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ORIGINAL ARTICLE
Vision for the Future Project: Screening impact on the prevention and treatment of visual impairments in public school children in São Paulo City, Brazil
Douglas Rodrigues da Costa
Corresponding author
douglas.costa@fm.usp.br

Corresponding author.
, Iara Debert, Fernanda Nicolela Susanna, Janaina Guerra Falabreti, Mariza Polati, Remo Susanna Júnior
Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">In 1999&#44; the World Health Organization &#40;WHO&#41; initiated the project &#8220;Vision 2020 - The Right to Sight&#8221; to combat blindness and low vision&#46; The goal was to eliminate preventable blindness by 2020 &#40;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#41;&#46; Despite the efforts worldwide&#44; recent meta-analyses have pointed to an increasing number of avoidable blindness&#44; primarily because of cataracts and uncorrected refractive errors &#40;myopia&#44; hyperopia&#44; and astigmatism&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#44;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#41;&#46; Non-developed countries account for the largest share of these cases&#44; as they present more obstacles to reaching quality health units&#46; According to the last &#8220;Human Development Report 2019&#8221; from the United Nations Development Programme&#44; scholars&#39; level and income are directly proportional to health access&#46; In Brazil&#44; blindness and low vision are approximately three times more in the poor than in the rich population &#40;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#41;&#46; Considering pre-scholar and scholar populations&#44; approximately 20&#37;-30&#37; of children have an ophthalmologic condition that can lead to blindness or low vision&#44; particularly uncorrected refractive errors&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">Vision plays a significant role in a child&#39;s development&#46; Healthy visual maturation in the early years of a child&#39;s life is responsible for creating permanent connections to form neuro-ophthalmological pathways &#40;<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#44;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#41;&#46; Precocious detection and treatment of ophthalmological disturbances that might harm visual maturation are critical to enhancing various abilities such as motor skills&#44; reading&#44; and writing&#44; as well as for self-esteem and quality of life &#40;<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#44;<a class="elsevierStyleCrossRef" href="#bib7">7</a>&#44;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#41;&#46; Furthermore&#44; regions with a higher prevalence of untreated ophthalmic conditions have worse socioeconomic indicators &#40;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#44;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#41;&#46; In this context&#44; social programs for visual screening in the early years have become a tool for tracing&#44; diagnosing&#44; and treating ophthalmological affections&#44; particularly for children within that socioeconomic portion &#40;<a class="elsevierStyleCrossRef" href="#bib9">9</a>&#41;&#46;</p><p id="para30" class="elsevierStylePara elsevierViewall">The project &#8220;Vision for the Future&#8221; is a social action that was initiated in 2009 in S&#227;o Paulo&#44; Brazil&#46; It has been promoted by government educational entities and created to reach underprivileged children who are enrolled in the early phases of elementary school&#46; The main goal of this program is based on visual screening&#44; free medical aid&#44; and donation of corrective spectacles&#44; if necessary&#46; This study aimed to describe the &#8220;Vision for the Future&#8221; program and to evaluate its impact on the prevention and treatment of children&#39;s visual disabilities&#44; outline suggestions for the program&#39;s improvement&#44; and furnish new epidemiological data to the studied population&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">METHODS</span><p id="para40" class="elsevierStylePara elsevierViewall">This was a retrospective&#44; cross-sectional&#44; and observational study&#46; Data collected from 2018&#39;s &#8220;Vision for the Future&#8221; campaigns were analyzed&#46; The protocols of this study were elaborated according to the Declaration of Helsinki and approved by the University&#39;s Ethical Committee on Research&#46; APPROVAL NUMBER &#40;Plataforma Brasil&#41;&#58; CAAE&#58; 29047520&#46;9&#46;0000&#46;0068&#46;</p><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">Program description</span><p id="para50" class="elsevierStylePara elsevierViewall">The program initiated with the public&#44; municipal&#44; or federal schools from any region within S&#227;o Paulo city&#46; It was divided into two main parts&#58; School&#39;s Screening and Hospital&#39;s Campaigns &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>&#41;&#46; In the first part&#44; the children were evaluated by teaching professionals using the Snellen Chart visual acuity &#40;VA&#41; test and naked eye examination&#46; They were referred to the Hospital&#39;s Campaigns if they presented at least one of the following&#58; VA &#60;0&#46;7 &#40;decimal score&#41; and&#47;or a difference equal