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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 112  |  Issue : 3  |  Page : 90-98

Twenty-three-gauge pars plana approach versus limbal approach for removal of congenital cataracts


Ophthalmology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission15-May-2019
Date of Acceptance17-Jul-2019
Date of Web Publication25-Sep-2019

Correspondence Address:
MD Sameh Saleh
Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura, PO 35516
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejos.ejos_27_19

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  Abstract 

Purpose To compare the 23-G vitrectomy system via pars plana approach with the limbal approach for the management of congenital cataract in Egyptian infants attending Mansoura Ophthalmic Center, Delta, Egypt.
Patients and methods A total of 30 eyes of 21 infants with congenital cataract who attended Mansoura Ophthalmic Center, Egypt, were included. They were sorted out into two groups; each included 15 eyes. Group I underwent pars plana approach and group II underwent anterior limbal approach for phacoaspiration, posterior capsulorhexis, and anterior vitrectomy. Postoperative examination and follow-up results were recorded.
Results There was significant statistical increase in mean duration of surgery in group I (59.27±12.69) than group II (39.93±9.04), with P value less than or equal to 0.001. There was no significant statistical difference in intraocular pressure values at preoperative period, at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively in the studied groups .There was no significant statistical difference in the incidence of visual axis opacification, secondary glaucoma, anterior chamber reaction, capsular phimosis, and wound leak between the two groups. However, there was a significant statistical increase in the incidence of preretinal hemorrhage in group I (26.7%, n=4) when compared with group II (0%, n=0), with P value of 0.032. There was no significant statistical difference in the incidence of secondary glaucoma during a 6-month follow-up period.
Conclusion Posterior approach and anterior approach can be used safely for infantile cataract, and the application of the technique depends on surgeon experience and skills.

Keywords: congenital cataract, limbal approach, posterior approach


How to cite this article:
Gawad SA, Awad EA, Saleh S, Ellayeh A. Twenty-three-gauge pars plana approach versus limbal approach for removal of congenital cataracts. J Egypt Ophthalmol Soc 2019;112:90-8

How to cite this URL:
Gawad SA, Awad EA, Saleh S, Ellayeh A. Twenty-three-gauge pars plana approach versus limbal approach for removal of congenital cataracts. J Egypt Ophthalmol Soc [serial online] 2019 [cited 2019 Oct 21];112:90-8. Available from: http://www.jeos.eg.net/text.asp?2019/112/3/90/267824


  Introduction Top


Congenital cataract is defined as an opacity of the normally transparent lens detected at birth or at an early stage of childhood, impairing image clarity with reduced visual acuity and impaired contrast sensitivity. Congenital cataract is the main preventable cause of blindness during childhood [1].

Screening, early detection, and intervention are very important to prevent the development of irreversible stimulus-deprivation amblyopia [2],[3].

For nearly 30 years, the 20-G vitrectomy system has been the primary weapon in the pediatric cataract surgery, and then it was replaced by the smaller sized instrumentation of 23- and 25-G vitrectomy, with the latter introduced in the early 2000s [4].

After the establishment of primary posterior capsulotomy and anterior vitrectomy as a routine step during the surgical management of congenital cataract, there was a significant improvement in the outcome regarding the secondary membrane formation and visual axis opacification (VAO) [5].

Despite the marvelous results that followed this advancement, children may still develop many vision-threatening complications, such as secondary glaucoma, iritis, anterior chamber reaction with subsequent synechiae formation, and retinal detachment [6].

An issue of great debate is about whether the limbal or the pars plana approach is better. Although the anterior approach has a faster learning curve and it is more commonly used, the self-sealing suture-less transconjunctival pars plana sclerotomy offers a number of potential advantages, including decreased surgical trauma, less postoperative inflammation, and faster postoperative recovery time [7].

