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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 108  |  Issue : 3  |  Page : 117-123

Implantation of posterior chamber foldable intraocular lens in the absence of adequate capsular support: iris fixation versus scleral fixation


Ophthalmology Departement, Zagazig University, Zagazig, Egypt

Date of Submission17-Jan-2015
Date of Acceptance17-Jan-2015
Date of Web Publication30-Oct-2015

Correspondence Address:
Tamer Gamal Elsayed
Zagazig Sharqeyia, 44519
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.168681

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  Abstract 

Purpose
The aim of the study was to evaluate and compare the advantages and disadvantages of iris fixation with scleral fixation of posterior chamber foldable intraocular lenses (IOLs) in eyes without adequate capsular support.
Patients and methods
Aphakic eyes without adequate capsular support and planned to be corrected with posterior chamber foldable IOL implantation were randomly distributed between two groups. Group A included eyes treated with the scleral fixation technique and group B included eyes treated with the iris suture fixation technique. Preoperative, intraoperative, and postoperative data included uncorrected and best-corrected visual acuity, refraction, intraocular pressure, signs of anterior segment inflammation, areas of capsular remnants, vitreous prolapse, surgical time, intraoperative difficulties, IOL malposition, and postoperative complications. Patients were followed up for at least 6 months.
Results
Eighty eyes were randomly distributed between two groups; each included 40 eyes. The mean duration of surgery was 48.3 ± 12.6 min in group A and 38.9 ± 7.8 min in group B (P < 0.05). The grades of anterior chamber cells and flare were higher in group B than in group A, and the differences were statistically significant (P < 0.05) until the first week only. IOL tilt was found in seven (17.5%) eyes in group A and in two (5%) eyes in group B (P < 0.05). After 6 months, the mean best-corrected visual acuity was 0.82 ± 0.28 in group A and 0.77 ± 0.22 in group B (P > 0.05). Macular edema was found in two (5%) eyes in group A and in five (12.5%) eyes in group B (P < 0.05). Except for two eyes in group B, none of the eyes in either group required antiglaucoma treatment.
Conclusion
In the absence of adequate capsular support, fixation of posterior chamber foldable IOL by iris suturing is associated with significantly less IOL malposition and consumes a shorter operative time compared with scleral fixation. However, iris suture fixation is associated with a higher incidence of postoperative iridocyclitis in the early postoperative period.

Keywords: Iris fixation foldable intraocular lens, posterior chamber foldable intraocular lens in the absence of capsular support, scleral fixation foldable intraocular lens


How to cite this article:
Elsayed TG, Solaiman KA, Shawky MM, Elmasry AM. Implantation of posterior chamber foldable intraocular lens in the absence of adequate capsular support: iris fixation versus scleral fixation. J Egypt Ophthalmol Soc 2015;108:117-23

How to cite this URL:
Elsayed TG, Solaiman KA, Shawky MM, Elmasry AM. Implantation of posterior chamber foldable intraocular lens in the absence of adequate capsular support: iris fixation versus scleral fixation. J Egypt Ophthalmol Soc [serial online] 2015 [cited 2022 Sep 28];108:117-23. Available from: http://www.jeos.eg.net/text.asp?2015/108/3/117/168681


  Introduction Top


Intraocular lens (IOL) placement in eyes without adequate capsular support can be achieved in several ways, including anterior chamber angle-supported IOLs, anterior chamber iris-fixated IOLs, posterior chamber iris-fixated IOLs, and posterior chamber scleral-fixated IOLs. Although the anterior chamber IOL is easily inserted, ensuring proper size of the lens and its fixation in the angle can be difficult. As a result, these lenses have been associated with increased risk for glaucoma, iritis, and corneal edema [1]. In contrast, posterior chamber IOL implantation is the most suitable method for IOL implantation as it preserves the eye anatomy. Being nearer to the nodal point, it achieves better optical correction and less pseudophacodonesis [2].

