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Results of a modified ab-external trabeculectomy surgical technique in patients with open angle glaucoma
Resultados de una técnica quirúrgica de trabeculectomía ab-externo modificada en pacientes con glaucoma de ángulo abierto
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Ortiz-Arismendi, M. Huertas-Bello, C.J. Castro Cárdenas, O. Albis-Donado" "autores" => array:4 [ 0 => array:4 [ "nombre" => "G.E." "apellidos" => "Ortiz-Arismendi" "email" => array:1 [ 0 => "geortiza@unal.edu.co" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Huertas-Bello" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "C.J." "apellidos" => "Castro Cárdenas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "O." "apellidos" => "Albis-Donado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Ophthalmologist, Glaucoma Subspecialist, Universidad Nacional de Colombia, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Ophtalmologist, Universidad Nacional de Colombia, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Ophtalmologist, Glaucoma Subspecialist, Private Practice, Visual Sense, Mexico City, México" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados de una técnica quirúrgica de trabeculectomía ab-externo modificada en pacientes con glaucoma de ángulo abierto" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1461 "Ancho" => 1508 "Tamanyo" => 146565 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0730" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Scatterplot comparing baseline vs. Final IOP. Successful cases are represented by circles. The horizontal lines represent the upper and lower limits of success criteria, and the diagonal lines represent both the 0% and 20% reduction of IOP.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Glaucoma is the leading cause of irreversible blindness in the world. Glaucoma management focuses on lowering intraocular pressure (IOP), which remains the primary proven treatment method.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Medical therapy has traditionally been the first-line therapy for glaucoma; however, adherence, adverse effects, inconvenience, and costs lead to the search for alternative therapies.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Minimally invasive glaucoma surgeries (MIGS) cannot lower IOP to the same degree as traditional transscleral incisional surgeries.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Glaucoma surgeries have remained virtually unchanged over the last half-century.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and can be broadly classified according to whether they are performed ab-internal or ab-external, where the objective is to increase subconjunctival, trabecular, or suprachoroidal outflow or decrease aqueous production. Trabeculectomy remains the most performed traditional incisional glaucoma procedure in the United States and is considered the gold standard. However, despite its well-documented effectiveness in lowering intraocular pressure (IOP), trabeculectomy can be associated with significant complications and requires close follow-up.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Also, many variations in the trabeculectomy technique exist.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">First described by the Colombian ophthalmologist Eduardo Arenas, Ab-externo Trabeculectomy (AET) is among the non-penetrating surgical techniques for treating glaucoma.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Other options include Non-penetrating Deep sclerectomy (NPDS), Viscocanalostomy, and Canaloplasty. The main advantage of non-penetrating methods lies in the lower incidence and severity of intra and post-operative complications, like athalamia, hypotony, choroidal detachment (serous and hemorrhagic), endophthalmitis, and cataract.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Studies from prior decades suggest that, when compared to conventional trabeculectomy, the non-penetrating surgical techniques had less reduction of intraocular pressure (IOP) and a more arduous and prolonged learning curve.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a> However, recent publications have shown improved outcomes after the debugging of the technical surgical aspects as well as its indications and contraindications, making them a good alternative for the surgical treatment of open-angle glaucoma (OAG).<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Currently, non-penetrating glaucoma filtering surgery is indicated, among others, for primary open-angle glaucoma, high myopia, pseudo exfoliative and pigmentary glaucoma, some variants of juvenile, uveitic glaucoma, congenital glaucoma associated to Sturge Weber Syndrome, pseudophakic and aphakic glaucoma.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,14,16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The principle of both AET and the Modified Ab-externo Trabeculectomy surgical technique we propose consists of eliminating the places with the most significant resistance to aqueous humor outflow by removing the endothelial layer of Schlemm’s canal (SC) and the juxtacanalicular tissue (JCT).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the original surgical technique described by Arenas, a small layer of scleral tissue was first dissected. Scleral tissue was removed until exposing SC using a high-speed micro-burr, removing the endothelium and the internal wall of the canal, at which point filtration is seen, leaving only a fine layer of the uveal and scleral trabecular meshwork (TM) between the lumen of the channel and the anterior chamber.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Arenas had introduced several variants to his surgical technique with improved outcomes, such as the resection of the scleral flap.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a> Contrastingly, NPDS implies performing first a superficial scleral flap, and then a second, deeper sclero-corneal flap, un-roofing Schlemm’s canal, but also removing a portion of the corneal stroma, to construct a trabecular-Descemet’s window, removing JCT and obtaining filtration into the so-called scleral lake. In NPDS, a spacer to maintain this lake is usually left in place and covered by suturing the superficial scleral flap over the spacer.