Evaluation of the insertion distance of the medial rectus in consecutive exotropia by means of intraoperative measure and optical coherence tomography | Archivos de la Sociedad Española de Oftalmología (English Edition)

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It can be seen that when the medial rectus were more retroinserted there were greater differences between the two measurement techniques and, therefore, less agreement." ] ] ] "textoCompleto" => "IntroductionConsecutive exotropia (cXT) is a type of divergent strabismus that mostly occurs after endotropia surgery, although it can also appear after deenervation, optical treatments or even spontaneously.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Incidence varies greatly from series to series, ranging from 2 to 29% of patients who have undergone endotropia surgery,<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> and is higher in studies with longer follow-up time.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> These are generally adult subjects who underwent surgery for endotropia in childhood (in many cases the surgery performed is unknown), and who maintained good ocular alignment for months or years, but later developed divergent deviation.Different risk factors for the development of cXT<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> have been described: anisometropia, amblyopia, high hyperopia, absence of stereopsis, alphabetic pattern, early surgery (before 6 months of age), multiple previous surgeries, limited post-surgical adduction and neurological diseases.<a class="elsevierStyleCrossRefs" href="#bib0015">3–9</a> However, these risk factors have not clarified the origin of exodeviation.<a class="elsevierStyleCrossRefs" href="#bib0045">9–11</a> After medial rectus (MR) recession, anomalous scleral reinsertion may occur due to a mechanism of muscle slippage or tendon lengthening<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> which would explain the appearance of adductor weakness, sometimes very delayed in time and more accentuated if there is also fibrosis or adhesions of the ipsilateral lateral rectus.In the presence of significant deviations, surgical correction is the treatment of choice for cXT. Advancement of the MR, with or without retroinsertion of one or both lateral rectus, is usually the most commonly used technique, with a success rate of between 56% and 79%, according to the different series published.<a class="elsevierStyleCrossRefs" href="#bib0045">9–13</a> Preoperatively, adduction limitation (MR weakness) and the intraoperative forced duction test (inelasticity of the lateral rectus) provide valuable information for surgical planning.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> However, surgery on previously operated muscles is technically more complicated and the response to treatment is less predictable than on non-operated muscles.<a class="elsevierStyleCrossRefs" href="#bib0045">9–13</a>In recent years, different authors such as De-Pablo-Gómez de Liaño et al. and Liu et al. have described the usefulness of optical coherence tomography (OCT) in the assessment of extraocular rectus muscles, with the advantage of being a fast and non-invasive imaging technique.<a class="elsevierStyleCrossRefs" href="#bib0070">14–19</a> Early studies with OCT found good agreement with the limbus-insertion distance measured intraoperatively in non-operated muscles.<a class="elsevierStyleCrossRefs" href="#bib0070">14,16</a> Subsequently, some studies have focused on assessing the insertion distance in previously operated muscles.<a class="elsevierStyleCrossRefs" href="#bib0090">18,20,21</a>However, to date there have been no studies performed with OCT in a series of patients with cXT to determine its agreement with the intraoperative measurement, which could be a great help for better surgical planning by revealing the location of the MRI prior to surgery.The purpose of this work is to assess the agreement between the preoperative OCT measurement and the intraoperative measurement of the distance from the MRI insertion to the corneal limbus on cXT.Material and methodsA prospective study of 14 medial rectus muscles from 14 patients with post-surgical cXT who underwent reoperation between June 2019 and June 2020 was conducted. The study protocol adhered to the Declaration of Helsinki guidelines and was approved by the Research Ethics Committee. Informed consent was obtained from all patients participating in the study. Inclusion criteria were: patients with post-surgical cXT in whom the MR had been retro-inserted and who were to undergo further corrective surgery. Patients in whom the OCT image quality did not allow muscle identification were excluded. The mean preoperative ocular deviation of the XT was measured in prismatic dioptres (PD).cXT correction surgery was based on surgical exploration of the retroinserted medial rectus and advancement of the retroinserted rectus to the original insertions, anchoring them with a 6/0 polyglactin resorbable suture. In cases of large exodeviations (> 30 DP) or with positive forced duction test, retroinsertion of one or both lateral rectus was also associated. General anaesthesia was performed in 3 patients (13, 17 and 17 years respectively), while topical anaesthesia with sedation was performed in the rest.The corneal insertion-limb distance of the MR was measured preoperatively by OCT and intraoperatively using a Castroviejo compass (Storz Ophthalmics, Tuttlingen, Germany). When the MR was exposed using a strabismus hook (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), the measurement was taken from the central part of the muscle insertion on the hook, to verify the effective anchorage zone of the muscle to the sclera, to the corneal limbus.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>All SD-OCT scans and measurements were performed by the same explorer (LDPGL), with intraoperative measurements performed by a single surgeon (ARS). The intraoperative scan was performed in a masked fashion, as the surgeon was unaware of the preoperative SD-OCT measurement.The medial rectus muscles were scanned using the Spectralis SD-OCT (Heidelberg Engineering Inc., Heidelberg, Germany). The module and the anterior segment lens were used with the sclera mode of the software. This SD-OCT device performs 40,000 scans per second, with an axial resolution of 7 μm. The exploratory protocol consisted of 7–11 parallel scans of 16.7 mm in length and 5.7 mm in height, with a spacing between each scan of 278 μm.<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a> The scan was guided by external light fixation, and patients performed maximal temporal gaze to scan the MR muscle.As previously described in several previous studies by different authors,<a class="elsevierStyleCrossRefs" href="#bib0070">14–18</a> the tendon and muscle are identified on OCT as a hyper-reflective structure between a hyper-reflective band corresponding to the sclera below the muscle and the Tenon’s capsule and conjunctiva overlying the muscle. In addition, with the Spectralis device used, the posterior limbus was identified and marked on the image provided by the device software, which shows the ocular anterior segment. By marking it, a vertical line is automatically displayed pointing to the limbus, which is the reference point for the measurement. The distance from the muscle insertion (from the end of the tendon) to the posterior sclerocorneal limbus was measured using the device software (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).Statistical Package for Social Sciences, v18.0 (SPSS Inc., Chicago, IL) was used for statistical analysis. The intraclass correlation coefficient (ICC) was calculated for individual measures and absolute agreement, with the 95% confidence interval (95% CI). A Bland–Altman analysis was performed to assess the agreement of the measurement with SD-OCT and intraoperatively. In addition, the correlation between measurements was assessed using Spearman’s Rho. The percentage of measurements with a difference ≤ 1 mm or more was assessed.