Original article
Correlation study in the measurements of oblique passive ductions and cyclorotation
Estudio de correlación en las medidas de ducciones pasivas oblicuas y de ciclorrotación
E. Hernández García
, M.R. Gómez de Liaño Sánchez
Corresponding author
Hospital Clínico San Carlos, Madrid, Spain
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Hernández García, M.R. Gómez de Liaño Sánchez" "autores" => array:2 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Hernández García" "email" => array:1 [ 0 => "elenahergar@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.R." 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There are few studies on this subject and the exploration of the upper oblique muscle has been more described than the lower oblique muscle.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">As for the upper oblique muscle, in 1972 Scott and Knapp described the usefulness of retropulsion of the eyeball to explore patients with Brown syndrome. In 1975, Scott described a knife-edge sensation when exploring the upper oblique muscle in Brown syndrome. Since then, several references have been found about upper oblique muscle examination before and after surgery or in various pathologies.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In 1979, Toosi and von Norden<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> were the first to describe a generally negative passive duction in inferior oblique hyperfunction cases. In 1981, Guyton<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> published the most widely used technique for exploring oblique muscles today, i.e., the exaggerated forced duction test involving balloon traction at oblique quadrants, retropulsion and torsion. In said study the muscle tension is graduated from 0 to 4 crossings, comparing the results with those obtained by a trained assistant during the performance of the test. A reasonably correlation was observed between both measurements, although without statistical analysis. Plager<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> also describes a duction test to exploring the laxity of upper obliques with a scale. Both techniques base their results on qualitative measures and the scales are 0 to +4 for the limitations and −1 to -4 for assessing laxity. In relation to ocular rotations, there are two authors, Kushner<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and Ludwig,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> who described methods for estimating rotational or torsional duction, but without establishing a quantification method. In 2015. Jung and Holmes<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> described a quantitative and torsional forced duction test. They explored retrospectively the maximum non-retropulsive eye rotation under general anesthesia, using Mendez's ring as a degree meter. Said authors compared results between controls and patients with different oblique muscle alterations. The measurements are made by the surgeon, a photographic record is made and another measurement is made by another observer through photography. A correlation coefficient of 0.97 and 0.82 respectively was obtained for the measurements of the surgeon and the observer through photography. These measurements will be applied in a practical way in subsequent studies to evaluate the involvement of oblique muscles during thyroid strabismus surgery or muscle transpositions.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> Finally, in 2017–2018 Connor and Kraft<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> published a study that analyzed the correlation between the forced intorsor duction test in surgery, with hyperfunction of the lower oblique graduated in clinical exploration. This is a retrospective study. The duction test used was performed with retropulsion of the balloon and the intorsion is measured in clock hours, each hour being equivalent to 30°. A control group was used and repeated measurements were made by a senior surgeon and fellow with experience in pediatric ophthalmology. There are hardly any references on excision and inclyclotorsion normal values, except for the values found in the patients of the control groups of the published studies.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the present study, the objective is to analyze the normal values of excyclo and inclyclotorsion and passive oblique ductions in addition to the correlation of the measurements between 2 observers.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0025" class="elsevierStylePara elsevierViewall">Forty-four eyes from 22 patients aged 8–64 years were studied. Patients with diagnosis of horizontal strabismus without oblique muscle alterations were included. Patients with a history of previous strabismus surgery, eye trauma or restriction of horizontal or vertical muscles were excluded. Scans were taken under deep general anaesthesia before any surgical procedure. No muscle relaxant was used in the patients except in 7 of them, who were given succinylcholine as a short term relaxant.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> The scan was performed at least after 10 min after administration to eliminate the possibility of any residual effect.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Before taking the measurements, the limbus was marked at 12, 3, 6 and 9 o’clock with a blue marker. A Mendez ring (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) was then aligned with these reference marks. The eye was then held by 2 tweezers at the 9 and 3 o'clock position. First, the passive oblique ductions were explored by means of the first 2 steps of the exaggerated forced duction test described by Guyton, which includes traction of the eyeball towards upper and lower oblique positions with ocular globe retropulsion (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Movement limitation was evaluated and graduated from 0 to -4. Secondly, with the tweezers holding the globe in the same position, the eye was excised with retropulsion up to the first resistance. Using the Mendez ring, the degrees obtained were recorded. The same procedure was performed with the inclyclorotation (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). All measurements were made in duplicate by each of the 2 observers.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The measurements obtained were analyzed by comparing the repeatability results between the same observer and between the 2 observers. Cronbach's intraclass alpha correlation coefficient was calculated with a 95% confidence interval. The results are expressed in intra- and interobserver reliability coefficients. Differences of 0.5 points in the oblique duct test and up to 5° in the rotation test have been taken into account for the analysis. The statistical analysis was performed with IBM SPSS Statistics v21 software (SPSS Inc., Chicago, USA).