to or bigger than two lines between eyes and&#47;or visible ophthalmic disturbs at the naked eye &#40;corneal and&#47;or palpebral alterations&#44; strabismus&#44; and others&#41; and&#47;or previous use of spectacles&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p id="para60" class="elsevierStylePara elsevierViewall">The Hospital&#39;s Campaigns took place in a public hospital in S&#227;o Paulo&#46; Ophthalmologists and ophthalmology residents performed the examinations&#44; and other professionals from the Department of Ophthalmology were responsible for the organization of the examination circuit&#46; Children were accompanied by their guardians who possessed a unique file to be filled by the medical staff&#46; The Hospital&#39;s Campaigns were also divided into two phases&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">In the first phase&#44; children underwent a VA test using the Snellen chart&#44; ocular movement tests&#44; and a naked eye examination &#40;ectoscopy&#41;&#46; The cutoffs were the same as those in the School&#39;s Screening&#44; as aforementioned&#46; Children who were classified as normal in the first phase were considered false positives since they should not be referred&#46; The second phase comprised a slit-lamp examination&#44; objective refraction &#40;automated and&#47;or retinoscopy&#41;&#44; subjective refraction&#44; and a fundoscopy examination&#44; all performed after cycloplegia &#40;cyclopentolate hydrochloride 1&#37;&#44; 1 drop every 5 min&#44; twice&#41;&#46; All results were then submitted to a final table&#44; where ophthalmologists decided whether the child needed spectacle prescription and&#47;or referral to a specialized follow-up&#46; All glasses were given free&#44; and they could be withdrawn from the schools&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">Data analysis</span><p id="para80" class="elsevierStylePara elsevierViewall">Children&#8217;s files were transferred to an online platform&#44; Research Electronic Data Capture &#40;REDCap&#41;&#44; and analyzed using IBM SPSS Statistics 24 &#40;IBM&#44; Endicott&#44; New York&#44; USA&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#44;<a class="elsevierStyleCrossRef" href="#bib11">11</a>&#41;&#46; All data collected from January to December 2018 were included in the analyses&#46; The investigators that evolved in the project had full access to the data&#46; Patients with missing data were excluded from the study&#46; Confidence intervals &#40;CIs&#41; with a 95&#37; confidence level were calculated using the binomial &#8220;exact&#8221; method&#46; As patients were pre-selected on school screening&#44; an intrinsic selection bias existed&#59; therefore&#44; statistical analysis for epidemiological extrapolation was not performed&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">Data obtained included sex&#59; age&#59; the number of children dismissed on the First Phase of Hospital&#39;s Campaigns &#40;false positives&#41;&#59; previous use of spectacles&#59; VA with and without refractive correction&#59; refractive errors &#40;spherical&#44; cylinder&#44; and axis&#41;&#59; slit lamp and fundoscopy findings&#59; ocular movement disorders&#59; and the number of glasses donated&#46; Visual impairment is generally classified as a decrease in VA caused by any condition &#40;<a class="elsevierStyleCrossRef" href="#bib12">12</a>&#41;&#46; Low vision is characterized as a VA of &#8804;0&#46;3 and legal blindness as a VA of &#8804;0&#46;1 &#40;<a class="elsevierStyleCrossRef" href="#bib13">13</a>&#41;&#46; To classify ametropia&#44; the following values were considered&#58; hyperopia as a cylinder power &#62;&#43;2&#46;00 diopters &#40;D&#41;&#44; myopia if &#60;-0&#46;50 D&#44; and astigmatism if the cylinder power was at least -0&#46;75 D &#40;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#41;&#46; Astigmatism was also classified as&#58; &#8220;with the rule&#8221; astigmatism when the weakest refractive power was between the axis of 20&#176; and 160&#176;&#59; &#8220;against the rule&#8221; when between 70&#176; and 110&#176;&#59; and as obliquus if the axis was elsewhere &#40;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#41;&#46; Finally&#44; we calculated the number of amblyopia detected&#44; for which the definition was of two or more lines of difference in VA between the eyes&#44; which could not be explained by other subjacent conditions &#40;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#41;&#46;</p></span></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">RESULTS</span><p id="para100" class="elsevierStylePara elsevierViewall">Data from 1080 children who went to Hospital&#39;s Campaigns in 2018 were analyzed&#46; All children were born in Brazil and were currently studying in public schools in S&#227;o Paulo city&#46; There were 534 boys &#40;49&#46;4&#37;&#41; and 546 girls &#40;50&#46;6&#37;&#41;&#46; The mean age was 6&#46;24&#177;0&#46;45 years&#44; the youngest aged 6 years&#44; and the oldest aged 9 years&#46; The distribution of VA without refractive correction is shown in <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#46; It was found that 117 &#40;10&#46;8&#37;&#59; CI&#58; 9&#46;0&#37;-12&#46;8&#37;&#41; children had ocular movement disorders&#44; with tropias being the most prevalent &#40;26&#46;4&#37; of esotropias and 25&#46;6&#37; of exotropias&#44; <a class="elsevierStyleCrossRef" href="#tbl2">Table 2</a>&#41;&#46; A total of 489 children &#40;45&#46;3&#37;&#59; CI&#58; 42&#46;3&#37;-48&#46;3&#37;&#41; were selected in the second phase&#44; and 52 of these already made use of spectacles &#40;<a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a>&#41;&#46; Therefore&#44; 591 &#40;54&#46;7&#37;&#44; 95&#37; CI&#58; 51&#46;7&#37;-57&#46;7&#37;&#41; were wrongly selected on School&#39;s Screening and were classified false positives&#46;</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><elsevierMultimedia ident="tbl2"></elsevierMultimedia><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para110" class="elsevierStylePara elsevierViewall">In the second phase of the Hospital&#39;s Campaigns&#44; 489 selected children were analyzed&#46; Of these&#44; 164 &#40;33&#46;5&#37;&#41; presented a myopic component&#44; 190 &#40;38&#46;8&#37;&#41; presented a hyperopic component&#44; and 330 &#40;67&#46;4&#37;&#41; had an astigmatism component &#40;79&#46;5&#37; with the rule&#44; 5&#46;8&#37; against the rule&#44; and 14&#46;6&#37; obliquus&#41;&#46; When compared with the total 1080 children&#44; the refractive error distributions were 15&#46;2&#37;&#44; 17&#46;6&#37;&#44; and 30&#46;5&#37;&#44; respectively&#46; The total number of children with amblyopia was 54 &#40;5&#37;&#59; CI&#58; 3&#46;1&#37;-6&#46;4&#37;&#41;&#46; VA analyses showed that 114 &#40;10&#46;5&#37;&#41; children presented a VA of &#8804;0&#46;3&#59; hence&#44; they were classified as having low vision&#46; Of the 114 children with low vision&#44; 94 &#40;82&#46;4&#37;&#59; CI&#58; 74&#46;4&#37;-88&#46;9&#37;&#41; achieved normal vision after refractive correction using spectacles&#46; A total of 220 functional and structural alterations were diagnosed&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl3">Table 3</a>&#46; At the end of the circuit&#44; 147 &#40;13&#46;6&#37;&#59; CI&#58; 11&#46;6&#37;-15&#46;8&#37;&#41; children were referred for specialized follow-up&#44; 420 &#40;38&#46;8&#37;&#59; CI&#58; 35&#46;9&#37;-41&#46;8&#37;&#41; glasses were donated&#44; and 342 children could be dismissed with a normal ophthalmological examination after the spectacles were donated&#46;</p><elsevierMultimedia ident="tbl3"></elsevierMultimedia></span><span id="cesec60" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle110">DISCUSSION</span><p id="para120" class="elsevierStylePara elsevierViewall">In this study&#44; we described the social project &#8220;Vision for the Future&#8221; and analyzed its epidemiological data in 2018&#46; We intend to outline new proposals to enhance this project and others alike and to supplement the current literature&#44; as there is a lack of new epidemiological data for this population&#44; mainly in developing countries&#46; The results of this report corroborate those of previous studies and demonstrate the importance of screening programs for children &#40;<a class="elsevierStyleCrossRef" href="#bib12">12</a>&#44;<a class="elsevierStyleCrossRef" href="#bib16">16</a>&#41;&#46;</p><p id="para130" class="elsevierStylePara elsevierViewall">Meta-analytical data and WHO reports indicate that uncorrected refractive errors are the leading cause of visual impairment and second leading cause of blindness worldwide&#44; affecting approximately 102 million individuals and blinding up to 6 million individuals of all ages &#40;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#44;<a class="elsevierStyleCrossRef" href="#bib17">17</a>&#44;<a class="elsevierStyleCrossRef" href="#bib18">18</a>&#41;&#46; The prevalence of visual impairments and reversible blindness is higher in low-and middle-income countries&#44; and it has an inversely proportional curve with health investments&#46; Uncorrected refractive errors and visual impairments in childhood are even more important as they can lead to amblyopia &#40;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#41;&#46; Since the amblyopic eye will no longer develop its full VA potential&#44; this pathology may lead to irreversible visual impairment or even blindness if not properly treated &#40;<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#41;&#46;</p><p id="para140" class="elsevierStylePara elsevierViewall">In our cohort&#44; we detected amblyopia in 5&#37; &#40;95&#37; CI&#58; 3&#46;5&#37;-6&#46;4&#37;&#41; of the children&#46; The prevalence of this effect is highly dependent on the region&#44; age&#44; and socioeconomic status &#40;<a class="elsevierStyleCrossRef" href="#bib19">19</a>&#41;&#46; Meta-analytic studies&#44; including all ages&#44; have shown a pooled prevalence estimate of amblyopia of 1&#46;75&#37; &#40;95&#37; CI&#58; 1&#46;17&#37;-1&#46;88&#37;&#41;&#44; ranging from 0&#46;51&#37; to 3&#46;67&#37; &#40;<a class="elsevierStyleCrossRef" href="#bib20">20</a>&#41;&#46; Another systematic review had a similar result&#44; with a pooled estimate of 1&#46;44&#37; &#40;95&#37; CI&#58; 1&#46;17&#37;-1&#46;78&#37;&#41; and prevalence of 2&#46;90&#37;&#44; 2&#46;41&#37;&#44; 1&#46;09&#37;&#44; and 0&#46;72&#37; in Europe&#44; North America&#44; Asia&#44; and Africa&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#bib21">21</a>&#41;&#46; These numbers range from 1&#37; to 