<a class="elsevierStyleCrossRefs" href="#bib0080">16,18,20,21</a> A p < 0.05 was considered clinically significant.ResultsThe mean age of the patients was 36.3 ± 16.0 years (range 13–60 years), with 57% being female. The mean preoperative ocular deviation of XT was 38.7 ± 16.9 DP (range 16−65 DP). No patient had a marked adduction deficit. The forced duction test of the lateral rectus was not significant in any of the cases. The mean postoperative ocular deviation was +1.3 ± 6.3 DP (range −12 to +10) between 6 and 12 months after surgery (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> and <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Fifteen previously operated MR muscles were explored by SD-OCT, the surgery performed being unknown in 11 cases. One patient was excluded from the study due to the poor image quality obtained (due to conjunctival scarring from 3 previous surgeries), so 14 patients were finally studied, i.e. there were 6.6% of cases in which the muscle was not identifiable by OCT.The mean distance at which the limbus MR insertion was found intraoperatively was 8.7 ± 2.1 mm (range 5.5–12.0), while with SD-OCT the mean was 7.7 ± 1.2 mm (range 5.3–10.0) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The ICC showed moderate-good agreement (0.659; 95% CI 0.157−0.885; p < 0.001) between the measurements obtained by both methods. A good correlation (R = 0.792; p = 0.011) was observed between the two measurement techniques.In the Bland–Altman analysis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) the differences between intraoperative and SD-OCT measurements were plotted and shown against the joint mean of the measurements with both techniques. It was found that when the MRs were more retro-inserted there were greater differences between the two measurement techniques and, therefore, lower agreement.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>In this series of patients in 7/14 muscles the difference between the two measurement techniques was less than 1 mm. However, it should be noted that in 2 cases the difference was >1.5 mm, and in these cases the muscle was retroinserted at 12 mm.DiscussionIn recent years OCT has emerged as a useful alternative for the assessment of extraocular muscles.<a class="elsevierStyleCrossRefs" href="#bib0070">14–21</a> In the present study, moderate to good agreement was found in the insertion-limb distance of MRI scans of cXT patients (previously operated) measured preoperatively with OCT and intraoperatively with compass. Other authors, such as Liu et al. similarly obtained good agreement between these measurements (CCI = 0.85) of the horizontal rectus in adult patients with strabismus who had not previously undergone surgery.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Ngo et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> obtained a CCI of 0.73 (95% CI 0.53−0.85) in children, including vertical rectus and previously operated muscles in their study. It should be noted that, being the first studies performed, these authors used a time-domain OCT having an image resolution lower than that offered by spectral-domain devices, such as the one used in the present work. Rosseto et al. observed that visualisation of the extraocular muscles was higher in those without previous surgery (83%) than in those who had undergone surgery (58%), including 33 muscles in the latter group.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>In the present study, we have obtained greater agreement between the 2 measurement techniques in those MRs in which lesser previous retroinsertions had been performed. This is fundamentally due to the fact that a greater trajectory of the muscle is visualised, being able to locate its insertion with greater precision than when the muscle is located more posteriorly. A case with 3 previous surgeries on this muscle was excluded as the image obtained had many artefacts due to scarring changes.Reoperations in strabismus are complex and must be individualised to obtain an optimal surgical outcome. Chatzistefanou et al.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> described a success rate of 79%, while other authors have given values of around 56–79% for XTc.<a class="elsevierStyleCrossRefs" href="#bib0045">9–12</a> As recognised by different authors, despite the high surgical success rates, the result achieved in cXT is not definitive, as recurrences may occur.<a class="elsevierStyleCrossRefs" href="#bib0045">9–12</a>Detailed clinical reports of previous surgeries performed are often lacking. The ability to assess the position of muscle attachments may have important implications for preoperative planning in these patients.<a class="elsevierStyleCrossRefs" href="#bib0090">18,20,21</a>In the study by Rosetto et al. in 33 previously operated muscles, the differences between OCT versus intraoperative measurements were within 1 mm in 77% of cases.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> Phiblad et al. also used OCT prior to new surgery to assess the extraocular muscles in 10 muscles in 9 patients who had previously undergone surgery, also assessing 4 muscles that had no previous surgery.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> In this series the insertion could be identified in 6/10 previously operated muscles, and in 4/4 non-operated muscles. The difference between OCT and preoperative measurements in previously operated muscles was ≤ 1 mm in 3/6 and ≤ 1,5 mm in 6/6. In our case it coincides that in 7/14 cases the difference between both techniques was less than 1 mm. However, it should be noted that in 2 cases the difference was greater than 1.5 mm. In these cases the muscle was retroinserted at 12 mm, and by OCT the muscle was erroneously identified at 8 mm and 9.1 mm respectively, possibly due to artefacts caused by scar changes. Phiblad et al. described that of the 4 muscle insertions that could not be identified by OCT, 2 showed the presence of a fibrotic scar, and the other 2 were not visualised, probably because they were heavily retro-inserted.