Clinical-epidemiological characteristics of keratoconus in Asturias | Archivos de la Sociedad Española de Oftalmología (English Edition)

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Fernández Berdasco, L.B. Alfaya Muñoz, C.R. Corzo Fernández, A. Señaris González, B. Baamonde Arbaiza" "autores" => array:5 [ 0 => array:4 [ "nombre" => "K." "apellidos" => "Fernández Berdasco" "email" => array:1 [ 0 => "karinafdezb@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L.B." "apellidos" => "Alfaya Muñoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C.R." "apellidos" => "Corzo Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Señaris González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "B." "apellidos" => "Baamonde Arbaiza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Características clínico-epidemiológicas del queratocono en Asturias" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2236 "Ancho" => 3341 "Tamanyo" => 412438 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0235" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Correlation plots and trend lines between: A) mean K and BCVA (Spearman's Rho 0.545; p < 0.001), B) K max and BCVA (Spearman’s Rho 0.515; p < 0.001), C) CYL 3 mm and BCVA (Spearman’s Rho -0.323; p = 0.004) and D) TCT and BCVA (Spearman’s Rho -0.381; p = 0.001)." ] ] ] "textoCompleto" => "IntroductionKeratoconus is the most common ectasia and is characterised by an alteration of the posterior face and abnormal thinning and distribution of corneal thickness.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> This alteration causes progressive irregular astigmatism which, if not treated adequately, leads to significant visual impairment. Although it has traditionally been considered a non-inflammatory disease,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> there are indications that some interleukins such as IL-6 or tumour necrosis factor-alpha (TNF-α) may play a relevant role in the development of the disease.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Its etiology is multifactorial, involving up to 24 genes such as VSX1, ZNF469, SOD1, miR184, FOXO1, COL5A1, FNDC3B, PNPLA2, LOX and DOCK9<a class="elsevierStyleCrossRef" href="#bib0015">3</a> with an unestablished pattern of inheritance and also involving environmental factors such as pollution or living in an urban environment.<a class="elsevierStyleCrossRefs" href="#bib0020">4–6</a> There is also an ethnic disparity, being more common in Asia<a class="elsevierStyleCrossRef" href="#bib0035">7</a> or in countries such as New Zealand<a class="elsevierStyleCrossRef" href="#bib0040">8</a> than in Europe or America. Keratoconus is also associated with several risk factors such as Down syndrome,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Mitral valve prolapse,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> diabetes mellitus,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> eye rubbing,<a class="elsevierStyleCrossRefs" href="#bib0060">12–16</a> asthma,<a class="elsevierStyleCrossRefs" href="#bib0065">13,17,18</a> atopic dermatitis,<a class="elsevierStyleCrossRefs" href="#bib0065">13,17–19</a> ocular atopy,<a class="elsevierStyleCrossRefs" href="#bib0020">4,12,20,21</a> floppy eyelid syndrome,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> sleep apnoea syndrome<a class="elsevierStyleCrossRefs" href="#bib0110">22,23</a> or even mental illness.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> Consanguinity and family history are additional factors involved.<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a>The prevalence of keratoconus varies according to geographical area and ranges from 1.38 per 1000 population to 8.59%,<a class="elsevierStyleCrossRefs" href="#bib0040">8,27–35</a> together with an incidence between 3.60 and 28.47 cases per 100,000 population.<a class="elsevierStyleCrossRefs" href="#bib0045">9,35,36</a> The development of modern corneal tomographs has enabled more accurate diagnosis and detection of cases in subclinical stages, so prevalence and incidence figures have increased.<a class="elsevierStyleCrossRefs" href="#bib0005">1,4,9</a> The clinical and epidemiological characteristics of keratoconus have been studied in several studies carried out in different parts of the world. However, in Spain there are hardly any studies.<a class="elsevierStyleCrossRefs" href="#bib0185">37–39</a> Bearing in mind that keratoconus is the second cause of keratoplasty in the world, the aim of the present study is to estimate the incidence of keratoconus in Asturias and to find out the clinical and topographical characteristics of patients at the time of diagnosis, as well as the stage of the disease at which they are first assessed in specialised cornea and ocular surface consultations.MethodsA cross-sectional study was conducted analysing all cases of keratoconus seen in the first consultations of the Cornea and Surface section of the Hospital Universitario Central de Asturias (Oviedo) and Hospital Universitario de Cabueñes (Gijón) between 2017 and 2020. Cases diagnosed and even treated in other centres were included in the study if the date of diagnosis was between 2017 and 2020. The study design and data collection were conducted in accordance with the Declaration of Helsinki. Informed consent waiver was requested from the Research Ethics Committee of the Principality of Asturias. Variables such as sex, age and best corrected visual acuity (BCVA) were collected. All patients underwent corneal topography with the CSO Sirius tomograph and aberrometer (Florence, Italy) and the variables referring to curvature and thickness were collected. In bilateral cases, only the eye with the most advanced stage according to the Amsler-Krumeich classification was taken into account and, if they were in the same stage, the eye with worse visual acuity or greater astigmatism was included. The clinical phenotype of each keratoconus was also analysed according to the Fernández-Vega/Alfonso morphological classification. For the statistical study, quantitative variables were analysed with the Kolmogorov-Smirnov test and it was found that there was no normal distribution. Therefore, for hypothesis testing, the Kruskal-Wallis test was used for quantitative variables and Fisher’s exact test for qualitative variables. For correlations between quantitative variables, Spearman’s rho was used. Finally, the estimated annual cumulative incidence of keratoconus in Asturias was calculated using official population figures from the National Institute of Statistics.ResultsA total of 112 patients with recent keratoconus diagnosis were seen at both centres during 2017–2020 (97 at the Hospital Universitario Central de Asturias and 15 at the Hospital Universitario de Cabueñes). A total of 42.0% of the patients were female 58.0% were male. The mean age was 36.84 ± 15.59 (14–74), being 39 ± 17 (15–74) years for women and 35 ± 14 (14–71) for men. Of the patients diagnosed, 18.8% were under 20 years of age, while 22.3% were aged 20–30 years, 19.6% were aged 30–40 years and 39.3% were over 40 years. The estimated average cumulative incidence for the period 2017–2020 is 2.78 cases/100,000 population (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The mean BCVA of all eyes was 0.42 ± 0.46 (0 - 2.00) (LogMAR scale). No statistically significant difference was found between visual acuity and age classified in groups (Kruskal-Wallis, p = 0.490), but between age and stage according to the Amsler-Krumeich classification (Fisher's Exact, p = 0.006) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The mean mean keratometry in the central 3 mm (Kmean) was 50.38 ± 6.73 (41.74–69.12), while the mean maximum keratometry (Kmax) was 63.41 ± 14.92 (47.24–115.11). The mean astigmatism in the central 3 mm (CYL3mm) was −5.56 ± 3.22 (−16.40, −0.13) and the minimum corneal thickness (TCT) was 442.55 ± 63.74 (304-568). A statistically significant positive correlation was found between BCVA and Kmean (p < 0.001), as well as Kmax (p < 0.001) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). On the other hand, a statistically significant negative correlation was found between BCVA and CYL3mm (p = 0.004) and TCT (p = 0.001).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Analysis by morphological phenotypes and evolutionary stageIn terms of keratoconus phenotype, 17.6% corresponded to the Croissant phenotype, 15.4% to the Duck, 13.2% to the Snowman, 55.7% to the Nipple and 1.1% to the Bowtie. No statistically significant difference was found between median BCVA, CYL3mm or TCT, while there was with Kmean (Kruskal-Wallis, p = 0.003) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>According to the Amsler Krumeich classification, 31.8% were stage I, 28.0% stage II, 15.0% stage III and 25.2% stage IV. The median BCVA, age, CYL3mm, TCT and Kmean can be found in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Pre-treatment and therapeutic managementOverall, 21.6% of the patients who came for consultation were already wearing soft, rigid gas permeable or scleral support contact lenses. 