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"apellidos" => "Valvecchia" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 4 => array:3 [ "nombre" => "E." "apellidos" => "Barraquer-Compte" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] 5 => array:3 [ "nombre" => "J." "apellidos" => "Fernández" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Facultad de Medicina, Universidad de Málaga, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Fundación Elena Barraquer, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Oftalmología, Vithas Málaga, Málaga, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Qvision, VITHAS Hospital, Almería, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Departamento de Cirugía, Área de Oftalmología, Universidad de Sevilla, Sevilla, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Clínica de Ojos Quilmes, Quilmes, Buenos Aires, Argentina" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Centro de Oftalmología Barraquer, Barcelona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Misiones humanitarias y resultado visual en cirugía de cataratas: revisión de la literatura" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Adequate ophthalmic care for patients in remote areas of developing or underdeveloped countries remains a challenge.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> According to the World Health Organization (WHO), uncorrected refractive errors and cataracts are the most frequent causes of visual impairment and blindness globally,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> with cataract being the cause of visual impairment in approximately 94 million people.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> 90 % of these patients live in developing countries.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although cataract surgery has been shown to be a cost-effective intervention,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> there are many difficulties in performing this procedure in developing countries, where the volume of cataract patients continues to grow.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,8,9</span></a> It has been shown in several studies, which compared the quality-adjusted cost/life-year (QALY) gain of each intervention, that cataract surgery is one of the most cost-effective ophthalmic and non-ophthalmic surgical interventions available.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7,10,11</span></a> Phacoemulsification of cataract improves vision-related quality of life (VR-QOL) as assessed by the American National Eye Institute Visual Function Questionnaire (NEI-VFQ-25).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The main barriers to access to cataract surgery in developing countries are financial difficulty, geographic distance, fear of surgical complications, poor results in some patients and lack of awareness of the possibility of surgery.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13–16</span></a> Advanced age and being a widowed or unmarried woman could also be considered limiting factors, due to the lack of social support in some of these countries.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Humanitarian missions play an important role, carrying out a large number of surgeries in a short period of time and with limited resources.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a> Planning using logistical and humanitarian methods is essential for a successful campaign.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20,21</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Surgical techniques of choice for cataracts have evolved over the years. Initially, intracapsular cataract extraction (ICCE) without intraocular lens implantation (IOL) was the most commonly used technique. However, acceptable visual acuity (VA) was only possible with the use of spectacles, which most patients could not afford.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22–24</span></a> Subsequently, extracapsular surgery (ECCE) with IOL implantation was advocated, due to the better results obtained in VA. Currently, the techniques of choice are ECCE, phacoemulsification with IOL implantation,<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25–27</span></a> and to a greater extent, manual small incision cataract extraction (MSICS).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,28,29</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The quality of cataract surgery depends, to a large extent, on the accuracy of IOL power calculation, which is well known to vary in each patient.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> In the past, due to the difficulties in performing this type of campaign and the high costs, it was advocated to use only one type of IOL, in model and power, or at most a small range of IOL powers to reduce costs. However, with this strategy, an optimal and acceptable visual result was not achieved.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Ocular biometry plays an essential role in ophthalmologic assessment, allowing the calculation of the power of the IOL implanted during cataract surgery. Ultrasound biometry (USB) has been the traditional technique for measuring anterior chamber depth (ACD), axial length (AXL) and lens thickness, with the need to measure keratometry (K) using an external keratometer. USB values can be obtained by contact or immersion biometry, the latter having shown better refractive results.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Optical biometry, on the other hand, being a non-contact technique,represented a new advance in biometric calculation with highly repeatable, reproducible results, generally independent of the observer and interchangeable, thus improving the refractive results of patients.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> The immersion and optical methods could offer comparative results in expert hands according to some studies.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The objective of this work is to review the different technological options available and the results described in different humanitarian campaigns, as well as the strategies described therein, in order to secondarily try to improve their refractive results, based on what has been described to date in the literature.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">A literature review was conducted using the PubMed platform searching for prospective and retrospective studies and case series published up to August 23, 2023 using the terms "humanitarian mission" and "cataract camp" in combination with the keywords "biometry", "keratometry", "intraocular lens", "cataract" and "visual outcome".