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PART 3 REFRACTIVE SURGERY

Preoperative Evaluation for Refractive Surgery


Joshua A. Young and Ernest W. Kornmehl
Preoperative work-up: Preoperative work-up involves
screening, history taking, preoperative examination, and counseling.

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Immunologic disease  Autoimmune  l  Collagen vascular l  Immunodeficiency Pregnancy or nursing (not absolute contraindication)  Abnormal wound healing  l  Keloids (contraindicated for PRK only) l  Abnormal scars Diabetes mellitus (if corneal sensation is not intact)  Interference from systemic medications  l  Isotretinoin l  Amiodarone hydrochloride
l

BOX 3-2-1 SYSTEMIC CONTRAINDICATIONS TO PHOTOREFRACTIVE KERATECTOMY AND LASER-ASSISTED IN SITU KERATOMILEUSIS
l l l l l

Patient selection
n n

 mportant factors that determine likelihood of success in refractive I surgery. Improper preoperative evaluation may result in:  n  Treatment of patients who should not be treated (e.g., those who have keratoconus). n  Denial of treatment to some who show only transient abnormalities at the time of examination (e.g., corneal distortion because of contact lens wear). n  Unnecessary prolongation of the postoperative course (e.g., patients affected by undiagnosed dry eye).

INTRODUCTION
Comprehensive preoperative evaluation of patients considering refractive surgery is often preceded by a brief screening examination. The purpose of screening is to eliminate patients who are clearly not candidates for refractive surgery. Areas of inquiry may include age and the type and degree of refractive error. Although all excimer lasers perform grossly the same tasks, their approved ranges of photorefractive keratectomy and laser-assisted in situ keratomileusis (LASIK) differ. Contact lenses must be removed prior to the preoperative examination (3weeks for hard or rigid gas-permeable lenses and 714days for soft contact lenses). In addition, patients must be asked to bring copies of old spectacle prescriptions if available or the old spectacles themselves so that refractive stability may be assessed.

(or infant exposure in the case of nursing mothers) to topical and systemic postrefractive surgery medications. Third, refractive surgery is delayed until after childbirth because of possible changes that occur in the tear layer during pregnancy (discussed subsequently). Thyroid disease and related orbitopathy are important in relation to the tear layer as well. Abnormalities of wound healing, such as keloid formation, may lead to postoperative complications following PRK, which include corneal haze. Although anecdotal evidence suggests that keloid formers may not be at greater risk of complications,6 it is advisable not to perform PRK on these patients. Keloid formation is not a contraindication to LASIK.7 Ophthalmic contraindications (Table 3-2-1) fall into three categories disorders that interfere with the tear layer, disorders that themselves may be exacerbated by photoablation, and abnormalities of corneal topography. Herpetic reactivation is a reasonable concern because ultraviolet exposure may initiate dendritic eruption, and the excimer laser, which uses ultraviolet radiation, may provide such a trigger. Indeed, anecdotal reports of herpetic reactivation after photoablation have been published.8 Bialasiewicz et al.9 described a patient who underwent photo therapeutic keratectomy for treatment of a herpetic scar, was noted subsequently to have stromal infiltration, and progressed to descemetocele and eventually to corneal perforation. Opinions differ, however, as to whether photoablation may be impli cated in herpetic reactivation. Fagerholm et al.10 reported a series of 20 eyes in 20 patients for whom recurrence after photoablation occurred no more frequently than prior to ablation. Another indication that herpetic reactivation may be incidental to excimer exposure is that when reactivation does occur, it often does so several months after treatment.8 Such recurrences may be related to topical corticosteroid therapy rather than to laser exposure itself. A history of ocular herpes simplex is not an absolute contraindication to LASIK. Patients should be treated with an oral antiviral 3days prior to surgery and must not have had a recurrence in the previous 12months. Experimental work that involved a murine model demonstrated the shedding of virus after photoablation.11 It is unclear whether this shedding is a result of excimer exposure or a result of mechanical irritation, as