84.7% had no previous surgical treatment, while 8.1% had undergone corneal segment or ring surgery and another 7.2% had undergone keratoplasty at another centre. Of the patients who had been treated with corneal segments or rings, 2 were in stage I, 2 in stage II, 2 in stage III and 2 in stage IV. 100% of the patients who came for keratoplasty were stage IV.As for therapeutic management, 74.5% of the cases were followed up, while 7.5% underwent corneal segment or ring implantation, 4.7% underwent cross-linking and 13.2% underwent keratoplasty. In 75.0% of cases, the reason for treatment was refractive, while in 25.0% it was due to progression of ectasia.DiscussionThere are few studies on the incidence or prevalence of keratoconus in Spain and, to date, no population-based studies have been carried out, only studies focusing on hospitals and clinics.<a class="elsevierStyleCrossRefs" href="#bib0185">37–39</a> Likewise, there are few studies on the incidence of keratoconus in Europe with which to compare our results. In the present study, the estimated cumulative annual incidence of keratoconus in Asturias is 2.78 cases/100,000 inhabitants, which is lower than in other European countries such as Denmark,<a class="elsevierStyleCrossRef" href="#bib0180">36</a> the Netherlands or the United Kingdom.<a class="elsevierStyleCrossRefs" href="#bib0140">28,40,41</a> This difference may be due to environmental and/or genetic factors that are not fully known, although our study population does not include patients with keratoconus who are treated in opticians' surgeries or private centres. A 1986 study in Finland,<a class="elsevierStyleCrossRef" href="#bib0210">42</a> based on one hospital, estimated an incidence of 1.5 cases/100,000 inhabitants, but the patients were diagnosed by keratometry and retinoscopy. The development and widespread use of modern corneal tomographs has made it possible to diagnose keratoconus with more defined criteria and at earlier stages, and recent work suggests that the incidence and prevalence of keratoconus may be higher. In any case, more studies are needed on the incidence and prevalence of keratoconus in Europe and Spain, preferably population-based studies with a large sample size, which will allow us to gain a greater understanding of the extent of this health problem within the healthcare system.Taking into account the progressive and disabling nature of the disease, as well as knowing the magnitude of the problem in a given geographical area, it is relevant to assess the stage or severity at which ectasia is first diagnosed. Approximately 40% of the patients seen in our centres consult with an Amsler-Krumeich stage III or IV, i.e. in advanced stages which already involves visual loss that may require surgical treatment. In other published studies, these figures are similar,<a class="elsevierStyleCrossRefs" href="#bib0030">6,7,35,43</a>,<a class="elsevierStyleCrossRef" href="#bib0220">44</a> which suggests that an earlier diagnosis is necessary to avoid visual sequelae that may be permanent. If we analyse the mean keratometry of the patients at the time of diagnosis, the results are very similar in all publications. The Collaborative Longitudinal Evaluation of Keratoconus (CLEK)<a class="elsevierStyleCrossRef" href="#bib0225">45</a> study was carried out in the United States with a total of 1209 participants with keratoconus in which almost half had a mean K greater than 50 dioptres, and the Dundee University Scottish Keratoconus (DUSK)<a class="elsevierStyleCrossRef" href="#bib0085">17</a> showed that the mean simulated keratometry (simK) value was 52 dioptres. Other more recent works also show mean keratometric values close to 50 dioptres<a class="elsevierStyleCrossRefs" href="#bib0030">6,8,44</a>. In the present study, a statistically significant association was found between mean curvature, keratoconus thickness, astigmatism and BCVA, so these data imply an impact on the patient’s visual quality.One of the main barriers to early diagnosis of keratoconus is the lack of availability of corneal topographers or corneal tomographs in all clinics and hospitals, as well as the lack of awareness of the disease among healthcare professionals, together with the asymptomatic nature of the disease in its earliest stages. Recently, Philipp B. Baenninger et al.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> published the results of a survey in Switzerland to assess the general knowledge among general ophthalmologists about keratoconus, and the results showed some lack of knowledge about the disease, risk factors and treatment modalities, with the disease being more unknown among those with more years of practice. It is also worth mentioning that an unknown proportion of patients with keratoconus are being managed in optical centres.The results of an anonymous survey on the management of keratoconus by optometrists in the UK, Portugal and Spain have recently been published,<a class="elsevierStyleCrossRef" href="#bib0235">47</a> showing that in Spain 50% of optometrists refer keratoconus to the ophthalmologist at diagnosis, while 29.9% wait until progression is observed and 5.6% when there is visual loss.<a class="elsevierStyleCrossRef" href="#bib0235">47</a> In addition to requiring the necessary devices to establish a diagnosis, collaboration between the optometrist, primary care specialist and general ophthalmologist is crucial for early detection of corneal ectasia and referral to the specialised cornea unit.Also in relation to the above, it is surprising that the majority of patients are over 40 years of age, by which time the disease is sufficiently advanced for surgical treatment to be necessary. The average age at which a patient is referred to the cornea unit in Asturias is over 35 years and higher than in other published studies focusing on Asia and the Middle East,<a class="elsevierStyleCrossRefs" href="#bib0030">6,7,35,43</a>,<a class="elsevierStyleCrossRef" href="#bib0220">44</a> but in line with other studies with a predominantly white Caucasian population (39.3 - 42 years).<a class="elsevierStyleCrossRefs" href="#bib0225">45,48</a> Studies by Pearson et al.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> and Georgiou et al.,<a class="elsevierStyleCrossRef" href="#bib0205">41</a> both from the UK, showed that the age at presentation was 21.5 years in patients of Asian origin compared to 26.4 years in patients of Caucasian origin. This suggests that there are a number of unstudied genetic, ethnic and environmental factors that strongly influence disease presentation and severity.In our case, a statistically significant association was found between age and severity according to the Amsler-Krumeich classification. Other published studies have not found this relationship,<a class="elsevierStyleCrossRef" href="#bib0215">43</a> while other studies have found greater severity in younger patients.<a class="elsevierStyleCrossRefs" href="#bib0245">49,50</a> In the present case, we believe that the greater severity of keratoconus in older patients is due to the fact that younger patients tend to consult earlier than older patients.In this study we have found a higher incidence of keratoconus in males than in females. Although the literature often maintains that there are no gender differences,<a class="elsevierStyleCrossRefs" href="#bib0035">7,31</a> most studies show that there is a higher prevalence and incidence in men.<a class="elsevierStyleCrossRefs" href="#bib0030">6,17,35,40</a>,<a class="elsevierStyleCrossRef" href="#bib0245">49</a> It has been proposed that this difference may be due to hormonal or environmental factors.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>Another important aspect of our study was to quantify the percentage of patients who required keratoplasty, either penetrating or lamellar. Previous studies have mentioned that keratoplasty is performed in around 4% of cases.