It is important to understand that cataract extraction in an infant is not a static event, but it has a significant effect on ocular structures and their subsequent growth [8],[9]. Evaluating postoperative intraocular pressure (IOP), corneal thickness, anterior chamber anatomical changes, axial growth, and corneal biomechanics is the main issue adopted nowadays by all pediatric cataract surgeons [10].

The aim of this study is to compare the 23-G vitrectomy system via pars plana approach with the limbal approach for the management of congenital cataract in Egyptian infants who attended Mansoura Ophthalmic Center, Delta, Egypt, regarding the VAO, anterior chamber reaction, and secondary glaucoma.


  Patients and methods Top


This prospective, randomized, comparative study was conducted at Mansoura Ophthalmic Center, Mansoura University, from May 2016 to June 2017. This study included 30 eyes of 21 patients. Patients were randomized using closed envelope method into two equal groups (n=15 each). This study follows the declaration of Helsinki and was approved by the ethical committee, Faculty of medicine, Mansoura University (IRB) under code number (MS/16.04.10). Informed written consent was obtained from parents of all participating infants in the study after assuring confidentiality. Infants less than 2 years with unilateral or bilateral, visually significant congenital cataract were included in the study. Exclusion criteria were parents’ refusal; previous ocular surgery; associated anterior segment diseases such as uveitis, glaucoma, microphthalmia, and corneal opacity, and associated posterior segment diseases, such as persistent hyperplastic primary vitreous, retinopathy of prematurity, retinal detachment, retinoblastoma, traumatic cataract, and lens subluxation.

For each patient, full history taking from the parents was done, including age, sex, date of birth and any systemic or genetic disease, with special attention to consanguinity and family history, history of low birth weight and prematurity, or if they were admitted to neonatal ICU, and mothers were asked about the prenatal history (any febrile illness, drug use, exposure to radiation, vaccination, or preeclampsia). Each patient underwent full ocular examination, which was done under sedation with sevoflurane using operating microscope, with comment on the following: type and laterality of congenital cataract, IOP, red reflex, and white-to-white diameter; anterior segment examination regarding conjunctiva, cornea, sclera, anterior chamber, pupil and iris configuration; and posterior segment assessment if possible. For each patient, B-scan was done to assess posterior segment and to exclude any intraocular pathology such as persistent hyperplastic primary vitreous or retinoblastoma. Axial length was measured by ultrasonic A-scan (Nidek US-800; Nidek, Fremont, California, USA), and keratometric (K) readings were recorded.

In group I (posterior approach)

Fashioning of two transconjunctival sclerotomies was done using a 23-G trocar with a microcannula at the pars plana. The entry was beveled to ensure wound self-sealing. One of the two incisions was fashioned superionasal and superiotemporal. The site of the sclerotomies was measured using a compass depending on the age of the child: 2.0 mm posterior to the limbus in children below age of 1 year and 2.5 mm in those from 1 to 2 years. A 23-G trocar was passed in the direction of the optic papilla, just deep enough to ensure that the widest portion of the trocar was past the nonpigmented ciliary epithelium. The trocar was turned upward to be parallel with the iris plane. An infusion cannula was inserted through one of the two sclerotomies but without opening the flow of Lactated Ringer’s solution to avoid vitreous incarceration in the wound. Through the other sclerotomy, hydration to the lens matter was done through the stab incision at the lens equator. A 23-G vitrectomy cutter was introduced in the direction parallel to the iris plane. The cutter entered the pars plana incision and then into the lens matter through the stab incision done at the lens equator. Removal of the lens matter was performed using the cutter with vitrectomy settings; cutting was 800 cuts per minute and suction pressure of 250 mmHg until the lens matter was cut into very small pieces and carefully aspirated, and then a central anterior capsulotomy (vitrectorhexis) with a 5.0 mm diameter was done. Polishing of the capsular remnant was done using low-vacuum settings of 150 mmHg ([Figure 1]).
Figure 1 Intraocular pressure (mmHg) course in the two groups over a six-month follow period.