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,20</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">This paper presents our experience and results obtained with a Modified Ab-externo Trabeculectomy surgical technique.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0045" class="elsevierStylePara elsevierViewall">This retrospective analysis of a case series included a population with open-angle glaucoma diagnosis undergoing Modified Ab-externo Trabeculectomy surgical technique at the Eye Clinic in Bogota, Colombia, between January 2008 and March 2015 with at least one year of follow-up or identified failure before one year after the surgical procedure. Signed informed consent was obtained from all the patients after explaining the surgical procedure, risks, and expectations. Helsinki Declaration was strictly followed. A single surgeon performed surgeries. Ethical approval was granted by the Faculty of Medicine Ethics Committee and Eye Clinic Ethics Committee. Data of patient age, gender, visual acuity before the procedure and after the last follow-up, central corneal thickness (CCT), baseline IOP and at one, two, six months, and on the final postoperative follow-up, the need for laser goniopuncture, needling and surgical complications with their respective treatments were collected. Visual field information was also gathered before surgery and classified according to the Hodapp-Anderson-Parrish classification into mild, moderate, and severe damage.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Visual field changes were not measured due to the study’s retrospective nature and the lack of sufficient postoperative follow-up. Success was defined as a final IOP<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm Hg and <18<span class="elsevierStyleHsp" style=""></span>mmHg, along with ≥20% IOP reduction. Complete success when adequate IOP was achieved without the need for anti-glaucoma medications, qualified success when the reduction was achieved with the aid of supplementary medicines and failure when IOP control was not achieved, the light perception was lost, or when the patient required further surgical procedures excluding laser Gonio puncture, needling, cataract surgery, or procedures for resolve transient hypotony.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A statement of consent to publish their case information and unidentifiable photographs was gathered from every participant. Patients were given the opportunity to review the final manuscript and photographs and accepted their publication.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical technique</span><p id="par0055" class="elsevierStylePara elsevierViewall">The procedure is conducted under local anaesthesia with sedation. Dissection of both superficial and deep scleral flaps is performed, but no corneal stroma is eliminated, so filtration is only through the remaining TM tissue with the JCT removed. In addition, if JCT removal can be performed without perforating the anterior chamber and adequate filtration is achieved, we partially amputate the superficial flap without attempting to suture it back and without spacers.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Modified Ab-externo Trabeculectomy surgical technique, by Gabriel Ortiz (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>):<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a)</span><p id="par0065" class="elsevierStylePara elsevierViewall">Corneal traction suture with 7-0 silk.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0070" class="elsevierStylePara elsevierViewall">Superior conjunctiva-tenon fornix-based flap.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c)</span><p id="par0075" class="elsevierStylePara elsevierViewall">Design and dissection the first scleral flap 40%–50% of thickness in a triangular or rectangular manner.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d)</span><p id="par0080" class="elsevierStylePara elsevierViewall">Topical application of mitomycin 0.04% with cellulose sponges for one to three minutes.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">e)</span><p id="par0085" class="elsevierStylePara elsevierViewall">Dissection of a deep scleral flap to expose the SC and TM lumen.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">f)</span><p id="par0090" class="elsevierStylePara elsevierViewall">Resection of the deep scleral flap with scissors.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">g)</span><p id="par0095" class="elsevierStylePara elsevierViewall">Removal of the endothelium and thinning the inner wall of Schlemm’s canal (JCT) until achieving adequate filtration, which must be constant but not excessive.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">h)</span><p id="par0100" class="elsevierStylePara elsevierViewall">Partial amputation of the superficial scleral flap with scissors.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">i)</span><p id="par0105" class="elsevierStylePara elsevierViewall">Closure of the conjunctiva-tenon fornix-based flap.</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0110" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using SPSS version 19. Means for continuous variables were compared among the different groups using ANOVA. Associations between categorical variables were studied with the chi-square test; Fisher’s exact test was used when fewer than 5 cases were present in a given category. Multivariate models were constructed to determine the effect of risk factors on the final survival rate. As both eyes of 10 patients were included in the analysis, generalized estimating equations were used for multivariate analysis of risk factors for failure, adjusting for dependencies when both eyes of the same patient had been operated on, repeated measures, and missing data. The final multivariate model used forward stepwise selection of covariates and factors significant in the simple analysis. Survival analysis was performed using the Kaplan-Meier Life-Table method.