<a class="elsevierStyleCrossRefs" href="#bib0175">35,44</a> In our case this figure is considerably higher and could be reduced with earlier diagnosis and greater knowledge of the disease on the part of patients and healthcare professionals.The present study has estimated the incidence of keratoconus in Asturias, and at the same time we carried out a descriptive study with the most relevant clinical-epidemiological characteristics and the therapeutic modality indicated in each case. The main limitation of this study is that we have worked with information from two hospitals and not with population data. Although the Hospital Universitario Central de Asturias together with the Hospital Universitario de Cabueñes are the two hospitals in the public network that have a corneal tomographer in the entire autonomous community and where the follow-up and treatment of all cases in the region is carried out, the study population does not include those who are regularly treated in opticians' shops or private clinics. The other main limitation is the inherent limitation of a cross-sectional study to establish causal relationships.ConclusionsThe estimated cumulative annual incidence of keratoconus in Asturias is 2.78 cases/100,000 inhabitants. Approximately 40% of cases are detected in advanced stages and at an age over 40. Keratoconus continues to be a frequent indication for keratoplasty in our environment, with a considerable percentage of these cases requiring transplantation at the time of evaluation (13%). For this reason, it is necessary to implement new measures to improve the early diagnosis of keratoconus in Asturias.FinancingThe authors declare that they have not received any type of funding or scholarship for the preparation of the research work.Conflict of interestsThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1853068" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1610938" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1853067" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1610937" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Analysis by morphological phenotypes and evolutionary stage" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Pre-treatment and therapeutic management" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Financing" ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-03-29" "fechaAceptado" => "2022-09-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1610938" "palabras" => array:4 [ 0 => "Keratoconus" 1 => "Ectasia" 2 => "Asturias" 3 => "Incidence" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1610937" "palabras" => array:4 [ 0 => "Queratocono" 1 => "Ectasia" 2 => "Asturias" 3 => "Incidencia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionKeratoconus is the most frequent corneal ectasia and second most common cause of keratoplasty worldwide. The clinical and epidemiological characteristics of keratoconus have rarely been studied in Spain, and to date, no study has been done in Asturias. Material and methodsA cross-sectional study was conducted to analyze all cases of keratoconus diagnosed in the first consultations of the Cornea and Surface section of the Hospital Universitario Central de Asturias (Oviedo) and Hospital Universitario de Cabueñes (Gijón) between 2017 and 2020. Demographic data, visual acuity and corneal topography were collected. ResultsA total of 112 patients (42.0% women and 58.0% men) were included. The mean age was 36.84 ± 15.59, with 39.3% being older than 40 years. 31.8%, 28.0%, 15.0%, and 25.2% were in stages I, II, III and IV, Amsler-Krumeich scale, respectively. Corneal segments were implanted in 7.5% of patients, cross-linking was performed in 4.7%, and keratoplasty was performed in 13.2%. ConclusionApproximately 40% of keratoconus cases are detected at advanced stages and another 40% are detected at an age over 40 years. 13% of these patients require keratoplasty, which is why it is frequently performed in our setting. Therefore, early diagnosis before irreversible visual loss is necessary." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl queratocono es la ectasia corneal más frecuente y la segunda causa de queratoplastia en el mundo. Las características clínicas y epidemiológicas del queratocono no han sido apenas estudiadas en España y, hasta la fecha, no se ha hecho ningún trabajo en Asturias. Material y métodosSe realizó un estudio transversal analizando todos los casos de queratocono diagnosticado en las primeras consultas de la sección de Córnea y Superficie de los centros Hospital Universitario Central de Asturias (Oviedo) y Hospital Universitario de Cabueñes (Gijón) entre 2017 y 2020. A todos los pacientes se les recogieron datos demográficos, agudeza visual y se les realizó una topografía corneal. ResultadosSe incluyeron un total de 112 pacientes (42,0% mujeres y 58,0% hombres). La edad media era de 36,84±15,59; teniendo un 39,3% una edad superior a 40 años. Un 31,8%, 28,0%, 15,0% y un 25,2% se encontraban en los estadios I, II, III y IV respectivamente en la escala Amsler-Krumeich. En un 7,5% se implantaron segmentos corneales, en un 4,7% se realizó cross-linking y en un 13,2% se realizó queratoplastia. ConclusiónAproximadamente un 40% de los queratoconos se detectan en estadios avanzados y otro 40% a una edad superior a los 40 años. Un 13% de los mismos requieren queratoplastia, por lo que sigue siendo una indicación frecuente en nuestro medio. Es necesario por tanto realizar un diagnóstico precoz para actuar antes de que exista una pérdida visual irreversible." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2236 "Ancho" => 3341 "Tamanyo" => 412438 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0235" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Correlation plots and trend lines between: A) mean K and BCVA (Spearman's Rho 0.545; p < 0.001), B) K max and BCVA (Spearman’s Rho 0.515; p < 0.001), C) CYL 3 mm and BCVA (Spearman’s Rho -0.323; p = 0.004) and D) TCT and BCVA (Spearman’s Rho -0.381; p = 0.001)." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0240" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "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">Year \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of inhabitants in Asturias<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of cases \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cumulative incidence<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95% CI<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \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">2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.034.960 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.78-3.82 \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">2018 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.028.244 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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">3.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.95-4.08 \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">2019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.022.800 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.56-3.52 \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">2020 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1018.754 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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">2.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.73-3.77 \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">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.026.197 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.5 \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">2.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.76-3.80 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Data from the National Statistics Institute (INE)." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Number of cases per 100,000 inhabitants." ] ] ] "descripcion" => array:1 [ "en" => "Estimated cumulative incidence of keratoconus in Asturias in 2017-2020." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0245" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "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 " rowspan="3" align="left" valign="middle" scope="col">Amsler Krumeich</th><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="8" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age</th></tr><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">≤ 20 years</th><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">21-30 years</th><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">31-40 years</th><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">≥ 41 years</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \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">Pre-clinical (I) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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">55.0% \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"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.5% \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">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">42.1% \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">27.3% \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">Mild (II) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.0% \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"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50.0% \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"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.6% \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"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.9% \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">Moderate (III) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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">15.0% \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"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.7% \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">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">5.