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   Table of Contents - Current issue
September-December 2017
Volume 29 | Issue 3
Page Nos. 151-257

Online since Tuesday, January 30, 2018

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The final cut Highly accessed article p. 151
Ashok Nataraj
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Evolution of retinal surgery - what are we heading to? Highly accessed article p. 152
Lingam Gopal
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Retinopathy of prematurity-An overview Highly accessed article p. 154
Natasha Radhakrishnan, Gopal S Pillai, KR Kiran, A Lekshmypriya
Retinopathy of prematurity (ROP) is a vasoproliferative disease that affects premature infants. ROP is on a rise in India as a result of the improved neonatal care and better neonatal survival rate. Identifying and screening of at-risk premature infants performed by an experienced ophthalmologist remains the most important strategy in the management of ROP. In developing countries, the introduction of Retcam-assisted screening enables screening and follow-up of the rural population where an experienced ophthalmologist may not be available. Currently, laser photocoagulation of avascular retina has replaced cryotherapy as the gold standard treatment for ROP depending on the severity of disease. Among the various ongoing treatment approaches currently under trial to suppress the neovascularization, anti-vascular endothelial growth factor drugs provide valuable and encouraging information, especially in Zone 1 disease. Although many ongoing animal trials aimed at finding an ideal treatment have come out with newer treatment options, their safety and efficacy in humans are yet to be established.
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Eyelid malpositions: An overview Highly accessed article p. 160
Marian Pauly, TJ Maya
Eyelid malpositions are the result of forces acting upon the eyelid margin. A normal eyelid should have a quick return snap to the eyeball. Frequently, tendon laxity at the medial and lateral canthi will render the eyelid margin unstable making it susceptible to contractile forces. Based on the contractile forces either entropion, ectropion, retraction or lagophthalmos can occur. The goal in treating a given eyelid malposition is to reposition the eyelid so that the new healing forces will overcome the pathologic forces. The common approaches include eyelid and canthal tendon tightening, eyelid retractor advancement or recession and skin grafting or transposition flaps. This review article briefly describes the various aspects of lid malpositions in detail.
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Rosacea and eye Highly accessed article p. 168
Lalit Gupta, Anubhav Chauhan
Rosacea is a multisystem disorder and to the general practitioner, involvement of the skin is what comes to the mind first of all. A broad array of ocular manifestations encompasses this condition and ocular examination is as essential as examination of other part of body when rosacea is talked about. Here, we present an in depth review of ocular rosacea so that adequate knowledge is shared among all the doctors regarding thglalit7@gmail.come subject.
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Patient satisfaction - Mission impossible p. 173
Ashley Thomas Jacob
Achieving patient satisfaction in a clinical setting is a perennially difficult yet much sought-after goal for every physician. There are many ways to realize this goal including reducing prices, offering new procedures, creating new amenities, and such. However, none of these tend to produce the elusive loyalty. This review shines a laser focus on ways to increase loyalty among your patients and encourage them to act as your ambassadors.
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Etiopathogenesis of presenile cataracts in Central Kerala: A cross-sectional observational study p. 179
R Jyothi, Sanitha Sathyan
Aim: The aim of this study was to determine the factors responsible for the development of presenile cataracts in patients between 18 and 50 years in Central Kerala. Materials and Methods: This cross-sectional observational study was done on patients diagnosed with presenile cataracts (age group 18–50 years) at Little Flower Hospital, Angamaly, Kerala, from March 2016 to June 2016. A detailed history including the risk factors such as residence and occupation, diabetes mellitus (DM), atopy, and thyroid disorders was taken. Cataract was graded according to the Lens Opacities Classification System III. Statistical analysis of descriptive data was done with bar charts and pie diagrams. Results: Out of 200 participants included in the study, there were 88 males and 112 females. The mean age of the study population was 41.88 years. Pre senile cataract was associated with Diabetes mellitus in 31%, with atopy in 8.5%and with thyroid disorders in 5%of cases. Posterior subcapsular cataract (42%) was the most common type of cataract found. Total cataract was present in 23.5%. The odds of developing cortical cataract was higher in those with thyroid disorder (odds ratio (OR) = 6.97), nuclear cataract was higher in those with uveitis (OR = 6.18) and high myopia (OR = 7.97), and total cataract was higher in those with a history of trauma (OR = 8.95). Conclusion: Apart from DM and atopy, the place of residence and occupation (and thus possibly exposure to ultraviolet radiations) is also associated with the development of presenile cataract. Posterior subcapsular cataract is the most common type of presenile cataract in Central Kerala.