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>As for the limitations of the study, it should be noted that it is a small sample of patients and that the large MRI retroinsertions are difficult to visualise by OCT due to the masking produced by the caruncular tissue and the limited exploratory field allowed by the device. Furthermore, it is not known whether the use of the strabismus hook for muscle exposure could be slightly anteriorising the insertion, which could give rise to artefacts in the measurement.The most common case of cXT is usually secondary to retroinsertion of the medial rectus. Excessive weakening of the medial rectus, whether immediate (due to the mm of recession indicated) or delayed (due to tendon changes), can sometimes lead to the development of consecutive exodeviation. When planning an effective surgical correction of said exodeviation, especially in the presence of significant angles, MR scans are of great value, and the location of the insertions that have been modified by previous surgeries can be checked by means of OCT. Therefore, this technique could be very useful for such examination, with the advantage of being able to be performed preoperatively, quickly and non-invasively. In MRs that could be clearly identified as “poorly retroinserted”, a priori, a reintervention could even be ruled out.Future studies, coupled with advances in the development of OCT technology with higher image resolution and a wider exploratory field, should clarify whether this imaging technique can play a relevant role in the planning of strabismus surgery, especially in muscles where previous surgery is unknown, missing or slipped muscles, or in those where insertion alteration is suspected, such as the presence of adhesions.In the knowledge of the authors, this is the first study to evaluate MR position in a series of cXT patients by OCT assessing agreement with intraoperative measurement.In conclusion, SD-OCT can be a useful technique for assessing the limbo-insertion distance of previously retroinserted MR, with moderate to good agreement with the intraoperative measurement. However, agreement was low in highly retroinserted muscles.Conflict of interestNo conflict of interest related to this work was declared by the authors." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1583664" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1425292" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1583665" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Propósito" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1425293" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-10-13" "fechaAceptado" => "2020-10-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1425292" "palabras" => array:5 [ 0 => "Optical coherence tomography" 1 => "Extraocular muscles" 2 => "Consecutive exotropia" 3 => "Medial rectus insertion" 4 => "Limbus-insertion distance" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1425293" "palabras" => array:5 [ 0 => "Tomografía de coherencia óptica" 1 => "Músculos extraoculares" 2 => "Exotropia consecutiva" 3 => "Inserción recto medio" 4 => "Distancia inserción-limbo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "PurposeTo assess the agreement between the measurements of the distance from the medial rectus muscles insertion to the limbus measured by intra-operative spectral-domain optical coherence tomography (SD-OCT) in consecutive exotropia (cXT). MethodsAn analysis was performed on total of 14 medial rectus (MR) muscles of 14 patients who underwent surgery for the treatment of cXT. The limbus-insertion distance of the MR muscles was measured using preoperative SD-OCT and intraoperatively using a calliper. The intraclass correlation coefficient (ICC) and Bland Altman plots were calculated to determine the agreement between the two methods, as well as the correlation. ResultsMean age was 36.3 ± 16.0 years (range 13–60), with 60% being women. Mean preoperative deviation was 38.7 ± 16.9 prismatic dioptres (PD) (range 16–65), being +1.3 ± 6.3 PD (range −12 to +10 PD) after surgery. Intraoperatively the MR insertion was found at 8.7 ± 2.1 mm (range 5.5–12.0) and by OCT at 7.7 ± 1.2 mm (range 5.3–10.0). The ICC showed a moderate to good agreement (0.659; 95% confidence interval: 0.157−0.885; p < 0.001), with a correlation of R = 0.792 (p = 0.011). A better agreement was observed in those MR that were less retro-inserted. ConclusionsSD-OCT is able to measure the insertion to the limbus distance of the medial rectus muscles that have been previously operated on, showing moderate to good agreement with intraoperative measurements. However, the agreement was poor in muscles with a large retro-insertion." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "PropósitoValorar la concordancia de la medición intraoperatoria de la distancia de la inserción del recto medio (RM) al limbo corneal con la obtenida preoperatoriamente mediante tomografía de coherencia óptica de dominio espectral (SD-OCT) en pacientes con exotropia consecutiva (XTc). MétodosSe analizaron 14 RM de 14 pacientes con XTc posquirúrgica que iban a ser reintervenidos. La distancia inserción-limbo fue medida preoperatoriamente mediante SD-OCT y de forma intraoperatoria con compás. Se calculó el coeficiente de correlación intraclase (CCI) y un análisis de Bland Altman para analizar la concordancia de las medidas, estudiándose además la correlación de las mismas. ResultadosLa edad media fue 36,3 ± 16,0 años (rango 13–60), siendo el 57% mujeres. La desviación ocular media preoperatoria de la XT fue 38,7 ± 16,9 dioptrías prismáticas (DP) (rango 16 a 65), siendo el resultado tras la cirugía de +1,3 ± 6,3 DP (rango −12 a +10 DP). Intraoperatoriamente se halló la inserción del RM a 8,7 ± 2,1 mm (rango 5,5–12,0) y con OCT a 7,7 ± 1,2 mm (rango 5,3–10,0). El CCI mostró una concordancia moderada-buena (0,659; intervalo de confianza al 95%: 0,157–0,885; p < 0,001), hallándose una correlación de R = 0,792 (p = 0,011). Se observó una mayor concordancia en aquellos RM que se hallaban menos retroinsertados. ConclusionesLa SD-OCT puede ser una técnica útil para valorar la distancia de la inserción al limbo corneal de los RM previamente retroinsertados, hallándose una concordancia moderada-buena con la medida intraoperatoria. Sin embargo, la concordancia fue baja en músculos muy retroinsertados." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Propósito" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: de-Pablo-Gómez-de-Liaño L, Reche-Sainz JA, Fernández-Vigo JI, Ferro-Osuna M. Evaluación de la distancia al recto medio en la exotropía consecutiva mediante tomografía de coherencia óptica y medida intraoperatoria. Arch Soc Esp Oftalmol. 2021;96:521–526." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 598 "Ancho" => 1874 "Tamanyo" => 204004 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Measurement of the distance from the medial rectus muscle insertion (thick arrow) to the sclerocorneal limbus by intraoperative measurement with the compass (left images) and by optical coherence tomography (OCT; centre images). The image on the right shows the ocular anterior segment with the asterisk indicating the sclerocorneal limbus reference and corresponding to the white vertical line in the OCT image." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 430 "Ancho" => 1674 "Tamanyo" => 120144 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Photos of 2 patients before and after consecutive exotropia surgery." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1207 "Ancho" => 1508 "Tamanyo" => 108986 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Bland Altman analysis of the measurements from the muscle insertion to the limbus by intraoperative measurement with compass and optical coherence tomography. It can be seen that when the medial rectus were more retroinserted there were greater differences between the two measurement techniques and, therefore, less agreement." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "The measurement of the deviation is shown in prismatic dioptres (PD; negative values indicate exotropia and positive values endotropia).F, female; OCT, optical coherence tomography; MR, medial rectus; M, male." "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">Case \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">Previous surgery \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">Type of anaesthesia \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">Pre-operative deviation \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">Postoperative deviation \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">MRI OCT (mm) \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">Intraoperative MRI (mm) \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">1 \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"> \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">Unknown \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">General \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−30 \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"> \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"> \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">9.5 \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"> \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">45 \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">Unknown \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">Topic \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">−45 \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">–4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.5 \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">7.5 \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"> \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 \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">Unknown \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">Topic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−30 \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">–4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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"> \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"> \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">Known \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">General \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 \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"> \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">6.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \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">5 \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 \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">Unknown \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">Topic \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">−65 \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">–6 \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">5.25 \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">5.5 \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"> \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"> \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">Unknown \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">Topic \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">−35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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"> \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">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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">Known \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">Topic \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">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.5 \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"> \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">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">Unknown \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">Topic \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">−35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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"> \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"> \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">Unknown \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">Topic \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">−40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.1 \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"> \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"> \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"> \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">Known \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">Topic \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">−45 \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">–12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.5 \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"> \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"> \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"> \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">Known \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">General \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">−35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.75 \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"> \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">45 \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">Unknown \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">Topic \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"> \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">8.7 \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"> \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"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \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">Unknown \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">Topic \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">−35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">6.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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"> \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">31 \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">Unknown \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">Topic \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">−65 \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"> \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">7.1 \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">7.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2712667.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics and measurements of patients with consecutive exotropia whose limbal distance was assessed by optical coherence tomography and measured intraoperatively." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and surgical risk factors for consecutive exotropia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. 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Evaluation of the insertion distance of the medial rectus in consecutive exotropia by means of intraoperative measure and optical coherence tomography

Evaluación de la distancia al recto medio en la exotropía consecutiva mediante tomografía de coherencia óptica y medida intraoperatoria

L. de-Pablo-Gómez-de-Liañoa,

Corresponding author

depablo.lucia@gmail.com

Corresponding author.