Ophthalmic Contraindications

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The medical history interview must include questions about allergies, autoimmune disease, diabetes mellitus, pregnancy, thyroid disease, collagen vascular disorders, and abnormal wound healing (Box 3-2-1). Autoimmune history is particularly important. Seiler et al.1 reported one patient who was found to have unrecognized systemic lupus erythematosus after postoperative complications severe enough to require penetrating keratoplasty. Recent studies suggest that patients with collagen vascular disease can undergo LASIK safely with satisfactory results.2, 3 Diabetes mellitus with absent corneal sensation is a contra indication for LASIK and photorefractive keratectomy (PRK). If the diabetic patients corneal sensation is intact LASIK can be performed with satisfactory results. Pregnancy is a contraindication for a number of reasons. First, pregnancy is believed to induce refractive fluctuations. Although, Hefetz et al.4 reported no unexpected outcomes in 11 eyes of eight women who became pregnant shortly after undergoing PRK, Sharif 5 reported a greater risk for corneal haze and myopic regression in women who become pregnant within 5months of PRK. Second, postponement of surgery until after childbirth or weaning avoids fetal exposure

Systemic Contraindications for Keratorefractive Surgery

TABLE 3-2-1 OPHTHALMIC CONTRAINDICATIONS TO PHOTOREFRACTIVE KERATECTOMY


Relative Contraindications Ocular surface disease Mild dry eye l  Lid disorders that affect the tear layer Absolute Contraindications Severe dry eye l  Keratoconjunctivitis sicca; l  Exposure keratitis; l  Lid disorders that affect the tear layer Neurotrophic keratics Herpes zoster ophthalmicus/herpetic keratitis (especially if active during the previous 6 months) Glaucoma Corneal ectasias l  Keratoconus l  Pellucid marginal degeneration l  Keratoglobus High, irregular astigmatism

BOX 3-2-2 SYSTEMIC MEDICATIONS THAT MAY INDUCE DRY EYE


ANTIHYPERTENSIVES Clonidine Methyldopa Prazosin Propranolol Reserpine ANTISPASMODICS Cyclobenzaprine Methocarbamol CARDIAC MEDICATIONS Disopyramide Mexiletine DECONGESTANTS Ephedrine Pseudoephedrine DERMATOLOGIC MEDICATIONS Isotretinoin GASTROINTESTINAL MEDICATIONS Metoclopramide ORAL CONTRACEPTIVES PARKINSON MEDICATIONS Benztropine Biperiden Procyclidine Trihexyphenidyl (benzhexol) PSYCHIATRIC MEDICATIONS Amitriptyline Amoxapine Desipramine Doxepin Imipramine Nortriptyline Phenelzine Tranylcypromine Trimipramine

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Preoperative Evaluation for Refractive Surgery

Disorders that may be exacerbated by photorefractive keratectomy Abnormalities of corneal shape

Herpes zoster ophthalmicus/herpetic keratitis (if inactive for>1 year unproved) Shape changes induced by contact lens Mild irregular astigmatism

Prior ophthalmic surgery that involved the central cornea Other ophthalmic disorders

Radial keratotomy (unproved) Penetrating keratoplasty, etc. Uveitis Diabetic retinopathy Progressive retinal disease

suggested by Tervo and Tuunanen.12 Subsequent work by Dhaliwal et al.13 with a rabbit model suggests that herpes simplex virus (HSV) shedding occurs following excimer exposure in both surface ablations and LASIK. Moreover, some evidence suggests that HSV may be spread in the laser plume. Moreira et al.14 exposed cell monolayers infected with HSV or adenovirus to excimer photoablation and demonstrated viral spread to sentinel dishes. Presence of vacuum aspiration influenced the direction of spread of the virus toward dishes in the direction of the vacuum.14 Although it does not demonstrate evidence of spread in the clinical setting, this study raises concerns for the treating physician, staff, and other patients. Glaucoma may be exacerbated indirectly by PRK. Corticosteroid responders may be difficult to manage after PRK. Although LASIK may be performed in the well-managed glaucoma patient, a decrease in central corneal thickness, resulting from photoablation or otherwise, will result in an apparent reduction in intraocular pressure as measured by applanation with Goldmann Tonometry.15, 16 Newer modalities such as Pascal tonometry are now available that are not dependent on corneal thickness. Visual field defects have been documented in patients after LASIK.17, 18 Barotrauma and ischemia have been suggested as etiologies for postLASIK optic neuropathy. Topographic contraindications to PRK include keratoconus, pellucid marginal degeneration, and topographic abnormalities that signify irregular astigmatism. Patients known to have ectatic conditions such as keratoconus and pellucid marginal degeneration must not undergo photoablation for the obvious reason that ablation thins the cornea. Ocular conditions that interfere with wound healing include previous radial keratotomy, neurotrophic corneas, and dry eye. Prior radial keratotomy with epithelium in the incisions is an absolute contra indication to LASIK. PRK with mitomycin can be performed on these eyes. Success, as defined by the likelihood of achieving 20/40 (6/12) or better uncorrected visual acuity, is substantially lower in patients who have undergone radial keratotomy prior to PRK without mitomycin compared with patients who have not undergone refractive surgery previously.19 However, in the light of anecdotal success in PRK after radial keratotomy,20 radial keratotomy must remain no more than a relative contraindication. Anecdotal reports exist of success with LASIK after radial keratotomy, but well-controlled studies need to be carried out. Even in the absence of recurrent corneal erosions, poor adherence of the epithelium resulting from epithelial basement membrane disease