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Visual outcomes and complications of posterior iris-claw intraocular lens implantation in aphakic postvitrectomized eyes p. 184
Awaneesh M Upadhyay, Ashok Nataraj
Purpose: To evaluate refractive outcome, anatomical outcome, complications of posterior chamber iris-claw aphakic intraocular lens (IOL) implantation after pars plana vitrectomy. Methods: A retrospective analysis of consecutive 25 eyes of 25 pts (12 males & 13 females) without capsular support in which we performed posterior chamber iris-claw implantation after pars plana vitrectomy. Retro-pupillary iris claw lens were either implanted in the same procedure along with vitrectomy (15 eyes, Group A) or later in different procedure (10 eyes, Group B) in post vitrectomised eyes. Posterior vitrectomy procedures were performed with 23- or 25-gauge techniques for different associated anterior or posterior segment indications. Visual outcomes, anatomical outcome, stability of the implants, and complications were analysed. Results: The mean patient age was 62.3 years(range, 21–78 years) in group A; 60.1 years (range, 19-80 years) in group B. The mean follow-up time was 4.12 months (range, 1-12 months). In Group A 6 eyes had lens dislocation aphakia (5 traumatic, 1 surgical) & 7 IOL dislocation aphakia (3traumatic, 4 surgical). In Group B 5 eyes had lens dislocation aphakia(4 traumatic,1 surgical) and 2 IOL dislocation aphakia(1 traumatic,1 surgical). At the end of the follow up the mean post-operative best-corrected LogMAR visual acuity was 0.244±0.25 in group A; 0.286±042 in group B which was statistically significant as compared preoperatively. Intergroup best corrected visual acuity comparisons at the end of follow up were not statistically significant. Similarly within group spherical equivalent decreased statistically when compared to the preoperative values. Between group comparisons, spherical equivalent values were not significant. Intra-op anterior chamber collapse was not seen in any case. Disenclavation of iris claw lens was not seen in any case. No corneal edema was observed. 1 case of uveitis was observed. 1 case of post-op macular edema was observed. 3 cases had increased post-op intraocular pressure.1 case had post-op vitreous hemorrhage which resolved spontaneously, retina attached in all cases. Conclusion: In summary posterior chamber iris-claw IOL implantation in aphakic eyes without capsular support in post vitrectomized is an effective, predictable and safe procedure.
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A retrospective study about clinical profile of vernal keratoconjunctivitis patients at a tertiary care hospital in Patiala, Punjab, India p. 189
Harvinder Nagpal, Nidhi Rani, Mandeep Kaur
Objective: To study variations in clinical profile of vernal keratoconjunctivitis (VKC) among local population with data collected at our tertiary care hospital over a period of 6 months. Materials and Methods: A retrospective study was carried out in the Department of Ophthalmology at Government Medical College, Patiala, Punjab, India. A total of 150 patients with VKC were diagnosed on the grounds of their history, the presence of characteristic symptom, and on the basis of their clinical features, over a period of 6 months from March 2017 to August 2017. The history of each patient was taken including a record of age, sex, place of residence, change of place of residence, age at onset of the disease, seasonal variations, associated allergic or “atopic” illnesses, and family history of VKC or associated allergic or atopic conditions. Best-corrected visual acuity was assessed and each patient was thoroughly examined with a slit lamp. Follow-up was done every 4 weeks for 6 months. Results: Out of 150 patients, 110 (73.33%) were male and 40 (26.67%) were female. The highest incidence of VKC occurred in the age group of 11–15 years. Maximum cases (62%) had palpebral form followed by mixed form (23.33%) and bulbar form (14.67%). Corneal complications occurred in 22 (14.67%) patients; 20 patients had minor complications and 2 had major complications. The minor complications usually consisted of superficial punctate keratopathy (SPK) or other epithelial disturbance. Major complications consisted of superior pannus. Although patients with VKC often give a history of allergy or of atopic diseases such as allergic rhinitis, asthma, or hay fever, in the present study, coexisting allergic conditions could be detected in only 45 (30%) patients. Conclusion: VKC is a common form of allergic conjunctivitis and the disease tends to occur in males of 11–15 years age group. Most common is palpebral form followed by mixed and bulbar forms. Some cases showed history of atopy and other allergic conditions.