3&#37; in childhood worldwide &#40;<a class="elsevierStyleCrossRef" href="#bib22">22</a>&#41;&#46; The prevalence in our study was higher since our cohort was previously selected by an initial school screening&#46; All patients were forwarded for specialized follow-up and treatment&#46;</p><p id="para150" class="elsevierStylePara elsevierViewall">Amblyopia treatment should ideally begin between 2 and 8 years of age&#46; During that period&#44; crucial neuronal connections are made to form neuro visual paths that will remain for life &#40;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#44;<a class="elsevierStyleCrossRef" href="#bib23">23</a>&#44;<a class="elsevierStyleCrossRef" href="#bib24">24</a>&#41;&#46; In this social project&#44; children&#39;s ages ranged from 6 to 9 years&#46; Although the detection and treatment are still efficient&#44; younger children should also be screened and included in this and other screening programs &#40;<a class="elsevierStyleCrossRefs" href="#bib25">25&#8211;27</a>&#41;&#46; The major obstacle is the difficulty in examining the preverbal and illiterate&#46; Larger investments would be required to cover the extra population&#44; which is hardly a viable option &#40;<a class="elsevierStyleCrossRef" href="#bib28">28</a>&#41;&#46; New instruments for photorefraction&#44; such as smartphone-based applications&#44; are promising for this purpose&#46; These devices exhibit high-performance metrics for the detection of amblyopia risk factors such as ametropias and strabismus &#40;<a class="elsevierStyleCrossRefs" href="#bib28">28&#8211;31</a>&#41;&#46;</p><p id="para160" class="elsevierStylePara elsevierViewall">Photorefractive devices have been compared with VA testing in infants for amblyopia screening&#46; For younger elementary children and for those with special needs&#44; the sensitivity and specificity of photoscreening are considerably higher than those of patched VA testing &#40;<a class="elsevierStyleCrossRef" href="#bib32">32</a>&#41;&#46; An Alaskan study reported two different devices that achieved sensitivity&#47;specificity of 77&#37;&#47;99&#37; and 85&#37;&#47;99&#37;&#44; respectively&#44; while that of VA testing was only 39&#37;&#47;99&#37; &#40;<a class="elsevierStyleCrossRef" href="#bib32">32</a>&#41;&#46; In addition&#44; approximately a third of the pre-scholar children could not complete the VA test because of a lack of cooperation&#46; Additionally&#44; a retrospective analysis of the photoscreening of 21367 children showed better results for detecting amblyopia&#44; particularly owing to the possibility of examining younger children &#40;<a class="elsevierStyleCrossRef" href="#bib33">33</a>&#41;&#46; Children were treated earlier and presented better visual results during the follow-up&#46; These results corroborate the idea of using photorefractive devices to detect refractive errors and amblyopia risk factors&#46;</p><p id="para170" class="elsevierStylePara elsevierViewall">Uncorrected refractive error was the most prevalent finding in this study&#46; Within our 1080 children cohort&#44; we found 15&#46;2&#37;&#44; 17&#46;6&#37;&#44; and 30&#46;5&#37; of myopia&#44; hyperopia&#44; and astigmatism components&#44; respectively&#46; A meta-analytic study showed that for children&#44; the globally estimated pooled prevalence of myopia&#44; hyperopia&#44; and astigmatism was 11&#46;7&#37;&#44; 4&#46;6&#37;&#44; and 14&#46;9&#37;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#bib17">17</a>&#41;&#46; In a Brazilian cohort of patients aged &#60;10 years&#44; the prevalence of myopia&#44; hyperopia&#44; and astigmatism was 3&#46;8&#37;&#44; 86&#46;9&#37;&#44; and 25&#37;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#bib34">34</a>&#41;&#46; The cutoff values the authors used were a cylinder power of at least -0&#46;50 D and &#43;0&#46;50 D for myopia and hyperopia&#44; respectively&#44; and a cylinder power of -0&#46;50 D for astigmatism&#46; The reason for the remarkably high prevalence of hyperopia can be explained by the lower cutoff adopted by the authors&#46; The prevalence of myopia is surprisingly lower than that reported in our findings and global estimated pools&#44; which is closer to our findings&#46; The prevalence of the astigmatism component was similar to that reported in a Malaysian study &#40;21&#46;3&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib35">35</a>&#41;&#46; Finally&#44; a total of 420 &#40;38&#46;8&#37;&#59; 95&#37; CI&#58; 35&#46;9&#37;-41&#46;8&#37;&#41; spectacles were donated in 2018&#46;</p><p id="para180" class="elsevierStylePara elsevierViewall">The strategy of donating spectacles is one of the most important factors for compliance in refractive social campaigns&#44; particularly in developing countries &#40;<a class="elsevierStyleCrossRef" href="#bib16">16</a>&#41;&#46; Our data suggested that approximately 67&#37; of the children selected for the Hospital&#39;s Campaigns did not show up&#46; All children who were forwarded to the hospital were taken from their schools by pre-paid charter buses by governmental institutions&#46; Therefore&#44; approximately two-thirds of the expenses in that manner were wasted&#46; Additionally&#44; we found a high number of false positives that were screened by teaching professionals&#46; From 1080 children evaluated in the