, J.A. Reche-Sainza, J.I. Fernández-Vigob, M. Ferro-Osunaa

a Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Madrid, Spain

b Servicio de Oftalmología, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria (IdISSC), Madrid, Spain

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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Bland Altman analysis of the measurements from the muscle insertion to the limbus by intraoperative measurement with compass and optical coherence tomography&#46; It can be seen that when the medial rectus were more retroinserted there were greater differences between the two measurement techniques and&#44; therefore&#44; less agreement&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Consecutive exotropia &#40;cXT&#41; is a type of divergent strabismus that mostly occurs after endotropia surgery&#44; although it can also appear after deenervation&#44; optical treatments or even spontaneously&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Incidence varies greatly from series to series&#44; ranging from 2 to 29&#37; of patients who have undergone endotropia surgery&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> and is higher in studies with longer follow-up time&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> These are generally adult subjects who underwent surgery for endotropia in childhood &#40;in many cases the surgery performed is unknown&#41;&#44; and who maintained good ocular alignment for months or years&#44; but later developed divergent deviation&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Different risk factors for the development of cXT<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> have been described&#58; anisometropia&#44; amblyopia&#44; high hyperopia&#44; absence of stereopsis&#44; alphabetic pattern&#44; early surgery &#40;before 6 months of age&#41;&#44; multiple previous surgeries&#44; limited post-surgical adduction and neurological diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;9</span></a> However&#44; these risk factors have not clarified the origin of exodeviation&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a> After medial rectus &#40;MR&#41; recession&#44; anomalous scleral reinsertion may occur due to a mechanism of muscle slippage or tendon lengthening<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> which would explain the appearance of adductor weakness&#44; sometimes very delayed in time and more accentuated if there is also fibrosis or adhesions of the ipsilateral lateral rectus&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the presence of significant deviations&#44; surgical correction is the treatment of choice for cXT&#46; Advancement of the MR&#44; with or without retroinsertion of one or both lateral rectus&#44; is usually the most commonly used technique&#44; with a success rate of between 56&#37; and 79&#37;&#44; according to the different series published&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;13</span></a> Preoperatively&#44; adduction limitation &#40;MR weakness&#41; and the intraoperative forced duction test &#40;inelasticity of the lateral rectus&#41; provide valuable information for surgical planning&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However&#44; surgery on previously operated muscles is technically more complicated and the response to treatment is less predictable than on non-operated muscles&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In recent years&#44; different authors such as De-Pablo-G&#243;mez de Lia&#241;o et al&#46; and Liu et al&#46; have described the usefulness of optical coherence tomography &#40;OCT&#41; in the assessment of extraocular rectus muscles&#44; with the advantage of being a fast and non-invasive imaging technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;19</span></a> Early studies with OCT found good agreement with the limbus-insertion distance measured intraoperatively in non-operated muscles&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;16</span></a> Subsequently&#44; some studies have focused on assessing the insertion distance in previously operated muscles&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;20&#44;21</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; to date there have been no studies performed with OCT in a series of patients with cXT to determine its agreement with the intraoperative measurement&#44; which could be a great help for better surgical planning by revealing the location of the MRI prior to surgery&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The purpose of this work is to assess the agreement between the preoperative OCT measurement and the intraoperative measurement of the distance from the MRI insertion to the corneal limbus on cXT&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A prospective study of 14 medial rectus muscles from 14 patients with post-surgical cXT who underwent reoperation between June 2019 and June 2020 was conducted&#46; The study protocol adhered to the Declaration of Helsinki guidelines and was approved by the Research Ethics Committee&#46; Informed consent was obtained from all patients participating in the study&#46; Inclusion criteria were&#58; patients with post-surgical cXT in whom the MR had been retro-inserted and who were to undergo further corrective surgery&#46; Patients in whom the OCT image quality did not allow muscle identification were excluded&#46; The mean preoperative ocular deviation of the XT was measured in prismatic dioptres &#40;PD&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">cXT correction surgery was based on surgical exploration of the retroinserted medial rectus and advancement of the retroinserted rectus to the original insertions&#44; anchoring them with a 6&#47;0 polyglactin resorbable suture&#46; In cases of large exodeviations &#40;&#62;&#160;30&#160;DP&#41; or with positive forced duction test&#44; retroinsertion of one or both lateral rectus was also associated&#46; General anaesthesia was performed in 3 patients &#40;13&#44; 17 and 17 years respectively&#41;&#44; while topical anaesthesia with sedation was performed in the rest&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The corneal insertion-limb distance of the MR was measured preoperatively by OCT and intraoperatively using a Castroviejo compass &#40;Storz Ophthalmics&#44; Tuttlingen&#44; Germany&#41;&#46; When the MR was exposed using a strabismus hook &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; the measurement was taken from the central part of the muscle insertion on the hook&#44; to verify the effective anchorage zone of the muscle to the sclera&#44; to the corneal limbus&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">All SD-OCT scans and measurements were performed by the same explorer &#40;LDPGL&#41;&#44; with intraoperative measurements performed by a single surgeon &#40;ARS&#41;&#46; The intraoperative scan was performed in a masked fashion&#44; as the surgeon was unaware of the preoperative SD-OCT measurement&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The medial rectus muscles were scanned using the Spectralis SD-OCT &#40;Heidelberg Engineering Inc&#46;&#44; Heidelberg&#44; Germany&#41;&#46; The module and the anterior segment lens were used with the sclera mode of the software&#46; This SD-OCT device performs 40&#44;000 scans per second&#44; with an axial resolution of 7&#160;&#956;m&#46; The exploratory protocol consisted of 7&#8211;11 parallel scans of 16&#46;7&#160;mm in length and 5&#46;7&#160;mm in height&#44; with a spacing between each scan of 278&#160;&#956;m&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> The scan was guided by external light fixation&#44; and patients performed maximal temporal gaze to scan the MR muscle&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">As previously described in several previous studies by different authors&#44;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;18</span></a> the tendon and muscle are identified on OCT as a hyper-reflective structure between a hyper-reflective