Predicción de ocurrencia de fosfenos en pacientes sometidos a irradiación con fotones a estructuras oculares por tumor cerebral | Archivos de la Sociedad Española de Oftalmología

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En oncolog&#237;a&#44; a parte de la localizaci&#243;n de un tumor que podr&#237;a afectar directa o indirectamente la v&#237;a visual&#44; los fosfenos tambi&#233;n est&#225;n presentes&#44; especialmente durante la radioterapia para pacientes con tumores del sistema nervioso central&#44; ojos&#44; cabeza y cuello&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Los rayos X tambi&#233;n pueden inducir fosfenos&#44; el mecanismo es planteado por la activaci&#243;n directa de los fotorreceptores de la retina o las neuronas de la v&#237;a visual por radiaci&#243;n ionizante<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a>&#46; Tambi&#233;n se ha afirmado que la generaci&#243;n de luz de Cherenkov en el globo ocular&#44; es el mecanismo dominante responsable de los fosfenos percibidos durante la radioterapia de electrones y fotones&#44; produci&#233;ndose un resplandor azul homog&#233;neo y luminoso a trav&#233;s del campo visual&#46; La luz de Cherenkov se genera cuando una part&#237;cula cargada viaja a trav&#233;s de un medio diel&#233;ctrico &#40;cargado&#41; y su velocidad de fase excede a la luz&#44; cre&#225;ndose un &#171;boom fot&#243;nico&#187; de luz<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; Para la radioterapia con fotones de haz externo&#44; el umbral de energ&#237;a de un electr&#243;n para generar radiaci&#243;n de Cherenkov en el humor v&#237;treo del ojo &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;336&#41; es 0&#44;260 megaelectronvoltio &#40;MeV&#41;&#46; El n&#250;mero de fotones de Cherenkov aumenta con la energ&#237;a de los fotones &#40;disminuci&#243;n de la longitud de onda&#41;&#44; por lo que los humanos perciben la radiaci&#243;n de Cherenkov como azul&#46; Con el aumento de energ&#237;a fuera del espectro visual&#44; la intensidad disminuye a cero&#44; ya que el &#237;ndice de refracci&#243;n tambi&#233;n disminuye con la energ&#237;a de los fotones<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La experiencia de los fosfenos var&#237;a mucho entre los pacientes&#44; desde luces&#44; destellos&#44; parpadeos y rayas de diferentes colores&#44; pero principalmente la coloraci&#243;n azul y blanco&#46; Adem&#225;s&#44; la experiencia no ocurre en todas las fracciones de irradiaci&#243;n para todos los pacientes<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; Blumenthal et al&#46; postulaN que la radiaci&#243;n de Cherenkov puede causar el efecto de fosfenos&#44; pero que este efecto tambi&#233;n puede deberse al tratamiento con radiaci&#243;n en diferentes partes de la v&#237;a visual<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>&#46; Este fen&#243;meno se informa aproximadamente en un 64&#37; de los pacientes con lesiones cerebrales&#44; como destellos de luz y&#47;o luz de color en una o m&#225;s fracciones&#46; Si el paciente percibe en una sesi&#243;n&#44; se reporta en una media del 66&#37; de las fracciones totales de radioterapia<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El presente estudio inicia con la incomodidad del paciente por la sensaci&#243;n desagradable&#44; especialmente en los que recib&#237;an irradiaci&#243;n en la cabeza o en el enc&#233;falo&#46; Por lo tanto&#44; para conocer si existe una predicci&#243;n entre la dosis de irradiaci&#243;n recibida a nivel de las estructuras oculares como retina y humor v&#237;treo&#44; con la presencia de fosfenos en los pacientes oncol&#243;gicos sometidos a irradiaci&#243;n&#46; Se dise&#241;&#243; esta cohorte prospectiva en 2 m&#225;quinas de tratamiento con la misma iluminaci&#243;n ambiental&#46; Este documento informa sobre los resultados &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">figs&#46; 1 y 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Metodolog&#237;a</span><p id="par0025" class="elsevierStylePara elsevierViewall">Previamente el proyecto fue aprobado por el comit&#233; de &#233;tica institucional&#46; Se pidi&#243; a los pacientes que iban a ser tratados con radioterapia nivel del enc&#233;falo que participaran en el estudio para investigar sus experiencias al ver luz constante y&#47;o destellos de luz durante el tratamiento con radiaci&#243;n&#46; Se incluyeron pacientes