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">The correlation results obtained between both observers for the lower and upper oblique ductions and for the excycloduction and inclycloduction are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The correlation of measurements between both observers is higher for the upper oblique muscle, but still high for all measurements.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Taking into account maximum differences between the measurements of oblique ductions of the lower oblique muscle for the first observer, 90.9% of the measurements had differences of 0.5 points or less. Assessing 100% of the patients, all measures differed by a maximum of 1 point on the measurement scale. For the second observer, 97.7% of the measures were within 1 point of each other. In the first measurement between the 2 observers, the results agreed by 86.4% on 0.5-point differences, reaching 100% on 1-point differences. In the second measurement between the 2 observers, these results were 84.1 and 97.7% for 0.5 and 1 point differences respectively.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Analyzing maximum differences between measures of oblique ducts of the upper oblique muscle for the first observer, 100% of the measures had differences of 0.5 points or less. For the second observer, 94.1% of the measurements were 0.5 point differences and no patients had differences greater than 1 point. In the first measurement between the 2 observers, the results coincide by 94.1% in differences of 0.5 points, reaching 100% in differences of one point. In the second measurement between the 2 observers, these results were 88.2% and 100% for differences of 0.5 and 1 point respectively.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the study of excycloduction, analyzing maximum differences between measurements for both observers separately, 100% of the measurements had differences of 10° or less. 97.7% of the measures were only 5° different for the first observer. For the second observer, 93.2% of the measurements were consistent with differences of 5°. In the first measure between the two observers, the results were 93.2% in 10° differences. In the second measure between the two observers, these results were 84.1 and 95.5% for 5° and 10° differences, respectively.</p><p id="par0060" class="elsevierStylePara elsevierViewall">When analyzing maximum differences between inclycloduction measures for both observers separately, 100% of the measures had differences of 10° or less. 95.5% of the measures differed by only 5° for the first observer. For the second observer, 95.5% of the measures were consistent with differences of 5°. In the first measure between the two observers, the results were 72.7% for 10° differences and 100% for 10° differences. In the second measure between the two observers, these results were 81.8 and 100% for 5° and 10° differences, respectively.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The intraclass correlation coefficient between the two measurements of the first and second observer (intra-observer) is summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The correlation between the 2 measures of all ductions for the same observer is strong for both, being also somewhat lower for the lower oblique muscle in both cases.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The median [interquartile range] of all the scans is summarized in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">There are few references documenting normal eye rotation values. Different tests have been studied to assess the degree of elasticity of the upper and lower oblique muscle, the most widespread being Guyton's exaggerated forced duction test.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However, ocular rotation has hardly been studied.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The present study evaluated the passive ductions of the upper and lower oblique muscles according to Guyton's test and the ocular rotations in normal eyes or with purely horizontal strabismus, to assess the values of normality of these ductions and the correlation of the measurements in the clinic between 2 observers.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the oblique forced duction test, the correlation of the measurements between the 2 observers is very good, being superior for the upper oblique muscle (very high correlation) than for the lower one (moderate-high correlation). The results are even more reliable between measurements from the same observer than between observers.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The tests for exploring oblique muscles are based primarily on qualitative data. The Guyton test (exaggerated forced duction test) is indispensable for the evaluation of laxity or rigidity of oblique muscles. It is graded on a scale of subjective measurement from 0 to +4 or from -1 to -4. Kushner<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> described a rotational forced duction test to identify the incarceration syndrome of the upper oblique muscle. It evaluates the symmetry or asymmetry between an excyclorotation and estimated maximum inclyclorotations, but does not specifically quantify the test or the normality values. Jung and Holmes<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> published a quantitative rotational forced duction test, offering a value in degrees. In this test the ocular globe is not explored in retropulsion, according to the authors to facilite a more physiological exploration of the rotation thereof. Data from eyes with oblique muscle alterations are compared with controls and with the slanting eye. In our study, the exploration of the oblique ducts is performed with retropulsion of the eyeball in an attempt to analyze the normal values without the artifact produced by the action of the rest of the extraocular muscles. Connor and Kraft<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> studied the correlation of the torsional duction test at the time of surgery with hyperfunction of the inferior oblique muscle graduated in clinic. This is a retrospective study. In surgery, the Guyton force duction test is used, but the torsion is measured in clock hours, with each clock hour being equivalent to 30° of torsion.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Guyton<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> described a normal upper oblique muscle strain of 1.5+ and a normal lower oblique strain of approximately 1+. In the present study, the median value for the lower oblique is 0.5+ and for the upper oblique 0+. Since these are subjective measures and, in our case, since we did not perform the third part of the exaggerated duction test, these differences in results could be explained. In the rest of the publications, no data on normality are documented with the exception of test results for different oblique muscle pathologies.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In the thoracic duction test, the correlation in results is moderate-high between observers and very strong in the measurements of each observer independently. The values of excyclorotation are more reliable than the inclyclorotation.