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0115" class="elsevierStylePara elsevierViewall">Between January 2008 and March 2015, 53 eyes had planned Modified Ab-externo Trabeculectomy surgical technique. 5 eyes had to be converted to a conventional trabeculectomy due to insufficient filtration, micro or macro-perforations were excluded. Forty-eight eyes of 38 patients, 31 women and 17 men with an average age of 63.1 years (range 25−85 years), were included in the study: 21 patients were Caucasian, 15 mestizos, and two were of African descent. The average follow-up time was 35.3 months (range 1−147 months, <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The diagnoses included primary open-angle glaucoma (POAG) in 34 eyes, pseudophakic glaucoma in 5, pigmentary glaucoma, post penetrating keratoplasty glaucoma, steroid-induced glaucoma, and aphakic glaucoma in two cases each, and one eye with posttraumatic glaucoma (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>)</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Initial visual acuity was between 20/20 and LP, and at the end of follow-up, between 20/20 and no-light perception, it remained stable in 40 eyes, improved in 4 cases, and deteriorated in 4 eyes, 3 of them due to cataracts. Forty-three eyes had an initial visual field with a mild defect in 12 patients, moderate defect in 23, and severe defect in 8 eyes. The average CCT was 532.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>37<span class="elsevierStyleHsp" style=""></span>μ (473–683<span class="elsevierStyleHsp" style=""></span>μ).</p><p id="par0125" class="elsevierStylePara elsevierViewall">The preoperative IOP was 25.21<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.48<span class="elsevierStyleHsp" style=""></span>mmHg (between 19 and 34<span class="elsevierStyleHsp" style=""></span>mmHg); the IOP at one month, three months, six months, and at the end of the follow-up was 13.31<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.01<span class="elsevierStyleHsp" style=""></span>mmHg, 14.97<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.41<span class="elsevierStyleHsp" style=""></span>mmHg, 16.17<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.03<span class="elsevierStyleHsp" style=""></span>mmHg, and 15.83<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.4<span class="elsevierStyleHsp" style=""></span>mmHg respectively with an average final reduction of 9.37<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.4<span class="elsevierStyleHsp" style=""></span>mmHg (36%) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The number of hypotensive drugs decreased on average from 2.82 to 1.29. Fourteen cases (29.2%) required goniopuncture with YAG laser, achieving adequate pressure control in 10. At the end of the follow-up, the procedure was rated as successful in 18 eyes (37.5%) and qualified success in 17 (35.4%), for a total effectiveness rate of 72.9% and failure in 13 cases (27.1%). Conventional trabeculectomy was performed in eleven failed cases; Ahmed was implant in one case, and one eye with complex post-traumatic glaucoma was not operated on because his vision went from light perception to non-light perception.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Kaplan-Meier survival analysis shows a success rate of 81.7% at two years and 54.9% from year 4 to year 12. (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) Multivariate analysis with generalized estimating equations (GEE) shows an increase in the risk of failure of 7.4% per decade, making younger age the only predictor of failure. The final IOP was between 10 and 15<span class="elsevierStyleHsp" style=""></span>mmHg in 25 cases (52%), between 16 and 18<span class="elsevierStyleHsp" style=""></span>mmHg in 10 eyes (21%), and ≥18<span class="elsevierStyleHsp" style=""></span>mmHg in 13 (27%) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Complications included transient shallow anterior chamber with choroidal detachments in two eyes (managed with medical treatment), early and transient bleb leak in five cases and cataract progression in three eyes. There were no complications such as malignant glaucoma, hypotony, hyphema, significant intraocular inflammation, hemorrhage, endophthalmitis, or bleb infections.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">The results showed that the Modified Ab-externo Trabeculectomy surgical technique is a safe and effective technique for long-term control of IOP in open-angle glaucoma with a significant reduction in hypotensive medications and a low rate of complications. None of the complications were severe or required management with additional procedures. The mean IOP obtained at the end of the follow-up is slightly higher than those reported by our group,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and other authors with conventional trabeculectomy.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,24</span></a> Regardless, somewhat more than half of the cases obtained IOP levels of 15<span class="elsevierStyleHsp" style=""></span>mmHg or lower, considered safe to prevent disease progression and functional decline in most eyes.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The results are comparable to those presented by Arenas in a series of AET with scleral flap resection. However, his study group included patients with angle-closure glaucoma, and the mean follow-up was shorter (eight months).<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Modified Ab-externo Trabeculectomy surgical technique seems to be an exciting alternative with similar results to other non-penetrating procedures like NPDS and Canaloplasty, with the advantage of not requiring unique supplies or sophisticated technological tools that limit its use in many scenarios, especially in developing countries. It can be a helpful procedure in glaucoma with mild or moderate damage that does not require IOP levels in the lower limit of normality. In glaucoma with advanced damage, a conventional trabeculectomy is more likely to generate a more drastic and sufficient IOP reduction.