Trans-scleral fixation of a polymethyl methacrylate (PMMA) IOL through a large incision is the traditional surgical method that most surgeons prefer to use in aphakic eyes without enough capsular support. However, after the appearance of the foldable IOL, trans-scleral fixation of posterior chamber foldable IOLs in such eyes through a small incision takes less operative time and results in fewer complications and achieves better visual outcomes [3]. The first trial of iris-sutured posterior chamber IOL dates back to 1976, when McConnell proposed the idea of a retrievable suture that the surgeon could pass through anterior segment tissues [4]. Stutzman and Stark [5] conceived a method for suturing foldable IOLs to the iris through a small incision, eliminating relatively traumatic surgery with incisions much larger than those routinely required for modern cataract surgery. Thus, the aim of this study was to evaluate and compare the advantages and disadvantages of iris suture fixation versus scleral fixation of posterior chamber foldable IOLs in eyes without adequate capsular support.


  Patients and methods Top


This was a prospective interventional comparative randomized study that was performed between October 2011 and September 2014 in Ophthalmolgy Department, Zagazig University Hospitals, Egypt. It included aphakic eyes with accidental rupture of the posterior capsule during phacoemulsification in which no primary sulcus-fixed IOL could be implanted because of the absence of adequate capsular support. Eyes with significant corneal opacities or edema, elevated intraocular pressure (IOP), active anterior segment inflammation, posterior segment pathology, and those with sector iridectomy or aniridia were excluded. Fully informed consent was obtained from each patient. Eyes were randomly distributed between two groups according to their order of presentation, so that eyes with even numbers were included in group A and those with odd numbers were included in group B. Eyes of group A were subjected to scleral fixation of posterior chamber foldable IOLs, whereas eyes of group B were subjected to iris fixation of posterior chamber foldable IOLs.

All surgeries were performed under general anesthesia by the same surgeon. A full history was taken from each patient before surgery. All eyes were subjected to a complete ophthalmic examination before surgery, including visual acuity (unaided and best corrected), IOP, signs of anterior segment inflammation, examination of the iris and shape of the pupil, areas of capsular remnants, vitreous prolapse, and fundus. Macular optical coherence tomography was performed on all eyes preoperatively and at 1 week and 6 months postoperatively. Follow-up visits were carried out daily during the first week, then weekly during the first month, and then monthly up to 6 months. At each visit after surgery, eyes were subjected to a full ophthalmic examination as was done before surgery in addition to IOL stability, tilt, and decentration. IOL decentration was measured by evaluating the distance between the edge of the optic and the edge of the fully dilated pupil or the limbus if the pupil was distorted. IOL tilt was detected in this study by the slit lamp beam method. Also, any increase in astigmatism after surgery is attributed partly to the IOL tilt. The difference between the preoperative and postoperative cylindrical correction would be an indicator of the degree of the IOL tilt.

Scleral fixation of posterior chamber foldable intraocular lenses

Half-thickness rectangular 3*2 mm scleral flaps were applied superotemporally and inferonasally, unless a useful capsular remnant was found; the sites were adjusted so that the haptics were placed above them. A double-armed 10/0 prolene suture on straight and curved needles was used and the straight needle was introduced 1 mm behind the limbus directed perpendicularly toward the midvitreous until it appeared in the pupil; it was then redirected to be parallel to the iris plane. On the opposite site, an insulin syringe with a 27-G needle bent 120° was introduced in the same way until it met the straight needle. The 27-G needle was then withdrawn, carrying in its hollow the straight needle of 10/0 prolene out of the scleral bed at the desired exit site. A 3.00-mm clear corneal tunnel was made and the prolene suture was withdrawn through it and cut. Each of the two ends was tied to the corresponding haptic of the foldable acrylic IOL at the junction of the inner 2/3 and outer 1/3 of the haptic. Thereafter, the lens with suture at each haptic was folded and grasped using McPherson forceps and implanted through the clear corneal tunnel with the lower haptic as the leading haptic, accompanied by gentle tension of the prolene suture to guide the haptic. The tension on both haptics was adjusted so that the IOL was seen to be well centered. The curved needle at the lower end of the suture was passed in the sclera just near the suture exit, making a loop to which the suture was tied. The same was repeated in the other site after the long needle was bent to facilitate its passage in the sclera. The knot was trimmed and the scleral flap was closed with 10/0 silk sutures. The corneal tunnel was closed using stromal hydration or a 10/0 suture if needed.