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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">18.2% \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">Severe (IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " 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">5.0% \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">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">20.8% \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">21.1% \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">38.6% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Distribution of Amsler-Krumeich stages by age group. There is a clear predominance of more severe stages at older ages (Fisher’s Exact. p = 0.006)." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0250" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "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">Phenotype \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BCVA \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">K media \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CYL 3 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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TCT \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">Croissant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.31 ± 0.31 \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">40 ± 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">46.54 ± 4.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−6.08 ± 4.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">463 ± 64 \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">Duck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.27 ± 0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 ± 17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46.62 ± 2.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−4.58 ± 1.91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">445 ± 29 \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">Snowman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.21 ± 0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 ± 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">48.81 ± 4.66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−3.99 ± 2.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">464 ± 44 \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">Nipple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.44 ± 0.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 ± 17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52.96 ± 6.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−5.84 ± 2.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">424 ± 57 \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">Bowtie \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.30 \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">45.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−8.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">522 \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">p \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.508 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.176 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.003 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.247 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.304 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Visual and topographical characteristics by morphological phenotypes (Kruskal-Wallis)." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0255" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "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">Stage \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BCVA \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">K media \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CYL 3 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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TCT \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">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.16 ± 0.16 \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">34 ± 15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.90 ± 1.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−3.71 ± 2.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">486 ± 40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.33 ± 0.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 ± 14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49.19 ± 2.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−6.08 ± 2.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">446 ± 35 \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">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.51 ± 0.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 ± 17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53.06 ± 3.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−7.08 ± 3.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">412 ± 45 \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">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.79 ± 0.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 ± 15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58.36 ± 8.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−6.52 ± 3.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">392 ± 90 \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">p \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.003 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Visual and topographical characteristics by developmental stage (Kruskal-Wallis)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:50 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Group of Panelists for the Global Delphi Panel of Keratoconus and Ectatic Diseases. 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Meng" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/s41598-021-87291-y" "Revista" => array:5 [ "tituloSerie" => "Sci Rep" "fecha" => "2021" "volumen" => "11" "paginaInicial" => "7559" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33824422" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characteristics of keratoconic patients at two main eye centres in Palestine: a cross-sectional study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Shanti" 1 => "I. Beshtawi" 2 => "S.H. Zyoud" 3 => "A. Abu-Samra" 4 => "A. Abu-Qamar" 5 => "R. Barakat" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s12886-018-0762-x" "Revista" => array:5 [ "tituloSerie" => "BMC Ophthalmol" "fecha" => "2018" "volumen" => "18" "paginaInicial" => "95" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29661163" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Keratoconus prevalence among high school students in New Zealand" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.T. Papaliʼi-Curtin" 1 => "R. Cox" 2 => "T. Ma" 3 => "L. Woods" 4 => "A. Covello" 5 => "R.C. Hall" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ICO.0000000000002054" "Revista" => array:6 [ "tituloSerie" => "Cornea" "fecha" => "2019" "volumen" => "38" "paginaInicial" => "1382" "paginaFinal" => "1389" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31335534" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of keratoconus in persons with Down syndrome: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "O. Kristianslund" 1 => "L. Drolsum" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "BMJ Open Ophthalmol" "fecha" => "2021" "volumen" => "6" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The association between keratoconus and mitral valve prolapse: a meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.A. Siordia" 1 => "J.C. 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Clinical-epidemiological characteristics of keratoconus in Asturias

Características clínico-epidemiológicas del queratocono en Asturias

K. Fernández Berdascoa,

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karinafdezb@gmail.com

Corresponding author.