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Ludwig<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> published a normal rotation of the eye in children of 60 to 70° of excyclorotation and 60 to 70° of inclyclorotation, while, in adults, both measurements ranged from 20 to 60°. The study does not explain how to quantify degrees of rotation. Jung and Holmes<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> made quantitative measurements of rotation using a Mendez ring. In their control group (n = 31), they reported values ranging from 25 to 35° of maximum excyclorotation and between 30 and 35° of inclyclorotation. In their study, Connor and Kraft<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> published inclyclorotation results in the control patient group (n = 23) of 1.89 clock hours, equivalent to 56.7°.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In our study, excyclorotation values range from minimum values of 25 and maximum values of 40° for both observers, with a median for the first observer of 32.5° and 30° for the second observer. In inclyclorotation, values are between 25 and 35°, with the median for the first observer being 30°, identical to that of the second observer. These results are comparable to those found by Jung and Holmes<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> although in their case they do not use eyeball retropulsion in the exploration. Our inclyclorotation values are discreetly lower than those of excyclorotation.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The coincidences between eye rotation measurements, both interobserver and between the measurements of the same observer, are greater than 90% if limited to 5°. If differences of 10° or less are considered, we found that 100% of the measurements do not exceed this difference. In the study by Connor and Kraft,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> acceptable differences between 2 observers of up to 15° are considered.</p><p id="par0120" class="elsevierStylePara elsevierViewall">There are no studies with normal values in exploration of ocular rotation ducts. The only comparable data are those obtained in the control groups of 2 studies published with quantitative measures.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The measurements obtained with these tests involve a learning curve although the results show an excellent correlation, especially in the same observer, which can be objectified with simple instruments such as a Mendez ring. By knowing how to determine reliable normality values, we will be able to establish with greater precision when a pathology is really affecting the eye movements of a patient and to what extent we can adjust it by means of less aggressive surgery.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">This research has not received specific support from public sector agencies, commercial sector or non-profit entities.</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 by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1371324" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 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" => "xpalclavsec1260310" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1371323" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1260311" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-02-06" "fechaAceptado" => "2020-04-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1260310" "palabras" => array:3 [ 0 => "Traction test" 1 => "Passive duction" 2 => "Oblique muscle" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1260311" "palabras" => array:3 [ 0 => "Test de tracción" 1 => "Ducción pasiva" 2 => "Músculo oblicuo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">To evaluate intraoserver and inteobserver repeatability of the “exaggerated forced duction test” or “oblique traction test” (OTT) and the “excyclo and incyclo passive rotation test” or “Cyclorotation traction test” (CTT).</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">44 eyes of 22 patients were evaluated under deep general anesthesia. Passive duction was tested on supraduction and infraduction by the “exaggerated duction test”. The limitation on movement was graduated from 0 to - 4. Passive cyclorotation test was evaluated with retropulsion of the globe until the first resistance is noted. We used the Mendez ring and blue dots marked on the limbus to measure the amount of cyclorotation. The results obtained of excyclo and incyclorotation were recorded. All measurements were made in duplicate for each of the two observers.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The intraclass correlation of the OTT coefficient between the two observers was for the IO was 0,738 (95% confidence interval, 0,62–0,83) and 0,910 for the superior oblique (SO) (95% confidence interval, 0,85–0,94). The CTT intraclass correlation coefficient of the between the two observers was 0,827 (95% confidence interval, 0,74–0,89) for exclycloduction and 0,792 (95% confidence interval, 0,67–0,85) for inclycloduction. The percentage of patients within 5º of rotation interobserver was 84,1% for excyclorotation and 81,8% for inclyclorotation. Both tests had better correlation on the intraobserver than interobserver evaluation.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Evaluation of the OTT and CyRTT had moderate to good correlation between the two observers and good to excellent on the intraobserver evaluation.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 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="spar0070" class="elsevierStyleSimplePara elsevierViewall">Evaluar la repetibilidad intraobservador e interobservador de la "prueba de ducción forzada exagerada" o "prueba de tracción oblicua" (OTT) y la "prueba de exciclo e inciclorotación pasiva " o "prueba de tracción de ciclorotación" (CTT).</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y métodos</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se estudiaron 44 ojos de 22 pacientes. Fueron evaluados bajo anestesia general profunda. La ducción pasiva se probó en supraducción e infraducción mediante la "prueba de ducción exagerada". La limitación en el movimiento se graduó de 0 a - 4. La prueba de ciclorotación pasiva se evaluó con retropulsión del globo hasta que se observa la primera resistencia. Utilizamos el anillo de Mendez y los puntos azules marcados en el limbo para medir la cantidad de ciclorotación. Se registraron los resultados obtenidos de exciclo e inciclorotación. Todas las mediciones se realizaron por duplicado para cada uno de los dos observadores.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">El coeficiente de correlación intraclase del OTT entre los dos observadores para el oblicuo inferior fue 0,738 (intervalo de confianza del 95%, 0,62-0,83) y 0,910 para el oblicuo superior (intervalo de confianza del 95%, 0,85-0,94). El coeficiente de correlación intraclase de CTT de los dos observadores fue de 0,827 (intervalo de confianza del 95%, 0,74-0,89) para excicloducción y 0,792 (intervalo de confianza del 95%, 0,67-0,85) para incicloducción. El porcentaje de pacientes dentro de 5º de rotación interobservador fue de 84,1% para exciclo y 81,8% para inciclorotación. Ambas pruebas tuvieron una mejor correlación intraobservador que en la evaluación interobservador.