band corresponding to the sclera below the muscle and the Tenon&#8217;s capsule and conjunctiva overlying the muscle&#46; In addition&#44; with the Spectralis device used&#44; the posterior limbus was identified and marked on the image provided by the device software&#44; which shows the ocular anterior segment&#46; By marking it&#44; a vertical line is automatically displayed pointing to the limbus&#44; which is the reference point for the measurement&#46; The distance from the muscle insertion &#40;from the end of the tendon&#41; to the posterior sclerocorneal limbus was measured using the device software &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Statistical Package for Social Sciences&#44; v18&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#41; was used for statistical analysis&#46; The intraclass correlation coefficient &#40;ICC&#41; was calculated for individual measures and absolute agreement&#44; with the 95&#37; confidence interval &#40;95&#37; CI&#41;&#46; A Bland&#8211;Altman analysis was performed to assess the agreement of the measurement with SD-OCT and intraoperatively&#46; In addition&#44; the correlation between measurements was assessed using Spearman&#8217;s Rho&#46; The percentage of measurements with a difference &#8804;&#160;1&#160;mm or more was assessed&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;18&#44;20&#44;21</span></a> A p&#160;&#60;&#160;0&#46;05 was considered clinically significant&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">The mean age of the patients was 36&#46;3&#160;&#177;&#160;16&#46;0&#160;years &#40;range 13&#8211;60 years&#41;&#44; with 57&#37; being female&#46; The mean preoperative ocular deviation of XT was 38&#46;7&#160;&#177;&#160;16&#46;9&#160;DP &#40;range 16&#8722;65&#160;DP&#41;&#46; No patient had a marked adduction deficit&#46; The forced duction test of the lateral rectus was not significant in any of the cases&#46; The mean postoperative ocular deviation was &#43;1&#46;3&#160;&#177;&#160;6&#46;3&#160;DP &#40;range &#8722;12 to &#43;10&#41; between 6 and 12 months after surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> and <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Fifteen previously operated MR muscles were explored by SD-OCT&#44; the surgery performed being unknown in 11 cases&#46; One patient was excluded from the study due to the poor image quality obtained &#40;due to conjunctival scarring from 3 previous surgeries&#41;&#44; so 14 patients were finally studied&#44; i&#46;e&#46; there were 6&#46;6&#37; of cases in which the muscle was not identifiable by OCT&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The mean distance at which the limbus MR insertion was found intraoperatively was 8&#46;7&#160;&#177;&#160;2&#46;1&#160;mm &#40;range 5&#46;5&#8211;12&#46;0&#41;&#44; while with SD-OCT the mean was 7&#46;7&#160;&#177;&#160;1&#46;2&#160;mm &#40;range 5&#46;3&#8211;10&#46;0&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The ICC showed moderate-good agreement &#40;0&#46;659&#59; 95&#37; CI 0&#46;157&#8722;0&#46;885&#59; p&#160;&#60;&#160;0&#46;001&#41; between the measurements obtained by both methods&#46; A good correlation &#40;R&#160;&#61;&#160;0&#46;792&#59; p&#160;&#61;&#160;0&#46;011&#41; was observed between the two measurement techniques&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the Bland&#8211;Altman analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; the differences between intraoperative and SD-OCT measurements were plotted and shown against the joint mean of the measurements with both techniques&#46; It was found that when the MRs were more retro-inserted there were greater differences between the two measurement techniques and&#44; therefore&#44; lower agreement&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">In this series of patients in 7&#47;14 muscles the difference between the two measurement techniques was less than 1&#160;mm&#46; However&#44; it should be noted that in 2 cases the difference was &#62;1&#46;5&#160;mm&#44; and in these cases the muscle was retroinserted at 12&#160;mm&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">In recent years OCT has emerged as a useful alternative for the assessment of extraocular muscles&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;21</span></a> In the present study&#44; moderate to good agreement was found in the insertion-limb distance of MRI scans of cXT patients &#40;previously operated&#41; measured preoperatively with OCT and intraoperatively with compass&#46; Other authors&#44; such as Liu et al&#46; similarly obtained good agreement between these measurements &#40;CCI&#160;&#61;&#160;0&#46;85&#41; of the horizontal rectus in adult patients with strabismus who had not previously undergone surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Ngo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> obtained a CCI of 0&#46;73 &#40;95&#37; CI 0&#46;53&#8722;0&#46;85&#41; in children&#44; including vertical rectus and previously operated muscles in their study&#46; It should be noted that&#44; being the first studies performed&#44; these authors used a time-domain OCT having an image resolution lower than that offered by spectral-domain devices&#44; such as the one used in the present work&#46; Rosseto et al&#46; observed that visualisation of the extraocular muscles was higher in those without previous surgery &#40;83&#37;&#41; than in those who had undergone surgery &#40;58&#37;&#41;&#44; including 33 muscles in the latter group&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In the present study&#44; we have obtained greater agreement between the 2 measurement techniques in those MRs in which lesser previous retroinsertions had been performed&#46; This is fundamentally due to the fact that a greater trajectory of the muscle is visualised&#44; being able to locate its insertion with greater precision than when the muscle is located more posteriorly&#46; A case with 3 previous surgeries on this muscle was excluded as the image obtained had many artefacts due to scarring changes&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Reoperations in strabismus are complex and must be individualised to obtain an optimal surgical outcome&#46; Chatzistefanou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> described a success rate of 79&#37;&#44; while other authors have given values of around 56&#8211;79&#37; for XTc&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;12</span></a> As recognised by different authors&#44; despite the high surgical success rates&#44; the result achieved in cXT is not definitive&#44; as recurrences may occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;12</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Detailed clinical reports of previous surgeries performed are often lacking&#46; The ability to assess the position of muscle attachments may have important implications for preoperative planning in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;20&#44;21</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In the study by Rosetto et al&#46; in 33 previously operated muscles&#44; the differences between OCT versus intraoperative measurements were within 1&#160;mm in 77&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Phiblad et al&#46; also used OCT prior to new surgery to assess the extraocular muscles in 10 muscles in 9 patients who had previously undergone surgery&#44; also assessing 4 muscles that had no previous surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In this series the insertion could be identified in 6&#47;10 previously operated muscles&#44; and in 4&#47;4 non-operated muscles&#46; The difference between OCT and preoperative measurements in previously operated muscles was &#8804;&#160;1&#160;mm in 3&#47;6 and &#8804;&#160;1&#44;5&#160;mm in 6&#47;6&#46; In our case it coincides that in 7&#47;14 cases the difference between both techniques was less than 1&#160;mm&#46; However&#44; it should be noted that in 2 cases the difference was greater than 1&#46;5&#160;mm&#46; In these cases the muscle was