Iris suture fixation posterior chamber foldable intraocular lenses

With the pupil not dilated, a 3.00-mm clear corneal tunnel was made and the anterior chamber was filled with a viscoelastic substance. Two paracenteses each of 90° from the main corneal tunnel and directed toward the center of the cornea were made. A double-armed 10/0 prolene suture on straight needles (STC-610/0 Prolene 16 mm, 23 cm; Ethicon, New Jersey, USA) was tied to the middle of one haptic of the foldable posterior chamber IOL. Thereafter, one needle was introduced through the main corneal incision into the pupil to pierce the iris midperiphery opposite the first paracentesis and was pulled out of the eye through the paracentesis. The same was repeated with the other haptic at the opposite paracentesis. The foldable posterior chamber IOL was grasped and introduced through the main corneal incision to be implanted in the posterior chamber guided by gentle traction on the prolene sutures on both sides. The two ends of each prolene suture were tied on the iris and cut through the paracentesis. The two paracenteses and the main corneal tunnel were closed using stromal hydration or a10/0 silk suture if needed.

Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) program, version 16 (SPSS Inc., Chicago, Illinois, USA). The Student t-test was used to compare results between groups, and the paired t-test was used to compare preoperative and postoperative results within the same group. P values less than 0.05 were considered significant.


  Results Top


The study included 80 aphakic eyes (76 patients) that were randomly distributed between two groups (A and B) according to their order of presentation. Each group comprised 40 eyes. In four patients both eyes were involved, and one eye from each of them was included in each group. In group A, 23 (57.5%) were male and 17 (42.5%) were female and the mean age was 51.6 ± 21.3 years. In group B, 24 (60%) were male and 16 (40%) were female and the mean age was 55.3 ± 19.2 years. The mean duration between cataract extraction and the secondary IOL implantation was 6.34 ± 2.15 months in group A and 5.41 ± 1.93 months in group B, with no statistically significant differences between groups (P > 0.05).

In group A, the mean uncorrected visual acuity (UCVA) was 0.039 ± 0.21 and the mean best-corrected visual acuity (BCVA) was 0.75 ± 0.53 before surgery. One week after surgery, the mean UCVA was 0.63 ± 0.23 (P < 0.05) and the mean BCVA was 0.70 ± 0.36 (P > 0.05). One month after surgery, the mean UCVA was 0.67 ± 0.27 (P < 0.05) and the mean BCVA was 0.79 ± 0.31 (P > 0.05). After 6 months, the mean UCVA was 0.68 ± 0.25 (P < 0.05) and the mean BCVA was 0.82 ± 0.28 (P > 0.05) [Table 1].

In group B, the mean UCVA was 0.028 ± 0.19 and the mean BCVA was 0.77 ± 0.61 before surgery. One week after surgery, the mean UCVA was 0.60 ± 0.33 (P < 0.05) and the mean BCVA was 0.70 ± 0.36 (P > 0.05). One month after surgery, the mean UCVA was 0.68 ± 0.37 (P < 0.05) and the mean BCVA was 0.76 ± 0.21 (P > 0.05). After 6 months, the mean UCVA was 0.71 ± 0.25 (P < 0.05) and the mean BCVA was 0.77 ± 0.22 (P > 0.05) [Table 1].
Table 1: The mean preoperative and 6 months' postoperative results in group A and group B

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Before IOL implantation, the mean cylindrical correction was 1.72 ± 0.24 D in group A and 1.78 ± 0.20 D in group B (P > 0.05). One week after surgery, the mean cylindrical correction was 3.56 ± 0.98 D in group A and 2.46 ± 0.36 D in group B (P < 0.05). After 1 month, the mean cylindrical correction was 3.39 ± 0.92 D in group A and 2.47 ± 0.35 D in group B (P < 0.05). Six months after surgery and after removal of corneal stitches if any, the mean cylindrical correction was 2.87 ± 0.67 D in group A and 1.99 ± 0.41 D in group B (P < 0.05) [Table 2].
Table 2: Mean cylindrical correction ± SD before and after surgery in group A and group B

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The mean central corneal thickness (CCT) before surgery was 505.5 ± 29.5 μm in group A and 503 ± 31.1 μm in group B (P > 0.05). One week after surgery, the mean CCT was significantly increased to 565.6 ± 45.1 μm in group A and to 544 ± 47.6 μm in group B (P < 0.05). However, 1 month postoperatively the mean CCT returned to near its preoperative values: 511.6 ± 37.5 μm in group A and 513.1 ± 37.9 μm in group B (P > 0.05).