</p><p id="par0045" class="elsevierStylePara elsevierViewall">Search results:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0050" class="elsevierStylePara elsevierViewall">((Humanitarian mission) OR (cataract camp)) AND (biometry): 7 items.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0055" class="elsevierStylePara elsevierViewall">((Humanitarian mission) OR (cataract camp)) AND (keratometry): one item.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0060" class="elsevierStylePara elsevierViewall">((Humanitarian mission) OR (cataract camp)) AND (intraocular lens): 30 articles.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0065" class="elsevierStylePara elsevierViewall">((Humanitarian mission) OR (cataract camp)) AND (cataract): 128 items.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0070" class="elsevierStylePara elsevierViewall">((Humanitarian mission) OR (cataract camp)) AND (visual outcome): 36 articles.</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">A review was made of all the abstracts published in Spanish and English. Duplicate articles were checked including only the original version. A total of 202 abstracts were considered for the article; 157 articles were excluded because they were not relevant to the review, resulting in a final number of 49 articles.</p><p id="par0080" class="elsevierStylePara elsevierViewall">All articles were read and their respective references were cross-checked, identifying 10 articles that had not been found in the initial search and were included in the review.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Finally, a total of 60 articles were included in the review.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results and discussion</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Devices used and anatomical population measurements</span><p id="par0090" class="elsevierStylePara elsevierViewall">According to the publications, the most commonly used biometers in the humanitarian campaigns were: A-Scan Model 300AP (Sonomed®, USA)<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,33</span></a>; INC.5500 Ultrasound A-scan machine (Sonomed®, USA)<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>; A-Scan Palmscan AP2000 (Micromedical Devices®, USA)<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and A-Scan (Alcon®, Geneva, Switzerland) Ocuscan (Alcon®, Switzerland).<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35–37</span></a> The most commonly used keratometers were: Retinomax (AJL Ophthalmic®, Spain) <a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,37</span></a>; Bausch & Lomb Keratometer (Bausch & Lomb®, USA)<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>; Nidek KM 500 (Bimedis®, USA)<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,33</span></a>; Auto Ref-Keratometer (Rodenstock®, Germany) CX500<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> and Javal-Schiotz (Haag-Streit®, Switzerland).<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Multiple studies have described the means of the main ocular biometric population parameters of different ethnicities from developing countries such as Ethiopia,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Nepal, Vietnam<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> and Kenya<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">From the table we can extract some interesting data, such as the results from the Ethiopian population suggesting that AXL could be influenced by sex in a statistically significant way.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> These results of higher AXL in men are also supported by the study in Nepal by Baral et al.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> A somewhat higher mean AXL was found in the Nepalese and Kenyan populations.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,35</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The main formulas used by the authors for the calculation of IOL power were SRK-T and SRK-II.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,30,33,35</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Visual results</span><p id="par0110" class="elsevierStylePara elsevierViewall">According to WHO criteria, based on postsurgical VA measured with the Snellen scale (6 m), we can classify visual outcomes as good (VA 6/6-6/18), intermediate (6/24-6/60) and poor (<6/60).<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Globally, more than 80% of patients are expected to obtain a postoperative VA greater than or equal to 6/24 and best-corrected distance visual acuity equal to or greater than 6/24 in more than 90%.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Humanitarian missions that have used standard IOLs (without biometry for their calculation) in developing countries have generally reported good visual results and, in addition, an easier to manage inventory and lower costs.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> However, on many occasions they have been shown to be below the standards recommended by the WHO.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,42</span></a><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the visual results obtained with IOL implantation after cataract surgery. The improvement in visual outcomes with the use of biometry for IOL calculation and correction of the postoperative refractive error is noteworthy.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Briesen et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> published their results of an expedition in Kenya in which 267 eyes (82.2%) of 239 patients they operated on achieved an BCVA of 6/18 or better. Similarly, they report that the comorbidity of the patients prevented better results. An expedition in northeastern Thailand reported visual results in which the mean uncorrected VA went from 20/327 to 20/57, an improvement of 7.5 lines on the Snellen test. In addition, they gave patients glasses for near and far vision, achieving an BCVA for the far of 20/43.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Farmer et al.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> published the results of a cohort of patients who underwent surgery in a humanitarian mission in Bali (Indonesia). Ninety-nine point eight percent of the patients had a preoperative BCVA of less than 6/60. Six months after surgery 85% of patients had an BCVA of 6/18 by far.</p><p id="par0130" class="elsevierStylePara elsevierViewall">On the other hand, Ezeggui and Ajewole<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> published the results of an expedition in Nigeria in which biometry was not used due to lack of availability. They used the refraction of the other eye as a guide for IOL calculation. At 12 weeks after surgery, according to WHO criteria, 35.4% of patients had good VA, 50% had intermediate VA and 14.6% had poor VA. They reported that the main cause of these results, in addition to the lack of biometry, is the comorbidity of the patients because they could not diagnose lesions such as macular chorioretinal scars or diabetic retinopathies until after surgery. In addition, corneal opacity may limit visual prognosis, being related to worse visual outcomes post-surgery.