retroinserted at 12&#160;mm&#44; and by OCT the muscle was erroneously identified at 8&#160;mm and 9&#46;1&#160;mm respectively&#44; possibly due to artefacts caused by scar changes&#46; Phiblad et al&#46; described that of the 4 muscle insertions that could not be identified by OCT&#44; 2 showed the presence of a fibrotic scar&#44; and the other 2 were not visualised&#44; probably because they were heavily retro-inserted&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">As for the limitations of the study&#44; it should be noted that it is a small sample of patients and that the large MRI retroinsertions are difficult to visualise by OCT due to the masking produced by the caruncular tissue and the limited exploratory field allowed by the device&#46; Furthermore&#44; it is not known whether the use of the strabismus hook for muscle exposure could be slightly anteriorising the insertion&#44; which could give rise to artefacts in the measurement&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The most common case of cXT is usually secondary to retroinsertion of the medial rectus&#46; Excessive weakening of the medial rectus&#44; whether immediate &#40;due to the mm of recession indicated&#41; or delayed &#40;due to tendon changes&#41;&#44; can sometimes lead to the development of consecutive exodeviation&#46; When planning an effective surgical correction of said exodeviation&#44; especially in the presence of significant angles&#44; MR scans are of great value&#44; and the location of the insertions that have been modified by previous surgeries can be checked by means of OCT&#46; Therefore&#44; this technique could be very useful for such examination&#44; with the advantage of being able to be performed preoperatively&#44; quickly and non-invasively&#46; In MRs that could be clearly identified as &#8220;poorly retroinserted&#8221;&#44; <span class="elsevierStyleItalic">a priori</span>&#44; a reintervention could even be ruled out&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Future studies&#44; coupled with advances in the development of OCT technology with higher image resolution and a wider exploratory field&#44; should clarify whether this imaging technique can play a relevant role in the planning of strabismus surgery&#44; especially in muscles where previous surgery is unknown&#44; missing or slipped muscles&#44; or in those where insertion alteration is suspected&#44; such as the presence of adhesions&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In the knowledge of the authors&#44; this is the first study to evaluate MR position in a series of cXT patients by OCT assessing agreement with intraoperative measurement&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In conclusion&#44; SD-OCT can be a useful technique for assessing the limbo-insertion distance of previously retroinserted MR&#44; with moderate to good agreement with the intraoperative measurement&#46; However&#44; agreement was low in highly retroinserted muscles&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">No conflict of interest related to this work was declared by the authors&#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 assess the agreement between the measurements of the distance from the medial rectus muscles insertion to the limbus measured by intra-operative spectral-domain optical coherence tomography &#40;SD-OCT&#41; in consecutive exotropia &#40;cXT&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">An analysis was performed on total of 14 medial rectus &#40;MR&#41; muscles of 14 patients who underwent surgery for the treatment of cXT&#46; The limbus-insertion distance of the MR muscles was measured using preoperative SD-OCT and intraoperatively using a calliper&#46; The intraclass correlation coefficient &#40;ICC&#41; and Bland Altman plots were calculated to determine the agreement between the two methods&#44; as well as the correlation&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mean age was 36&#46;3&#160;&#177;&#160;16&#46;0 years &#40;range 13&#8211;60&#41;&#44; with 60&#37; being women&#46; Mean preoperative deviation was 38&#46;7&#160;&#177;&#160;16&#46;9 prismatic dioptres &#40;PD&#41; &#40;range 16&#8211;65&#41;&#44; being &#43;1&#46;3&#160;&#177;&#160;6&#46;3 PD &#40;range &#8722;12 to &#43;10 PD&#41; after surgery&#46; Intraoperatively the MR insertion was found at 8&#46;7&#160;&#177;&#160;2&#46;1&#160;mm &#40;range 5&#46;5&#8211;12&#46;0&#41; and by OCT at 7&#46;7&#160;&#177;&#160;1&#46;2&#160;mm &#40;range 5&#46;3&#8211;10&#46;0&#41;&#46; The ICC showed a moderate to good agreement &#40;0&#46;659&#59; 95&#37; confidence interval&#58; 0&#46;157&#8722;0&#46;885&#59; <span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;001&#41;&#44; with a correlation of R&#160;&#61;&#160;0&#46;792 &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;011&#41;&#46; A better agreement was observed in those MR that were less retro-inserted&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">SD-OCT is able to measure the insertion to the limbus distance of the medial rectus muscles that have been previously operated on&#44; showing moderate to good agreement with intraoperative measurements&#46; However&#44; the agreement was poor in muscles with a large retro-insertion&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Purpose"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Prop&#243;sito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Valorar la concordancia de la medici&#243;n intraoperatoria de la distancia de la inserci&#243;n del recto medio &#40;RM&#41; al limbo corneal con la obtenida preoperatoriamente mediante tomograf&#237;a de coherencia &#243;ptica de dominio espectral &#40;SD-OCT&#41; en pacientes con exotropia consecutiva &#40;XTc&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 14 RM de 14 pacientes con XTc posquir&#250;rgica que iban a ser reintervenidos&#46; La distancia inserci&#243;n-limbo fue medida preoperatoriamente mediante SD-OCT y de forma intraoperatoria con comp&#225;s&#46; Se calcul&#243; el coeficiente de correlaci&#243;n intraclase &#40;CCI&#41; y un an&#225;lisis de Bland Altman para analizar la concordancia de las medidas&#44; estudi&#225;ndose adem&#225;s la correlaci&#243;n de las mismas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La edad media fue 36&#44;3&#160;&#177;&#160;16&#44;0 a&#241;os &#40;rango 13&#8211;60&#41;&#44; siendo el 57&#37; mujeres&#46; La desviaci&#243;n ocular media preoperatoria de la XT fue 38&#44;7&#160;&#177;&#160;16&#44;9 dioptr&#237;as prism&#225;ticas &#40;DP&#41; &#40;rango 16 a 65&#41;&#44; siendo el resultado tras la cirug&#237;a de &#43;1&#44;3&#160;&#177;&#160;6&#44;3 DP &#40;rango &#8722;12 a &#43;10 DP&#41;&#46; Intraoperatoriamente se hall&#243; la inserci&#243;n del RM a 8&#44;7&#160;&#177;&#160;2&#44;1&#160;mm &#40;rango 5&#44;5&#8211;12&#44;0&#41; y con OCT a 7&#44;7&#160;&#177;&#160;1&#44;2&#160;mm &#40;rango 5&#44;3&#8211;10&#44;0&#41;&#46; El CCI mostr&#243; una concordancia moderada-buena &#40;0&#44;659&#59; intervalo de confianza al 95&#37;&#58; 0&#44;157&#8211;0&#44;885&#59; p&#160;&#60;&#160;0&#44;001&#41;&#44; hall&#225;ndose una correlaci&#243;n de R&#160;&#61;&#160;0&#44;792 &#40;p&#160;&#61;&#160;0&#44;011&#41;&#46; Se observ&#243; una mayor concordancia en aquellos RM que se hallaban menos retroinsertados&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La SD-OCT puede ser una t&#233;cnica &#250;til para valorar la distancia de la inserci&#243;n al limbo corneal de los RM previamente retroinsertados&#44; hall&#225;ndose una concordancia moderada-buena con la medida intraoperatoria&#46; Sin embargo&#44; la concordancia fue baja en m&#250;sculos muy retroinsertados&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Prop&#243;sito"
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            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; de-Pablo-G&#243;mez-de-Lia&#241;o L&#44; Reche-Sainz JA&#44; Fern&#225;ndez-Vigo JI&#44; Ferro-Osuna M&#46; Evaluaci&#243;n de la distancia al recto medio en la exotrop&#237;a consecutiva mediante tomograf&#237;a de coherencia &#243;ptica y medida intraoperatoria&#46; Arch Soc Esp Oftalmol&#46; 2021&#59;96&#58;521&#8211;526&#46;</p>"
