Original article
Multimodal imaging in phototoxic maculopathy: Description of findings in a series of 12 patients
Imagen multimodal en la maculopatía fototóxica: descripción de hallazgos en una serie de 12 pacientes
M. Ortiz Salvador
, J. Montero Hernández, V. Castro Navarro, E. Cervera Taulet, C. Navarro Palop, C. Monferrer Adsuara, L. Remolí Sargues, N. Gonzalez Girón
Corresponding author
Servicio de Oftalmología, Hospital General Universitario de Valencia, Valencia, Spain
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Figura A; pacientes 1-5: maculopatías por puntero láser. Figura B; pacientes 6-12: maculopatía solar. En todos ellos se observa la disrupción de la capa elipsoides. En la figura 5OD, 5OI, 10OD y en menor medida en 9OD, 9OI se aprecia el signo de hiperreflectividad del EPR. En 2OD y 5OD se distinguen las lesiones hiperreflectivas centrífugas.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Ortiz Salvador, J. Montero Hernández, V. Castro Navarro, E. Cervera Taulet, C. Navarro Palop, C. Monferrer Adsuara, L. Remolí Sargues, N. Gonzalez Girón" "autores" => array:8 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Ortiz Salvador" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Montero Hernández" ] 2 => array:2 [ "nombre" => "V." "apellidos" => "Castro Navarro" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Cervera Taulet" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Navarro Palop" ] 5 => array:2 [ "nombre" => "C." 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Ortiz Salvador, J. Montero Hernández, V. Castro Navarro, E. Cervera Taulet, C. Navarro Palop, C. Monferrer Adsuara, L. Remolí Sargues, N. Gonzalez Girón" "autores" => array:8 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Ortiz Salvador" "email" => array:1 [ 0 => "miorsal@icloud.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Montero Hernández" ] 2 => array:2 [ "nombre" => "V." "apellidos" => "Castro Navarro" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Cervera Taulet" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Navarro Palop" ] 5 => array:2 [ "nombre" => "C." "apellidos" => "Monferrer Adsuara" ] 6 => array:2 [ "nombre" => "L." "apellidos" => "Remolí Sargues" ] 7 => array:2 [ "nombre" => "N." "apellidos" => "Gonzalez Girón" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmología, Hospital General Universitario de Valencia, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Imagen multimodal en la maculopatía fototóxica: descripción de hallazgos en una serie de 12 pacientes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2637 "Ancho" => 2917 "Tamanyo" => 511912 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">OCT detail of all patients. Figure A; patients 1–5: laser pointer maculopathies. Figure B; patients 6-12: solar maculopathy. Disruption of ellipsoid layer is observed in all cases. Figure 5RE, 5LE, 10RE and to a lesser extent 9RE, 9LE show the RPE hyperreflectivity sign. Centrifugal hyperreflective lesions are distinguished in 2RE and 5RE.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Phototoxic retinopathy is a group of macular alterations that exhibit macular damage caused by exposure to intense light radiation. Since its appearance in the fundus was first described in 1943<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>, similar of macular lesions associated to sunlight, welding arches<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>, surgical luminance systems<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> or laser light<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> have been described.</p><p id="par0010" class="elsevierStylePara elsevierViewall">To date, no study has compared injuries produced by the main mechanisms that cause phototoxic maculopathy in search of possible clinical or imaging differences.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A series of 20 phototoxic maculopathy cases associated to sunlight and laser light is presented, with the aim of describing clinical, imaging and epidemiological characteristics of each, as well as evolution and possible differences between the different causing mechanisms.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">In this retrospective case series, all patients that came into our center’s emergency room (General University Hospital of Valencia, Spain) presenting macular lesions of phototoxic origin between 2013 and 2019 were included.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At the time of diagnosis, a detailed clinical history was performed in all patients, exploring possible macular damage risk factors, as well as a complete ophthalmological examination including best corrected visual acuity (BCVA) in Snellen notation and funduscopy. In order to calculate average visual acuity, a conversion to an equivalent logarithm of minimum resolution angle (logMAR) was made.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Likewise, multimodal imaging tests were carried out to confirm diagnosis in cases in which exposure history was not evident, performing differential diagnosis with other pathologies to better characterize the patient’s injury. As part of the protocol, infrared retinography and spectral domain optical coherence tomography (OCT) were performed in all patients using Heidelberg (Heidelberg Engineering, Heidelberg, Germany) and Topcon 3d-2000 (Topcon Medical, Tokyo, Japan) systems.</p><p id="par0035" class="elsevierStylePara elsevierViewall">As part of the differential diagnosis and follow-up, 2 patients had fluorescein angiography (FA) and indocyanine green angiography (ICGA) studies performed. Autofluorescence (AF) images and laser retinography studies were also obtained in 15 of the 20 eyes. All of them were acquired using the Heidelberg Retina Angiograph 2 (HRA2) system from Heidelberg systems (Heidelberg Engineering, Heidelberg, Germany).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Patients were followed up on a monthly-quarterly basis to assess damage evolution and appearance of possible complications. Average follow-up time was 20 months. BCVA, a complete ophthalmologic examination including funduscopy under mydriasis, OCT scan and infrared retinography were performed in each checkup visit. Follow-up periods lasted a minimum of 6 months and a maximum of 5.8 years.