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Original article
Inferior oblique retro-equatorial myopexy: An alternative weakening
Miopexia retroecuatorial del músculo oblicuo inferior: un debilitamiento alternativo
G. García de Oteyzaa,
Corresponding author
gonzalo_gdeoteyza@hotmail.com

Corresponding autor.
, M. Iglesiasb, J. García de Oteyzaa
a Clínica Oftalmológica García de Oteyza, Barcelona, Spain
b Hospital Universitario de Orense, Orense, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In the mid-seventies&#44; C&#252;ppers<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> described a new and innovative surgical technique to avoid the large recessions used in nystagmus surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The procedure consists of fixing a straight muscle to the sclera at a retroequatorial level &#40;between 12 and 14&#8239;mm of the primitive insertion&#41; using non-absorbable sutures&#46; This intervention creates a new muscle insertion&#44; diminishing or annulling the contact arch and&#44; consequently&#44; diminishing the balloon rotation effect in benefit of the traction effect&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main advantages of this technique are that it has no influence on the primary gaze position in addition to respecting the muscle tone&#44; being reversible and creating an artificial paresis by theoretically modifying the innervational factor&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The purpose of the present study is to present and describe this debilitating technique at the level of the inferior oblique muscle&#46; Following C&#252;ppers&#39;s theoretical and practical foundations<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the retroequatorial anchoring of the inferior oblique without disinserting it from its primitive insertion is described&#46; This technique can be used in patients with lower oblique hyperaction &#40;primary or secondary to upper oblique palsy&#41;&#44; in elevation syndromes in adduction and in V-alphabetic syndromes in both endotropy and exotropy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">In this prospective interventional study 6 consecutive eyes were selected of 6&#8239;patients between 3 and 7&#8239;years of age with inferior oblique hyperaction to perform debilitating surgery on that muscle&#46; Three of them presented esotropia associated with lower oblique hyperaction&#46; The fourth case presented exotropia due to excess divergence associated with inferior obliqu ehyperaction&#46; The fifth case was an elevation syndrome in pure adduction&#44; and sixth&#44; an upper oblique paresis&#46; In all cases bilateral surgery was performed&#44; except in the case of unilateral lower oblique paresis&#46; In the cases of bilateral inferior oblique surgery with similar hyperaction in both&#44; retroequatorial myopia was performed in one of them and in the other a classic Parks plus technique &#40;retroinsertion of the inferior oblique to 8&#8239;mm of the temporal border of the inferior rectum&#41;&#46; In cases where horizontal muscles were approached&#44; no vertical displacements of the insertions were performed&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In all patients&#44; age&#44; sex&#44; corrected visual acuity and ocular motility were determined by means of the cover&#47;uncover test and study of versions&#46; To determine deviation in the primary position&#44; the cover test with prisms was used in distant vision &#40;5&#8239;m&#41; and in near vision &#40;33&#8239;cm&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">To graduate the deviation in tertiary positions&#44; the method described by Lim et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> was utilized&#46; After taking photographs of the 9 cardinal gaze positions by means of a 26&#46;2 megapixel digital reflex camera &#40;EOS 6D Mark 2&#59; Canon Inc&#46;&#44; Tokyo&#44; Japan&#41; they were processed with the Photoshop 6&#46;0 program &#40;Adobe&#44; San Jose&#44; California&#44; USA&#41;&#46; Finally&#44; the ImageJ program &#40;software version 1&#46;46&#59; National Institutes of Health&#44; Bethesda&#44; Maryland&#44; USA&#41; was used to measure the lower oblique hyperaction degrees&#46; In this way it was possible to calibrate the inferior oblique hyperaction at 4&#8239;degrees&#46; In the maximum lateral version&#44; a vertical deviation of between 10 and 19&#8239;degrees was categorized as 1&#43;&#44; between 20 and 29&#8239;degrees as 2&#43;&#44; between 30 and 39&#8239;degrees as 3&#43;&#44; and if it exceeded 40&#8239;degrees&#44; as 4&#43;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The inclusion criteria were eyes with unilateral or bilateral hyperaction of the oblique inferiormuscle&#44; which could present in an isolated way or associated to horizontal deviations&#46; All causes of lower oblique involvement could be included&#46; All