, L.B. Alfaya Muñoza, C.R. Corzo Fernándeza, A. Señaris Gonzálezb, B. Baamonde Arbaizab

a Servicio de Oftalmología, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain

b Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain

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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Correlation plots and trend lines between&#58; A&#41; mean K and BCVA &#40;Spearman&#39;s Rho 0&#46;545&#59; <span class="elsevierStyleItalic">p&#8239;&#60;</span>&#8239;0&#46;001&#41;&#44; B&#41; K max and BCVA &#40;Spearman&#8217;s Rho 0&#46;515&#59; <span class="elsevierStyleItalic">p&#8239;&#60;</span>&#8239;0&#46;001&#41;&#44; C&#41; CYL 3&#8239;mm and BCVA &#40;Spearman&#8217;s Rho -0&#46;323&#59; <span class="elsevierStyleItalic">p&#8239;&#61;&#8239;0</span>&#46;004&#41; and D&#41; TCT and BCVA &#40;Spearman&#8217;s Rho -0&#46;381&#59; <span class="elsevierStyleItalic">p&#8239;&#61;&#8239;0</span>&#46;001&#41;&#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">Keratoconus is the most common ectasia and is characterised by an alteration of the posterior face and abnormal thinning and distribution of corneal thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This alteration causes progressive irregular astigmatism which&#44; if not treated adequately&#44; leads to significant visual impairment&#46; Although it has traditionally been considered a non-inflammatory disease&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> there are indications that some interleukins such as IL-6 or tumour necrosis factor-alpha &#40;TNF-&#945;&#41; may play a relevant role in the development of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Its etiology is multifactorial&#44; involving up to 24 genes such as VSX1&#44; ZNF469&#44; SOD1&#44; miR184&#44; FOXO1&#44; COL5A1&#44; FNDC3B&#44; PNPLA2&#44; LOX and DOCK9<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> with an unestablished pattern of inheritance and also involving environmental factors such as pollution or living in an urban environment&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> There is also an ethnic disparity&#44; being more common in Asia<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> or in countries such as New Zealand<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> than in Europe or America&#46; Keratoconus is also associated with several risk factors such as Down syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Mitral valve prolapse&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> diabetes mellitus&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> eye rubbing&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;16</span></a> asthma&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;17&#44;18</span></a> atopic dermatitis&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;17&#8211;19</span></a> ocular atopy&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;12&#44;20&#44;21</span></a> floppy eyelid syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> sleep apnoea syndrome<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> or even mental illness&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Consanguinity and family history are additional factors involved&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The prevalence of keratoconus varies according to geographical area and ranges from 1&#46;38 per 1000 population to 8&#46;59&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;27&#8211;35</span></a> together with an incidence between 3&#46;60 and 28&#46;47 cases per 100&#44;000 population&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;35&#44;36</span></a> The development of modern corneal tomographs has enabled more accurate diagnosis and detection of cases in subclinical stages&#44; so prevalence and incidence figures have increased&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;9</span></a> The clinical and epidemiological characteristics of keratoconus have been studied in several studies carried out in different parts of the world&#46; However&#44; in Spain there are hardly any studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#8211;39</span></a> Bearing in mind that keratoconus is the second cause of keratoplasty in the world&#44; the aim of the present study is to estimate the incidence of keratoconus in Asturias and to find out the clinical and topographical characteristics of patients at the time of diagnosis&#44; as well as the stage of the disease at which they are first assessed in specialised cornea and ocular surface consultations&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">A cross-sectional study was conducted analysing all cases of keratoconus seen in the first consultations of the Cornea and Surface section of the Hospital Universitario Central de Asturias &#40;Oviedo&#41; and Hospital Universitario de Cabue&#241;es &#40;Gij&#243;n&#41; between 2017 and 2020&#46; Cases diagnosed and even treated in other centres were included in the study if the date of diagnosis was between 2017 and 2020&#46; The study design and data collection were conducted in accordance with the Declaration of Helsinki&#46; Informed consent waiver was requested from the Research Ethics Committee of the Principality of Asturias&#46; Variables such as sex&#44; age and best corrected visual acuity &#40;BCVA&#41; were collected&#46; All patients underwent corneal topography with the CSO Sirius tomograph and aberrometer &#40;Florence&#44; Italy&#41; and the variables referring to curvature and thickness were collected&#46; In bilateral cases&#44; only the eye with the most advanced stage according to the Amsler-Krumeich classification was taken into account and&#44; if they were in the same stage&#44; the eye with worse visual acuity or greater astigmatism was included&#46; The clinical phenotype of each keratoconus was also analysed according to the Fern&#225;ndez-Vega&#47;Alfonso morphological classification&#46; For the statistical study&#44; quantitative variables were analysed with the Kolmogorov-Smirnov test and it was found that there was no normal distribution&#46; Therefore&#44; for hypothesis testing&#44; the Kruskal-Wallis test was used for quantitative variables and Fisher&#8217;s exact test for qualitative variables&#46; For correlations between quantitative variables&#44; Spearman&#8217;s rho was used&#46; Finally&#44; the estimated annual cumulative incidence of keratoconus in Asturias was calculated using official population figures from the National Institute of Statistics&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0020" class="elsevierStylePara elsevierViewall">A total of 112 patients with recent keratoconus diagnosis were seen at both centres during 2017&#8211;2020 &#40;97 at the Hospital Universitario Central de Asturias and 15 at the Hospital Universitario de Cabue&#241;es&#41;&#46; A total of 42&#46;0&#37; of the patients were female 58&#46;0&#37; were male&#46; The mean age was 36&#46;84&#8239;&#177;&#8239;15&#46;59 &#40;14&#8211;74&#41;&#44; being 39&#8239;&#177;&#8239;17 &#40;15&#8211;74&#41; years for women and 35&#8239;&#177;&#8239;14 &#40;14&#8211;71&#41; for men&#46; Of the patients diagnosed&#44; 18&#46;8&#37; were under 20 years of age&#44; while 22&#46;3&#37; were aged 20&#8211;30 years&#44; 19&#46;6&#37; were aged 30&#8211;40 years and 39&#46;3&#37; were over 40 years&#46; The estimated average cumulative incidence for the period 2017&#8211;2020 is 2&#46;78 cases&#47;100&#44;000 population &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The mean BCVA of all eyes was 0&#46;42&#8239;&#177;&#8239;0&#46;46 &#40;0 - 2&#46;00&#41; &#40;LogMAR scale&#41;&#46; No statistically significant difference was found between visual acuity and age classified in groups &#40;Kruskal-Wallis&#44; <span class="elsevierStyleItalic">p&#8239;&#61;&#8239;0</span>&#46;490&#41;&#44; but between