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">The importance of biometrics</span><p id="par0135" class="elsevierStylePara elsevierViewall">Postoperative emmetropia is of great relevance, and this fact in underdeveloped countries is extremely important since their population generally has limited access to subsequent optical correction, with glasses or contact lenses to achieve adequate VA, thus decreasing their quality of life if they do not achieve emmetropia or at least low refractive errors postoperatively.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the past, some studies advocated using an IOL of a standard power for each population, or having a small range of IOL powers to decrease the costs of intervention. However, with this strategy, many patients would achieve suboptimal results due to the resulting refractive errors.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Under optimal conditions, corneal refractive power (K) and AXL or ACD values are readily available for IOL calculation, although complete biometry is not always available in developing countries.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Refractive surprises are relatively frequent in these situations where the reference standard for IOL calculation has unfortunately not yet been implemented.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Ezegwui and Ajewole published the results of cataract surgery using the ECCE technique with standard power posterior chamber IOL implantation in a mission in Nigeria. Biometry was not performed due to lack of availability. Therefore, the refraction of the other eye was taken into account when deciding IOL power. In case of bilateral cataracts, an IOL of power between 20 and 22D was used. At 12 weeks after surgery, 35.4% of patients had good VA, 50% had intermediate VA and 14.6% had poor VA.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> On the other hand, Kassa et al. in their study described that, if instead of calculating the IOL power for each patient they chose to implant an IOL of average power for the Ethiopian population, 10% of the eyes operated on for cataract would have presented a refractive error greater than or equal to 6D.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Similar results were published by Briesen et al. in Kenya. Without biometry, 20% of patients would have a refractive error of more than 2D after implantation of a standard IOL (+22D), which is equivalent to a VA of 6/60, and 7% would have a refractive error of more than 3D, with a VA < 6/60. Only 57% of eyes would have an optimal refractive outcome (+1 and −1.5D). However, using IOLs with USB-calculated powers, 71% of the patients in the study obtained a good refractive outcome. They reported that with an optimized A constant good refractive outcomes would have been expected in more than 80% of patients.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,35</span></a> Similarly, Antwi-Adjei et al. concluded that BCVA after surgery seems to be related to the performance of pre-surgical biometry.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> With these data we can infer that the visual results published in campaigns in which biometry was used could be superior, giving a more accurate refraction to the patients who underwent surgery.</p><p id="par0150" class="elsevierStylePara elsevierViewall">On the other hand, Lombard et al. described a prediction model based on the tolerance strategy to determine the optimal IOL set, minimizing IOL number and cost, while allowing more than 95% of patients to receive an IOL of adequate power. In their study, they generated multiple hypothetical random populations of patients to calculate the theoretical standard deviation (SD) from the Gaussian distribution at each IOL power. A statistical model was applied to empirically determine an algorithm to calculate the ideal number of IOLs required at each power. This showed that the SD of the number of IOLs for each power was equal to the square root of the mean number of IOLs for that power. However, the number of IOLs required would be excessive. Based on this, they developed the tolerance strategy. With this strategy all patients would receive IOL powers calculated for emmetropia until no more IOLs of that power were available. In the latter case, the tolerance strategy would allow the surgeon to choose one of the higher or lower power IOLs available up to 1.0D above or 0.5D below the emmetropic IOL power. A statistical model was used to vary the parameters in the formula for IOL distribution depending on the tolerance strategy. The resulting formula would decrease the likelihood of a patient being rejected due to unavailability of an adequately powered IOL, while limiting the number of excess IOLs. It was empirically observed that, if N<span class="elsevierStyleInf">ideal</span> is equal to the number of IOLs for each given power for the population as a whole, the following formula would allow determining the number of IOLs in a given power to order for a mission (<span class="elsevierStyleItalic">N</span> = <span class="elsevierStyleItalic">N</span><span class="elsevierStyleInf">ideal</span> + 0.75 × (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleInf">ideal</span>)0.25), where the number of extra IOLs required for each IOL power is proportional to the fourth root of the mean number of IOLs required for that power.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Although numerous formulas are currently available that yield optimal refractive results<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> their use requires biometers and keratometers that, again, are often not yet available to the majority of people in less developed countries. Therefore, there is still a need to improve the accuracy of IOL calculation to minimize residual refractive errors, improving surgical outcomes and the quality of life of these patients.</p><p id="par0160" class="elsevierStylePara elsevierViewall">The role of keratometry</p><p id="par0165" class="elsevierStylePara elsevierViewall">On the other hand, accurate preoperative mean keratometry (Km) measurement is of great importance for IOL power calculation and prediction of postoperative refraction, since most formulas for IOL power calculation are based on Km, AXL and ACD.