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Role of internal limiting membrane peeling for cases of recalcitrant diabetic macular edema p. 192
Sujit Das, Rakesh Maggon
Background/Aims: To investigate the efficacy of internal limiting membrane (ILM) peeling following pars plana vitrectomy for cases of recalcitrant diabetic macular edema in terms of improved visual acuity and reduced central macular thickness (CMT). Materials and Methods: A prospective randomized interventional study of 60 eyes with recalcitrant diabetic macular edema between age groups of 30–75 years of either sex were included if they are unresponsive to at least one intravitreal steroid after 4 weeks followed by at least one intravitreal antivascul©ar endothelial growth factors followed by conventional laser treatment after 8 weeks at least within or <8 weeks before enrollment into the study. The absence of macular ischemia and CMT of more than 350 μ were included. The main outcome measures were corrected and uncorrected visual acuity, reduction of CMT, early and postoperative complications, and intraocular pressure. Results: The mean (standard deviation [SD]) of coherence tomography (OCT) was 558.3 (74.2) and 537.6 (52.6) in ILM and non-ILM group, respectively. On day 1, OCT was reduced to 419.0 in ILM peeling group (558.3–419.0, P< 0.001, statistically significant) and increased to 543.8 in non-ILM peeling group (537.6–543.8, P = 0.002, statistically significant) from baseline. The mean (SD) of best-corrected visual acuity (BCVA) at baseline in ILM peeling and non-ILM peeling were 1.24 (0.15) and 1.27 (0.15), respectively. The reduction in mean of BCVA at 6 and 12 weeks from baseline (1.24–1.16, P = 0.010 and 1.24–1.15, P = 0.014) was found to be statistically significant in ILM peeling whereas there is no change in the mean BCVA over 12 weeks. Conclusion: ILM peeling gives satisfactory results in recalcitrant diabetic macular edema.
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A comparative study of the incidence of retinopathy of prematurity between small-for-gestational-age and appropriate-for-gestational-age preterm babies in North Kerala p. 197
Ratheesh Raj, NV Latha, AV Asha, Twinkle Ann George, Shamin Jacob, KK Praveena
Purpose: The purpose of this study is to compare the incidence of retinopathy of prematurity (ROP) in small-for-gestational-age (SGA) infants with appropriate-for-gestational-age (AGA) infants. Materials and Methods: A hospital-based prospective descriptive study was conducted on all cases of preterm babies <34 weeks of gestation and/or <1500 g of birth weight admitted in a tertiary care center, who were sent for ROP screening. Babies were divided into two groups using Lubchenco growth chart. Group 1 consisted of all AGA preterm babies. Group 2 consisted of SGA preterm babies. Screening and staging of ROP were done. Babies were managed appropriately. Data were entered and analyzed. Results: Out of the 300 babies examined, 67 babies were SGA and rest 233 were AGA. The overall incidence of ROP was 29% and it was increased in SGA group to 40% compared to AGA group, which was 25.8%. SGA had a significant association with ROP. Other significant factors were oxygen delivery, mechanical ventilation, sepsis, respiratory distress syndrome, surfactant, apnea, blood transfusions, and acidosis. Maternal factors such as oligohydramnios, premature rupture of membranes, and preeclampsia were also associated with ROP significantly. On multivariate analysis, apnea, blood transfusion, low partial pressure of oxygen, lower gestational age, and maternal gestational diabetes mellitus were independent risk factors. Conclusion: The incidence of ROP is higher in SGA compared to AGA. Being small for gestation is a risk factor for developing ROP.
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Our experience with ocular perforation resulting from peribulbar anesthesia p. 203
Balbir Khan, Rajwinder Kaur, Mandeep Kaur, Harijot Singh, Kulbir Kaur
Purpose: The purpose of this study is to analyze the clinical presentation and outcome of treatment for globe perforation secondary to peribulbar perforation. Materials and Methods: A total of 10 patients were included in the study, of which nine patients referred to vitreoretina unit from outside for the management and one patient, that is, eye with altered axial length (eye with previous buckle), at our setting. Three eyes were myopic. One patient underwent indirect argon laser photocoagulation to seal the retinal break, another patient underwent peripheral break sealed with cryotherapy, and six patients underwent pars plana vitrectomy with fluid gas exchange and endolaser. Two patients had sclera buckling in addition. Results: The final visual acuity after follow-up of 1 year was better than 20/30 in two patients, between 20/30 and 20/40 in four patients, and perception of light in two patients. One eye became phthyesical due to recurrent retinal detachment. Conclusion: If diagnosed early and treated adequately, a majority of patients with globe perforation during peribulbar anesthesia can have a good visual outcome.
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Comparison of retropupillary fixated iris-claw lenses and sulcus placed intraocular lenses for the treatment of aphakia p. 207
Sanitha Sathyan, Renjini Kurian
Purpose: The purpose of this study is to compare the visual outcomes and safety profile of retropupillary fixated iris claw lenses (RPICLs) and sulcus placed posterior chamber intraocular lenses (SIPCIOL) in the management of aphakia. Materials and Methods: This was a comparative, observational study, which included 87 eyes of 84 patients who underwent RPICL or SIPCIOL for aphakia. BCVA at 6 weeks, mean prediction error, post-eperative complications were compared between the two groups. Results: Group 1 (RPICL group) consisted of 47 eyes of 45 patients and Group 2 (SIPCIOL group) consisted of 40 eyes of 39 patients. Mean age was 67.13 ± 9.33 years in Group 1 and 59.91 ± 16.62 years in Group 2. There was statistically significant difference between preoperative best-corrected visual acuity (BCVA) and post op BCVA at 6 weeks in Group 1 (P = 0.001, paired t-test) and Group 2 (P = 0.001, paired t-test). There was no significant difference in BCVA between the groups at 6 weeks (P = 0.54, unpaired t-test). There was no statistically significant difference in BCVA at 6 weeks between primary surgery and secondary surgery in Group 1 (P = 0.34, unpaired t-test) and Group 2 (P = 0.59, unpaired t-test). The mean prediction error in Group 1 was 0.41 ± 0.58 D and in Group 2 was 0.18 ± 0.20 and was not significant (P = 0.61, unpaired t-test). There was no significant difference between the two groups in mean intraocular pressure at 1 week (P = 0.43, paired t-test) and at 6 weeks (P = 0.83, paired t-test). There was no significant difference between the two groups in operative complications. Conclusion: RPICL was comparable with SIPCIOLs in terms of BCVA at 6 weeks, intraocular lens prediction error, and operative complications.
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Suprachoroidal buckling: A novel technique for rhegmatogenous retinal detachment and vitreoretinal interface pathologies p. 213
Ayisha Suhana, Ashok Nataraj, Ehab N El-Rayes
Suprachoroidal buckling (SCB) technique is a new approach developed by Ehab N El Rayes and Oshima for treating rhegmatogenous retinal detachment (RRD). SCB uses a specially designed catheter to inject and place a suprachoroidal filler (long-lasting hyaluronic acid solution) in the suprachoroidal space. This filler indents the choroid alone and creates a suprachoroidal buckling effect thereby closing retinal tears and supporting the overlying retina. The sclera itself is not involved in the indentation. SCB can also be used as an alternative to episcleral macular buckling for managing myopic traction maculopathy (MTM).
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Double-trouble p. 218
Marian Pauly, Mekhla Naik, TJ Maya
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Spontaneous migration of periocular glass foreign body: An interesting case p. 220
Padma B Prabhu, Deepak Vellarikkal, Babitha Valiayaveettil
The occurrence of soft-tissue foreign bodies (FBs) in and around the orbit is often seen after trauma. Wound exploration and removal of the embedded materials is the standard of care. Relevant investigations help to detect retained FBs in suspected cases. However, hidden FB and their migration, both early and late, has been reported often and associated with morbidity and mortality. Here, we report a case of spontaneous migration of sharp-edged glass splinter retained in the periocular area in a young female who had sustained trauma in the past. Evaluation of the splinter under high-power magnification will help to identify the morphology and source of injury in such cases.
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Torpedo maculopathy p. 223
Remya Mareen Paulose
Torpedo maculopathy is a rare congenital maculopathy clinically seen as a “torpedo”-shaped lesion temporal to the fovea. We hereby report a 4-year-old female child who on routine evaluation for refractive correction was discovered to have a temporal macular RPE defect with a pointed-oval shape directed toward the foveola. The ophthalmic examination revealed best-corrected visual acuity of 6/12 in both eyes without any changes in biomicroscopy. Her ocular and systemic medical history was unremarkable. Torpedo maculopathy diagnosis was based on the characteristic shape and peculiar location.
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Conjunctival melanosis with retinal vessel tortuosity: An unusual presentation of Sturge–Weber syndrome p. 226
Padma B Prabhu, Deviprasad Soman, V Babitha
Sturge–Weber syndrome (SWS) is a rare neuro-oculocutaneous disorder. The classical signs are unilateral facial port wine stain, leptomeningeal angiomas, and their sequele with ipsilateral glaucoma. Here, we are reporting two cases of SWS associated with conjunctival melanosis and retinal vascular tortuosity. This unusual coincidence maybe representative of a unique entity named phacomatosis pigmentovascularis.