First Phase of the Hospital&#39;s Campaigns&#44; 591 &#40;54&#46;7&#37;&#44; 95&#37; CI&#58; 51&#46;7&#37;-57&#46;7&#37;&#41; were dismissed and classified false positives&#46; Together&#44; these two factors point to an exceptionally low cost-effective screening program&#46; Besides economics&#44; two major problems are highlighted&#58; lack of compliance by parents and children&#44; and teaching professionals&#39; poor ophthalmic examination training&#46;</p><p id="para190" class="elsevierStylePara elsevierViewall">School-based screening programs have been demonstrated to be more cost-effective than other primary eye care models &#40;<a class="elsevierStyleCrossRef" href="#bib36">36</a>&#41;&#46; Additionally&#44; teaching professionals can be trained and qualified for visual screening &#40;<a class="elsevierStyleCrossRef" href="#bib37">37</a>&#44;<a class="elsevierStyleCrossRef" href="#bib38">38</a>&#41;&#46; However&#44; it is costly to train all the teachers&#46; However&#44; simultaneously&#44; it has been shown that more teachers doing screening improve the rates of true positives &#40;<a class="elsevierStyleCrossRef" href="#bib39">39</a>&#44;<a class="elsevierStyleCrossRef" href="#bib40">40</a>&#41;&#46; In our cohort&#44; false-positive rates were three to five times higher than those found in an Indian study&#44; which found the rates to be 16&#46;6&#37; and 9&#46;7&#37;&#44; respectively&#44; when adopting the method of screening by only a few selected teachers or by all school teachers&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#bib39">39</a>&#41;&#46; As the literature indicates&#44; the number of children screened per teacher must be lowered&#46; Therefore&#44; new ophthalmic programs for teaching professionals&#39; capacitation must be implemented&#46; Another option is the adjoint use of smartphone-based photorefractive applications mentioned above&#44; which reduces the time of screening&#44; particularly for less cooperative individuals &#40;<a class="elsevierStyleCrossRefs" href="#bib28">28&#8211;30</a>&#41;&#46;</p><p id="para200" class="elsevierStylePara elsevierViewall">Another key aspect to improve social programs is the compliance of the population&#46; The expressive amount of children&#39;s absence suggests poor community sensitization&#46; Good community sensitization is critical for the success and sustainability of screening programs&#46; Teachers&#44; parents&#44; care holders&#44; and children must be aware of the reasons and benefits of such programs&#46; Methods to address specific communities must be adopted&#44; such as posters&#44; the use of radio and television&#44; and communication via religious groups and community leaders&#46; The awareness of the goals and targets of the programs will yield results and long-term compliance to the screening program&#44; leading to better community health indices&#46;</p><p id="para210" class="elsevierStylePara elsevierViewall">The main limitation of this study is the impossibility of statistical extrapolation&#44; as with boot-strap techniques&#44; since our cohort was already pre-selected and school screening was considered a selection bias&#46; However&#44; as discussed above&#44; the epidemiological findings in this study are consistent with those of previous studies and can be considered in our population&#46; In addition&#44; we could not measure the impact of the treatment for children with conditions that required longer follow-ups&#44; such as amblyopia&#46; Nonetheless&#44; the number of donated spectacles and high ratio of children who acquired normal vision after visual treatment states the impact of such programs on visual rehabilitation&#46; Finally&#44; epidemiological data regarding this population in Brazil are scarce and outdated&#59; thus&#44; trustworthy sources of information should be shared&#46;</p><p id="para220" class="elsevierStylePara elsevierViewall">In conclusion&#44; this study intended to describe the &#8220;Vision for the Future&#8221; social program&#44; to analyze its epidemiological outcomes&#44; and to outline suggestions for the improvement of this program and others alike&#46; School-based screening programs are essential for eye care settings&#44; especially in developing countries&#46; More studies are needed to improve the cost-effectiveness and efficiency of social and screening programs&#46;</p></span><span id="cesec70" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle120">AUTHOR CONTRIBUTIONS</span><p id="para230" class="elsevierStylePara elsevierViewall">Costa DR was responsible for the manuscript elaboration and revision&#44; and data collection and analysis&#46; Debert I was responsible for the manuscript elaboration and revision&#44; and orientation&#46; Susanna FN was responsible for the manuscript elaboration and revision&#46; Falabreti JG was responsible for the data collection and analysis&#46; Polati M and Susanna J&#250;nior R were responsible for the manuscript revision and orientation&#46;</p></span></span>"
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        1 => array:2 [
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          "titulo" => "REFERENCES"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2021-05-12"
    "fechaAceptado" => "2021-07-19"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