age and stage according to the Amsler-Krumeich classification &#40;Fisher&#39;s Exact&#44; <span class="elsevierStyleItalic">p&#8239;&#61;&#8239;0</span>&#46;006&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The mean mean keratometry in the central 3&#8239;mm &#40;K<span class="elsevierStyleInf">mean</span>&#41; was 50&#46;38&#8239;&#177;&#8239;6&#46;73 &#40;41&#46;74&#8211;69&#46;12&#41;&#44; while the mean maximum keratometry &#40;K<span class="elsevierStyleInf">max</span>&#41; was 63&#46;41&#8239;&#177;&#8239;14&#46;92 &#40;47&#46;24&#8211;115&#46;11&#41;&#46; The mean astigmatism in the central 3&#8239;mm &#40;CYL<span class="elsevierStyleInf">3mm</span>&#41; was &#8722;5&#46;56&#8239;&#177;&#8239;3&#46;22 &#40;&#8722;16&#46;40&#44; &#8722;0&#46;13&#41; and the minimum corneal thickness &#40;TCT&#41; was 442&#46;55&#8239;&#177;&#8239;63&#46;74 &#40;304-568&#41;&#46; A statistically significant positive correlation was found between BCVA and K<span class="elsevierStyleInf">mean</span> &#40;p&#8239;&#60;&#8239;0&#46;001&#41;&#44; as well as K<span class="elsevierStyleInf">max</span> &#40;p&#8239;&#60;&#8239;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; On the other hand&#44; a statistically significant negative correlation was found between BCVA and CYL<span class="elsevierStyleInf">3mm</span> &#40;p&#8239;&#61;&#8239;0&#46;004&#41; and TCT &#40;p&#8239;&#61;&#8239;0&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Analysis by morphological phenotypes and evolutionary stage</span><p id="par0030" class="elsevierStylePara elsevierViewall">In terms of keratoconus phenotype&#44; 17&#46;6&#37; corresponded to the Croissant phenotype&#44; 15&#46;4&#37; to the Duck&#44; 13&#46;2&#37; to the Snowman&#44; 55&#46;7&#37; to the Nipple and 1&#46;1&#37; to the Bowtie&#46; No statistically significant difference was found between median BCVA&#44; CYL<span class="elsevierStyleInf">3mm</span> or TCT&#44; while there was with K<span class="elsevierStyleInf">mean</span> &#40;Kruskal-Wallis&#44; <span class="elsevierStyleItalic">p&#8239;&#61;&#8239;0</span>&#46;003&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">According to the Amsler Krumeich classification&#44; 31&#46;8&#37; were stage I&#44; 28&#46;0&#37; stage II&#44; 15&#46;0&#37; stage III and 25&#46;2&#37; stage IV&#46; The median BCVA&#44; age&#44; CYL<span class="elsevierStyleInf">3mm</span>&#44; TCT and K<span class="elsevierStyleInf">mean</span> can be found in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Pre-treatment and therapeutic management</span><p id="par0040" class="elsevierStylePara elsevierViewall">Overall&#44; 21&#46;6&#37; of the patients who came for consultation were already wearing soft&#44; rigid gas permeable or scleral support contact lenses&#46; 84&#46;7&#37; had no previous surgical treatment&#44; while 8&#46;1&#37; had undergone corneal segment or ring surgery and another 7&#46;2&#37; had undergone keratoplasty at another centre&#46; Of the patients who had been treated with corneal segments or rings&#44; 2 were in stage I&#44; 2 in stage II&#44; 2 in stage III and 2 in stage IV&#46; 100&#37; of the patients who came for keratoplasty were stage IV&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">As for therapeutic management&#44; 74&#46;5&#37; of the cases were followed up&#44; while 7&#46;5&#37; underwent corneal segment or ring implantation&#44; 4&#46;7&#37; underwent cross-linking and 13&#46;2&#37; underwent keratoplasty&#46; In 75&#46;0&#37; of cases&#44; the reason for treatment was refractive&#44; while in 25&#46;0&#37; it was due to progression of ectasia&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">There are few studies on the incidence or prevalence of keratoconus in Spain and&#44; to date&#44; no population-based studies have been carried out&#44; only studies focusing on hospitals and clinics&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#8211;39</span></a> Likewise&#44; there are few studies on the incidence of keratoconus in Europe with which to compare our results&#46; In the present study&#44; the estimated cumulative annual incidence of keratoconus in Asturias is 2&#46;78 cases&#47;100&#44;000 inhabitants&#44; which is lower than in other European countries such as Denmark&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> the Netherlands or the United Kingdom&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;40&#44;41</span></a> This difference may be due to environmental and&#47;or genetic factors that are not fully known&#44; although our study population does not include patients with keratoconus who are treated in opticians&#39; surgeries or private centres&#46; A 1986 study in Finland&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> based on one hospital&#44; estimated an incidence of 1&#46;5 cases&#47;100&#44;000 inhabitants&#44; but the patients were diagnosed by keratometry and retinoscopy&#46; The development and widespread use of modern corneal tomographs has made it possible to diagnose keratoconus with more defined criteria and at earlier stages&#44; and recent work suggests that the incidence and prevalence of keratoconus may be higher&#46; In any case&#44; more studies are needed on the incidence and prevalence of keratoconus in Europe and Spain&#44; preferably population-based studies with a large sample size&#44; which will allow us to gain a greater understanding of the extent of this health problem within the healthcare system&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Taking into account the progressive and disabling nature of the disease&#44; as well as knowing the magnitude of the problem in a given geographical area&#44; it is relevant to assess the stage or severity at which ectasia is first diagnosed&#46; Approximately 40&#37; of the patients seen in our centres consult with an Amsler-Krumeich stage III or IV&#44; i&#46;e&#46; in advanced stages which already involves visual loss that may require surgical treatment&#46; In other published studies&#44; these figures are similar&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7&#44;35&#44;43</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> which suggests that an earlier diagnosis is necessary to avoid visual sequelae that may be permanent&#46; If we analyse the mean keratometry of the patients at the time of diagnosis&#44; the results are very similar in all publications&#46; The Collaborative Longitudinal Evaluation of Keratoconus &#40;CLEK&#41;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> study was carried out in the United States with a total of 1209 participants with keratoconus in which almost half had a mean K greater than 50 dioptres&#44; and the Dundee University Scottish Keratoconus &#40;DUSK&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> showed that the mean simulated keratometry &#40;simK&#41; value was 52 dioptres&#46; Other more recent works also show mean keratometric values close to 50 dioptres<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8&#44;44</span></a>&#46; In the present study&#44; a statistically significant association was found between mean curvature&#44; keratoconus thickness&#44; astigmatism and BCVA&#44; so these data imply an impact on the patient&#8217;s visual quality&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">One of the main barriers to early diagnosis of keratoconus is the lack of availability of corneal topographers or corneal tomographs in all clinics and hospitals&#44; as well as the lack of awareness of the disease among healthcare professionals&#44; together with the asymptomatic nature of the disease in its earliest stages&#46; Recently&#44; Philipp B&#46; Baenninger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> published the results of a survey in Switzerland to assess the general knowledge among general ophthalmologists about keratoconus&#44; and the results showed some