may interfere with the production and subsequent healing of the flap after LASIK. Complications associated with epithelial sloughing resulting from microkeratome use in patients with epithelial basement membrane dystrophy include flap distortion, interface epithelial ingrowth, flap keratolysis, and corneal scarring.21 The most important disorder of the tear layer is keratoconjunctivitis sicca. Unrecognized dry eye may substantially delay re-epithelialization22 and result in increased postoperative haze after PRK23 and keratitis after LASIK. An inadequate tear volume may fail to dilute proteolytic enzymes such as plasmin and growth mediators such as epithelial growth factor.23 Moreover, a decreased tear volume may result in decreased levels of tear immunoglobulins, lactoferrin, and lysozyme and thereby increase the susceptibility of the cornea to infection.24 A variety of conditions predispose the patient to dry eye. Long-term contact lens wear causes dry eye by decreasing corneal sensation.25 Hormonal causes of lacrimal insufficiency include pregnancy and menopause.26 Infectious causes include syphilis, tuberculosis, trachoma, hepatitis B and C, and diffuse infiltrative lymphadenopathy syndrome associated with human immunodeficiency virus.27 Lymphoma, amyloidosis, hemochromatosis, and sarcoidosis cause dry eye through infiltrative mechanisms.27 Multiple sclerosis and seventh nerve cranial neuropathies may cause dry eye. Sjgrens syndrome causes dry eye but is unlikely to remain undetected in the thorough refractive pre operative evaluation. Also, many medications have been implicated in the incitement or worsening of dry eye (Box 3-2-2).28 Depending upon the cause, dry eye is a readily treatable pathology. Seiler and McDonnell22 recommend frequent use of nonpreserved artificial tears, temporary or permanent punctal plugs, and or Restasis. It is mandatory that dry eye be addressed before the procedure to obtain the best surgical result and reduce complications. Patients who have progressive retinal pathologies are also ruled out for refractive surgery. Similarly, patients who have myopic degeneration, uveitis, or visually significant cataracts are not suitable for refractive surgery. Family ocular history is important, especially with regard to corneal ectatic disorders, progressive retinal disease, glaucoma, and cataracts.

OPHTHALMIC EXAMINATION
The preoperative ophthalmic examination consists of determining ocular dominance, pupil size measurement in dim light, manifest and cyclo plegic refraction, wavescan measurement, topography, pachymetry, slit-lamp examination, and dilated funduscopy (Box 3-2-3). Special care is required when manifest refraction is performed, with emphasis on an accurate measurement without accommodation. Proper fogging and binocular balance are central because it is ultimately only the value obtained by refraction that is entered into the excimer. Cycloplegic

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REFRACTIVE SURGERY

BOX 3-2-3 OPHTHALMIC EXAMINATION


VISUAL ACUITY Distance with and without correction Reading with and without correction REFRACTION Current spectacle correction Manifest refraction Cycloplegic refraction with cyclopentolate 1% TOPOGRAPHIC ANALYSIS Keratometry (measures central 3 mm) Computerized videokeratography INTRAOCULAR PRESSURE MEASUREMENT EXTERNAL EXAMINATION Ocular motility Ocular dominance Gross external examination measurements in bright and dim light SLIT-LAMP EXAMINATION Fluorescein stain Vital stain (if symptoms warrant) DILATED FUNDUSCOPY JONES BASAL TEAR SECRETION RATE (IF SYMPTOMS/SIGNS WARRANT) PACHYMETRY