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0150" class="elsevierStylePara elsevierViewall">Modified Ab-externo Trabeculectomy surgical technique can be an excellent alternative in situations of risk for choroidal hemorrhagic detachments such as vitrectomized eyes, high myopia, or those that have presented this complication in the fellow eye; it can also be a safer alternative in eyes with the presence of vitreous in the anterior chamber or silicone oil in the vitreous cavity. However, one limitation of this study is the lack of a control group. Further studies are required to confirm our findings.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Declaration of conflicting interests</span><p id="par0155" class="elsevierStylePara elsevierViewall">The author(s) declared no potential conflicts of interest concerning this article's research, authorship, and publication.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0160" class="elsevierStylePara elsevierViewall">The author(s) received no financial support for the research, authorship, and publication of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres2008252" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods and analysis" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1720623" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2008253" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método y análisis" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1720624" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Declaration of conflicting interests" ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-04-18" "fechaAceptado" => "2023-08-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1720623" "palabras" => array:3 [ 0 => "Glaucoma" 1 => "Glaucoma surgery" 2 => "AB-external trabeculectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1720624" "palabras" => array:3 [ 0 => "Glaucoma" 1 => "Cirugía de glaucoma" 2 => "Trabeculectomía ab-externo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Assess the safety and efficacy of a Modified Ab-externo Trabeculectomy surgical technique in controlling intraocular pressure (IOP) in open-angle glaucoma patients.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods and analysis</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Patients diagnosed with primary or secondary open-angle glaucoma underwent this modified technique as the first filtering surgical treatment were included. The preoperative and final follow-up assessed IOP, hypotensive medications, the need for additional treatments, and early and late complications.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Forty-eight eyes of 38 patients were included. The mean age was 63.1 years (25–85 years), and the mean follow-up time was 35.3 months (range of 1147 months). The mean preoperative IOP was 25.21<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.48<span class="elsevierStyleHsp" style=""></span>mmHg and 15.83<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.4<span class="elsevierStyleHsp" style=""></span>mmHg by the follow-up end. Subsequent laser goniopuncture was performed on 14 eyes (29%) and needling in 4 eyes (8.4%). Complete success was achieved in 18 eyes (37.5%), qualified success in 17 (35.4%), and failed in 13 eyes (27.1%). Kaplan-Meier survival analysis shows a success rate of 81.7% at two years and 54.9% from year 4 to year 12. Multivariate analysis with generalized estimating equations (GEE) shows younger age as the main predictor for failure. Two eyes had choroidal detachment, three eyes progressed to cataracts that needed surgery, and five eyes had early bleb leaks.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">This proposed technique is an effective surgical procedure for treating open-angle glaucoma with effective long-term IOP control and a low incidence of surgical complications and could be used in selected complex cases based on these results.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods and analysis" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Evaluar la seguridad y eficacia de una técnica quirúrgica de Trabeculectomía AB-Externo modificada en el control de la presión intraocular (PIO) en pacientes con glaucoma de ángulo abierto.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Método y análisis</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de corte transversal en el que se incluyeron pacientes con glaucoma de ángulo abierto sometidos a Trabeculectomía AB-Externo modificada como primer tratamiento quirúrgico filtrante entre enero de 2008 a marzo de 2015. En el postoperatorio se evaluó la PIO, los medicamentos hipotensores, los tratamientos adicionales y las complicaciones tempranas y tardías.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se analizaron datos de 48 ojos de 38 pacientes. La media de edad fue de 63,1 años (25 a 85 años) y el tiempo medio de seguimiento fue de 35,3 meses (rango 147 meses). La PIO preoperatoria media fue de 25,21<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3,48<span class="elsevierStyleHsp" style=""></span>mmHg y de 15,83<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4,4<span class="elsevierStyleHsp" style=""></span>mmHg al final del seguimiento. 14 ojos (29%) requirieron gonio punción con láser y 4 ojos gonio punción (8,4%). El análisis de supervivencia de Kaplan-Meier mostro una tasa de éxito del 81,7% a los dos años y del 54,9% del año 4<span class="elsevierStyleHsp" style=""></span>al año 12. Dos ojos presentaron desprendimiento coroideo, tres ojos cataratas que requirieron cirugía y cinco ojos tuvieron fugas tempranas de la ampolla.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La Trabeculectomía AB-Externo modificada es eficaz para el tratamiento del glaucoma de ángulo abierto con un buen control de la PIO a largo plazo y una baja incidencia de complicaciones quirúrgicas y podría utilizarse en casos complejos seleccionados de acuerdo con los resultados obtenidos.