produced the following results (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>):<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1</span><p id="par0100" class="elsevierStylePara elsevierViewall">Hypotropia in LE, supraduction and adduction limitation in LE grade <span class="elsevierStyleSmallCaps">I</span> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2</span><p id="par0105" class="elsevierStylePara elsevierViewall">In diplopia chart, neutralization with difficulty, without maintaining fusion over a few seconds with LE superior base prism, measurements in PD.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">3</span><p id="par0110" class="elsevierStylePara elsevierViewall">Iconography showed more extreme supraduction limitation in adduction (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p></li></ul></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Suspecting left IOb adherence syndrome, the patient was proposed surgery with local anesthesia and sedation 20 weeks after blepharoplasty:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1</span><p id="par0120" class="elsevierStylePara elsevierViewall">Passive ductions: limitation for supraduction in LE adduction.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2</span><p id="par0125" class="elsevierStylePara elsevierViewall">Dissection of left IOb lateral to IR. Fibrosis bridges were found between IOb and IR at 8 mm of insertion.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">3</span><p id="par0130" class="elsevierStylePara elsevierViewall">Release of adherences.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">4</span><p id="par0135" class="elsevierStylePara elsevierViewall">Intrasurgery, the patient did not exhibit diplopia in primary gaze position (PGP) or in 30° infraversion.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">5</span><p id="par0140" class="elsevierStylePara elsevierViewall">Covering anterior portion of IOb with AM.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">6</span><p id="par0145" class="elsevierStylePara elsevierViewall">Persistence of passive duction with slight limitation in supraduction; desiccation of additional muscle was discarded due to requiring orbital access.</p></li></ul></p><p id="par0150" class="elsevierStylePara elsevierViewall">Despite the intra-surgery resolution of diplopia, 24 h postoperative the patient exhibited a condition similar to the preoperative situation with limitation in supraduction of LE, diplopia in PGP and in supra- and dextroversion that neutralized the base prism of LE.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Videonystagmography was taken 30 weeks after strabismus surgery, which showed endotropia in primary position (1 PD) and supraduction limitation in LE (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) which was well tolerated and does not impair the patient’s day-to-day activity.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0160" class="elsevierStylePara elsevierViewall">Post-blepharoplasty diplopia constitutes a difficult to manage complication that does not produce satisfactory results in all cases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Baseline management involves the use of prisms and observation in small angle strabismus (<10 PD), but if the condition does not resolve or if the strabismus is larger (>10 PD), surgery is required. Some series describe spontaneous resolution after several months and this is what happened in one of the present cases. Other series refer persistence of diplopia despite muscular retroinsertions. In surgery the authors consider it necessary to release muscular adherences but also to avoid future adherences motivated or reactivated by the strabismus surgery itself. Several agents have been proposed for this purpose, both mechanical (hyaluronic acid) and pharmaceutical (mitomycin C, triamcinolone, etc.). However, MA appears to be more appropriate due to its safety profile and to the number of publications.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">It must be taken into account that IOb separates the medial and central fat packages and accordingly any maneuver with them could damage the muscle. In addition, all extraocular muscles are connected by intramuscular spindles, and therefore dissection maneuvers around the IOb could give rise to fibrotic adherences to the inferior rectus (IR).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The dissection and extraction of preaponeurotic factor must be done with extreme care in order to minimize the formation of adherences.</p><p id="par0170" class="elsevierStylePara elsevierViewall">The approach of transconjunctival blepharoplasty is carried out at 3–4 mm inferior to the tarsus.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Perhaps a more anterior approach closer to the tarsus could diminish surgical trauma of muscular bellies.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Cauterization has also been involved although it could create adherences that could restrict muscular movements, particularly of the IOb due to its proximity to the preaponeurotic fat packages. Finally, periocular anesthesia is capable of decompensating previous phorias.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This mechanism could explain the rare described dysfunctions of horizontal rectus muscles.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In order to resolve diplopia, the authors propose releasing adherences and placing AM in between, surrounding the adherence area. In the absence of deviation or presence of very small deviation, the authors do not consider it necessary to associate muscle retroinsertion. In the first case, the postoperative limitation resolved completely whereas in the second case it improved considerably with persistence of slight restriction in elevation.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Recent studies postulate the need to individualize the location of the AM implant where larger adherences or inflammatory activity is found,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> for instance in intramuscular partitions, subconjunctival base, etc.</p><p id="par0190" class="elsevierStylePara elsevierViewall">AM complications described in the literature include migration, hematomas, granulomas or persistent inflammation, but these were not observed in the present patients. Histopathological studies in rabbits utilizing AM as adjuvant for the retroinsertion of extraocular muscles<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> observed the initial appearance of a pro-inflammatory effect that could last for the first weeks, although a diminished medium-term tissue fibrosis reaction was also observed.