lack of knowledge about the disease&#44; risk factors and treatment modalities&#44; with the disease being more unknown among those with more years of practice&#46; It is also worth mentioning that an unknown proportion of patients with keratoconus are being managed in optical centres&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The results of an anonymous survey on the management of keratoconus by optometrists in the UK&#44; Portugal and Spain have recently been published&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> showing that in Spain 50&#37; of optometrists refer keratoconus to the ophthalmologist at diagnosis&#44; while 29&#46;9&#37; wait until progression is observed and 5&#46;6&#37; when there is visual loss&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> In addition to requiring the necessary devices to establish a diagnosis&#44; collaboration between the optometrist&#44; primary care specialist and general ophthalmologist is crucial for early detection of corneal ectasia and referral to the specialised cornea unit&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Also in relation to the above&#44; it is surprising that the majority of patients are over 40 years of age&#44; by which time the disease is sufficiently advanced for surgical treatment to be necessary&#46; The average age at which a patient is referred to the cornea unit in Asturias is over 35 years and higher than in other published studies focusing on Asia and the Middle East&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7&#44;35&#44;43</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> but in line with other studies with a predominantly white Caucasian population &#40;39&#46;3 - 42 years&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;48</span></a> Studies by Pearson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> and Georgiou et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> both from the UK&#44; showed that the age at presentation was 21&#46;5 years in patients of Asian origin compared to 26&#46;4 years in patients of Caucasian origin&#46; This suggests that there are a number of unstudied genetic&#44; ethnic and environmental factors that strongly influence disease presentation and severity&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In our case&#44; a statistically significant association was found between age and severity according to the Amsler-Krumeich classification&#46; Other published studies have not found this relationship&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> while other studies have found greater severity in younger patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a> In the present case&#44; we believe that the greater severity of keratoconus in older patients is due to the fact that younger patients tend to consult earlier than older patients&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In this study we have found a higher incidence of keratoconus in males than in females&#46; Although the literature often maintains that there are no gender differences&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;31</span></a> most studies show that there is a higher prevalence and incidence in men&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;17&#44;35&#44;40</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> It has been proposed that this difference may be due to hormonal or environmental factors&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Another important aspect of our study was to quantify the percentage of patients who required keratoplasty&#44; either penetrating or lamellar&#46; Previous studies have mentioned that keratoplasty is performed in around 4&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;44</span></a> In our case this figure is considerably higher and could be reduced with earlier diagnosis and greater knowledge of the disease on the part of patients and healthcare professionals&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The present study has estimated the incidence of keratoconus in Asturias&#44; and at the same time we carried out a descriptive study with the most relevant clinical-epidemiological characteristics and the therapeutic modality indicated in each case&#46; The main limitation of this study is that we have worked with information from two hospitals and not with population data&#46; Although the Hospital Universitario Central de Asturias together with the Hospital Universitario de Cabue&#241;es are the two hospitals in the public network that have a corneal tomographer in the entire autonomous community and where the follow-up and treatment of all cases in the region is carried out&#44; the study population does not include those who are regularly treated in opticians&#39; shops or private clinics&#46; The other main limitation is the inherent limitation of a cross-sectional study to establish causal relationships&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">The estimated cumulative annual incidence of keratoconus in Asturias is 2&#46;78 cases&#47;100&#44;000 inhabitants&#46; Approximately 40&#37; of cases are detected in advanced stages and at an age over 40&#46; Keratoconus continues to be a frequent indication for keratoplasty in our environment&#44; with a considerable percentage of these cases requiring transplantation at the time of evaluation &#40;13&#37;&#41;&#46; For this reason&#44; it is necessary to implement new measures to improve the early diagnosis of keratoconus in Asturias&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Financing</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have not received any type of funding or scholarship for the preparation of the research work&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interests</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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    "fechaAceptado" => "2022-09-27"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Keratoconus is the most frequent corneal ectasia and second most common cause of keratoplasty worldwide&#46; The clinical and epidemiological characteristics of keratoconus have rarely been studied in Spain&#44; and to date&#44; no study has been done in Asturias&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A cross-sectional study was conducted to analyze all cases of keratoconus diagnosed in the first consultations of the Cornea and Surface section of the Hospital Universitario Central de Asturias &#40;Oviedo&#41; and Hospital Universitario de Cabue&#241;es &#40;Gij&#243;n&#41; between 2017 and 2020&#46; Demographic data&#44; visual acuity and corneal topography were collected&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A total of 112 patients &#40;42&#46;0&#37; women and 58&#46;0&#37; men&#41; were included&#46; The mean age was 36&#46;84&#8239;&#177;&#8239;15&#46;59&#44; with 39&#46;3&#37; being older than 40 years&#46; 31&#46;8&#37;&#44; 28&#46;0&#37;&#44; 15&#46;0&#37;&#44; and 25&#46;2&#37; were in stages I&#44; II&#44; III and IV&#44; Amsler-Krumeich scale&#44; respectively&#46; Corneal segments were implanted in 7&#46;5&#37; of patients&#44; cross-linking was performed in 4&#46;7&#37;&#44; and keratoplasty was performed in 13&#46;2&#37;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Approximately 40&#37; of keratoconus cases are detected at advanced stages and another 40&#37; are detected at an age over 40 years&#46; 13&#37; of these patients require keratoplasty&#44; which is why it is frequently performed in our setting&#46; Therefore&#44; early diagnosis before irreversible visual loss is necessary&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El queratocono es la ectasia corneal m&#225;s frecuente y la segunda causa de queratoplastia en el mundo&#46; Las caracter&#237;sticas cl&#237;nicas y epidemiol&#243;gicas del queratocono no han sido apenas estudiadas