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In some cases, sodium hyaluronate 1.4% (Healon-GV; Abbott Medical Optics, NDC: 05047-4508-54) was injected in the capsular bag during lensectomy to avoid premature opening of the posterior capsule. A posterior capsulotomy with a 4.5 mm diameter was created with the vitrectomy cutter. Anterior vitrectomy for the anterior one third of the vitreous was performed with the same vitrectomy settings. Careful cutting and removal of the prolapsed vitreous through the scleral incision was done. The microcannula of the pars plana incision was removed, without conjunctival or sclera suturing. Only two cases showed marked intraoperative hypotony, so the sclerotomies were sutured using vicryl 7/0. The infants were left aphakic.

For group II (anterior approach)

Two corneal stab incisions were made, usually at the 10 and 4 o’clock positions. The incisions should be made at the terminal end of the limbal blood vessels as they approach the cornea. The incisions were made with a 19-G microvitreoretinal blade. Adrenalin solution (1.0 ml) was injected for maximal pupillary dilatation, and then sodium hyaluronate ophthalmic solution 1.4% (Healon-GV) was injected. 0.1% trypan blue can assist in capsule visualization during capsulorhexis. A microcapsulorhexis was used to grasp the leading edge of the flap. To overcome the stretchability of the capsule, several repeated grasps at the leading edge of the flap were done. Lactated Ringer’s solution was injected under the anterior lens capsule for multiquadrant hydrodissection. Phacoaspiration of the nucleus was done by phacoprobe, and then meticulous aspiration of the lens matter with the irrigation-aspiration (I/A) mode. The capsular remnants were polished using the bimanual aspiration cannula. Posterior capsulorhexis (P CCC) was started using a sharp cystotome or a 26-G needle to make a small central flap in the posterior capsule after injecting Healon-GV.

Healon-GV was injected through the puncture hole within the space of Berger until the size of the blister is slightly larger than the anterior capsulorhexis, and avoid overfilling the space of Berger. The microcapsulorhexis forceps were used to complete the posterior capsulorhexis.

After opening the posterior capsule, the vitrector was inserted port down below the posterior capsule. The anterior vitrectomy was performed to remove the vitreous core from the visual axis using the same vitrectomy settings used previously. After removing Healon-GV with I/A mode, the anterior chamber was refilled with lactated Ringer’s solution. Closure of the two side ports was done by Nylon 10/0 ([Figure 2]).
Figure 2 Relation between incidence of secondary glaucoma and the age of the twenty-one children in the study.

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Postoperatively, each patient was given topical moxifloxacin antibiotic ophthalmic solution 0.5% for 1 week; topical prednisolone acetate ophthalmic suspension 1% was given every hour in the first day postoperative, and then five times daily for the first 2 weeks with gradual withdrawal over 3 months; and cyclopentolate (Ciclopléjico) was given three times daily.

Patients were followed on the first day after surgery, first and second week, and 1, 3, and 6 months ([Figure 3]) looking for postoperative signs of inflammation such as aqueous flare and cells, iris synechiae, vitreous escape in anterior chamber, or incarceration in the wound. In addition, posterior capsular opacification and IOP were measured. IOP was assessed using tonopen. Hypotony was defined if IOP was below 8 mmHg. Starting from 1-month postoperatively, refraction was assessed during each visit, with glasses prescription. Cases of unilateral cataract and asymmetrical bilateral cataract, occlusion therapy to the sound eye was done as visual rehabilitation to eliminate amblyopia. The amount of occlusion was titrated according to the age of the patient and the degree of amblyopia. Data Were analyzed by SPSS program versions 17 using Microsoft Windows 10.
Figure 3 Relation between incidence of secondary glaucoma and the mean axial length of the thirty eyes at time of surgery.

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Qualitative data were described using number, percent, and number of cases. Association between these variables was tested using χ2 or Fisher exact test. Continuous variables were presented as mean±SD.