Before IOL implantation, the mean IOP before surgery was 15.8 ± 2.8 mmHg in group A and 15.3 ± 2.3 mmHg in group B (P > 0.05). One day after surgery, the mean IOP showed a nonsignificant increase to 17.8 ± 4.2 mmHg in group A and to 18.3 ± 3.9 mmHg in group B (P > 0.05). Antiglaucoma treatment to control IOP was required in six eyes in group A and in eight eyes in group B. However, this decreased to one eye in group A and to four eyes in group B by 1 month. At the sixth month, except for two eyes in group B none of the eyes in either group required antiglaucoma treatment. The two eyes in group B each required only one topical medication to control IOP. At the last visit, the mean IOP was 15.4 ± 2.1 in group A and 16.3 ± 2.9 mmHg in group B (P > 0.05). No eye in either group required surgery to control IOP [Table 1].

The mean duration of surgery was 48.3 ± 12.6 min in group A and 38.9 ± 7.8 min in group B (P < 0.05). Anterior vitrectomy was performed in 24 (60%) eyes in group A and in 20 (50%) eyes in group B (P > 0.05). Ciliary bleeding during needle passage occurred in six (15%) cases in group A, whereas iris bleeding occurred in two (5%) cases in group B.

Signs of postoperative anterior segment inflammation in both groups were reported on the first postoperative day, after 1 week and after 1 month. The grades of anterior chamber cells and flare were higher in group B than in group A, and the differences were statistically significant (P < 0.05) until the first week, after which the differences were not statistically significant (P > 0.05). Postoperative inflammatory membrane was detected in two eyes (5%) in group B in the early postoperative days. Both responded well to intensive topical and subconjunctival steroids as well as to cycloplegics.

The preoperative mean central macular thickness (CMT) was 283.1 ± 31.8 μm in group A and 278.2 ± 39.4 μm in group B (P > 0.05). Macular edema of different grades was detected in nine eyes in group A and in eight eyes in group B (P > 0.05). One week after surgery, the mean CMT was increased to 294.3 ± 28.7 μm in group A (P > 0.05) and to 304.5 ± 30.8 μm in group B (P > 0.05). After 6 months, the mean CMT decreased to 269.9 ± 26.1 μm in group A and to 281.2 ± 35.6 μm in group B (P > 0.05), and after 6 months increased macular thickness was found in two eyes in group A and in five eyes in group B (P < 0.05) by the end of the follow-up period [Table 1].

IOL tilt was found in seven (17.5%) eyes in group A and in two (5%) eyes in group B (P < 0.05). IOL decentration of different grades was evaluated in both groups and reported in [Table 3].
Table 3: Grades of intraocular lens decentration in groups A and B

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  Discussion Top


Suture fixation of a posterior chamber IOL is a widely accepted way of visual rehabilitation of aphakic eyes without adequate capsular support [6]. The implantation of foldable IOLs is preferable to the PMMA IOLs as it has the advantages of small sutureless incision, less postoperative astigmatism, and performing the surgery in a closed system that minimizes intraoperative hypotony and decreases the chance of devastating intraoperative complications such as expulsive hemorrhage.

The mean duration of the procedure was statistically significantly shorter in group B (38.9 ± 7.8 min) than in group A (48.3 ± 12.6 min). This is most probably because opening of the conjunctiva and creation of two scleral flaps, followed by reclosure, consume a longer time. Sharawy [7] reported a time range of 30-75 min for scleral fixation of PMMA IOLs.

Stability of the IOLs is necessary for optimal visual outcome. Stability means the presence of the IOL in its targeted site without decentration or tilting that can alter the final visual outcome. In the absence of capsular support, a posterior chamber IOL can potentially tilt around its points of fixation or decenter more easily. Also unequal distance from the limbus on different sides, or the fixation sutures not placed exactly 180° opposite each other, may lead to IOL decentration and tilt [8]. Because tilt mostly results in astigmatism, the difference between the preoperative and postoperative astigmatism could be used as a reflection of the degree of IOL tilt. In this study, IOL tilt was statistically significantly higher in the group of scleral fixation IOLs (17.5%) than in the group with iris suture fixation IOLs (5%). Condon et al. [9] reported no case of IOL tilt after iris suture fixation of IOLs. IOL tilt was reported to be common with two-point fixation to the sclera as reported by Solomon et al. [10] (10%) and Menezo et al. [11] (15.3%).

In contrast, in our study significant IOL decentration (1.5 mm or more) was higher in the scleral fixation IOL group (12.5%) than in the iris suture fixation IOL group (5%). These are less than the results of Jacobi et al. [12] who reported a decentration rate of 19.23% in their study on foldable scleral fixation IOLs. This could be because most of their cases had traumatic cataract with variable degrees of iridocapsular synechiae, which might interfere with proper IOL centration. This is emphasized by the low rate of decentration in studies in which most cases were aphakic after intracapsular cataract extraction (ICCE), as in the study by Uthoff and Teichmann [13].

At all follow-up visits, the BCVA showed no statistically significant differences with the preoperative values. In this study, many factors could affect vision, such as corneal edema, anterior segment inflammation, raised IOP, macular edema, and IOL misalignment. At all time points of follow-up, the postoperative mean cylindrical correction in both groups was statistically significantly higher than the preoperative values, except in group B after 6 months. At 6 months and after removal of corneal sutures if any, the mean cylindrical correction was statistically significantly higher in group A than in group B. The difference between the mean preoperative and postoperative cylindrical correction reflected the IOL tilt, which was higher in the scleral fixation group. This could be because the haptics of the iris-sutured IOL are in direct contact with the points of fixation in the iris, whereas in case of scleral fixation the haptics are away from the points of fixation in the sclera so that the IOL becomes more susceptible to tilt.

The increase in the mean CCT, which reflects corneal edema, was statistically significant in both groups at 1 week postoperatively, after which it gradually decreased to approach preoperative levels. The difference between the two groups was not significant at any time point. No case of corneal decompensation was reported in this study. This matches with other studies that reported no case of corneal decompensation after suture fixation of posterior chamber IOL and corneal edema, as a complication was not reported in many studies [9],[14],[15]. Higher incidences have been reported by studies that involved IOL exchange and vitrectomy [11],[16].

It has been reported that postoperative iridocyclitis was the most encountered postoperative complication after fixation of IOL in eyes with inadequate capsular support [9]. This agrees with our study in which the postoperative signs of anterior segment inflammation were higher in group B than in group A, and the differences were statistically significant until the first week. This might be because fixation of the IOL to the iris induces more inflammation than its fixation to the sclera. However, after the first week the inflammation gradually subsided in both groups with treatment. In contrast, Solomon et al. [10] reported that all patients in their study had a routine postoperative therapy without episodes of excessive inflammation after scleral fixation of IOLs. Also, Condon et al. [9] reported transient low-grade uveitis in three (6.5%) of 46 eyes who underwent iris suture fixation of a foldable acrylic IOL.

Hyphema and vitreous hemorrhage from ciliary and iris bleeding related to needle passage were reported in six eyes (15%) in group A and in two eyes (5%) in group B. Sewelam [17] reported ciliary bleeding in 10% of his cases during scleral fixation of IOLs. Condon et al. [9] reported no cases of bleeding from the iris during iris suture fixation of posterior chamber foldable IOLs. They stated that needle passes can be made easily in the stable peripheral iris. Also, the iris vessels are radial in distribution, encapsulated and small in diameter so that the risk of bleeding due to needle passage is minimal. This could explain the lower incidence of intraocular bleeding in group B than in group A.

Intraoperative hypotony occurred in two eyes (5%) in group A and in one eye (2.5%) in group B, in which extensive vitrectomy was performed. Osman [18] reported a higher incidence of intraoperative hypotony (37.5%) because he implanted the IOL through a large section opened throughout the surgery. He stated that hypotony led to prolongation of the time of the surgery because of the difficulty of passing the needles in hypotonus eyes. Condon [4] reported no cases of hypotony during iris fixation of foldable IOLs through a small corneal incision. The postoperative IOP showed a statistically nonsignificant increase in the early postoperative period. This might be due to postoperative inflammation as well as iris pigment release due to IOL friction at the back iris surface. Only two eyes in group B required topical antiglaucoma medication to control IOP after the sixth month. Variable percentages of postoperative glaucoma have been reported by different studies [11],[12],[14],[19].

Cystoid macular edema (CME) has been the leading cause of poor visual outcome in most eyes of sutured posterior chamber IOLs [12]. In this study, there was a statistically nonsignificant increase in the mean CMT in the early postoperative period, and it gradually decreased to approach the preoperative levels as detected by optical coherence tomography results. The mean CMT was slightly higher in group B than in group A, but the difference was not statistically significant. This could be due to higher incidence of postoperative anterior segment inflammation in group B than in group A. At 6 months, macular edema was found in two (5%) eyes in group A and in five (12.5%) eyes in group B. Those eyes underwent extensive anterior vitrectomy during surgery. They developed gradual deterioration of vision after initial improvement. Many studies stated that CME was a major etiology for uncorrected postoperative visual acuity after scleral fixation of IOLs [19],[20]. One randomized trial [21] compared three IOL fixation techniques in 176 eyes lacking adequate capsular support. Although visual outcomes were similar for the three groups, it was found that iris-sutured posterior chamber IOLs were associated with significantly less CME (20%) versus anterior chamber (AC) IOLs (38%) or scleral-sutured posterior chamber IOLs (41%) (P=0.02). However, in that study the IOL fixation was conducted with concomitant penetrating keratoplasty. On the other hand, many studies reported no cases of CME following IOL fixation in eyes with inadequate capsular support [11],[22],[23].

No suture erosion through the conjunctiva was reported in eyes of group A. Solomon et al. [10] stated that suture erosion was the most common complication in their study (22 cases, 73%). They related this high rate to the suturing technique together with thin scleral flaps. They recommended that the half-thickness scleral flap is optimal to protect against erosion while not compromising the integrity of the globe. In contrast, Helal et al. [14] reported no case of erosion in their work. The absence of conjunctival suture erosion in this study could be explained by applying a half-thickness scleral flap together with burying the knots below the flap.

Retinal detachment was not reported in any of the eyes in the study until the end of follow-up. This is similar to the results reported by Kaynak et al. [6] and Condon et al. [9] who reported no case of retinal detachment in their studies on posterior chamber IOL implantation in eyes without sufficient capsular support. However, some studies [6],[8],[21] reported different incidences of retinal detachment. Rhegmatogenous retinal detachment in such cases could be attributed to placing the sutures through the sulcus, near the vitreous base and peripheral retina, or to vitreous incarceration and traction through the suture track.

No case of suprachoroidal hemorrhage was detected in this study. This is a rare complication that could be related to several factors such as suture placement at 3 and 9 o'clock positions, suture pass at 2 mm behind the limbus, and double suture passes at each fixation site. Belluci et al. [24] reported one case that occurred in a patient with a microphthalmic eye. Price and Whitson [25] reported late suprachoroidal hemorrhage 6 days after scleral fixation of a posterior chamber IOL. Other studies [9],[23] reported no case of suprachoroidal hemorrhage after using foldable iris suture fixation IOLs.


  Conclusion Top


In the absence of adequate capsular support, fixation of posterior chamber foldable IOLs by iris suturing is associated with significantly less IOL malposition and consumes a shorter operative time compared with the scleral fixation technique. However, the iris fixation technique is associated with a higher incidence of postoperative iridocyclitis in the early postoperative period.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
Acknowledgements
References
Article Tables

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