ANCILLARY TESTING Wavefront Measurement (Aberrometry)


Wavefront testing should be the first examination performed before the eye is manipulated in any way. While the patient is waiting, he/she should not read magazines or other material in the waiting room since accommodation is increased and the eyes can dry. The application of drops or taking intraocular pressure with a Goldmann tonometer could alter the result. The results of the wavefront evaluation must be compared to the manifest and cycloplegic refractions to make certain the results are consistent. The results of the wavefront evaluation serve as a good starting point for the refraction. Computerized videokeratography is absolutely essential in the pre operative evaluation of patients for refractive surgery. It is the only way to uncover early or mild keratoconus.31 The population of patients who seek refractive surgery seems to carry an increased incidence of keratoconus (35%), perhaps as much as 10 times that of an expected random sample of myopes.31 These patients are probably a self-selected group for both keratoconus and dry eye because both pathologies manifest as contact lens intolerance. It is likely that many patients who exhibit keratoconus-like patterns that are undetectable by other means and cause no symptoms (so-called keratoconus suspects) remain subclinical. Only long-term follow-up differentiates these patients from those who go on to progressive ectasia.32 However, Seiler and Quurke33 reported a case of a patient with forme fruste keratoconus progressing to frank ectasia following LASIK. Therefore, these patients should be avoided. If there is a question of forme fruste keratoconus, inquire about a family history of keratoconus, look for high levels of coma on the wavefront evaluation, check for irregular mires on a keratometer, and look for a scissors reflex on retinoscopy of the dilated pupil. Corneal molding (warpage) is a transient corneal distortion produced primarily by rigid contact lens wear, but it may result from soft contact lens wear as well. Although transient, this distortion may persist for up to 5months.34 For this reason, it is advisable for a patient to discontinue contact lens wear before the preoperative examination for at least 3weeks for rigid lenses and 214days for soft lens wearers. If topographic examination is suggestive of corneal molding, a longer period of contact lens cessation is warranted until the topography stabilizes.

Computerized Videokeratography

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efraction with 1% cyclopentolate is mandatory because even the most r careful refraction may fail to disclose an accommodative component. A complete slit-lamp examination is necessary; special attention is paid to the lids, conjunctiva, and cornea. Eyelid malpositions, lagophthalmos, proptosis, and other external conditions that predispose the cornea to exposure must be recognized and treated before refractive surgery is attempted. Small interpalpebral fissures should be noted if LASIK is planned because of the difficulty of inserting the suction ring. Blepharitis and meibomian gland dysfunction are treated aggressively before photoablation to reduce the risk of bacterial superinfection, to improve the quality of the tear layer, and to prevent meibomian gland secretions and lash debris from becoming lodged in the interface between the flap and the corneal stroma. Patients affected by significant corneal neovascularization that extends into the central 7mm of the cornea are excluded from treat ment. Peripheral pannus may be associated with bleeding following the keratectomy. The tear meniscus must have a height of approximately 0.3mm and the tear-film breakup time must be at least 10seconds.24 Equivocal results or history of contact lens intolerance requires the ophthalmologist to carefully assess the tear film and lids and manage any pathology aggressively. An accurate preoperative measure of pupillary diameter is necessary. Several studies have suggested that a large pupil may not increase the risk of visual disturbances at night; however, patients with large pupils should be fully informed of the risk of glare and haloes. Wavefront ablations are recommended to minimize this risk. Pupillometry is performed in both room light and dimmed light. Although a pupillary diameter exceeding 6mm is not a contraindication to photoablation if the procedure is to be performed with a laser that has large optical diameter capability, modification of the surgical plan is required. Pupil diameters may be assayed by directly measuring the pupil with a Rosenbaum card, although measurements so performed often overestimate pupil size.29 Pupillometry may also be performed using a handheld infrared pupillometer.30 Keratometry is measured to assess the power of the central cornea, to gauge the quality of the mires, and to provide a basis for later intraocular lens calculations. As part of a thorough examination, tonometry is performed to ascertain intraocular pressure. Dilated funduscopy is performed to identify patients affected by progressive retinal disease; retinal holes, tears, or atypical lattice degeneration; unrecognized diabetic retinopathy; myopic degeneration; and other pathologies that preclude photoablative treatment.