cuyo tratamiento consisti&#243; en al menos 5 fracciones&#44; conservaban la agudeza visual&#44; el tumor maligno primario de enc&#233;falo o metast&#225;sico a enc&#233;falo&#59; se excluyeron a los pacientes con irradiaci&#243;n del enc&#233;falo previamente&#44; o en donde las lesiones tumorales compromet&#237;an la fosa orbitaria&#46; Todos los tratamientos comenzaron entre febrero del 2020 hasta enero del 2021&#44; debiendo recibir en una sala de tratamiento iluminada de la misma intensidad en todas las sesiones&#44; se cont&#243; con 2 salas de tratamiento&#44; una presentaba un acelerador lineal Synergy&#174; Full de Elekta &#40;Elekta&#44; Crawley&#44; Reino Unido&#41; y la otra sala presentaba un acelerador lineal Synergy&#174; Platform de Elekta &#40;Elekta&#44; Crawley&#44; Reino Unido&#41;&#44; ambas pertenecientes a la misma instituci&#243;n&#46; Los pacientes fueron tratados con una energ&#237;a de haz de fotones de 6<span class="elsevierStyleHsp" style=""></span>MeV con campos conformados&#46; Se registraron las sesiones de radioterapia que cumpl&#237;an con los criterios previamente establecidos&#46; Despu&#233;s de cada tratamiento&#44; el paciente rellen&#243; un cuestionario para evaluar la frecuencia con la que ve&#237;a destello luz y&#47;o luz establecida&#44; y una descripci&#243;n de la luz&#46; Seg&#250;n las respuestas del paciente se determin&#243; entre destello de luz y luz estable&#46; Se determin&#243; la dosis m&#225;xima de la retina y humor v&#237;treo&#44; mediante el sistema de planificaci&#243;n Monaco&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Usamos an&#225;lisis de regresi&#243;n log&#237;stica mediante el programa estad&#237;stico SPSS&#174; &#40;versi&#243;n 26&#46;0&#44; Chicago&#44; IL&#44; EE&#46; UU&#46;&#41;&#44; para examinar si los fosfenos visuales dependen de la intensidad de la dosis&#46; El modelo se ajust&#243; para cada uno de los 2 resultados dicot&#243;micos de ver destellos de luz &#40;no&#44; s&#237;&#41; y ver luz estable &#40;no&#44; s&#237;&#41;&#46; Para el an&#225;lisis de los destellos de luz y luz estable&#44; utilizamos la dosis m&#225;xima a la retina y humor v&#237;treo como predictores como predictores&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0035" class="elsevierStylePara elsevierViewall">En total&#44; se administraron 380 tratamientos a 25 pacientes&#44; de los cuales ning&#250;n paciente tuvo complicaci&#243;n ocular durante el tratamiento&#46; La <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> ofrece una descripci&#243;n general de las caracter&#237;sticas de la localizaci&#243;n del tumor&#44; la dosis m&#225;xima en retina y humor v&#237;treo por fracci&#243;n&#44; el evento percibido como destello de luz&#44; o luz estable&#46; Se percibe la presencia de cualquiera de los eventos en un predominio del 58&#44;7&#37; del total de fracciones&#44; el patr&#243;n de color identificado por los pacientes fue el color azul&#46; La distribuci&#243;n por la presencia de ambos eventos&#44; destello de luz y luz estable&#44; fue del 69&#44;1&#44; 20&#44;6 y 10&#44;3&#37;&#44; respectivamente&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">En las <a class="elsevierStyleCrossRefs" href="#fig0005">figuras 1 y 2</a>&#44; se observa la tendencia de presentar fosfenos a medida que aumenta la dosis de exposici&#243;n de irradiaci&#243;n tanto a nivel de retina como nivel del humor v&#237;treo&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se muestra los resultados de los an&#225;lisis de regresi&#243;n log&#237;stica&#44; cuando se somete los factores de dosis de retina y dosis v&#237;treo al an&#225;lisis de regresi&#243;n log&#237;stica binaria&#44; para que ocurra el evento destello de luz&#44; el factor dosis retina&#44; no es estad&#237;sticamente significativo &#40;OR&#58; 1&#44;70&#59; p&#58; 0&#44;187&#41;&#44; mientras que el factor dosis v&#237;treo&#44; es estad&#237;sticamente significativo &#40;OR&#58; 1&#44;74&#59; p&#58; 0&#44;001&#41;&#46; Para que ocurra el evento luz estable&#44; los factores dosis retina &#40;OR&#58; 1&#44;73&#59; p&#58; 0&#44;005&#41;&#44; y dosis humor v&#237;treo &#40;OR&#58; 1&#44;82&#59; p&#58; 0&#44;003&#41;&#44; son estad&#237;sticamente significativos&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">La muestra&#44; con un total de 380 fracciones de radioterapia en 25 pacientes&#44; el 72&#37; de los pacientes presentan cualquier evento de fosfeno&#46; El 69&#44;1&#37; de las fracciones presentaron cualquier evento de fosfeno&#44; el 20&#44;6&#37; de las fracciones presentaron &#171;destello de luz&#187; y el 10&#44;3&#37; presentaron &#171;luz estable&#187;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0050" class="elsevierStylePara elsevierViewall">Los fosfenos en el contexto de un tumor en el enc&#233;falo puede ser provocado por irritaci&#243;n de la v&#237;a &#243;ptica&#44; fen&#243;menos isqu&#233;micos y por producir edema alrededor&#44; conllevando a la hipertensi&#243;n intracraneal&#46; Siendo las caracter&#237;sticas de estos&#44; de presentarse en cualquier momento del d&#237;a&#46; Mientras que los fosfenos durante la administraci&#243;n de irradiaci&#243;n&#44; se notificaron por primera vez hace m&#225;s de un siglo<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#46; Se notifican hasta en un 70&#37; de los pacientes con melanoma ocular que reciben radioterapia<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a>&#44; y en un 64&#37; de los pacientes irradiados al cerebro<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a>&#46; Estos datos son equiparables con nuestros resultados de pacientes con irradiaci&#243;n cerebral&#44; ya que se ha presentado el evento en el 72&#37; de los pacientes&#44; y en un 58&#37; del total de fracciones de radioterapia&#46; Las caracter&#237;sticas de los fosfenos var&#237;an en color con predominio del 80&#37; en el azul y violeta&#44; forma&#44; intensidad&#44; extensi&#243;n y duraci&#243;n&#44; pero generalmente ocurren durante la irradiaci&#243;n y se detienen despu&#233;s<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46; Nuestros pacientes reportaron en su totalidad el color azul&#44; esto concuerda con literatura&#44; en el escenario de la radioterapia externa con fotones y la radioterapia guiada por im&#225;genes&#44; los pacientes que se han adaptado visualmente a la oscuridad con c&#225;ncer de cabeza y cuello&#44; y que son tratados con fotones de alta energ&#237;a experimentan principalmente fosfenos azules t&#237;picos<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Basado en las observaciones de los pacientes y en la literatura&#44; nos permite aseverar la existencia de 2 mecanismos diferentes para fosfenos visuales en la terapia con fotones de haz externo&#44; activaci&#243;n directa de las prote&#237;nas fotorreceptoras y la generaci&#243;n de radiaci&#243;n de Cherenkov en el humor v&#237;treo&#44; con predominio de este &#250;ltimo<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a>&#46; La predominancia de &#171;destello de luz&#187; o &#171;luz constante&#187;&#44; puede ser influenciado por la modalidad de entrega de dosis&#44; en el tratamiento conformacional tridimensional&#44; se espera el evento de &#171;luz constante&#187;&#44; mientras los tratamiento de arco volum&#233;trico modulado&#44; se espera el evento de &#171;destello de luz&#187;&#44; por la breve exposici&#243;n&#46; As&#237; mismo&#44; se reporta la midriasis transitoria &#40;dilataci&#243;n de la pupila&#41; despu&#233;s del inicio del haz de protones&#44; este evento ocurre en la mitad de los pacientes que experimentan fosfenos&#44; pero rara vez en los pacientes sin fosfenos&#44; lo que sugiere la participaci&#243;n de las c&#233;lulas ganglionares de la retina<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">En nuestro estudio se observa la tendencia de la relaci&#243;n directa de los fosfenos&#44; a partir de las dosis m&#225;ximas de la retina y humor v&#237;treo&#44; especialmente a partir de los 200<span class="elsevierStyleHsp" style=""></span>cGy&#46; Sin embargo&#44; al someterlo a la regresi&#243;n log&#237;stica solamente la dosis m&#225;xima de humor v&#237;treo fue significativa para predecir la totalidad de casos fosfenos&#44; a pesar que la dosis en retina no predijo significativamente en ambos eventos&#44; estos resultados son concordantes&#46; Ya que De Kruijf et al&#46; en su investigaci&#243;n&#44; las probabilidades de ver destellos de luz se multiplican por 0&#44;926 a medida que la intensidad de la luz ambiental aumenta en 10 unidades de lux&#46; De manera similar&#44; las probabilidades se multiplican por 1&#44;604 a medida que la dosis en la retina aumenta en 10<span class="elsevierStyleHsp" style=""></span>cGy&#59; y las probabilidades de ver una luz constante se multiplican por 1&#44;540 a medida que la dosis para el humor v&#237;treo aumenta en 10<span class="elsevierStyleHsp" style=""></span>cGy<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a>&#46; Esto muestra que la aparici&#243;n de fosfenos visuales se puede influir&#44; y adem&#225;s disminuir su presencia&#44; reduciendo la dosis en la retina y el humor v&#237;treo e iluminando la sala de tratamiento&#46; En nuestro estudio la presencia de iluminaci&#243;n del ambiente&#44; no altera los resultados&#44; ya que los ambientes se mantuvieron con la misma iluminaci&#243;n para todas las fracciones&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Cl&#237;nicamente&#44; el pron&#243;stico visual del paciente depende de la dosis administrada a las estructuras oculares responsables de la visi&#243;n&#46; La presencia de fosfenos en nuestros pacientes es indicativo que esta recibido irradiaci&#243;n a nivel de la retina y que se est&#225; generando la luz de Cherenkov&#44; como lo explican Tendler et al&#46; en su investigaci&#243;n con una c&#225;mara intensificada sincronizada con los pulsos de un acelerador lineal&#44; han podido capturar la emisi&#243;n de luz de los ojos y medido los espectros de emisi&#243;n en funci&#243;n de la profundidad del ojo&#44; demostrando que la se&#241;al solo est&#225; presente cuando se irradia el l&#237;quido v&#237;treo y aparece la luz de Cherenkov<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a>&#46; Sin embargo&#44; a&#250;n se desconoce si esto se correlaciona o proporciona informaci&#243;n adicional sobre la p&#233;rdida visual independientemente de la dosis calculada&#46; Se tiene que realizar investigaci&#243;n a largo plazo sobre la presencia de fosfenos y el deterioro de la visi&#243;n&#44; ya que es un s&#237;ntoma com&#250;n pero poco apreciado en oncolog&#237;a&#44; podr&#237;a no solo ayudar a desentra&#241;ar importantes mecanismos fisiol&#243;gicos o f&#237;sicos en la radioterapia&#44; sino que tambi&#233;n ayudar a predecir los resultados visuales&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusi&#243;n</span><p id="par0070" class="elsevierStylePara elsevierViewall">Los fosfenos visuales durante el tratamiento de radioterapia con fotones de haz externo&#44; es debido la mayor parte de veces por la generaci&#243;n de radiaci&#243;n de Cherenkov en el humor v&#237;treo&#46; La dosis m&#225;xima humor v&#237;treo predice la presencia de fosfenos&#44; mientras que la dosis m&#225;xima en retina predice solo la presencia del evento luz estable&#46; Estos resultados proponen a los centros de radioterapia&#44; tomen en cuenta estas estructuras anat&#243;micas para disminuir la incomodidad por la presencia de fosfenos en los pacientes&#46; As&#237; mismo contribuir&#237;a a disminuir los fosfenos&#44; manteniendo el &#225;rea del b&#250;nker iluminado durante el tratamiento&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Financiaci&#243;n</span><p id="par0075" class="elsevierStylePara elsevierViewall">No cuenta con financiamiento&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicto de intereses</span><p id="par0080" class="elsevierStylePara elsevierViewall">No existen potenciales conflictos de intereses con esta investigaci&#243;n&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Antecedentes y objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Los fosfenos son fen&#243;menos de luz visual que se experimentan cuando no hay luz aparente que estimule el ojo&#46; En oncolog&#237;a&#44; los fosfenos tambi&#233;n est&#225;n presentes durante la radioterapia para pacientes con tumores del sistema nervioso central&#44; ojos&#44; cabeza y cuello&#46; Debido a la incomodidad de los pacientes tratados con irradiaci&#243;n en las regiones de la cabeza&#44; se realiza investigaci&#243;n para determinar si la dosis en las estructuras oculares son predicci&#243;n para la ocurrencia de fosfenos&#46; El objetivo fue demostrar la relaci&#243;n entre las dosis de retina y humor v&#237;treo con la aparici&#243;n de fosfenos&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio descriptivo&#44; en una cohorte prospectiva en 25 pacientes mayores de 18 a&#241;os&#44; con tumores malignos localizados a nivel de enc&#233;falo&#44; tanto de origen primario como secundario&#44; sometidos a irradiaci&#243;n en aceleradores lineales de 6<span class="elsevierStyleHsp" style=""></span>MV&#44; durante febrero 2020 a enero del 2021&#46; Como variables