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          "identificador" => "xpalclavsec1577325"
          "palabras" => array:5 [
            0 => "Visual Screening"
            1 => "Refractive Error"
            2 => "Ophthalmic Epidemiology"
            3 => "Amblyopia"
            4 => "Social Refraction"
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    "resumen" => array:1 [
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        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">OBJECTIVES&#58;</span><p id="spara60" class="elsevierStyleSimplePara elsevierViewall">Uncorrected refractive errors are the leading cause of visual impairment in children&#46; In this cross-sectional retrospective study&#44; we analyzed a social visual screening program for school children in S&#227;o Paulo&#44; Brazil&#44; evaluated its impact on the prevention and treatment of children&#39;s visual disabilities&#44; and assessed its epidemiological outcomes to outline suggestions for its improvement&#46;</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHODS&#58;</span><p id="spara70" class="elsevierStyleSimplePara elsevierViewall">First-grade children from public schools were submitted to prior visual screening by their teachers&#46; Selected children were forwarded to the hospital&#39;s campaigns for a second screening by ophthalmologists and treatment if needed&#46; Data were analyzed for age&#44; sex&#44; visual acuity&#44; biomicroscopy&#44; refractive errors&#44; ocular movement disorders&#44; amblyopia&#44; number of donated spectacles&#44; and number of children forwarded to specialized care&#46;</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RESULTS&#58;</span><p id="spara80" class="elsevierStyleSimplePara elsevierViewall">A total of 1080 children were included with mean age of 6&#46;24&#177;0&#46;45 years&#46; Children with normal ophthalmological exam&#44; 591 &#40;54&#46;7&#37;&#59; 95&#37; confidence interval &#91;CI&#93;&#58; 51&#46;7&#37;-57&#46;7&#37;&#41; were dismissed and considered false-positives&#46; Myopia&#44; hyperopia&#44; and astigmatism components were found in 164 &#40;15&#46;2&#37;&#59; CI&#58; 13&#46;1&#37;-17&#46;4&#37;&#41;&#44; 190 &#40;17&#46;6&#37;&#59; CI&#58; 15&#46;3&#37;-20&#46;0&#37;&#41;&#44; and 330 &#40;30&#46;5&#37;&#59; CI&#58; 27&#46;8&#37;-33&#46;4&#37;&#41; children&#44; respectively&#46; Amblyopia was diagnosed in 54 &#40;5&#37;&#59; CI&#58; 3&#46;5&#37;-6&#46;4&#37;&#41; children&#44; and 117 &#40;10&#46;8&#37;&#59; CI&#58; 9&#46;8&#37;-12&#46;8&#37;&#41; presented ocular movement disorders&#46; A total of 420 glasses were donated&#46;</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSION&#58;</span><p id="spara90" class="elsevierStyleSimplePara elsevierViewall">Epidemiological findings for amblyopia and refractive errors are consistent with those of similar studies&#46; The expressive number of diagnoses performed and number of glasses donated to underprivileged children depict the importance of such projects&#46; New guidelines to improve their cost-effectiveness&#44; such as professional training and community sensitization&#44; are imperative&#46;</p></span>"
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          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">&#8220;Vision for the Future&#8221; children&#39;s participation flowchart for the year 2018&#46;</p>"
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                  \t\t\t\t">72 &#40;6&#46;7&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">154 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\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;50&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85 &#40;7&#46;9&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77 &#40;7&#46;1&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">162 &#40;7&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\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;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54 &#40;5&#46;0&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;5&#46;7&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">116 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\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;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49 &#40;4&#46;5&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43 &#40;4&#46;0&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\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;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 &#40;3&#46;5&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41 &#40;3&#46;8&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79 &#40;3&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\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;15&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;1&#46;6&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;1&#46;5&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\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;10&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;1&#46;4&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;1&#46;8&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Finger count&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;0&#46;3&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;0&#46;7&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hand movement&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;2&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Non-cooperation or inability to evaluate&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;2&#44;8&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;2&#46;6&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58 &#40;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1080 &#40;100&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1080 &#40;100&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2160 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