Pachymetry

Pachymetry must be performed prior to LASIK. It is mandatory that there be at least 250m of tissue in the bed after ablation.35 If this important parameter is ignored, the patient is at risk for cornea1 ecta sia and an unstable refraction. Controversy exists as to whether optical pachymetry as provided by the Orbscan device may be substituted for ultrasonic pachymetry. Although optical pachymetry has the advantage of providing an array of corneal thickness measurements throughout the cornea and therefore identifying areas of corneal thinning outside the central cornea, recommendations for minimum bed thickness have been based upon ultrasonic and not optical devices.35 Furthermore, the Orbscan algorithm seems to produce readings that are consistently higher than those obtained by ultrasonic means.36, 37

COUNSELING
Not all patients who meet medical and ophthalmic criteria for refractive surgery are necessarily good candidates for the procedure. Patients must be told that spectacles may be required for certain tasks such as driving at night. After surgery, patients should not expect to obtain perfect uncorrected distance acuity. Those who are dissatisfied with these projections are likely to be dissatisfied after surgery. Presbyopic myopes must be made aware that the removal of distance glasses to achieve a near addition is no longer possible after refractive surgery. However, if the patients lifestyle permits and the patient is motivated sufficiently, monovision may be a possibility. The preoperative evaluation of the patient for refractive surgery is lengthy and must be performed in an unrushed manner. However, it is time well spent because the best treatment for complications and disappointment is avoidance.