patients were requested to have the informed consent signed by their parents before surgery&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The exclusion criteria comprised the existence of previous eye surgery and the need to perform surgery on any vertical muscle in the same operation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The mean vertical deviation associated with inferior oblique hyperaction was 34&#8239;&#177;&#8239;4&#46;6&#44; which is equivalent to 3&#43;&#46; Preoperative data for all cases are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The patients&#39; legal guardians were informed of the surgery and all signed the informed consent&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All patients were operated under general anesthesia&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The inferior oblique approach was performed on the bisector between the rectus inferior and lateral rectus muscle&#46; The muscle was isolated and dissected with the help of an oblique hook&#46; After individualization&#44; the muscle body was surrounded and tied with a non-absorbable Dacron&#174; 5&#47;0 suture &#40;Invista&#59; Wichita&#44; Kansas&#44; USA&#41; as posteriorly as possible&#44; fixing it to the sclera by a stitch at 2&#8239;mm temporal and 8&#8239;mm posterior to the insertion of the lower rectus following its original anatomic pathway &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; leaving the muscle in retroequatorial position &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The conjunctive was sututed with 7&#47;0 silk&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Postoperative treatment consisted of tobramycin &#40;3&#8239;mg&#47;mL&#41; and dexamethasone &#40;1&#8239;mg&#47;mL&#41; eye drops &#40;Tobradex&#59; Alcon Cus&#237; S&#46;A&#46;&#44; Barcelona&#44; Spain&#41; 3 times per day during 2 weeks&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Post-operative follow-up was performed on the day of surgery&#44; weekly&#44; monthly and at 6&#8239;months&#46; The results obtained at 6&#8239;months were considered final when elaborating the present study&#46; Total success was defined as a degree of inferior oblique hyperaction less than 5 and a partial success between 5 and 9&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">At 6&#8239;months of the surgery all eyes decreased the degree of inferior oblique hyperaction &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Four of the 6&#8239;cases obtained total success&#44; one partial success and another one maintained inferior oblique hyperaction of 1&#43;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The mean post-operative degree of hyperaction was 5&#46;65&#8239;&#177;&#8239;2&#46;84 and the mean reduction was 28&#46;3&#8239;&#177;&#8239;1&#46;98&#46; Only one case was hypocorrected with a hyperaction of 1&#43;&#46; The results are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">No intraoperative complications arose in any of the cases&#46; There were no antielevation syndromes or adhesion syndromes&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The classic techniques of weakening the inferior oblique are based either on direct action on the muscular body &#40;tenotomies&#44; myotomies or myectomies&#41; or on the displacement of muscular insertions&#46; Among the latter&#44; the lower oblique anteroposition and retroinsertion techniques described by Parks&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Fink&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Apt and Call<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and by Elliot and Nankin<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> are noteworthy&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The efficacy and safety of these techniques have been broadly proven in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However&#44; the anatomical location and particular neighborhood relationships of the lower oblique muscle mean that surgery can lead to certain complications&#46; The lower oblique muscle is the only one that is born in the antero-internal part of the orbit following a front-to-back path to its scleral insertion in retro- equatorial position&#44; which gives it a large contact arc&#46; Scleral insertion is intimately related to two very delicate structures such as the macula and the inferotemporal vorticose vein&#46; The macula is located at 1&#8239;mm from the posteriormost edge of the muscle&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Any poor manipulation of the inferior oblique can produce a lesion at the macular level with consequent central vision alteration&#46; In their study&#44; Turan-Vural et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> warn that&#44; despite uncomplicated surgery&#44; there may be changes in foveal thickness when the lower oblique muscle is involved&#44; an opinion contradicted by