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método y análisis" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "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" => 839 "Ancho" => 1783 "Tamanyo" => 184104 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0725" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Modified surgical technique<span class="elsevierStyleBold">. A.</span> Fornix-based flap and scleral flap demarcation. <span class="elsevierStyleBold">B</span>. Dissection of first scleral flap until clear cornea. <span class="elsevierStyleBold">C.</span> Dissection of the second scleral flap to unroof and expose Schlemm's canal. <span class="elsevierStyleBold">D.</span> Resection of the deep scleral flap. <span class="elsevierStyleBold">E.</span> Checking for adequate filtration. <span class="elsevierStyleBold">F.</span> Partial ablation of the superficial scleral flap.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1461 "Ancho" => 1508 "Tamanyo" => 146565 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0730" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Scatterplot comparing baseline vs. Final IOP. Successful cases are represented by circles. The horizontal lines represent the upper and lower limits of success criteria, and the diagonal lines represent both the 0% and 20% reduction of IOP.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1250 "Ancho" => 1508 "Tamanyo" => 97194 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0735" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Kaplan-Meier survival curve shows a survival rate of 81.7% at 24 months, and a steady survival of 54.9% from month 48 and forward. The number of remaining cases is shown at each timepoint.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0740" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristic \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">Mean \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">Range \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age, yr (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.5 \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">25−85 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender, female, N (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (64.6%) \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></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">Eye OD, N (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (43.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Follow-up months (mean, ±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>29.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1−147 \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">Preoperative IOP mmHg (mean, ±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.5 \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">19−34 \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">Final IOP mmHg (mean, ±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9−25 \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">Central Corneal Thickness, microns (mean, ±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">532.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>37.6 \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">408−683 \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">Baseline Medications (mean, ±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.85<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0−5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Final Medications (mean, ±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.29<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.3 \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">0−4 \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">Preoperative visual field damage severity (N, %) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mild \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (27.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (53.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (18.6%) \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></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">Diagnoses: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>POAG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (70.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pseudophakic/aphakic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (14.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pigmentary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (4.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">Penetrating Keratoplasty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (4.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">Steroid-induced \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (4.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">Traumatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (2.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3334627.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patient demographics and baseline data.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0745" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Range IOP mmHG \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 \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">Percent \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">≤9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0% \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">10–15 \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">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">54% \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">16–17 \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">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19% \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">≥18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (Failures) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3334628.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Final intraocular pressure ranges.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Glaucoma treatment trends: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. 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