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            0 => array:3 [
              "identificador" => "tbl1fn1"
              "etiqueta" => "&#42;"
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          "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Distribution of Visual Acuity Without Correction<a class="elsevierStyleCrossRef" href="#tbl1fn1">&#42;</a>&#44; n &#40;&#37;&#41;&#46;</p>"
        ]
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        "identificador" => "tbl2"
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        "mostrarDisplay" => false
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            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="" 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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N &#40;&#37;&#41;&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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">X&#40;T&#41; - Exoforia&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;13&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">E&#40;T&#41; - Esoforia&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">X - Intermitent exotropia&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;18&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">E - Intermitent esotropia&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;6&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ET - Manifest esotropia&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;27&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">XT - Manifest exotropia&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;27&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">117 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Distribution of Ocular Movement Disorders&#46;</p>"
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        "tabla" => array:1 [
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              "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="" 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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n&#176; of occurrences&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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Strabismus&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">117&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ambliopia&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Myopic fundus&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RPE rarefaction&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Optic disc pallor&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased disc&#47;escavation relation&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Crowded disc&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Persistent hyperplastic primary vitreous&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Persistent myelinated fibers in the retina&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Choriorretinitis scar&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tilted disc&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Optic disc dysplasia&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fundus albinus&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Peripapillary atrophy&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retinal detachment&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total number of fundoscopy alterations&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Conjunctival papillae&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Microcornea&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Corneal opacifications&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Conjunctival melanocitoses&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Iris transillumination&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Persistent pupillary membrane&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Distichiasis&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Crystalline vacuoles&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="center" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total number of biomicroscopic alterations&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">220&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara50" class="elsevierStyleSimplePara elsevierViewall">Diagnoses and Alterations detected&#46;</p>"
        ]
      ]
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      "titulo" => "REFERENCES"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "VISION 2020-the right to sight&#58; from strategies to action"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => """
                              R Pararajasegaram \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
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                      "doi" => "10.1016/s0002-9394(99)00251-2"
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Ophthalmol"
                        "fecha" => "1999"
                        "volumen" => "128"
                        "numero" => "3"
                        "paginaInicial" => "359"
                        "paginaFinal" => "360"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10511033"
                            "web" => "Medline"
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                      "doi" => "10.1016/s0002-9394(99)00251-2"
                      "WWW" => array:1 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global causes of blindness and distance vision impairment 1990-2020&#58; a systematic review and meta-analysis"
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                            0 => """
                              SR Flaxman \n
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                            1 => """
                              RRA Bourne \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              S Resnikoff \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              P Ackland \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              T Braithwaite \n
                              \t\t\t\t\t\t\t\t
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                            5 => """
                              MV Cicinelli \n
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                        "numero" => "12"
                        "paginaInicial" => "e1221"
                        "paginaFinal" => "e1234"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29032195"
                            "web" => "Medline"
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              "etiqueta" => "3"
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                      "titulo" => "Magnitude&#44; temporal trends&#44; and projections of the global prevalence of blindness and distance and near vision impairment&#58; a systematic review and meta-analysis"
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                              RRA Bourne \n
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                            1 => """
                              SR Flaxman \n
                              \t\t\t\t\t\t\t\t
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                            2 => """
                              T Braithwaite \n
                              \t\t\t\t\t\t\t\t
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                            3 => """
                              MV Cicinelli \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              A Das \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              JB Jonas \n
                              \t\t\t\t\t\t\t\t
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                    0 => array:2 [
                      "doi" => "10.1016/S2214-109X(17)30293-0"
                      "Revista" => array:7 [
                        "tituloSerie" => "Lancet Glob Health"
                        "fecha" => "2017"
                        "volumen" => "5"
                        "numero" => "9"
                        "paginaInicial" => "e888"
                        "paginaFinal" => "e897"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28779882"
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                      "doi" => "10.1016/S2214-109X(17)30293-0"
                      "WWW" => array:1 [
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              "etiqueta" => "4"
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                  "referenciaCompleta" => "Ottaiana JAA&#44; &#193;vila MP&#44; Umbelino CC&#44; Taleb AC&#46; C As Condi&#231;&#245;es de Sa&#250;de Ocular no Brasil egueira e Baixa Vis&#227;o no Brasil&#46; In&#58; Oftalmologia CB de&#44; editor&#46; 2019&#59;6&#40;5&#41;&#58;35&#8211;63&#46;"
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            ]
            4 => array:3 [
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              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Critical period revisited&#58; impact on vision"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => """
                              H Morishita \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              TK Hensch \n
                              \t\t\t\t\t\t\t\t
                              """
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                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1016/j.conb.2008.05.009"
                      "Revista" => array:7 [
                        "tituloSerie" => "Curr Opin Neurobiol"
                        "fecha" => "2008"
                        "volumen" => "18"
                        "numero" => "1"
                        "paginaInicial" => "101"
                        "paginaFinal" => "107"
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ISSN: 18075932
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos