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"apellidos" => "Corretger" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669120303208" "doi" => "10.1016/j.oftal.2020.07.024" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669120303208?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579420302309?idApp=UINPBA00004N" "url" => "/21735794/0000009600000002/v1_202101300818/S2173579420302309/v1_202101300818/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Short communication</span>" "titulo" => "Early Penetrating Keratoplasty after interface fungal keratitis in Descemet Membrane Endothelial Keratoplasty" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "106" "paginaFinal" => "109" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Á. Sánchez-Ventosa, A. Cano-Ortiz, A. Villarrubia Cuadrado" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Á." "apellidos" => "Sánchez-Ventosa" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Cano-Ortiz" ] 2 => array:4 [ "nombre" => "A." "apellidos" => "Villarrubia Cuadrado" "email" => array:1 [ 0 => "alvillarrubia@hospitalarruzafa.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Instituto de Oftalmología la Arruzafa, Córdoba, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Queratoplastia penetrante temprana después de queratitis fúngica de la interface en la queratoplastia endotelial de la membrana de Descemet" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 985 "Ancho" => 1500 "Tamanyo" => 195922 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Interface keratitis by Candida albicans after Descemet Membrane Endothelial Keratoplasty (DMEK).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Round, whitish and very small infiltrates in the Descemet membrane ten days after DMEK.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(B) Optical coherence tomography showing some infiltrates protruding towards the anterior chamber. There are no signs that the infection has yet penetrated the anterior chamber.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(C) Four days later, the infiltrates are more diffuse and have increased in number and size.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(D) Optical coherence tomography in which it is clear that the infection has passed through the corneal endothelium and has penetrated the anterior chamber.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Endothelial Keratoplasty (EK) has quickly raised in surgical preference over the Penetrating Keratoplasty (PK) when treating endothelial dystrophies such as Fuchs Endothelial Corneal Dystrophy (FECD), or Pseudophakic and Aphakic Bullous Keratopathy. The Eye Bank Association of America reported that between 2007 and 2014 there has been a remarkable increase in EK procedures from 14,159 to 25,965, whereas PK has been reduced from 34,806 to 19,294.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Amongst some known complications in EK are pupillary block, graft dislocation, primary graft failure, endophthalmitis and interface keratitis(IK). Infectious keratitis was predominantly associated with EK in 67% of cases, followed by PK in 29%, anterior lamellar keratoplasty (ALK) and keratoprosthesis(KPro) in 2%. Candida species are the most common pathogen isolated showing a trending increase from 2 cases in 2007 to 13 cases in 2014 in the United States.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Since there are few cases of fungal interface keratitis after DMEK, no therapeutic guidelines have been created. To our knowledge, no case of early-onset fungal interface keratitis treated with successful PK during the active stage of infection has been published.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a>. We describe our diagnosis, follow-up and treatment with PK of a case of fungal interface keratitis after DMEK.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 70 years-old man underwent DSAEK combined with cataract extraction in the right eye secondary to FECD, on September 2, 2008 reaching a corrected distance visual acuity (CDVA) of 20/20. At his routine follow-up appointment on June 6, 2017 he referred severe glare disability and decrease in his right eye’s visual acuity, with CDVA of 20/133. On examination, mild stromal oedema was observed with folds in Descemet membrane and superior epithelial microcysts. A diagnosis of endothelial failure were done and, subsecuently, a DMEK was indicated and performed on his right eye on July 20, 2017 with donor cornea from the eye bank stored in CorneaMax® and transported in CorneaJet® (Laboratoires EUROBIO, Les Ulis Cedex B, France) both supplemented with penicillin/streptomycin and without antifungii medication. Descemet’s membrane and endothelium were stripped the day before and kept in its own broth medium at hermetic conditions. Surgery was uncomplicated <a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and concluded with intracameral injection of 0.1 ml of cefuroxime 0.1 mg/ml.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Donor age was 86 years, the death-to-preservation time was 3 hours, the culture storage duration was 17 days at 31 °C, and endothelial cell density was 2500 cells/mm<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Serologic tests, including HIV antibodies, HBsAg, HBc antibodies, HCV antibodies, anti-HTLV I/II antibodies, anti Trypanosoma cruzi antibodies and rapid plasma reagin were all negative. The rim and solution were cultured after surgery in blood agar, chocolate agar, Sabouraud agar and thioglycollate medium.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Standard topical treatment after surgery consisted of dexamethasone 1 mg/ml and moxifloxacin 5 mg/ml q.i.d., and cycloplegic 10 mg/ml, brimonidine/Timolol 2 mg/ml +5 mg/ml and bromfenac 0.9 mg/ml b.i.d.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was seen in follow-up 5 days later with an unremarkable exploration. On 12<span class="elsevierStyleSup">th</span> day after surgery, the microbiology laboratory called to report growth of Candida albicans. The patient was warned and explored that same day noting several small, round white, creamy appearing, interface infiltrates with no other anterior segment signs of inflammation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A-B). Hence, the treatment was drastically modified removing the corticosteroids and adding oral fluconazole 400 mg b.i.d., and topical fluconazole 2% q.1.d. Culture of the Candida albicans revealed sensibility to flucytosine, fluconazole, caspofungin and micafungin.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Three days after the diagnosis of fungal IK, the patient complained about worse vision, and infiltrates had grown associating a severe Tyndall reaction, hypopion and a fine fibrinous membrane attached to the pupillary margin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C-D). The graft was removed and sent for culture in agar Sabouraud with simultaneous washed-up of AC with BSS and 0.15 ml of fluconazole 1% followed by a PK. Five adjunctive intrastromal corneal injections of 0.15 ml of fluconazole 1% using a 30 G needle were placed intraoperatively in deep stroma at the edge of the graft and at the recipient cornea. Aliquots were prepared the previous day in the laminar flow hood and kept at 4 °C. In this case, donor cornea was stored in Eusol-C supplemented with gentamicin and presented 3000cells/mm<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Postoperative treatment included topical fluconazole 2% q.1.h, moxifloxacin 5 mg/ml q.i.d., ciprofloxacin ointment 3 mg/g b.i.d., cycloplegic 10 mg/ml t.i.d., and nepafenac 3% o.d. Three days later, 200 mg oral fluconazole q.d. was added for the first month after surgery. Dexamethasone 1 mg/ml q.d. was included 18 days after the PK to avoid graft rejection.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">Recovery was uneventful and at 12 months after PK, when all sutures were removed, the uncorrected distance visual acuity (UCVA) reached 20/25 improving to 20/20 with +2.50 (-1.50 at 60º). The specular microscopy showed 2369 cells/mm<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. He was stable on fluorometholone q.d. and artificial tears.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">The median time to onset of infectious keratitis after corneal transplant is of 29 days (1-216 days), whereas fungal infection keratitis have a longer median time to onset of 45 days (3-216 days).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> To the best of our knowledge, almost all IK in DMEK published so far, have been caused by yeast of Candida species.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> excluding a recent case of Mycobacterium chelonae.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">On the whole, 3 single case-reports and a case series of 6 patients have been published on fungal IK after DMEK. These patients were treated either with antifungal medication, DMEK/DSAEK regraft, vitrectomy, or intrastromal, intracameral or intravitreal injections.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5</span></a> There is one single case operated on with PK 8 weeks after diagnosis, being previously treated with antifungal therapy and intracameral injections.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In our experience, we had already a case of early-onset fungal IK after DSAEK, treated with oral, topical and intracameral antifungal medication without success, having to perform a hot PK and a pars plana vitrectomy 21 days after diagnosis since the infection had spread to AC and vitreous chamber, in addition to presenting a severe corneal melting; 4 months later we had to reoperate with another PK and an Ahmed valve implant due to an uncontrollable high intraocular pressure (IOP). Nevertheless, the optic nerve was damaged and there was retinal ischemia reaching a final CDVA hand motion.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Due to this bad experience, once we were aware that the infection was penetrating into AC despite its aggressiveness, we decided to perform an early PK (attached to adjunctive intrastromal corneal injections of fluconazole 1% at the edge of the graft), besides a profuse lavage with BSS with Simcoe's cannula to remove the fibrin, and the use of intracameral antifungals to avoid the passage of the infection to the vitreous chamber.</p><p id="par0065" class="elsevierStylePara elsevierViewall">As far as we know, this is the first case of fungal IK treated promptly with a PK published to date.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The time of preparation is considered a potential factor for a higher incidence of fungal infection after EK. As the graft should be conserved at low temperatures, the large time-consuming preparation process of the tissue alters the hypothermic conditions, increasing the temperature and enhancing a higher risk of fungal infection.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> At the Eye Bank, the usual microbiological controls were carried out and resulted negative before the graft was sent. Since it tested positive in our control, it is likely that dormant candida could have grown due to the fact that the tissue was stripped the day before surgery. Other risk factors proposed to contribute to donor fungal contamination are the cause of death, alcohol abuse and prolonged death-to-preservation time greater than 12 hours.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It has also been proposed that in endothelial keratoplasties, the interface resolved to be an optimal and isolated space for inoculation and uncontrolled growth of microorganisms.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Brothers KM et al proved that storage media at room temperature have a considerable increase in growth of pathogenic yeast during presurgical corneal processing, and thus, it should be limited as far as possible. They also showed that optisol-GS supplemented with either caspofungin or voriconazole was effective at reducing colony-forming unit (CFU) per milimetre of Candida species, not reaching fungicidal results, suggesting that the use of a combination of anti-fungal agents may be required.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Another study, concluded that there were neither viable colonies of C.albicans or C.glabrata in amphotericin B-supplemented vials, determining a reduction by 99% and 96% respectively.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Whenever an infiltrate is located at the interface along the early or late postoperative period of a lamellar keratoplasty, the differential diagnosis of fungal keratitis must be taken into account. Even without signs, if the microbiological report of either the broth or the donor rim is positive for any microorganism, it is necessary to carry out a close examination of the patient, even for months. For this reason, a microbiological study of the donor rim and broth medium should be mandatory after each corneal transplant. So far, both our experience and literature have shown us that an early surgical intervention may be a good option when a fungal infection arise from a contaminated donor graft.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,6,8</span></a>Amongst surgical options, in our opinion, early PK is a good choice when signs of involvement of AC are detected, mainly, to avoid the passage of the infection to the vitreous chamber, which would worsen the prognosis in a remarkable way. Finally, due to the increasing incidence and torpid evolution of fungal infections, supplementation of antifungals to Optisol-GS should be reconsidered to prevent these conditions after EK.</p></span><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0021">Conflict of interests</span><p id="par0001" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1456411" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1327693" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1456412" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1327694" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0001" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-10" "fechaAceptado" => "2020-05-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1327693" "palabras" => array:5 [ 0 => "Endothelial keratoplasty" 1 => "Candida" 2 => "Fungal interface keratitis" 3 => "DMEK" 4 => "Penetrating keratoplasty" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1327694" "palabras" => array:5 [ 0 => "Queratoplastia endotelial" 1 => "Candida" 2 => "Queratitis fúngica de la interface" 3 => "DMEK" 4 => "Queratoplastia penetrante" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">In this case-report we describe the first reported case of early-onset fungal interface keratitis (IK) after Descemet Membrane Endothelial Keratoplasty (DMEK) successfully treated with penetrating keratoplasty (PK) during the active stage of infection. A patient with graft failure after Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) was operated on with DMEK. Donor rim culture and broth were positive for Candida albicans. Several interface infiltrates were confirmed and localized using anterior segment optical coherence tomography. Three days after diagnosis, observing clear signs of intraocular infection, the graft was removed with simultaneous washed-up of anterior chamber with fluconazole 1% followed by a PK and intrastromal corneal injections of fluconazole. A best-corrected visual acuity of 20/20 was achieved. This case highlights the importance of analysing every donor rim and broth, despite the patient doesn’t show any symptoms or signs during the post-operative period. PK is a viable treatment option in early-onset interface keratitis.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Este caso clínico describe el primer caso reportado de queratitis fúngica de la interfaz (QI) de inicio temprano después de una Queratoplastia Endotelial de la Membrana de Descemet (DMEK) tratadas satisfactoriamente con queratoplastia penetrante (QP) durante la etapa activa de la infección. Un paciente con fracaso de injerto después de una Queratoplastic Endotelial Automatizada con Pelado de Descemet (DSAEK) fue intervenido con DMEK. El cultivo y el medio de cultivo del donante dieron positivo para Candida albicans. Se confirmaron y localizaron varios infiltrados de la interface utilizando tomografía de coherencia óptica de segmento anterior. Tres días después del diagnóstico, observándose signos claros de infección intraocular, se retiró el injerto con lavado simultáneo de cámara anterior con fluconazol al 1% seguido de una QP e inyecciones corneales intraestromales de fluconazol. Se consiguió una mejor agudeza visual corregida de 20/20. Este caso resalta la importancia de analizar cada pieza y medio de cultivo de donantes a pesar de que el paciente no exhiba síntomas o signos durante el período posoperatorio. La QP es una opción de tratamiento viable para la queratitis de interface de inicio temprano.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sánchez-Ventosa Á, Cano-Ortiz A, Villarrubia Cuadrado A. Queratoplastia penetrante temprana después de queratitis fúngica de la interface en la queratoplastia endotelial de la membrana de Descemet. Arch Soc Esp Oftalmol. 2021;96:106–109.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 985 "Ancho" => 1500 "Tamanyo" => 195922 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Interface keratitis by Candida albicans after Descemet Membrane Endothelial Keratoplasty (DMEK).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Round, whitish and very small infiltrates in the Descemet membrane ten days after DMEK.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(B) Optical coherence tomography showing some infiltrates protruding towards the anterior chamber. There are no signs that the infection has yet penetrated the anterior chamber.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(C) Four days later, the infiltrates are more diffuse and have increased in number and size.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(D) Optical coherence tomography in which it is clear that the infection has passed through the corneal endothelium and has penetrated the anterior chamber.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Report of the Eye Bank Association of America Medical Review Subcommittee on Adverse Reactions Reported from 2007 to 2014" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.L. 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Early Penetrating Keratoplasty after interface fungal keratitis in Descemet Membrane Endothelial Keratoplasty
Queratoplastia penetrante temprana después de queratitis fúngica de la interface en la queratoplastia endotelial de la membrana de Descemet
Á. Sánchez-Ventosa, A. Cano-Ortiz, A. Villarrubia Cuadrado
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Instituto de Oftalmología la Arruzafa, Córdoba, Spain