The two groups were compared with unpaired Student t test (parametric) and Mann–Whitney test (nonparametric). For intragroup comparisons, paired student t test (parametric) and Mann–Whitney test (nonparametric) were used. Statistical differences showing P value less than or equal to 0.05 was considered significant, and if less than or equal to 0.01, it was considered highly significant.


  Results Top


During the period of this study, from May 2016 to June 2017, 30 eyes of 21 infants (12 males and nine females) were included in this study after fulfillment of the inclusion criteria. Patients were classified into two equal groups (15 eyes each, n=15) using closed envelope method. Patients in group I were operated using posterior (pars plana) approach and patients in group II were operated using anterior (limbal) approach. Patients were followed up for 6 months, and data was recorded and analyzed. One patient of group I missed the last follow-up visit.

In this study, the mean age (in months) was 12.95±5.65 years, with no statistically significant difference between the two groups ([Table 1]).
Table 1 Mean age of the 21 children of the study

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In this study, 21 patients were operated, including 12 males and nine females. Nine cases (four males and five females) were bilateral and 12 cases were unilateral, of whom five males and one female were in group I. The remaining three males and three females were in group II ([Table 2]).
Table 2 Sex distribution and cataract laterality of the 21 children of the study

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There was no statistically significant difference in patient sex distribution between the two groups.

Regarding the medical history in the study, two cases reported positive family history of congenital cataract in the mother during infancy. Five cases showed positive consanguinity of the second degree between the parents. One case was presented with osteogenesis imperfecta. Three patients had general disease: hypoparathyroidism in one case and cerebral palsy in the other two.

No history of prenatal infection was reported. Six cases were admitted to the neonatal ICU; the cause in four of them was prematurity and low birth weight, another case was admitted for respiratory distress, and the last one was admitted for intrauterine meconium aspiration.

In this study, there was no significant statistical difference in presence of genetic disease, presence of general disease, family history, consanguinity, prenatal infection, history of prematurity, or history of incubation between the two groups ([Table 3]). Regarding the morphological classification of cataract in the study, eight eyes were diagnosed as total white cataract, six eyes were lamellar cataract, and five eyes were posterior polar cataract. Nuclear, anterior polar, and combined nuclear with posterior subcapsular types, each was detected in three eyes. Two eyes presented with blue dot cataract. In this study, the mean corneal diameter was 10.9±0.76 mm, mean IOP was 16.1±1.2 mmHg, and mean axial length was 19.7±1.4 mm ([Table 4]). Those previously mentioned parameters were not statistically significant between the two groups. In this study, there was a highly significant statistical increase in mean duration of surgery in group I (59.27±12.69) when compared with group II (39.93±9.04), with P value of less than or equal to 0.001([Table 5]). In this study, there was no significant statistical difference in IOP values at preoperative period and at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively in the studied groups. However, there was a highly significant statistical decrease in mean IOP on day 1 postoperatively in group I (12.74±2.51) when compared with group II (17.41±3.17), with P value of less than or equal to 0.001 ([Table 6], [Figure 1]). Regarding the postoperative complications, there was no significant statistical difference in the incidence of VAO, secondary glaucoma, anterior chamber reaction, capsular phimosis, and wound leak between the two groups. However, there was a significant statistical increase in the incidence of preretinal hemorrhage in group I (26.7%, n=4) when compared with group II (0%, n=0), with P value of 0.032. In this study, there was no significant statistical difference in the incidence of secondary glaucoma during a 6-month follow-up period in the studied groups ([Table 7]).
Table 3 Medical history of the 21 child in the study

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Table 4 Preoperative biometric data of the 30 eyes in the study

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Table 5 Operative time in both groups

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Table 6 Intraocular pressure (mmHg) in the two groups during the 6-month follow-up

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Table 7 Reported postoperative complications in both groups

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There were two cases of secondary glaucoma in group I: one was diagnosed as glaucoma suspect and was managed medically with topical dorzolamide/timolol (Cosopt) twice daily with good control to the IOP, and the other case showed persistent elevation of the IOP despite the topical dorzolamide/ timolol (Cosopt) twice daily and travoprost 0.004% (Travonorm) once at night, with persistent corneal edema and increase in the horizontal corneal diameter. This case was managed surgically by combined trabeculotomy and trabeculectomy with mitomycin C.