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> Furthermore, different articles have published that there are statistically significant differences in Km according to sex, which could affect the calculation of final IOL power<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,33,35,38</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0170" class="elsevierStylePara elsevierViewall">However, lack of resources or the presence of patient comorbidity may prevent the acquisition of these measures. In their study, Schmitz et al. described that there is a negative correlation between Km and AXL (<span class="elsevierStyleItalic">r</span><span class="elsevierStyleSup">2</span> = 0.34; <span class="elsevierStyleItalic">p</span> < 0.01). They propose that, if Km is not available, the Km estimated from the measured AXL could allow us to calculate IOL power with better results than if we used a standard power IOL or the standard Km together with the measured AXL. Employing Deming regression analysis, the formula for estimating K from the measured AXL was obtained (<span class="elsevierStyleItalic">K</span> = 74.56−1.317 × AXL). The mean absolute absolute refractive error (MAE) using the K estimated by this formula from the measured AXL was 0.90D. The MAE using the standard mean K and measured AXL to calculate IOL power was 1.11D. They report that, if AXL is not available, implanting a standard IOL for this population offers better postoperative refractive outcomes.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Therefore, it could be pointed out that whenever possible the incorporation of keratometric devices to calculate the Km could improve the refractive results. However, taking into account the lack of such devices in certain circumstances, theoretical formulas could be used to improve the results.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Ocular comorbidity</span><p id="par0180" class="elsevierStylePara elsevierViewall">Garay-Aramburu et al.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> described the main characteristics prior to cataract surgery that determine the presence of a final residual refractive error in a study conducted in a Spanish population. The risk factors for a spherical equivalent (SE) ≥  ± 1 are ocular comorbidity, the presence of white or hard cataract, and low presurgical VA. In their study they consider extreme biometric data, as well as the use of biometric formulas other than Barrett Universal II to be risk factors for obtaining a refractive outcome worse than ±1D. In addition, they consider the use of USB as a risk factor, obtaining differences in IOL power between USB and optical greater than or equal to 1D, as Chehab et al. reported in their study.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48,49</span></a> It is well known that this technology is not widely available in developing countries and, therefore, it is essential to train the personnel performing the biometry to do it correctly because it is an operator-dependent technique. However, different authors report that there is a good correlation between measurements performed with immersion and optical USB, with immersion biometry even being a better option in cataracts with high opacity in which quality optical biometry cannot be obtained.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,49,50</span></a> Gonzalez et al. compared the results of ICP, SS and immersion USB optical biometry in dense cataracts. Reliable AXL measurements were obtained in 100% of cataracts with immersion biometry, 78.57% with SS and only 31.43% with ICP biometry. The impossibility of measuring AXL in cataracts with ON5-ON6 nuclear opacity (ON), mixed cataracts with cortical and posterior subcapsular component and intumescent cataracts with optical biometry was evidenced.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Other studies consider the type of surgical technique performed and the surgeon's skill<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40,52,53</span></a> as risk factors for postoperative residual refractive error.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Socioeconomic level and sex do not seem to significantly influence the visual outcome of cataract surgery according to some authors, while age is related to poor visual outcomes, being 2.5 times more likely after 85 years of age, due to ocular comorbidity.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> However, there is some controversy regarding socioeconomic level, as other studies relate better visual outcomes with higher socioeconomic levels, due to the greater use of biometry and access to a wider range of IOL powers.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The main cause of poor visual outcomes has been identified as the patient's comorbidity, so it is essential to perform a complete preoperative examination and discard patients who are unlikely to benefit from the procedure.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,54,55</span></a> It is essential to explore the cup/disc ratio by ophthalmoscopy and, in case of suspicion, to take intraocular pressure if available. Funduscopy should be performed, preferably in mydriasis, in those patients with a VA less than 6/12 in either eye, to rule out underlying ocular disease, especially if the low VA is not due to refractive error, corneal or crystalline lens opacity.<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54,56</span></a> Corneal opacity may alter the ocular biometric parameters necessary for IOL power calculation.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> In cases where fundus visualization by ophthalmoscopy is not possible, it is recommended to perform, if resources allow, a preoperative B-mode ocular ultrasound, discarding cataract surgery in the presence of retinal detachment or suspicious mass in the posterior pole.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> Age-related macular degeneration, optic atrophy, macular hole, macular atrophy and glaucoma are the main causes of poor postoperative visual outcomes. Other causes would be refractive errors, surgical complications (mainly posterior capsule rupture) and posterior capsule opacification.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,54,55,58</span></a> Posterior capsule opacification could be related to inadequate cortex aspiration and the type of IOL implanted.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> The use of IOLs with a shape and material that reduce the risk of posterior capsule opacification and the provision of more YAG laser installations could be possible solutions to reduce the prevalence of this problem. However, given the difficulty in making this technology available in developing countries, other authors advocate the introduction of primary posterior capsulorhexis.