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">La evaluación de OTT y CTT tuvo una correlación de moderada a buena entre los dos observadores y buena a excelente en la evaluación intraobservador.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y 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: Hernández García E, Gómez de Liaño Sánchez MR. Estudio de correlación en las medidas de ducciones pasivas oblicuas y de ciclorrotación. Arch Soc Esp Oftalmol. 2020. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.oftal.2020.04.008">https://doi.org/10.1016/j.oftal.2020.04.008</span></p>" ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 724 "Ancho" => 1074 "Tamanyo" => 89774 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mendez ring.</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" => 998 "Ancho" => 1074 "Tamanyo" => 161612 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Oblique muscle forced duction test.</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" => 738 "Ancho" => 1074 "Tamanyo" => 94573 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Exploration of inclyclorotation.</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:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">ICC: intraclass correlation coefficient; OI: inferior oblique; OS: superior oblique.</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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">IO \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">SO \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Excicloduction \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Incicloduction \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CCI (95% confidence interval)</th></tr></thead><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">Between 2 observers \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">0.73 (0.62−0.83) \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">0.91 (0.85−0.94) \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">0.82 (0.74−0.89) \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">0.77 (0.67−0.85) \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">First measure \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">0.73 (0.55−0.84) \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">0.91 (0.82−0.95) \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">0.76 (0.60−0.86) \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">0.65 (0.44−0.79) \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">Second measure \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">0.73 (0.56−0.84) \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">0.86 (0.73−0.92) \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">0.77 (0.61−0.86) \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">0.72 (0.54−0.83) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2354931.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Correlation measurements inter-observers.</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:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">ICC:intraclass correlation coefficient; EHG: second observer; OI: inferior oblique; OS: superior oblique.; RGL: first observer.</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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">OI \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">OS \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Excicloduction \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Incicloduction \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CCI (95% confidence interval)</th></tr></thead><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">RGL \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">0.83 (0.71−0.90) \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">0.98 (0.97−0.99) \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">0.97 (0.95−0.98) \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">0.94 (0.89−0.96) \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">EHG \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">0.79 (0.65−0.88) \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">0.94 (0.88−0.96) \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">0.93 (0.88−0.96) \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">0.91 (0.84−0.95) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2354930.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Intraobserver correlation measurements.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">PD: passive duction; Obs1: first observer; Obs2: second observer; OI: inferior oblique; OS: superior oblique.</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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Examination \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Obs1 1 st measure \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Obs1 second measure \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Obs2 1 st measure \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Obs2 second measure \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><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">PD OI \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">−0.75 [−1.0; −0.12] \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">−0.50 [−1.0; 0.00] \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">−0.50 [−1.0;0.00] \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">−0.50 [−1.0; 0.00] \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">PD OS \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">0.00 [−0.62; 0.00] \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">0.00 [−1.00; 0.00] \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">0.00 [−0.62; 0.00] \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">0.00 [−0.50; 0.00] \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">Excyclotorsion \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">32.50 [25; 40] \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">32.5 [26.25; 40] \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">30 [25; 40] \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">30 [25; 40] \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">Incyclotorsión \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">30 [21.25; 30] \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">30 [25; 35] \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">30 [25; 35] \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">30 [25; 35] \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2354932.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Median of values obtained in examinations.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Quantitative forced duction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K.F. 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