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Anterior orbital cysticercosis: A case presentation p. 230
Sujit Das
One of the most important parasites which frequently cause blindness in humans is the cysticercus cellulosae. Cysticercus cellulosae, the larval form of the pork tapeworm Taenia solium, is the causative organism of cysticercosis, in which humans are the intermediate hosts in the life cycle. Cysticercus cellulosae may become encysted in various bodily tissues, usually the eyes, central nervous system, and subcutaneous tissues. An immunologic reaction with fairly intense inflammatory signs and symptoms may be produced, and the surrounding structures may be compressed. Acquired strabismus, diplopia, recurrent redness, and painful proptosis are some of the clinical signs in patients with orbital cysticercosis. Diagnosis of cysticercosis is based mainly on orbital imaging because of its highly specific appearance. Medical therapy is the main stay of treatment. Cysticercosis is the infestation by cysticercus cellulosae, the larval form of the pork tapeworm, T. solium. It is contracted by ingestion of the infective cysticerci in under cooked pork; ingestion of eggs of T. solium in contaminated water, food, or vegetables; and regurgitation of eggs from the small intestine. The sites for predilection for the development of cysticerci are the central nervous system, subcutaneous tissue, skeletal muscle, heart muscle, and the eye.
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Elderly female presenting with "lazy" giant intracranial aneurysm p. 234
Rajwinder Kaur, Mandeep Kaur, Harijot Singh
Multiple aneurysms of anterior intracranial circulation including a giant one are rare; progressing slowly, these “little pulsatile bumps” often present with ocular and neurological symptoms. This case reports a 70-year-old hypertensive female with multiple small and a single giant intracranial aneurysm, diagnosed on basis of ophthalmological manifestations 3 years back, and the patient still survives with these unruptured vascular deformations.
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Antivascular endothelial growth factor in treatment of choroidal osteoma not associated with choroidal neovascular membrane p. 237
Thomas Cherian, Remya Mareen Paulose, KR Reesha
To report the case of a 52-year-old female with recent complaint of decreased vision associated with a well-defined depigmented lesion in the macula in the right eye. She had a history of surgery for pituitary microadenoma and breast lump excision. Based on spectral-domain optical coherence tomography, fundus fluorescein angiography, indocyanine green angiography, and B-scan ultrasonography, a diagnosis of the right eye choroidal osteoma was made. Subretinal fluid (SRF) was noted in the absence of obvious classic choroidal neovascularization (CNV). The patient was given monthly intravitreal ranibizumab injection over 3 months. Visual acuity was 20/80 preinjection, which dramatically improved to 20/20 after the injections without any additional treatment. We report an interesting case where SRF was noted in the absence of evident CNV and that antivascular endothelial growth factor can be considered as an effective option even in the absence of an evident CNV.
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Blue sclera and osteogenesis imperfecta - A rare association p. 240
Sujit Das, Kavita Bhatnagar
The sclera is a dense poorly vascularized connective tissue structure composed of Types I, III, IV, V, VI, and VIII collagen. The characteristic blue sclera is caused by thinness and transparency of the collagen fibers of the sclera that allow visualization of the underlying uvea. The sclera may be thinned in congenital diseases such as osteogenesis imperfecta or in acquired diseases such as iron deficiency anemia.
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Shield ulcer: A very rare presentation p. 244
Sujit Das
Shield ulcer is a severe form of vernal keratoconjunctivitis (VKC). Shield ulcer is an uncommon, incapacitating corneal manifestation that occurs in 3%–11% of patients suffering from VKC. Patients might present with intense itching, sensitivity to light, and “ropy” discharge from the eyes. Shield ulcer, as a rare complication of VKC, should always be kept in mind for patients suffering from vernal conjunctivitis.
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Sixth nerve palsy - Window to a dreaded brain tumor in children (pontine glioma) p. 247
Sujit Das
Pontine glioma is a rare tumor and exclusively occurs in children. It originates from the glial (connective/supporting) cells of the brain. In children, they are the leading cause of deaths from brain tumors. The usual age of presentation is later half of first decade. Most of the children die within 18 months of diagnosis. It mostly affects 6th and 7th cranial nerves along with hearing defect.
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Cavernous hemangioma p. 250
Sharmil Gopal, Ashok Nataraj, Sreelatha Vinod, VA Jaison
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Journal Review p. 252
Hilda K Nixon
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Ocular surface squamous neoplasia: Missing links p. 255
Anubhav Chauhan, Shveta Chauhan
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Reply: Pigmented ocular surface squamous neoplasia p. 256
Philip Kuruvilla, Ashish George Kuruvilla
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What is the Diagnosis? p. 257
Ashok Nataraj
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