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="par0195" class="elsevierStylePara elsevierViewall">Diplopia is a rare complication of blepharoplasty which is difficult to manage and does not produce satisfactory results in all cases. Two cases are reported in which the release of adherences and insertion of AM enabled a significant improvement in a restrictive strabismus condition. Accordingly, it is considered that this is a valuable therapeutic tool for strabologists. At present, indications for the utilization of AM are imprecise and with very little evidence, although the authors believe that it should be considered in patients with multiple strabismus operations as well as adherence-based restrictions. Additional studies could investigate the etiopathogeny of this complication and the anti-inflammatory and anti-adherence effect of AM.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">No conflicts of interest were declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1250894" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1159782" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1250895" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1159783" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Case 2" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-02-23" "fechaAceptado" => "2019-05-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1159782" "palabras" => array:3 [ 0 => "Blepharoplasty" 1 => "Diplopia" 2 => "Amniotic membrane" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1159783" "palabras" => array:3 [ 0 => "Blefaroplastia" 1 => "Diplopía" 2 => "Membrana amniótica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Two consecutive cases are presented of vertical diplopia after blepharoplasty. They concern two women aged 41 and 63 years with vertical binocular diplopia after bilateral lower blepharoplasty using a trans-conjunctival approach. The diplopia was presented in both cases in the immediate postoperative period, being stable in one of the cases and pallrogressive in the other.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">With the suspicion of restrictive strabismus, it was decided to explore the affected extra-ocular muscles, eliminate adhesions and coat the muscular bellies with amniotic membrane.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Post-blepharoplasty diplopia is an uncommon, but very serious complication, given the expectations of these patients. The current literature reports unsatisfactory results in its management. In this study, it is considered that the muscular covering with amniotic membrane can provide better results in the surgical management of these patients, due to its anti-inflammatory and anti-adherence effect.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Presentamos dos casos consecutivos de diplopía vertical tras cirugía de blefaroplastia. Se trata de dos mujeres de 41 y 63 años que presentaron diplopía binocular vertical tras blefaroplastia inferior bilateral con abordaje transconjuntival. La diplopía se presentó en ambos casos en el postoperatorio inmediato, siendo en uno de los casos estable y en otro progresiva.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Con la sospecha de estrabismo restrictivo se planteó explorar los músculos extraoculares afectados, eliminar las adherencias y recubrimiento de los vientres musculares con membrana amniótica.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La diplopía postblefaroplastia es una complicación infrecuente pero muy grave, dadas las expectativas de estos pacientes. La literatura describe, hasta la fecha, resultados poco satisfactorios en su manejo. Consideramos que el recubrimiento muscular con membrana amniótica puede aportar mejores resultados en el manejo quirúrgico de estos pacientes, debido a su efecto antiinflamatorio y antiadherencial.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández Jiménez-Ortiz H, Gómez de Liaño Sánchez R, Navas Pérez S, Genol Saavedra I, Toledano Fernández N. Membrana amniótica en el tratamiento quirúrgico de diplopía postblefaroplastia. Arch Soc Esp Oftalmol. 2019. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.oftal.2019.05.008">https://doi.org/10.1016/j.oftal.2019.05.008</span></p>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2198 "Ancho" => 2928 "Tamanyo" => 386753 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sagittal section of eyelid, ocular globe and inferior and anterior region of the orbit, showing the proximity of the medial fat package with the inferior oblique, inferior rectus muscles and the Lockwood ligament. Original illustration by Dr. Héctor Fernández Jiménez-Ortiz.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2368 "Ancho" => 3177 "Tamanyo" => 470535 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Photographic history of case 2. A. Preblepharoplasty. B. After strabismus surgery: 2 weeks. C. After strabismus surgery: 6 months.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2385 "Ancho" => 3178 "Tamanyo" => 845378 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Videonystagmography and Lancaster screen at baseline (top) and final (bottom) for case 2. Final results: primary position, 1 dp microendotropia. Supraversion: 2 dp limitation left eye. Supra- and dextroversion: 5 dp limitation in left eye.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Supra- and dextroversion: 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Centered supraversion: 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Supra- and levoversion: 1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dextroversion: 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary gaze position: 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Levoversion: 0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infra- and dextroversion: 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infraversion: 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infra- and levoversion: 0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2139893.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pre-strabismus surgery deviation measurement in prism diopters of the 9 diagnostic gaze positions for case 1.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Supra- and dextroversion: 8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Centered supraversion: 8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Supra- and levoversion: 4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dextroversion: 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary gaze position: 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Levoversion: 0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infra- and dextroversion: 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infraversion: 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infra- and levoversion: 0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2139892.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pre-strabismus surgery deviation measurement in prism diopters of the 9 diagnostic gaze positions for case 2.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications of blepharoplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B. 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