independientes&#58; dosis a retina y dosis a humor v&#237;treo&#44; y como variables dependientes&#58; destellos de luz y luz estable&#46; Para la predicci&#243;n se utiliz&#243; el an&#225;lisis de regresi&#243;n log&#237;stica&#44; mediante el programa estad&#237;stico SPSS&#174; versi&#243;n 26&#46;0&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultado</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Una data final de 380 tratamientos de radioterapia externa&#46; La presencia de cualquiera de los eventos en un predominio del 58&#44;7&#37; del total de fracciones&#46; La distribuci&#243;n por la presencia de ambos eventos&#44; destello de luz y luz estable&#44; fue del 69&#44;1&#44; 20&#44;6 y 10&#44;3&#37;&#44; respectivamente&#46; En el an&#225;lisis de regresi&#243;n log&#237;stica&#44; para el destello de luz&#44; solo fue significativo el factor de dosis en v&#237;treo &#40;OR&#58; 1&#44;74&#59; IC 95&#37;&#58; 1&#44;059-2&#44;419&#59; p&#58; 0&#44;001&#41;&#46; Para la luz estable&#44; fueron significativos la dosis en retina &#40;OR&#58; 1&#44;73&#59; IC 95&#37;&#58; 1&#44;121-2&#44;341&#59; p&#58; 0&#44;005&#41; y dosis en humor v&#237;treo &#40;OR&#58; 1&#44;82&#59; IC 95&#37;&#58; 1&#44;335-2&#44;315&#59; p&#58; 0&#44;003&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Existe una relaci&#243;n predictiva entre las dosis de irradiaci&#243;n de la retina y del humor v&#237;treo&#44; para la generaci&#243;n de fosfenos&#46; Estos resultados ayudan a que los centros de radioterapia tomen en cuenta estas estructuras anat&#243;micas para disminuir la presencia de fosfenos en los pacientes&#46; As&#237; mismo contribuir&#237;a a disminuir los fosfenos&#44; manteniendo el &#225;rea del b&#250;nker iluminado durante el tratamiento&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Antecedentes y objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material y m&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultado"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusiones"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background and objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Phosphenes are visual light phenomena that are experienced when there is no apparent light that stimulates the eye&#46; In oncology&#44; phosphenes are also present during radiation therapy for patients with tumors of the central nervous system&#44; eyes&#44; head and neck&#46; Due to the discomfort of patients treated with irradiation to the head regions&#44; research is conducted to determine whether the dose to the ocular structures is predictive for the occurrence of phosphenes&#46; The objective was to demonstrate the relationship between the doses of the retina and vitreous humor with the appearance of phosphenes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A descriptive study was carried out in a prospective cohort in 25 patients older than 18 years&#44; with malignant tumors located at the level of the brain&#44; both of primary and secondary origin&#44; subjected to irradiation in 6<span class="elsevierStyleHsp" style=""></span>MV linear accelerators&#44; during February 2020 to January 2021&#46; As independent variables&#58; Retinal dose and vitreous humor dose&#44; and as dependent variables&#58; Light flashes and stable light&#46; Logistic regression analysis was used for prediction&#44; using the SPSS statistical program &#40;version 26&#46;0&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Result</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A final date of 380 external radiotherapy treatments&#46; The presence of any of the events in a prevalence of 58&#46;7&#37; of the total of fractions&#46; The distribution for the presence of both events&#44; flash of light and stable light&#44; was 69&#46;1&#37;&#44; 20&#46;6&#37; and 10&#46;3&#37; respectively&#46; In the logistic regression analysis&#44; for the light flare&#44; only the dose factor in vitreous was significant &#40;OR&#58; 1&#46;74&#59; 95&#37; CI&#58; 1&#46;059-2&#46;419&#59; p&#58; 0&#46;001&#41;&#46; For stable light&#44; the dose in the retina &#40;OR&#58; 1&#46;73&#59; 95&#37; CI&#58; 1&#46;121-2&#46;341&#59; p&#58; 0&#46;005&#41;&#44; and dose in the vitreous humor &#40;OR&#58; 1&#46;82&#59; 95&#37; CI&#58; 1&#46;335-2&#46;315&#59; p&#58; 0&#46;003&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">There is a predictive relationship between the doses of irradiation of the retina and vitreous humor&#44; for the generation of phosphenes&#46; These results help radiotherapy centers take these anatomical structures into account to reduce the presence of phosphenes in patients&#46; Likewise&#44; it would help to reduce phosphenes&#44; keeping the bunker area illuminated during the treatment&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Material and method"