en Espa&#241;a y&#44; hasta la fecha&#44; no se ha hecho ning&#250;n trabajo en Asturias&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio transversal analizando todos los casos de queratocono diagnosticado en las primeras consultas de la secci&#243;n de C&#243;rnea y Superficie de los centros Hospital Universitario Central de Asturias &#40;Oviedo&#41; y Hospital Universitario de Cabue&#241;es &#40;Gij&#243;n&#41; entre 2017 y 2020&#46; A todos los pacientes se les recogieron datos demogr&#225;ficos&#44; agudeza visual y se les realiz&#243; una topograf&#237;a corneal&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron un total de 112 pacientes &#40;42&#44;0&#37; mujeres y 58&#44;0&#37; hombres&#41;&#46; La edad media era de 36&#44;84&#177;15&#44;59&#59; teniendo un 39&#44;3&#37; una edad superior a 40 a&#241;os&#46; Un 31&#44;8&#37;&#44; 28&#44;0&#37;&#44; 15&#44;0&#37; y un 25&#44;2&#37; se encontraban en los estadios I&#44; II&#44; III y IV respectivamente en la escala Amsler-Krumeich&#46; En un 7&#44;5&#37; se implantaron segmentos corneales&#44; en un 4&#44;7&#37; se realiz&#243; cross-linking y en un 13&#44;2&#37; se realiz&#243; queratoplastia&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Aproximadamente un 40&#37; de los queratoconos se detectan en estadios avanzados y otro 40&#37; a una edad superior a los 40 a&#241;os&#46; Un 13&#37; de los mismos requieren queratoplastia&#44; por lo que sigue siendo una indicaci&#243;n frecuente en nuestro medio&#46; Es necesario por tanto realizar un diagn&#243;stico precoz para actuar antes de que exista una p&#233;rdida visual irreversible&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Correlation plots and trend lines between&#58; A&#41; mean K and BCVA &#40;Spearman&#39;s Rho 0&#46;545&#59; <span class="elsevierStyleItalic">p&#8239;&#60;</span>&#8239;0&#46;001&#41;&#44; B&#41; K max and BCVA &#40;Spearman&#8217;s Rho 0&#46;515&#59; <span class="elsevierStyleItalic">p&#8239;&#60;</span>&#8239;0&#46;001&#41;&#44; C&#41; CYL 3&#8239;mm and BCVA &#40;Spearman&#8217;s Rho -0&#46;323&#59; <span class="elsevierStyleItalic">p&#8239;&#61;&#8239;0</span>&#46;004&#41; and D&#41; TCT and BCVA &#40;Spearman&#8217;s Rho -0&#46;381&#59; <span class="elsevierStyleItalic">p&#8239;&#61;&#8239;0</span>&#46;001&#41;&#46;</p>"
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                  <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">Year&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of inhabitants in Asturias<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of cases&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cumulative incidence<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; CI<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2017&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">1&#46;034&#46;960&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">29&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">2&#46;80&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">1&#46;78-3&#46;82&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2018&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">1&#46;028&#46;244&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&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">1&#46;022&#46;800&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">26&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">2&#46;54&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">1&#46;56-3&#46;52&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">2020&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">1018&#46;754&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">2&#46;75&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">1&#46;73-3&#46;77&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">Mean&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">1&#46;026&#46;197&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">28&#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">2&#46;78&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">1&#46;76-3&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:3 [
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        ]
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estimated cumulative incidence of keratoconus in Asturias in 2017-2020&#46;</p>"
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                  <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  " rowspan="3" align="left" valign="middle" scope="col">Amsler Krumeich</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="8" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age</th></tr><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#8804; 20 years</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">21-30 years</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">31-40 years</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#8805; 41 years</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pre-clinical &#40;I&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">55&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">42&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \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">27&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mild &#40;II&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&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">25&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate &#40;III&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">5&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">18&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">5&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">20&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \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">38&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th 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" scope="col" style="border-bottom: 2px solid black">Phenotype&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BCVA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">K media&nbsp;\t\t\t\t\t\t\n
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                  \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">CYL 3&#8239;mm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TCT&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#8239;&#177;&#8239;16&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\ttop\n
                  \t\t\t\t">46&#46;54&#8239;&#177;&#8239;4&#46;33&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">&#8722;6&#46;08&#8239;&#177;&#8239;4&#46;07&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">463&#8239;&#177;&#8239;64&nbsp;\t\t\t\t\t\t\n
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                  \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">Duck&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
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                  \t\t\t\t  " align="left" valign="\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">445&#8239;&#177;&#8239;29&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">Snowman&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&#46;21&#8239;&#177;&#8239;0&#46;23&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">35&#8239;&#177;&#8239;12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">48&#46;81&#8239;&#177;&#8239;4&#46;66&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\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">52&#46;96&#8239;&#177;&#8239;6&#46;72&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Visual and topographical characteristics by morphological phenotypes &#40;Kruskal-Wallis&#41;&#46;</p>"
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      4 => array:8 [
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        "tabla" => array:1 [
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