Regarding the four cases of secondary glaucoma in group II, one case showed elevation of the IOP postoperatively, but other parameters (horizontal corneal diameter, axial length, and corneal edema) were stable. He was managed as glaucoma suspect with topical dorzolamide/timolol (Cosopt) twice daily and showed good control of the IOP. The other three cases were managed surgically by combined trabeculotomy and trabeculectomy with mitomycin C.


  Discussion Top


Congenital cataract surgery can be performed using a pars plana or a limbal approach. Because of the high incidence of secondary membranes formation and posterior capsular opacification (PCO) in children, the operation should be combined with posterior capsulotomy and anterior vitrectomy.

This study addressed the safety and efficacy of pars plana approach and limbal approach for management of congenital cataract, in a comparative study regarding VAO, secondary glaucoma, and anterior chamber reaction with synechiae formation. During our study, we found no significant statistical difference in age, sex distribution, and medical history, such as the presence of genetic disease, general disease, family history, consanguinity, prenatal infection, prematurity, or history of incubation between the two groups.

Moreover, the preoperative biometric data such as corneal diameter, IOP, and the axial length showed no significant statistical difference between the two groups.

Regarding the morphology of congenital cataract in our study of 30 eyes, we reported that total cataract and lamellar cataract were the commonest subtypes: eight (26.7%) eyes with total cataract and six (20%) eyes with lamellar cataract. Comparing these results with the systematic review and meta-analysis by Wu et al. [3], it was found that the prevalence of total cataract was the highest (31.2%) followed by nuclear cataract (27.2%).

Regarding the operative time in our study, there was a highly significant statistical increase in mean duration (in min) of surgery in group I (59.27±12.69) when compared with group II (39.93±9.04), with P value of less than or equal to 0.001. This may be explained by the faster learning curve of the anterior (limbal) approach. Moreover, it is the most accepted technique for congenital cataract management by most surgeons worldwide [7],[11].

In our study, the IOP course showed no significant statistical difference in the postoperative period and at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively between the two groups. However, there was a highly significant statistical decrease in mean IOP (in mmHg) on day 1 postoperatively in group I (12.74±2.51) when compared with group II (17.41±3.17), with P value of less than or equal to 0.001. This can be explained by the sufficient and easier vitrectomy done during the pars plana approach. This was reported by Ahmadieh and colleagues who mentioned that by inserting the 23-G vitrectomy cutter at the equator of the lens, the surgeon could turn the cutter upward to perform the anterior capsulotomy, forward and around to remove the lens materials, and downward to perform the posterior capsulotomy and anterior vitrectomy [12]. Ultrasonic biomicroscopy was done to exclude cyclodialysis.

Regarding the postoperative complications, there was no significant statistical difference in the incidence of VAO, aphakic glaucoma, anterior chamber reaction, capsular phimosis, and wound leak between the two groups. However, there was a significant statistical increase in the incidence of preretinal hemorrhage in group I (26.7%, n=4) when compared with group II (0%, n=0), with P value of 0.035. This may be related to the intraoperative hypotony, which occurred during the pars plana approach, or it may be owing to trickling of the blood through the sclerotomy into the vitreous cavity during incision fashioning. It resolved spontaneously over 2 weeks without any medications.

A single case of wound leak and VAO was diagnosed 1 week postoperative. Hypotony of less than 7 mmHg was observed with PCO noticed clinically, which was accelerated owing to the leaky incision. The case was admitted for closure of the sclerotomy using vicryl 7/0 and surgical removal of the secondary membrane aiming at clearing the visual axis with irrelevant postoperative course.

The secondary glaucoma was reported in the two groups, with higher incidence in the anterior approach group (26.7%) compared with the incidence in the posterior approach group (13.3%) but with no significant statistical difference during a 6-month follow-up period. The reported incidence of secondary glaucoma following pars plana lensectomy anterior vitrectomy by Miyahara et al. [13] was 26%, which is higher in incidence compared with our study, but this may be related to the larger sample size (80 eyes) and longer duration of follow-up (36 months). However, the exact mechanism is unclear. It may be explained by that the filtration angle of the infant eye is uniquely susceptible to postoperative inflammation, some vitreous component, or simply the mechanical absence of the lens [14].

It was noticed in our study that younger age of operation was associated with higher risk for secondary glaucoma, as shown in [Figure 2]. Beck et al. [15] founded similar results and stated that ‘cataract surgery in the first year of life and a small corneal diameter have been the most consistent risk factors for glaucoma development’. In addition, Mataftsi et al. [16] conducted a meta-analysis in 2014 and confirmed that young age is a strong risk factor for glaucoma development. Nineteen cases out of 80 children less than 4 weeks in age developed secondary glaucoma versus 61 cases out of 390 children more than 4 weeks in age.

An interesting study by Chak and Rahi [17] showed that a 10-fold increase in the age at detection (e.g. 30 days compared with 3 days) was associated with a 64% decrease in the hazard ratio (95% confidence interval, 41%–79%; P<0.001).

A study conducted by Ruddle et al. [18] also reported that younger children at the time of surgical intervention showed an increase in the incidence of secondary glaucoma. The incidence of glaucoma was 60.0% in surgeries performed in the first month of life compared with 38.5 and 12.5% in the sixth and eighth months, respectively.

Many studies debated about the ideal age at which the incidence of aphakic glaucoma after cataract removal is reduced. Ruddle and colleagues reported a cut-off point around the eighth month. This is similar to the 8-month cut-off found by Parks et al. [19], and 9-month of Rabiah [14]. Moreover, Haargaard et al. [20] reported that after a 10-year follow-up, 32% of eyes that underwent cataract surgery when less than 9 months of age developed secondary glaucoma, compared with only 4% of children more than 9 months of age.

The relation between the incidence of secondary glaucoma and the axial length at time of surgery was addressed in our study, as illustrated in [Figure 3]. The shorter the axial length of the eye at the time of operation, the higher the incidence of secondary glaucoma. By applying the same concept of Beck and colleagues, the small sized eye with immature anterior chamber angle in a young child may be associated with high incidence of secondary glaucoma. The IOP changes for each patient in groups I and II are illustrated in [Figure 4]a and b, respectively. The function of the immature angle structure can be easily influenced by the chemical vitreal mediators and the inflammatory iritis, rendering it dysfunctional [21].
Figure 4 (A) Intraocular pressure (mmHg) follow up for each case in group I. (B) Intraocular pressure (mmHg) follow up for each case in group II.

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Acknowledgements

Adel Ellayeh, Eman A. Awad, and Sameh Saleh designed the manuscript. Sara A. Gawad, Eman A. Awad, and Sameh Saleh collected the cases. Eman A. Awad and Sameh Saleh performed the clinical examination and investigation. Adel Ellayeh performed the surgery. Sara A. Gawad, Eman A. Awad, and Sameh Saleh assisted in the surgery. Eman A. Awad and Sameh Saleh followed up the cases. Sara A. Gawad, Eman A. Awad, and Sameh Saleh drafted the manuscript. Adel Ellayeh, Eman A. Awad, and Sameh Saleh critically revised the manuscript. All authors read and approved the final manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Miyahara S, Amino K, Tanihara H. Glaucoma secondary to pars plana lensectomy for congenital cataract. Graefe’s Arch Clin Exp Ophthalmol 2002; 240:176–179.  Back to cited text no. 13
    
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Rabiah PK. Frequency and predictors of glaucoma after pediatric cataract surgery. Am J Ophthalmol 2004; 137:30–37.  Back to cited text no. 14
    
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