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">Twenty eyes from 12 patients with macular injuries associated to light sources were identified; 6 female and 6 male. The causing mechanism was sunlight in 7 cases and exposure to laser pointers in 5 cases. A summary of characteristics as well as BCVA of each patient are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Average age was 47.57 ± 27.55 years in cases associated to sunlight and 15.60 ± 1.51 years in those produced by laser pointer. The injury occurred bilaterally in 6 of the 7 patients with sunlight lesions and in 3 of the 5 patients with laser pointer maculopathy.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The reason for consultation in 9 of the 12 patients was initially visual acuity loss and paracentral scotomas in 2 patients. In one case (patient 3 in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and Fig. 3</a>), a 16-year-old male, the finding was incidental. The examination was carried out in the context of his sister's study, a 14-year-old female (patient 2 in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) that presented injuries under study without reporting risk factors for phototoxic lesions. Later on, both would admit to staring into a laser pointer beam as part of a game.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Mean visual acuity in solar retinopathy diagnosis was 0.33 ± 0.27 logMAR and 0.16 ± 0.03 logMAR in laser pointer maculopathy. After an average follow-up of 20 ± 16.34 months, mean VA improved to 0.29 ± 0.28 logMAR in cases associated to sunlight and 0.07 ± 0.13 logMAR in those related to laser pointers.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Funduscopy images reveal varying degrees of macular and paramacular lesions. In the clearest cases, as those depicted in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, a well-defined yellowish macular lesion with irregular edges and occasionally surrounded by a pigment halo is observed. In other cases, lesions are limited to subtle pigment changes in the macular area or are hardly perceptible in funduscopy, having to resort to other imaging techniques. In all cases, infrared reflectance images provided by Spectralis systems (Heidelberg Engineering, Heidelberg, Germany) (images A2-D2 in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) provided a more defined image of the damage extent than those obtained by conventional retinographies (images A1-D1 in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Infrared reflectance images allowed classifying injuries into two types: a single macular or paramacular lesion, present in 100% of cases of solar retinopathy and in 14% of those produced by laser pointers, or multiple lesions clustered around the macular area, a pattern not observed in any solar retinopathy cases and in 86% of those related to laser light sources. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows 4 representative cases of this difference.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In all cases, OCT was the most useful imaging technique to confirm diagnosis. The main manifestation, present in all patients, was disruption of retinal outer layers. Retinal pigment epithelium reaction in the form of hyperreflective changes occurred almost universally in all patients. These hyperreflective changes tended to decrease through follow-up. On the other hand, regardless of the causing mechanism and evolution time, a disruption of photorreceptor outer segments was observed. The most commonly affected segment in all cases was ellipsoid. This is the most common expression and the only one found in all patients (2RE and 5RE in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><p id="par0070" class="elsevierStylePara elsevierViewall">The reflective void in these layers remained unchanged throughout follow-up. The largest mean disruption diameter in diagnosis was 203.4 ± 50.32 microns in solar retinopathy cases and 164.80 ± 87.58 microns in those produced by laser pointer. After follow-up, lesion size decreased by an average of 41.25 ± 12.23 microns in solar retinopathies and 76.2 ± 26.27 microns in laser pointer maculopathies. Only 2 patients showed complete ellipsoid layer recovery in OCT, a 14-year-old female and 17-year-old male, both with injuries produced by laser pointer (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><p id="par0075" class="elsevierStylePara elsevierViewall">Patients with short time intervals between exposure and first consultation exhibited paramacular hyperreflective lesions in the form of columns rising centrifugally from the pigment epithelium and merging with the outer plexiform layer. This manifestation, unlike the previously presented, did not persist over time, generally disappearing by the next checkup visit.</p><p id="par0080" class="elsevierStylePara elsevierViewall">“On face” OCT (images A3-D3 in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) reconstruction enabled a precise lesion delineation limiting segmentation to the ellipsoid layer. This imaging mode allowed confirmation of the different previously mentioned distribution lesion patterns and constitutes the most precise way of delimiting lesions. However, manual retinal outer layer segmentation was required to extract accurate images.</p><p id="par0085" class="elsevierStylePara elsevierViewall">ICGA test, in patients in which it was performed (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>), exhibited hypocyaniscent lesions corresponding to overlying external retinal injuries. Fluorescein angiography also revealed macular hypofluorescent lesions delimited by hyperfluorescent rings, although less evident than in indocyanine green tests.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Phototoxic maculopathy is an infrequent pathology, which makes describing its characteristics difficult.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Symptoms vary depending on the case, although most patients consult due to loss of visual acuity, appearance of predominantly central or paracentral scotomas, metamorphopsia or dyschromatopsia<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Usually, clinical history guides most cases. Observing eclipses without adequate protection, some religious rituals or psychiatric pathology can lead to solar retinopathy. Maculopathy associated to laser pointers can pose a greater diagnostic challenge since patients, generally of pediatric age, can hide exposure history<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Fundus examination allows visualizing a yellowish lesion in the macular or paramacular area. These manifestations have been described to subsequently evolve into a reddish lesion surrounded by pigment<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. In many cases lesions are subtle and difficult to define. OCT has made locating injuries in retinal outer layers possible, specifically in the retinal pigment epithelium and photoreceptor outer segments<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a>.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The series make it possible to describe multimodal imaging findings of a pathology that are usually described in reports of isolated cases or small series of less than a dozen cases.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The series results promote describing characteristics of different degrees of phototoxic lesions, differentiating between those produced by sunlight and by laser pointers, a perspective that no study had taken so far (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">The present study reinforces the idea found in other studies<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10,11</span></a> that laser pointer maculopathy is a pathology that mainly affects pediatric patients, and so these patients should be considered for differential diagnosis and prevention. Our experience in this series also confirms the difficulty of establishing the risk factor through patient anamnesis. Patients can hide exposure history for various reasons, which highlights the importance of sign description in imaging tests.</p><p id="par0125" class="elsevierStylePara elsevierViewall">On the other hand, solar retinopathy is usually found in patients of all ages and in our series the range goes from 14 to 86 years. It occurs bilaterally more often than in laser pointer maculopathy.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The mechanism by which retina is damaged is not fully understood. The most widely accepted hypothesis points towards a double mechanism, i.e., thermal and photochemical, where light damages retinal outer layers<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>. Temperature increases in the injured area are responsible for thermal damage and near ultraviolet spectrum radiation accounts for photochemical damage.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Despite being capable of transmitting the greatest amount of energy per unit of time<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,13</span></a>, ​​our series reveals that laser light seems to cause less impairment of visual acuity in cases of maculopathy caused by this energy source. Similarly, visual acuity recovery was greater and faster in cases of laser pointer retinopathy.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Fundus findings in this study are similar to those found by other authors<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,14,15</span></a>, although the subtlety of some of them must be noted, making funduscopy-based diagnosis extremely difficult.</p><p id="par0145" class="elsevierStylePara elsevierViewall">More profitable than funduscopy and conventional retinography are imaging techniques based on infrared light. De Silva et al. described the high autofluorescence diagnostic performance for long wavelengths, near infrared (stimulation at 787 nm)<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. However, this imaging technique is slow and requires equipment that is not always available in all centers. In this series, infrared reflectance images (820 nm), faster and more widely available, obtained lesion images of comparable quality and performance. The pathophysiological basis could be in the formation of free radicals that alter melanin properties, giving it different response characteristics to infrared light, closer to those of lipofuscin<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>.</p><p id="par0150" class="elsevierStylePara elsevierViewall">In this imaging modality, a tendency in laser maculopathy to form multifocal and clustered lesions was found, a discovery that could help in differential diagnosis when exposure history is not evident. The greater capacity of laser to cause damage in less time<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> may be behind this finding, with a single exposure being capable of producing several macular lesions with small eye movements.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Spectral domain OCT is confirmed to be the test of choice to diagnose both types of maculopathy. Thanks to the scope of our series, findings can be grouped into various types whether they represent potentially recoverable acute or chronic injuries. Hyperreflectivity columns and retinal pigment epithelial reaction seem to be findings related to acute injury and disappear rapidly. However, throughout very extensive follow-ups, ellipsoid disruption and interdigitation zones are not recovered and suggest irreversible damage to these sectors. In this imaging modality, laser pointer maculopathy appears to also give rise to less extensive lesions with greater tendency to resolution, making complete recovery possible. Spontaneous closure of macular holes produced by laser has been described<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>, but its frequency is extremely exceptional.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Despite posing a more time-consuming imaging modality that often requires manual segmentation, OCT “on face” is the most accurate way to delineate lesions. Indocyanine green angiography, although not necessary for diagnosis, seems to reveal that choriocapillaris is also damaged in this pathology.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Currently, Spanish laws<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a> require labeling laser light emission sources and impose a number of restrictions based on their damaging potential for skin and retina. Optical power limit (in watts) established for 3R class is 5 mW. Above these levels, legislation requires specific protective equipment and restricts its use to controlled areas. However, it is not difficult to find devices on Internet sales portals that widely exceed these limits promoted for recreational use.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0170" class="elsevierStylePara elsevierViewall">Despite having similar causing mechanisms and some common characteristics, solar retinopathy and laser pointer maculopathy are not overlapping pathologies. The most useful diagnostic test in both cases is OCT, in which the main sign is the disruption of ellipsoid layers and interdigitation zone, which is maintained over time. Imaging tests that make use of infrared or near infrared frequencies also produce images of great diagnostic value and with characteristic patterns depending on the etiology. Should recovery take place, it is much more common in injuries secondary to laser pointers.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Laser pointer maculopathy constitutes an emerging and probably underestimated health problem in pediatric populations, making it necessary to review regulations regarding the use and online purchase of laser pointer devices.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">No conflict of interest was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1472801" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1341211" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1472800" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1341212" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-30" "fechaAceptado" => "2020-07-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1341211" "palabras" => array:4 [ 0 => "Phototoxic maculopathy" 1 => "Multimodal image" 2 => "Laser pointer" 3 => "Solar retinopathy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1341212" "palabras" => array:4 [ 0 => "Maculopatía fototóxica" 1 => "Imagen multimodal" 2 => "Puntero láser" 3 => "Retinopatía solar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To study the differences between solar retinopathy (SR) and the maculopathy produced by laser pointer (LPM) using multimodal imaging.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A retrospective series is presented of 20 eyes of 12 patients with injuries associated with light, 7 with SR-compatible injuries, and 5 with LPM. At diagnosis, a complete opht-halmological examination was performed, including visual acuity (VA), retinography, andspectral domain optical coherence tomography (OCT). The patients were followed-up for a mean period of 20 months.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">LPM is common in paediatrics (mean age 15.60 ± 1.5 years), and SR affects patients of all ages (mean age 47.56 ± 1.51 years). VA at diagnosis in LPM is greater, and recovery is more complete than in solar retinopathy. In conventional retinography, SR is shown as a single lesion in the macular area (100% of cases), while LPM usually presents as multifocallesions (86% of cases). Infrared reflectance makes this difference clearer. The main sign in OCT is the disruption of the ellipsoid layer and interdigitation zone. This sign is maintained over time, and its size is greater in the SR than in the LPM. Hyper-reflective columns and hyper-reflective reaction of the retinal pigment epithelium are associated with the acutephase.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">LPM and SR show significant differences in the type of patient affected, as well as in the signs in multimodal imaging, as well as in functional impairment and their evolution.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 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="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudiar mediante imagen multimodal las diferencias entre la retinopatía solar (RS)y la maculopatía producida por puntero láser (MPL).</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Método</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Presentamos una serie retrospectiva de casos de 20 ojos de 12 pacientes con lesionesasociadas a fuentes de luz; 7 con lesiones compatibles con RS y 5 con MPL. Al diagnóstico, se realiza exploración oftalmológica completa incluyendo agudeza visual (AV), retinografíay tomografía de coherencia óptica (OCT) de dominio espectral. Se realiza un seguimiento delas lesiones durante un periodo medio de 20 meses.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La MPL es propia de la edad pediátrica (edad media 15,60 ± 1,51 aňos), mientrasque la RS afecta a pacientes de todas las edades (edad media 47,56 ± 27,55 aňos). La AV aldiagnóstico en la MPL es mayor y la recuperación más completa que en la RS. En retinografíaconvencional, la RS se muestra como una única lesión en el área macular (100% de los casos), mientras que las MPL se suelen presentar como lesiones multifocales (86% de los casos). Lareflectancia infrarroja evidencia de manera más clara esta diferencia. El principal signo enOCT es la disrupción de la capa elipsoides y zona de interdigitación. Este signo se mantieneen el tiempo y su tamaňo es mayor en la RS que en la MPL. Las columnas hiperreflectivas yla reacción hiperreflectiva del epitelio pigmentario de la retina se asocian a la fase aguda.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La MPL y la RS presentan diferencias significativas tanto en el tipo de pacienteafectado como en los signos en imagen multimodal, así como en la afectación funcional ysu evolución.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 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: Ortiz Salvador M, Montero Hernández J, Castro Navarro V, Cervera Taulet E, Navarro Palop C, Monferrer Adsuara C, Remolí Sargues L, Gonzalez Girón N. Imagen multimodal en la maculopatía fototóxica: descripción de hallazgos en una serie de 12 pacientes. Arch Soc Esp Oftalmol. 2021;96:133–140.</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" => 3801 "Ancho" => 2917 "Tamanyo" => 848761 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Comparison between conventional retinography (A1, B1, C1, D1), infrared reflectance (A2, B2, C2, D2) and OCT “on face” (A3, B3, C3, D3) in two patients (P2 and P3) affected by laser pointer maculopathy (A and B) and solar retinopathy (both eyes of P11, rows C and D). Better performance of infrared reflectance delimiting lesions produced by laser pointers that tend to adopt a multifocal pattern (A2 and B2) and a single central lesion in solar retinopathy (C2 and D2) can be seen. “On face” OCT provides a very precise lesion delineation, however, its acquisition is slower and many cases require manual segmentation.</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" => 2637 "Ancho" => 2917 "Tamanyo" => 511912 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">OCT detail of all patients. Figure A; patients 1–5: laser pointer maculopathies. Figure B; patients 6-12: solar maculopathy. Disruption of ellipsoid layer is observed in all cases. Figure 5RE, 5LE, 10RE and to a lesser extent 9RE, 9LE show the RPE hyperreflectivity sign. Centrifugal hyperreflective lesions are distinguished in 2RE and 5RE.</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" => 566 "Ancho" => 1900 "Tamanyo" => 100217 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lesion evolution in OCT in two patients. Figure A: damage evolution in a 14-year-old female with a laser pointer injury (P2). Throughout the 3-month follow-up, lesion resolution was observed with interdigitation layer and ellipsoid restructuring. Figure B, 6-year follow-up of a 36-year-old female (P10) with sunlight associated damage. Unlike the previous case, the absence of significant changes in ellipsoid disruption can be observed.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 3743 "Ancho" => 2500 "Tamanyo" => 644225 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Fluorescein (FA) and indocyanine green (ICGA) angiographies of 3 eyes from 2 patients (A and B both eyes from P5; C right eye P2). Hypofluorescent lesions delimited by a hyperfluorescent ring are evident in FA. Hypocyaniscent lesions are even more striking in indocyanine green angiography, which reveal choriocapillaris involvement.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "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=""><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">Pacient \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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age \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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sex \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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Symptomatology \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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Eyes \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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Visual acuity (Snellen) \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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Final visual acuity (follow-up) \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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Exposure history \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">P1 \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">14 \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">M \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">Visual acuity loss \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">Both \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">RE: 20/100 LE: 20/20 \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">RE: 20/20 LE: 20/20 (6 months) \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">Laser pointer (accidental) \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">P2 \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">14 \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">F \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">Visual acuity loss \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">Right \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">RE: 20/32 \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">RE: 20/25 (6 months) \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">Laser pointer (self-inflicted) \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">P3 \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">16 \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">M \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">None \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">Right \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">RE: 20/125 \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">RE: 20/50 (6 months) \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">Laser pointer (self-inflicted) \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">P4 \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">17 \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">M \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">Paracentral scotoma \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">Right \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">RE: 20/20 \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">RE: 20/20 (19 months) \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">Laser pointer (accidental) \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">P5 \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">17 \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">M \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">Paracentral scotoma \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">Both \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">RE: 20/20 LE: 20/20 \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">RE: 20/20 LE: 20/20 (22 months) \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">Laser pointer (accidental) \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">P6 \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">64 \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">F \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">Visual acuity loss \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">Both \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">RE: 20/50 LE: 20/50 \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">RE: 20/40 LE: 20/40 (17 months) \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">Sunlight \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">P7 \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">46 \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">M \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">Visual acuity loss \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">Both \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">RE: 20/63 LE: 20/100 \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">RE: 20/32 LE: 20/125 (23 months) \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">Sunlight \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">P8 \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">71 \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">F \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">Visual acuity loss \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">Right \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">RE: 20/200 \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">RE: 20/200 (17 months) \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">Sunlight \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">P9 \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">14 \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">F \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">Visual acuity loss \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">Both \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">RE: 20/32 LE: 20/25 \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">RE: 20/32 LE: 20/25 (18 months) \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">Sunlight \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">P10 \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">36 \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">F \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">Visual acuity loss \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">Both \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">RE: 20/32 LE: 20/32 \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">RE: 20/32 LE: 20/25 (68 months) \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">Sunlight \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">P11 \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">16 \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">F \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">Visual acuity loss \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">Both \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">RE: 20/32 LE: 20/32 \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">RE: 20/25 LE: 20/25 (21 months) \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">Sunlight \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">P12 \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">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">M \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">Visual acuity loss \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">Both \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">RE: 20/50 LE: 20/20 \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">RE: 20/50 LE: 20/20 (17 months) \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">Sunlight \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2534361.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "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=""><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"> \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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Solar retinopathy \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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Laser pointer maculopathy \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">Age at diagnosis \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">Any age \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">Second decade of life \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">Visual acuity at diagnosis \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">Lower \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">Better \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">Visual acuity recovery \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">Lower \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">Higher \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">Lesion pattern in infrared retinography and OCT “on face” \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">Single injury \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">Multifocal \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">Ellipsoid layer disruption size \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">Higher \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">Lower \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">Ellipsoid layer disruption recovery \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">Lower \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">Higher \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2534362.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Differences between solar retinopathy and laser pointer maculopathy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case of “<span class="elsevierStyleItalic">hole</span>” at macula due to looking at the sun" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.A. Pittar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bjo.27.1.36" "Revista" => array:6 [ "tituloSerie" => "Br J Ophthalmol" "fecha" => "1943" "volumen" => "27" "numero" => "1" "paginaInicial" => "36" "paginaFinal" => "38" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Macular phototoxicity caused by fiberoptic endoillumination during pars plana vitrectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Michels" 1 => "H. Lewis" 2 => "G.W. Abrams" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0002-9394(14)71792-1" "Revista" => array:7 [ "tituloSerie" => "Am J Ophthalmol" "fecha" => "1992" "volumen" => "114" "numero" => "3" "paginaInicial" => "287" "paginaFinal" => "296" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1524116" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Operating microscope-induced retinal phototocicity: pathophysiology, clinical manifestations and prevention" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Michels" 1 => "P. 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McLaren" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Ophthalmol" "fecha" => "2000" "volumen" => "118" "numero" => "12" "paginaInicial" => "1687" "paginaFinal" => "1691" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "American Academy of Ophthalmology “Solar Retinopathy.” Section 12: Retina and Vitreous. Singapore, 2013-2014 332-334." ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Improved Diagnosis of Retinal Laser Injuries Using Near-Infrared Autofluorescence" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.R. De Silva" 1 => "J.E. Neffendorf" 2 => "J. Birtel" 3 => "P. Herrmann" 4 => "S.M. Downes" 5 => "C.K. 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