Kasem&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The retroequatorial position of the muscle insertion and the path from nasal origin to temporary insertion explain that the main actions of the inferior oblique are elevation and excyclotorsion&#46; In anteriorization and retroinsertion procedures&#44; the muscle is disinserted and placed in a position prior to the equator&#46; Disinsertion of the muscle can injure adjacent structures and can have serious functional consequences&#46; With respect to the antero-posterior axis&#44; placement anteriorly to the equator causes the lower oblique muscle to cease to be excyclorotatory and&#44; with respect to the horizontal axis&#44; causes the muscle to become anti-lifting&#46; Its force vector changes from one of elevation to one that prevents elevation&#46; This impediment will be greater when the new insertion is placed earlier&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> One of the most serious complications of excessive anteriorization of the lower oblique muscle is the anti-elevation syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The aim of this paper is to describe an alternative technique to the classic techniques of weakening the lower oblique in order to minimize possible intra-operative and post-operative complications&#46; Retroequatorial inferior oblique myopia consists of a technique that does not disinsert the muscle&#44; thus avoiding any injury to the macular area or to the inferotemporal vorticose vein&#46; On the other hand&#44; anchoring the muscle in a retroequatorial position preserves the main actions of the inferior oblique&#46; The anchoring of the muscle to 8&#8239;mm following the lateral insertion of the inferior rectus muscle corresponds to a retroinsertion of the inferior oblique of 14&#8239;mm&#46; The anchor site acts as new muscle insertion&#44; so the rest of the muscle body ceases to have action&#46; Consequently&#44; this technique acts as a recession-resection&#44; and it is for that reason that it seems convenient to use the same name that C&#252;ppers coined to describe his technique on straight muscles&#46; A similar technique has already been described&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> with the difference that the proposed anchoring point is prior to that proposed with our retroequatorial myopia&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The efficacy of fixing the lower oblique posterior to the equator has been demonstrated in our cases where the decrease in vertical deviation angle was 28&#46;3&#176;&#46; In all cases an improvement in inferior oblique hyperaction was demonstrated&#46; There were no intraoperative complications&#46; Only in one case we found a hypocorrection &#40;from 4&#43; to 1&#43;&#41; and in no case did we obtain an anti-elevation syndrome&#46; This is why this technique could have indication in cases of inferior oblique hyperaction between 2&#43; and 3&#43;&#44; reserving a classic technique for cases of 4&#43;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Regarding the limitations of this technique&#44; we can cite the difficulty&#44; especially for a novice surgeon&#44; of anchoring a muscle to 15&#8239;mm of the limbus with the risk of scleral perforation that this entails&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The authors are aware that the data provided in this work is not sufficient&#44; but even so it can be&#44; concluded that the retroequatorial myopia technique is effective since it reduces inferior oblique hyperaction in all cases&#46; Said technique is safe and&#44; like any straight muscle myopia&#44; reversible&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The authors consider that the description of this technique&#44; as well as its first results&#44; establish an interesting alternative to the classic techniques of weakening the inferior oblique&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">This study has not received specific support from public sector agencies&#44; commercial sector or non-profit entities&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0135" class="elsevierStylePara elsevierViewall">No conflict of interests was declared I the authors in this article&#46;</p></span></span>"
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    "fechaRecibido" => "2020-03-05"
    "fechaAceptado" => "2020-04-28"
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            0 => "Faden operation"
            1 => "Retro-equatorial myopexy"
            2 => "Inferior oblique"
            3 => "Inferior oblique overaction"
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          "palabras" => array:4 [
            0 => "Fadenoperaci&#243;n"
            1 => "Miopexia retroecuatorial"
            2 => "Oblicuo inferior"