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Postoperative glasses</span><p id="par0195" class="elsevierStylePara elsevierViewall">Several authors have studied the impact of postoperative refraction on visual function after cataract surgery with IOL implantation. A study in Thailand, in which +2.50D reading glasses were provided to 57% of patients and distance glasses after refraction to 43% of patients after cataract surgery, showed an improvement in distance VA from 20/57 to 20/43 with glasses. However, although the total visual function questionnaire score (WHO/PBD-VFQ-20) improved after cataract removal statistically significantly (2.88–1.91), it did not improve significantly after spectacle correction, although it did improve for the global vision subscale (2.59–2.00) after refraction, the color vision subscale and the near vision subscale (2.04–1.87) statistically significantly. Of note is the fact that only 1/3 of the patients wore their glasses daily. These results could be related mainly to the level of education and type of work.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Possible areas of performance improvement</span><p id="par0200" class="elsevierStylePara elsevierViewall">It is imperative to improve the quality of cataract services in resource-poor countries. This requires new interventions focused on improving the WHO's seven core elements of quality: effectiveness, efficiency, equity, integration, people-centered care, safety and punctuality.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The performance of biometry in all patients prior to cataract surgery is imperative to improve the quality of cataract surgery. Under optimal conditions, it would be ideal to perform pre-surgical optical or SS biometry on all patients and to have US biometry, preferably immersion biometry for those cataracts in which measurement is not possible due to their density or lack of fixation. In addition, performing pre-surgical keratometry on all patients would optimize the calculation of IOL power and, therefore, improve post-surgical refractive outcomes. There are portable keratometers that could be useful and accessible on expeditions (Nidek KM 500 (Bimedis®, USA), HandyRef-K/ HandyRef® Portable Refractometer/Keratometer).</p><p id="par0210" class="elsevierStylePara elsevierViewall">In a population where resources are limited and the prevalence of dense and intumescent cataracts is higher, due to less access to cataract surgery, it seems evident that the best option is to have a keratometer, together with US biometry, preferably immersion biometry, allowing surgery to be performed effectively and with efficient results, while favoring patient-centered care in an equitable manner regardless of the type of cataract. However, on the downside, immersion biometry is known to be technically dependent and can be time-consuming in inexperienced hands.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusion</span><p id="par0215" class="elsevierStylePara elsevierViewall">The application of individualized keratometry and biometry techniques for the purpose of calculating IOL power has proven to be effective in reducing residual refractive errors that may arise after cataract surgery. This practice optimizes both the quality of the surgical procedure and the patients' quality of life. It is therefore pertinent to evaluate the adoption of keratometry and biometry, at least USB, preferably immersion as the reference standard in the presurgical evaluation of cataract surgery in developing countries.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Funding</span><p id="par0220" class="elsevierStylePara elsevierViewall">There has been no funding for the preparation of the manuscript.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">No conflicts of interests were declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2190273" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1843228" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2190272" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1843227" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results and discussion" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Devices used and anatomical population measurements" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Visual results" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "The importance of biometrics" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Ocular comorbidity" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Postoperative glasses" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Possible areas of performance improvement" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-09-05" "fechaAceptado" => "2023-12-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1843228" "palabras" => array:6 [ 0 => "Humanitarian mission" 1 => "Cataracts" 2 => "Biometry" 3 => "Keratometry" 4 => "Visual outcome" 5 => "Intraocular lens" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1843227" "palabras" => array:6 [ 0 => "Misión humanitaria" 1 => "Cataratas" 2 => "Biometría" 3 => "Queratometría" 4 => "Resultado visual" 5 => "Lente intraocular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The limited accessibility to ophthalmological services in remote regions of developing countries poses a significant challenge in visual healthcare. Cataracts and refractive errors are prominent causes of visual impairment, and surgery, despite being an efficient option, faces barriers in developing countries due to financial and geographical constraints. Humanitarian missions play a vital role in addressing this issue. The improvement in the accuracy of calculating IOL power through techniques such as keratometry and biometry is a fundamental step towards optimizing surgical outcomes and the quality of life for patients in these underserved regions. In this context, the consideration of keratometry and immersion ultrasound biometry as preoperative assessment standards in cataract surgeries in developing countries is presented as a pertinent and advisable strategy.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La limitada accesibilidad a servicios oftalmológicos en regiones remotas de países en desarrollo plantea un desafío significativo en la atención de la salud visual. Las cataratas y los errores refractivos son causas prominentes de discapacidad visual, y la cirugía, a pesar de ser una opción eficiente, enfrenta barreras en países en vías de desarrollo debido a restricciones financieras y geográficas. Las misiones humanitarias desempeñan una función vital en la mitigación de esta problemática. La mejora en la precisión del cálculo de la potencia de la LIO a través de técnicas como la queratometría y la biometría es un paso fundamental hacia la optimización de los resultados quirúrgicos y la calidad de vida de los pacientes en estas regiones desfavorecidas. En este contexto, la consideración de la queratometría y la biometría de ultrasonido de inmersión como estándares de evaluación prequirúrgica en cirugías de cataratas en países en desarrollo se presenta como una estrategia pertinente y recomendable.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Km: mean keratometry; AXL: axial length; IOL: intraocular lens; SD: standard deviation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study \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">Km ± SD (D) \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">Km male ± SD (D) \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">Km female ± SD (D) \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">AXL mean ± SD (mm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AXL male ± SD (mm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AXL female ± SD (mm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Average IOL power \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">Average IOL power male \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">Medium power female IOL \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kassa et al. (Ethiopia) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.98 ± 0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.12 ± 1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.88 ± 1.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.34 ± 0.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Murchison (Nepal) \t\t\t\t\t\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">43.69 ± 1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\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">23.08 ± 1.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.36 ± 3.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Baral et al. (Nepal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.11 ± 1.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43.76 ± 1.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.46 ± 1.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.68 ± 0.88 \t\t\t\t\t\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">22.85 ± 0.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.50 ± 0.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.60 ± 1.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.46 ± 1.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.74 ± 1.74 \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">Nauze et al. (Vietnam) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.24 ± 1.53 \t\t\t\t\t\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">43.97 ± 1.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.44 ± 1.49 \t\t\t\t\t\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">22.96 ± 0.99 \t\t\t\t\t\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">23.28 ± 0.99 \t\t\t\t\t\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">22.75 ± 0.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.44 ± 2.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.72 ± 2.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.94 ± 2.60 \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">Briesen et al. (Kenya) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.98 ± 1.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><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">23.44 \t\t\t\t\t\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">23.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.56 ± 1.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Briesen et al. (Kenya) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.99 ± 1.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43.99 ± 1.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\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">23.35 ± 1.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.64 ± 0.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.35 ± 2.03 \t\t\t\t\t\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">22.65 ± 1.72 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3580862.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Comparison of mean keratometry, axial length, IOL power between sexes in different studies.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">BCVA: best corrected visual acuity; UCVA: uncorrected visual acuity; D: diopters; IOL: intraocular lens; NE: not specified.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study \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">Biometrics \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">IOL \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">UCVA post-surgery (Snellen) \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">BCVA post-surgery (Snellen) \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">Population \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Briesen et al.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> \t\t\t\t\t\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">Yes \t\t\t\t\t\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">Calculated individual (+17 to +27D) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥6/18 (82%) \t\t\t\t\t\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">Kenya \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">Maki et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> \t\t\t\t\t\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">NE \t\t\t\t\t\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">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20/57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20/43 \t\t\t\t\t\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">Thailand \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">Farmer et al.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> \t\t\t\t\t\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">Yes \t\t\t\t\t\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">Calculated individual (+0 to +30D) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥6/18 (85%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Indonesia (Bali) \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">Ezegwui and Ajewole<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> \t\t\t\t\t\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">No \t\t\t\t\t\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">Based on refraction of fellow eye or standard IOL (+20 to +22D) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥6/18 (8.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥6/18 (35.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nigeria \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3580861.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Visual results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:60 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biometry in cataract camps: Experiences from north Kenya" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. 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