REFERENCES
1.  Seiler T, Holschbach A, Derse M, et al. Complications of myopic photorefractive keratectomy with the excimer laser. Ophthalmology. 1994;101:15360. 2.  Alio JL, Artola A, Belda JI, et al. LASIK in patients with rheumatic diseases. A pilot study. Ophthalmology. 2005;112:194854. 3.  Cobo-Soriano R, Beltran J, Baviera J. LASIK outcomes in patients with underlying systemic contraindications. Ophthalmology. 2006;113:111824. 4.  Hefetz L, Gershevich A, Haviv D, et al. Influence of pregnancy and labor on outcome of photorefractive keratectomy. J Refract Surg. 1996;12:5112. 5.  Sharif K. Regression of myopia induced by pregnancy after photorefractive keratectomy. J Refract Surg. 1997;13(Suppl):S4456. 6.  Tanzer DJ, Isfahani A, Schallhorn SC, et al. Photorefractive keratectomy in African Americans including those with known dermatologic keloid formation. Am J Ophthalmol. 1998;126:6259. 7.  Epstein R. Results of Internet poll on outcome of LASIK in keloid formers [letter]. J Refract Surg. 2000;16:3801. 8.  Vrabec MP, Durrie DS, Chase DS. Recurrence of herpes simplex after excimer laser keratectomy [letter]. Am J Ophthalmol. 1992;114:967. 9.  Bialasiewicz AA, Schaudig U, Draeger J, et al. Descemetocele after excimer laser phototherapeutic keratectomy in herpes simplex virus-induced keratitis: a clinico-pathologic correlation. Klin Monatsbl Augenheilkd. 1996;208:1203. 10.  Fagerholm P, Ohman L, Orndahl M. Phototherapeutic keratectomy in herpes simplex keratitis. Clinical results in 20 patients. Acta Ophthalmol (Copenh). 1994;72: 45760. 11.  Pepose JS, Laycock KA, Miller JK, et al. Reactivation of latent herpes simplex virus by excimer laser photokeratectomy. Am J Ophthalmol. 1992;114:4550. 12.  Tervo T, Tuunanen T. Excimer laser and reactivation of herpes simplex keratitis [letter; comment]. CLAO J. 1994;20:1523. 157. 13.  Dhaliwal DK, Romanowski EG, Yates KA, et al. Experimental laser-assisted in situ keratomileusis induces the reactivation of latent herpes simplex virus. Am J Ophthalmol. 2001;131:5067. 14.  Moreira LB, Sanchez D, Trousdale MD, et al. Aerosolization of infectious virus by excimer laser. Am J Ophthalmol. 1997;123:297302. 15.  Shah S. Accurate intraocular pressure measurement the myth of modern ophthalmology?. Ophthalmology. 2000;107:18057. 16.  Chatterjee A, Shah S, Bessant DAR, et al. Reduction in intraocular pressure after excimer laser photorefractive keratectomy. Correlation with pre-treatment myopia. Ophthalmology. 1997;104:3559. 17.  Cameron BD, Saffra NA, Strominger MB. Laser in situ keratomileusis-induced optic neuropathy. Ophthalmology. 2001;108:6605. 18.  Bushley DM, Parmley VC, Paglen P. Visual field defect associated with laser in situ keratomileusis. Am J Ophthalmol. 2000;129:66871. 19.  Ribeiro JC, McDonald MB, Lemos MM, et al. Excimer laser photorefractive keratectomy after radial keratotomy. J Refractive Surg. 1995;11:1659. 20.  Meza J, Perez-Santonja JJ, Moreno E, Zato MA. Photo refractive keratectomy after radial keratotomy. J Cataract Refract Surg. 1994;20:4859. 21.  Dastgheib KA, Clinch TE, Manche EE, et al. Sloughing of corneal epithelium and wound healing complications associated with laser in situ keratomileusis in patients with epithelial basement membrane dystrophy. Am J Ophthalmol. 2000;130:297303. 22.  Seiler T, McDonnell PJ. Excimer laser photorefractive keratectomy. Surv Ophthalmol. 1995;40:89118. 23.  Tervo T, Mustonen R, Tarkkanen A. Management of dry eye may reduce haze after excimer laser photorefractive keratectomy [letter]. Refract Corneal Surg. 1993;9:306. 24.  Nelson JD. Diagnosis of keratoconjunctivitis sicca. Int Ophthalmol Clin. 1994;34:3756. 25.  Liu Z, Pflugfelder SC. The effects of long-term contact lens wear on corneal thickness, curvature and surface irregularity. Ophthalmology. 2000;107:10511. 26.  Warren DW. Hormonal influences on the lacrimal gland. Int Ophthalmol Clin. 1994;34:1925. 27.  Fox RI. Systemic diseases associated with dry eye. Int Ophthalmol Clin. 1994;34:7187. 28.  Fraunfelder FT, LaBraico JM, Meyer SM. Adverse ocular reactions possibly associated with isotretinoin. Am J Ophthalmol. 1985;100:5347. 29.  Wachler BS, Krueger RR. Agreement and repeatability of infrared pupillometry and the comparison method. Ophthalmology. 1999;106:31923. 30.  Schnitzler EM, Baumeister M, Kohnen T. Scotopic measurement of normal pupils: Colvard versus Video Vision Analyzer infrared pupillometer. J Cataract Refract Surg. 2000;26:85966. 31.  Wilson SE, Klyce SD. Screening for corneal topographic abnormalities before refractive surgery. Ophthalmology. 1994;101:14752. 32.  Nesburn AB, Bahri S, Salz J, et al. Keratoconus detected by videokeratography in candidates for photorefractive keratectomy. J Refract Surg. 1995;11:194201. 33.  Seiler T, Quurke AW. Iatrogenic keratectasia after LASIK in a case of forme fruste keratoconus. J Cataract Refract Surg. 1998;24:10079. 34.  Wilson SE, Lin DT, Klyce SD, et al. Topographic changes in contact lens-induced corneal warpage. Ophthalmology. 1990;97:73444. 35.  Seiler T, Koufala K, Richter G. Iatrogenic keratectasia after laser in situ keratomileusis. J Refract Surg. 1998;14: 3127. 36.  Marsich MW, Bullimore MA. The repeatability of corneal thickness measures. Cornea. 2000;19:7925. 37.  Yaylali V, Kaufman SC, Thompson HW. Corneal thickness measurements with the Orbscan Topography System and ultrasonic pachymetry. J Cataract Refract Surg. 1997;23:134550.

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