            3 => "Hiperacci&#243;n oblicua inferior"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">To describe an alternative surgical approach to treat inferior oblique overaction&#44; and report the first results of this technique&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and Methods</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A total of six consecutive eyes of six patients with primary or secondary inferior oblique overaction underwent inferior oblique retro-equatorial myopexy under general anaesthesia&#46; The primary outcomes measured were the postoperative vertical deviation in the field of action of the inferior oblique muscle&#44; and the intra- and postoperative surgical complications&#46; Final results were evaluated at six-months after surgery</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The patient population consisted of three girls and three boys aged between three and seven years old&#46; The mean preoperative inferior oblique overaction was 34&#176; &#177; 4&#46;6&#176;&#44; equivalent to 3&#43;&#46; Inferior oblique overaction was reduced in all patients with a mean reduction of 28&#176; &#177; 1&#46;98&#176;&#44; and the mean postoperative deviation was 6&#176; &#177; 2&#46;84&#176;&#46; Total success was achieved in four out of six eyes&#44; and only one case remained under-corrected&#46; No intra- or postoperative complications were reported&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Inferior oblique retro-equatorial myopexy is an alternative surgical approach for inferior oblique overaction&#46; It is an efficient&#44; safe&#44; and reversible technique that could be used in cases of inferior oblique overaction between 2&#43; to 3&#43;&#46;</p></span>"
        "secciones" => array:4 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Describir una alternativa quir&#250;rgica para tratar la hiperacci&#243;n del oblicuo inferior y reportar los primeros resultados con dicha t&#233;cnica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Un total de seis ojos consecutivos de seis pacientes con hiperacci&#243;n primaria o secundaria del oblicuo inferior se sometieron a una operaci&#243;n de miopexia retro-ecuatorial del oblicuo inferior bajo anestesia general&#46; Los resultados primarios medidos fueron la desviaci&#243;n vertical postoperatoria en el campo de acci&#243;n del m&#250;sculo oblicuo inferior y las complicaciones quir&#250;rgicas intra y postoperatorias&#43;&#46; Los resultados finales se evaluaron despu&#233;s de seis meses de cirug&#237;a</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La muestra de pacientes consisti&#243; en tres ni&#241;as y tres ni&#241;os de entre tres y siete a&#241;os&#46; La media de la hiperacci&#243;n del oblicuo inferior preoperatoria fue 34&#186; &#177; 4&#44;6&#186; equivalente a 3&#43;&#46; La hiperacci&#243;n del oblicuo inferior se redujo en todos los pacientes siendo la media de reducci&#243;n de 28&#186; &#177; 1&#44;98&#186; y la desviaci&#243;n postoperatoria media de 6&#186; &#177; 2&#44;84&#186;&#46; Cuatro de seis ojos obtuvieron un &#233;xito total&#44; y solo un caso qued&#243; sin corregir&#46; No se produjeron complicaciones intra o postoperatorias&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La miopexia retro-ecuatorial del m&#250;sculo oblicuo inferior es un enfoque quir&#250;rgico alternativo para la hiperacci&#243;n del oblicuo inferior&#46; Es una t&#233;cnica eficiente&#44; segura y reversible que podr&#237;a usarse en casos de hiperacci&#243;n del oblicuo inferior entre 2&#43; a 3&#43;&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a de Oteyza G&#46;&#44; Iglesias M&#46;&#44; Garc&#237;a de Oteyza J&#46; Miopexia retroecuatorial del m&#250;sculo oblicuo inferior&#58; un debilitamiento alternativo&#46; Arch Soc Esp Oftalmol&#46; 2020&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.oftal.2020.04.024">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;oftal&#46;2020&#46;04&#46;024</span></p>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CTF&#58; RET 10 <span class="elsevierStyleSup">&#916;</span>CTN&#58; RET 35 <span class="elsevierStyleSup">&#916;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CTF&#58; RET 16 <span class="elsevierStyleSup">&#916;</span>CTN&#58; RET 25 <span class="elsevierStyleSup">&#916;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33&#46;2&#176;&#43;&#43;&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">CTF&#58; AET 45 <span class="elsevierStyleSup">&#916;</span>CTN&#58; AET 45 <span class="elsevierStyleSup">&#916;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">CTF&#58; AXT 35 <span class="elsevierStyleSup">&#916;</span>CTN&#58; AXT 14 <span class="elsevierStyleSup">&#916;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">CTF&#58; OrtoCTN&#58; Orto&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11&#46;1&#176; &#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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Article information
ISSN: 21735794
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos