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Original article
Spurectomy: A novel modification of non-penetrating deep sclerectomy
Espolonectomía: una nueva modificación de la esclerectomía profunda no perforante
E. Vila-Mascarella,b, J. Vila-Arteagaa,b, M.M. Surianoa,c,d,
Corresponding author
mayerlingsuriano@yahoo.it

Corresponding author.
, A. Fons Morenoe
a Clínica Oftalmológica Vila-Innova Ocular, Valencia, Spain
b Hospital La Fe, Valencia, Spain
c Hospital General de Castellón, Castellón, Spain
d Facultad de Medicina, Universidad Jaime I, Castellón, Spain
e Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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trabecular and supracoroidal&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Both <span class="elsevierStyleItalic">external ab</span> surgery and minimally invasive glaucoma surgery &#40;MIGS&#41; seek one of these three drainage routes<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Trabeculectomy and non-perforating deep sclerectomy &#40;NPDS&#41; are examples of subconjunctival drainage&#44; obtaining similar tension results&#44; although NPDS decreases the number of complications&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Surgeries that use the trabecular approach and supracoroid approach endeavour to decrease intraocular pressure without relying on a filtration bleb&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">NPDS also enables access to the supracoroid space to search for that drainage path&#46; This can be done through spurectomy&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The scleral spur is a band of fibrous tissue where the longitudinal fibers of the ciliary body are inserted&#46; A spurectomy consists of the excision of the scleral spur portion located in the NPDS area&#44; which facilitates the drainage of the aqueous humor and the opening of the suprachoroidal space&#46; The objective of the present study was to analyze the medium-term results and complications of this novel technique for the treatment of glaucoma in comparison with classic NPDS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">A retrospective and non-randomized observational study comparing two groups&#46; Group A included 98 glaucoma eyes from 76 patients operated on with our modified NPDS technique&#44; which we call spurectomy&#46; Group B included 53 glaucoma eyes from 43 patients operated on with the classic NPDS technique&#46; All patients received and signed an informed consent form stating their willingness to participate in the study for at least 12 months&#46; The study complied with the principles declared in Helsinki by the World Medical Association&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The inclusion criteria comprised patients with uncontrolled primary or secondary glaucoma &#40;poor IOP control with maximum medical treatment with signs of progression&#41; and over 18 years of age&#46; Exclusion criteria were unwillingness to participate in the study&#44; previous eye surgery for glaucoma&#44; narrow angle&#44; closed or neovascular glaucoma&#44; poorly controlled diabetes mellitus with a diagnosis of diabetic retinopathy at any stage&#44; macular degeneration and inflammatory eye diseases&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pre-operative evaluation</span><p id="par0045" class="elsevierStylePara elsevierViewall">Previous ophthalmic medical-surgical history&#46; Complete ophthalmological examination including visual acuity&#44; refraction&#44; study of the anterior segment with slit lamp&#44; gonioscopy&#44; intraocular pressure with Goldmann tonometer&#44; pachymetry&#44; fundoscopy&#44; optical nerve coherence tomography and visual field&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical technique</span><p id="par0050" class="elsevierStylePara elsevierViewall">All surgeries &#40;NPDS and spurectomy&#41; were performed under peribulbar anesthesia by four experienced surgeons from two eye centers using the same surgical team between 2008 and 2012&#46; In group A&#44; before performing the spurectomy&#44; the Mermoud forceps was used to remove the Schlemm &#40;CS&#41; canal&#59; then the scleral spur identified as a white cord was removed immediately after the removal of the canal&#46; For this purpose&#44; after cutting with a 30-degree blade&#44; the spur was excised with the Mermoud forceps &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Mitomycin C at 0&#46;02&#37; was applied to the scleral bed and subconjunctival space for 30&#8239;s and then washed&#46; The implant &#40;Esnoper&#174;&#44; AJL Ophthalmics&#44; &#193;lava&#44; Spain&#41;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> is inserted into the supra-ciliary space &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2&#8211;4</a>&#41;&#46; The scleral mat and conjunctiva were sutured with separate 10-0 nylon stitches&#46; Finally&#44; a subconjunctival injection of 0&#46;5&#8239;ml betamethasone &#40;3&#8239;mg&#47;ml&#41; and occlusion with oxytetracycline and hydrocortisone ointment was applied&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">In group B a conjunctival flap with a fornix base was made&#44; together with episcleral cauterization&#44; dissection of the scleral mat with a thickness of 1&#47;3 of the total sclera and&#44; penetrating 2&#8239;mm in the clear cornea&#44; the deep scleral mat was dissected and later removed&#46; Mitomycin C 0&#46;02&#37; was applied to the scleral bed and the subconjunctival space for 30&#8239;s and then washed away&#46; The implant was placed in the scleral bed &#40;Esnoper&#174;&#44; AJL Ophthalmics&#44; &#193;lava&#44; Spain&#41;&#44; the scleral mat and the conjunctiva were sutured &#40;separate stitches of 10-0 nylon&#41;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and occlusion with oxytetracycline and hydrocortisone ointment for 24&#8239;h&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Post-operative examination protocol</span><p id="par0060" class="elsevierStylePara elsevierViewall">Patients were scanned at 1 day&#44; 1 week and 1&#44; 3&#44; 6 and 12 months after surgery&#46; Postoperative treatment in all cases was&#58; topical ciprofloxacin for 7 days and tobramycin with dexamethasone &#40;Tobradex&#174;&#44; Alcon Laboratories&#44; Fort Worth&#44; USA&#41; in drops four times a day for one month with gradual reduction&#46; In all visits the IOP was measured between 8&#58;00 and 10&#58;00&#8239;h and the anterior segment was evaluated with a slit lamp&#46; Success was defined in both groups as absolute &#40;AS&#59; IOP&#8239;&#60;&#8239;21&#8239;mmHg without medication&#41; or relative &#40;RS&#59; IOP&#8239;&#60;&#8239;21&#8239;mmHg with medication&#41;&#46; Failure was defined as IOP&#8239;&#62;&#8239;21&#8239;mmHg with medication&#44; or when the eye required another drainage surgery&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The statistical analysis of the variables was done with the Student t-test and the chi-square test&#46; A value of p&#8239;&#8804;&#8239;0&#46;05 was considered significant&#46; Calculations were made using SPSS software version 20&#46;0 for Windows &#40;SPSS&#44; Chicago&#44; Illinois&#44; USA&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Overall&#44; 98 eyes were operated with spurectomy &#40;group A&#41; and 53 with NPDS &#40;group B&#41;&#46; Follow-up was 12 months in both groups&#46; Mean age was 64&#46;29&#8239;&#177;&#8239;12&#46;9 years &#40;range 23&#8211;85&#41; and 60&#46;87&#8239;&#177;&#8239;10&#46;04 years &#40;range 20&#8211;82&#41; in groups A and B&#44; respectively&#46; The sample in group A comprised 36 females &#40;47&#46;4&#37;&#41; and 40 males &#40;52&#46;6&#37;&#41;&#44; and in group B&#44; 26 males &#40;49&#37;&#41; and 27 females &#40;51&#37;&#41;&#46; The distribution according to the type of glaucoma in group A was&#58; 58 eyes with primary open angle glaucoma &#40;POAG&#41; &#40;59&#46;18&#37;&#41;&#44; 15 eyes with pigmentary glaucoma &#40;15&#46;3&#37;&#41;&#44; 20 eyes with pseudoexfoliative glaucoma &#40;20&#46;41&#37;&#41;&#44; 5 eyes with inflammatory glaucoma &#40;5&#46;1&#37;&#41;&#46; In the group B this distribution was&#58; 41 eyes with POAG &#40;77&#44;35&#37;&#41;&#44; 4 eyes with pseudo-exfoliative glaucoma &#40;7&#44;54&#37;&#41;&#44; 3 eyes with pseudo-exfoliative glaucoma &#40;5&#44;66&#37;&#41;&#44; 2 eyes with inflammatory glaucoma &#40;3&#44;77&#37;&#41;&#44; 2 eyes with closed angle glaucoma &#40;3&#44;77&#37;&#41; and 1 eye with iridocorneal syndrome &#40;1&#44;88&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Control of IOP</span><p id="par0075" class="elsevierStylePara elsevierViewall">Mean IOP in group A was 25&#46;69&#8239;&#177;&#8239;8&#46;11&#8239;mmHg before surgery and 15&#46;73 &#40;SD 4&#46;16&#41; mmHg &#40;CI&#58; 14&#46;86&#8211;16&#46;6&#41; at 12 months after surgery&#46; In group B the mean preoperative IOP was 26&#46;66&#8239;&#177;&#8239;5&#46;93&#8239;mmHg&#44; while the mean value at one year was 18&#46;19 &#40;SD 5&#46;93&#41; mmHg &#40;CI&#58; 16&#46;74&#8211;19&#46;64&#41;&#46; In both groups the change in IOP was statistically significant &#40;both p&#8239;&#60;&#8239;0&#46;05&#41;&#46; The reduction in IOP was greater in group A than in group B &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Pre- and post-operative medical treatment&#46; Success and failure rates</span><p id="par0080" class="elsevierStylePara elsevierViewall">One year after the spurectomy&#44; the average number of drugs was 0&#46;26 per eye&#44; while in the NPDS group it was 0&#46;91&#46; The total number of eyes requiring medication in group A was 13 and 28 in group B&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">With regard to goniopuncture treatment&#44; 13 patients in group A &#40;13&#46;26&#37;&#41; and 6 in group B &#40;11&#46;32&#37;&#41; were treated&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Group A showed AS in 75&#46;5&#37; of the cases &#40;74 eyes&#41;&#44; RS in 12&#46;25&#37; &#40;12 eyes&#41; and failure in 12&#46;25&#37; &#40;12 eyes&#41;&#46; On the other hand&#44; group B showed AS in 47&#46;17&#37; of the cases &#40;25 eyes&#41;&#44; RS in 41&#46;5&#37; &#40;22 eyes&#41; and failure in 11&#46;32&#37; &#40;6 eyes&#41;&#46; The differences in AS compared to RS between the two groups reached statistical significance&#46; With spurectomy&#44; more cases maintained IOP&#8239;&#60;&#8239;21 without medical treatment&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Complications</span><p id="par0095" class="elsevierStylePara elsevierViewall">As for complications&#44; in group A &#40;spurectomy&#41; a total of 20 &#40;20&#46;41&#37;&#41; were recorded&#44; including microperforation in 5 eyes &#40;5&#46;1&#37;&#41;&#44; incarcerating iris in 4 eyes &#40;4&#46;08&#37;&#41;&#44; hyphema in 4 eyes &#40;4&#46;08&#37;&#41;&#44; 3 eyes requiring <span class="elsevierStyleItalic">needling</span> &#40;3&#46;06&#37;&#41;&#44; positive Seidel test 2 eyes &#40;2&#46;04&#37;&#41;&#44; choroid detachment 1 eye &#40;1&#46;02&#37;&#41; and implant extrusion 1 eye &#40;1&#46;02&#37;&#41;&#46; In group B&#44; complications were reported in 20&#44;75&#37; of cases &#40;11 eyes&#41;&#58; microperforation in 6 eyes &#40;11&#44;3&#37;&#41;&#44; hyphema in 2 eyes &#40;3&#44;77&#37;&#41;&#44; Seidel test in 2 eyes &#40;3&#44;77&#37;&#41; and Dellen type ulcer in 1 eye &#40;1&#44;88&#37;&#41;&#46; There was no statistically significant difference in the rate of complications between both groups &#40;p&#8239;&#61;&#8239;0&#46;960&#41;&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The recent evolution of non-penetrating surgery for the treatment of glaucoma has made it possible to know that IOP can be successfully reduced without the creation of filtration blebs&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This new conceptual basis has reached consensus on the superior safety profile of non-penetrating procedures&#44; although there are no indexed agreements on efficacy&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> NPDS provides external filtration of aqueous humor in the subconjunctival space&#46; This technique&#44; with the addition of implants&#44; antimetabolites&#44; and goniopuncture&#44; can provide IOP results similar to those obtained with trabeculectomy&#44; but with fewer complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;17</span></a> Until now&#44; few studies have directly compared NPDS and trabeculectomy&#46; Rulli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> reviewed all of the available scientific literature on surgical treatment of glaucoma and found that trabeculectomy is the most effective surgical procedure for reducing IOP in patients with OAPG&#44; but it is associated with a higher incidence of complications compared to NPDS&#46; In addition&#44; Cheng et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> analyzed the efficacy of NPDS in treating OAPG and concluded that intraoperative use of mitomycin C and implants may improve success rates&#46; After reviewing available published research focused on this topic and selecting only randomized and controlled clinical trials&#44; these authors established a mean reduction of IOP after NPDS of 35&#46;2&#37;&#46; These results are comparable to those obtained in our case series&#46; Specifically&#44; in the NPDS group of our study the average achieved reduction was 31&#46;12&#37;&#44; and this value was even higher in the spurectomy group &#40;38&#46;77&#37;&#41;&#46; Therefore&#44; our results in terms of IOP reduction with NPDS were consistent with those previously reported&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> with spurectomy being the best&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Regarding the reduction of the amount of medication needed to lower the postoperative IOP pressure&#44; Al-Obeidan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> reported an average decrease of this value from 2&#46;95 to 0&#46;22 in a sample of 194 eyes operated with NPDS and mitomycin C and an average follow-up of 60&#46;9 months&#46; In our study&#44; at one year after spurectomy only 13 eyes &#40;13&#46;27&#37;&#41; required medical treatment &#40;mean 2&#8239;&#177;&#8239;0&#46;71 drugs&#41; and in the NPDS group 28 eyes &#40;52&#46;83&#37;&#41; &#40;1&#46;73&#8239;&#177;&#8239;0&#46;37&#41;&#44; noting that spurectomy is good for lowering IOP and requires less use of drugs&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Several modifications have been proposed to increase the effectiveness of NPDS combined with implants&#46; Mu&#241;oz<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> described a sutureless technique for placing the implant &#40;T-flux&#174;&#41; at the supracoroid level through an incision made after the scleral spur&#46; This author reported absolute and relative success rates of 73&#46;8 and 19&#46;6&#37;&#44; respectively&#46; Bonilla et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> conducted a 20-eye study of 16 patients with significant cataract and uncontrolled open-angle glaucoma with medical treatment to evaluate the results of a surgical procedure combining cataract surgery and NPDS with the Esnoper&#174; implantation 2 mm behind the scleral spur&#46; These authors found a 95&#37; success rate &#40;45&#37; absolute success and 50&#37; relative success&#41;&#46; This result is similar to that obtained in the present series with the spurectomy technique &#40;87&#46;75&#37; of total success&#59; AS&#58; 75&#46;5&#37;&#59; RS&#58; 12&#46;25&#37;&#41; using also the Esnoper implant&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">There is also another version of this implant &#40;Esnoper-Clip&#44; ALJ Ophthalmology&#44; &#193;lava&#44; Spain&#41; that has been developed after our study to maintain supra- and intra-scleral spaces&#46; A preliminary study has evaluated this implant and concludes that it is a promising alternative to avoid collapse over time&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Loscos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> have also reported on the safety and efficacy of NDPS combined with the above-mentioned implant in a 48-eye cohort of 41 patients&#46; They found a significant reduction in postoperative IOP&#44; as well as in the number of glaucoma medications required&#44; with a variety of mild intraoperative and postoperative complications that mostly resolved spontaneously&#46; Cheng et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> reported that the most frequent postoperative complications in nonperforating glaucoma surgery are hyphema &#40;10&#46;53&#37;&#41;&#44; shallow anterior chamber &#40;5&#46;9&#37;&#41;&#44; hypotony &#40;5&#46;33&#37;&#41;&#44; choroid detachment &#40;9&#46;7&#37;&#41; and cataract &#40;10&#46;77&#37;&#41;&#46; In our series&#44; these complications were significantly less frequent and severe&#46; Specifically&#44; in our study the complications were similar in both groups&#44; with no statistically significant differences&#46; In both groups we had cases of microperforations&#46; Many authors agree that this condition is related to the learning curve and report that the probability of microperforation is 30&#37; in the first 10&#8211;20 cases&#46; After the initial phase of learning the probability decreases until 2&#8211;3 &#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;24&#44;25</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The fact that better results were obtained in group A than in group B could be explained by the opening of the supra-ciliary space that allows the drainage of the aqueous humor&#44; in addition to the sub-conjunctival as well as by the supra-ciliary routes&#46; Furthermore&#44; it facilitates the implantation of the device without resistance in this space&#44; by the disinsertion of the longitudinal fibers of the ciliary body that were previously inserted in the portion that were extracted from the scleral spur&#46; Therefore&#44; the implant could be in a more anterior position &#40;supra-ciliary-supracoroid&#41; compared to the classic NPDS&#46; This situation may be beneficial in preventing obstruction of the supracoroid space and scarring of the scleral mat of the trabecular descematic membrane &#40;TDM&#41;&#46; This increases the effectiveness of the procedure and reduces the incidence of post-operative complications&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In conclusion&#44; a new surgical approach is proposed using a modification of the classic NPDS technique called spurectomy with the implantation of the Esnoper&#174; device&#46; Spurectomy is a safe and effective alternative for the surgical treatment of glaucoma in a medium-term follow-up&#46; Future studies with larger sample sizes and longer follow-ups are required to establish the safety and effectiveness of this technique in maintaining supracoroid drainage&#46; In addition&#44; more studies should be conducted to evaluate the efficacy of this technique with the use of other implants&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interests</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interest in this study&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To evaluate the outcomes of a novel modification of the non-penetrating deep sclerectomy &#40;NPDS&#41; approach for glaucoma management called spurectomy&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Observational comparative non-randomized retrospective study including 98 glaucomatous eyes of 76 patients operated on with the spurectomy technique consisting of the combination of the excision of the scleral spur with NPDS &#40;group A&#41;&#46; A control group &#40;group B&#41; including 53 glaucomatous eyes of 43 patients operated on with classical NPDS was also included&#46; Changes in intraocular pressure &#40;IOP&#41; and medications required as well as complications were recorded in a 12-month follow-up&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mean IOP decreased from 25&#46;69&#8239;&#177;&#8239;8&#46;11 preoperatively to 15&#46;73&#8239;&#177;&#8239;4&#46;16&#8239;mm Hg postoperatively in group A &#40;p&#8239;&#60;&#8239;0&#46;001&#41;&#46; In group B&#44; mean IOP decreased from 26&#46;66&#8239;&#177;&#8239;5&#46;93 preoperatively to 18&#46;19 &#177; 5&#46;93 mm Hg postoperatively &#40;P&#8239;&#60;&#8239;&#46;001&#41;&#46; Differences between groups in postoperative IOP was statistically significant &#40;P&#8239;&#60;&#8239;&#46;001&#41;&#46; At 12 months after surgery&#44; 13&#46;27&#37; and 52&#46;83&#37; of eyes in groups A and B required topical antihypertensive therapy &#40;P&#8239;&#60;&#8239;&#46;001&#41;&#46; The rate of absolute success after surgery was 87&#46;5&#37; and 47&#46;17&#37; in groups A and B&#44; with significantly higher rate of relative success in group B &#40;P&#8239;&#60;&#8239;&#46;001&#41;&#46; No significant differences among groups were found in the complication rate &#40;P&#8239;&#61;&#8239;&#46;960&#41;&#46; The most common postoperative complication was microperforation of the trabeculo-descemetic membrane in both groups&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Spurectomy is a safe and effective technique when compared with conventional NPDS and seems a promising alternative in the surgical management of glaucoma&#44; optimizing the efficacy of the treatment and minimizing complications&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
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            "titulo" => "Purpose"
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          1 => array:2 [
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            "titulo" => "Results"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Evaluar los resultados de una nueva modificaci&#243;n de la esclerectom&#237;a profunda no perforante &#40;EPNP&#41; denominada espolonectom&#237;a&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo no aleatorizado y comparativo que incluy&#243; 98 ojos &#40;grupo A&#41; operados con espolonectom&#237;a&#44; que consiste en la combinaci&#243;n de la escisi&#243;n del espol&#243;n escleral con EPNP&#46; El grupo control &#40;B&#41; incluy&#243; 53 ojos operados con EPNP cl&#225;sica&#46; Durante 12 meses se estudiaron la presi&#243;n intraocular &#40;PIO&#41;&#44; los medicamentos antiglaucomatosos que requirieron y las complicaciones&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La PIO media disminuy&#243; de 25&#44;69&#8239;&#177;&#8239;8&#44;11 preoperatoria a 15&#44;73&#8239;&#177;&#8239;4&#44;16 mmHg despu&#233;s de la cirug&#237;a en el grupo A &#40;p&#8239;&#60;&#8239;0&#44;001&#41;&#46; En el grupo B disminuy&#243; de 26&#44;66&#8239;&#177;&#8239;5&#44;93 preoperatoria a 18&#44;19&#8239;&#177;&#8239;5&#44;93 mmHg postoperatoria &#40;p&#8239;&#60;&#8239;0&#44;001&#41;&#46; Las diferencias entre grupos de la PIO postoperatoria fue estad&#237;sticamente significativa &#40;p&#8239;&#60;&#8239;0&#44;001&#41;&#46; A los 12 meses despu&#233;s de la cirug&#237;a&#44; el 13&#44;27 y el 52&#44;83&#37; de ojos en los grupos A y B requirieron tratamiento antihipertensivo t&#243;pico &#40;p&#8239;&#60;&#8239;0&#44;001&#41;&#46; La tasa de &#233;xito absoluto despu&#233;s de la cirug&#237;a fue del 87&#44;5 y del 47&#44;17&#37; en los grupos A y B&#44; con una tasa significativamente mayor de &#233;xito relativo en el grupo B &#40;p&#8239;&#60;&#8239;0&#44;001&#41;&#46; No hubo diferencias significativas entre los grupos en la tasa de complicaciones &#40;p&#8239;&#61;&#8239;0&#44;960&#41;&#46; La complicaci&#243;n postoperatoria m&#225;s frecuente fue la microperforaci&#243;n de la membrana trabeculo-descem&#233;tica en ambos grupos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La espolonectom&#237;a es una t&#233;cnica segura y eficaz en comparaci&#243;n con la EPNP convencional y parece una alternativa prometedora en el tratamiento quir&#250;rgico del glaucoma&#44; optimizando la eficacia del tratamiento y minimizando las complicaciones&#46;</p></span>"
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            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Vila-Mascarell E&#44; Vila-Arteaga J&#44; Suriano MM&#44; Fons Moreno A&#46; Espolonectom&#237;a&#58; una nueva modificaci&#243;n de la esclerectom&#237;a profunda no perforante&#46; Arch Soc Esp Oftalmol&#46; 2021&#59;96&#58;195&#8211;201&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.oftal.2020.09.009">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;oftal&#46;2020&#46;09&#46;009</span></p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Spurectomy diagram&#46; A&#41; shows the structures that the surgeon must identify to perform the surgery &#40;C&#58; conjunctiva&#59; S&#58; Schlemm&#8217;s channel&#59; L&#58; Schwalbe&#8217;s line&#59; T&#58; trabecular meshwork&#59; EE&#58; scleral spur&#59; CC&#58; ciliary body&#59; I&#58; iris&#41;&#46; B&#41; Peritomy of the base of the fornix and intraoperative dissection of the superficial scleral mat&#46; C&#41; Intraoperative excision of the deep scleral mat&#46; D&#41; Showing the structures underneath the removed deep scleral mat&#46; E&#41; The open suprachoroidal space after the removal of the scleral spur F&#41; Schematic view of the completion of surgery with the Esnoper implant in the suprachoroidal space&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Spurectomy&#46; A&#44;B&#41; Intraoperative exeresis of the scleral spur with the help of a 30 degree blade and Mermoud forceps &#40;the red arrow points to the spur&#41;&#46; C&#41; Insertion of the Esnoper&#174; implant &#40;red asterisk&#41; in the suprachoroidal space&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pre-operative &#40;A&#41; and post-operative &#40;B&#41; gonioscopic image&#44; showing how the trabeculum &#40;T&#41; and the scleral spur &#40;E&#41; are interrupted when reaching the trabeculodescemetic membrane &#40;asterisk&#41; where the Snoper&#174; can be seen&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Anterior segment OCT vision of eye structures in one eye after spurectomy&#46;</p>"
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        "etiqueta" => "Fig&#46; 5"
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        "mostrarFloat" => true
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Post-operative changes in IOP with the two assessed surgical techniques&#58; spurectomy and deep non-perforating sclerectomy A&#41; Distribution of mean preoperative and postoperative IOP values in both groups&#46; B&#41; Confidence intervals of the average level of the post-operative IOP in both groups&#46;</p>"
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                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
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \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">Group A&nbsp;\t\t\t\t\t\t\n
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                  \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">Group B&nbsp;\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"><span class="elsevierStyleItalic">Age</span>&nbsp;\t\t\t\t\t\t\n
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                  \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&#46;29&#8239;&#177;&#8239;12&#46;9&nbsp;\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">60&#46;87&#8239;&#177;&#8239;10&#46;04&nbsp;\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"><span class="elsevierStyleItalic">Sex</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Females&nbsp;\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">47&#46;4&#37;&nbsp;\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">51&#37;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Males&nbsp;\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">52&#46;6&#37;&nbsp;\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">49&#37;&nbsp;\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"><span class="elsevierStyleItalic">Type of glaucoma</span>&nbsp;\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">&nbsp;\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">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>OAPG&nbsp;\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">59&#46;18&#37;&nbsp;\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">77&#46;35&#37;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Pigmentary glaucoma&nbsp;\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">15&#46;3&#37;&nbsp;\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">&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Pseudoexfoliative glaucoma&nbsp;\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">20&#46;41&nbsp;\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">5&#46;66&#37;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Inflammatory glaucoma&nbsp;\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">5&#46;1&#37;&nbsp;\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
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                  \t\t\t\t">3&#46;77&#37;&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pseudophakic glaucoma&nbsp;\t\t\t\t\t\t\n
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                  \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">&nbsp;\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">7&#46;54&#37;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Other type&nbsp;\t\t\t\t\t\t\n
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                  \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">&nbsp;\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">5&#46;65&#37;&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleItalic">Pre-operative IOP</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25&#46;69&#8239;&#177;&#8239;8&#46;11&#8239;mmHg&nbsp;\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
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                  \t\t\t\t">26&#46;66&#8239;&#177;&#8239;5&#46;93&#8239;mmHg&nbsp;\t\t\t\t\t\t\n
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