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    ]
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      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
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        "mostrarFloat" => true
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Measurement of the distance from the medial rectus muscle insertion &#40;thick arrow&#41; to the sclerocorneal limbus by intraoperative measurement with the compass &#40;left images&#41; and by optical coherence tomography &#40;OCT&#59; centre images&#41;&#46; The image on the right shows the ocular anterior segment with the asterisk indicating the sclerocorneal limbus reference and corresponding to the white vertical line in the OCT image&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          0 => array:4 [
            "imagen" => "gr2.jpeg"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Fig&#46; "
            "rol" => "short"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Photos of 2 patients before and after consecutive exotropia surgery&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1207
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
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            "rol" => "short"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Bland Altman analysis of the measurements from the muscle insertion to the limbus by intraoperative measurement with compass and optical coherence tomography&#46; It can be seen that when the medial rectus were more retroinserted there were greater differences between the two measurement techniques and&#44; therefore&#44; less agreement&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The measurement of the deviation is shown in prismatic dioptres &#40;PD&#59; negative values indicate exotropia and positive values endotropia&#41;&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">F&#44; female&#59; OCT&#44; optical coherence tomography&#59; MR&#44; medial rectus&#59; M&#44; male&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\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
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\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&nbsp;\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">Previous surgery&nbsp;\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">Type of anaesthesia&nbsp;\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">Pre-operative deviation&nbsp;\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">Postoperative deviation&nbsp;\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">MRI OCT &#40;mm&#41;&nbsp;\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">Intraoperative MRI &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">M&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">Unknown&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">General&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">&#8722;30&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">&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">9&#46;5&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</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">45&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">M&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">Unknown&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">Topic&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">&#8722;45&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">&#8211;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;5&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;5&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">&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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Topic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;30&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">&#8211;4&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">6&#46;8&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">&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
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \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><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&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">Known&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">General&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">&#8722;20&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">6&#46;2&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">8&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">5&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&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">M&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">Unknown&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">Topic&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">&#8722;65&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">&#8211;6&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;25&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;5&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">&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">M&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">Unknown&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">Topic&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">&#8722;35&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">0&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;4&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">&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">35&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">F&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">Known&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">Topic&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">&#8722;16&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">8&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">8&#46;5&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">8&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">F&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">Unknown&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">Topic&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">&#8722;35&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">8&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">&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">F&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">Unknown&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">Topic&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">&#8722;40&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">0&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">9&#46;1&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">&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">M&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">Known&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">Topic&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">&#8722;45&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">&#8211;12&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">8&#46;5&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">&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">F&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">Known&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">General&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">&#8722;35&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">8&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">8&#46;75&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">&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">45&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">F&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">Unknown&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">Topic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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