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            "identificador" => "abst0040"
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        "etiqueta" => "Figura 2"
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Relaci&#243;n entre la dosis humor v&#237;treo y la presencia de evento de destello o luz estable&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">N&#46;&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Ubicaci&#243;n del tumor&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Energ&#237;a &#40;MV&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">Dosis retina &#40;cGy&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Dosis v&#237;treo&#40;cGy&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evento</th><th class="td" title="\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Porcentaje&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">Total fracciones&nbsp;\t\t\t\t\t\t\n
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                  \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="" 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="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><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="" 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">Destellos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Luz estable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ambos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Parietal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">29&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">M&#250;ltiple&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \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
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">M&#250;ltiple&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \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
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parietal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \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
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">M&#250;ltiple&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parietal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parietal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frontal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parietal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">M&#250;ltiple&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frontal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">M&#250;ltiple&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">M&#250;ltiple&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">M&#250;ltiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">621&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">100&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eventos sumados&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">154&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">223&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">380&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Proporci&#243;n de eventos &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">69&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">58&#44;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Odds ratio</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valor de p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Dosis retina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;701&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;151-2&#44;251&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;731&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;121-2&#44;341&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;005&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Dosis v&#237;treo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;059-2&#44;419&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;003&nbsp;\t\t\t\t\t\t\n
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