6/2/2019 - coavision.org Symposium... · 6/2/2019 3 Not Your Typical Dry Eye Clinical...
Transcript of 6/2/2019 - coavision.org Symposium... · 6/2/2019 3 Not Your Typical Dry Eye Clinical...
6/2/2019
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Not Your Typical Dry EyeContemporary Management Strategies for Challenging Cases
Michael DePaolis, OD, FAAO
Flaum Eye Institute / UR Medicine
Michael DePaolis, OD, FAAO
FINANCIAL DISCLOSURE STATEMENT
▪ Associate Professor of Clinical OphthalmologyFlaum Eye Institute @ UR Medicine
▪ Clinical Investigator, Advisor, Consultant, Lecturer▪ Alcon▪ Allergan▪ AMO▪ Bausch & Lomb▪ Cooper Vision▪ Paragon Vision Sciences▪ Shire▪ SynergEyes▪ J&J Vision Care
▪ Optometric Editor, PRIMARY CARE OPTOMETRY NEWS
What do a …..
▪ 63 yof with non-small cell lung cancer
▪ 68 yof with filamentary keratitis & ABMD
▪ 44 yof with monthly subconjunctival hemorrhages
▪ 36 yom post PRK
▪ 56 yof with bilateral 7th nerve crush injury
…. have in common?
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
TFOS DEWS II Report
▪ 150 clinical & basic researchers from 23 countries
▪ 10 subcommittees and over 2 years in duration
▪ 400 page report published in Ocular Surface (July 2017)
Goals …
▪ Update definition & classification of DED
▪ Evaluate epidemiology, pathophysiology, mechanism &
impact
▪ Recommendations for diagnosis & management
▪ Recommendations for future study designs
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
TFOS DEWS II Report
Definition & Classification
“Dry eye is a multifactorial disease of the ocular surface
characterized by a loss of homeostasis of the tear film, and
accompanied by ocular symptoms, in which tear film instability
and hyperosmolarity, ocular surface inflammation and damage,
and neurosensory abnormalities play etiological roles.”
▪ Aqueous deficient dry eye (ADDE)
▪ Evaporative dry eye (EDE)
▪ Most often DED is a continuum
Not Your Typical Dry Eye
Clinical Considerations for Complex CasesTFOS DEWS II Report
Epidemiology
▪ Study prevalence ranges from 5 – 50%
▪ Most studies from North America, Europe, and Africa
Risk factors
▪ Age, sex (estrogen), and race (Asian)
▪ MGD
▪ CT disorders, Sjogren’s, androgen deficit, & stem cell transplantation
▪ Contact lens wear, computer use, low humidity, and medications
Possible risk factors
▪ Diabetes, rosacea, thyroid disease, viral disease, and psychiatric disease
▪ Allergic conjunctivitis and pterygium
▪ Refractive surgery
▪ Low fatty acid intake and certain other medications
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
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TFOS DEWS II Report
Pathophysiology
▪ Core mechanism is evaporation induced hyperosmolarity
▪ In ADDE hyperosmolarity results from reduced secretion
▪ In EDE hyerosmolarity results from evaporation
▪ Hyperosmolarity leads to goblet cell, epithelium, and glycocalyx damage
▪ In ADDE there is sensory blockage to lacrimal gland and blink mechanism
▪ Gland infiltration, nerve damage, drugs, refractive surgery, etc
▪ In EDE there is increased evaporation due to MG dysfunction
▪ Poor blinking, rosacea, MG dropout
▪ Ultimately, tissue damage results in local neuronal dysfunction
Not Your Typical Dry Eye
Clinical Considerations for Complex CasesTFOS DEWS II Report
Tear Film
▪ 2 phase model of tear film
▪ Lipid layer – wax and cholesterol
▪ Muco-aqueous layer – 4 major mucins and 1500+ proteins & peptides
▪ No hallmark changes in lipid layer in DED
Pain & Sensation
▪ Nociceptive pain – results from actual tissue stimuli
▪ Neuropathic pain – due to lesion w/in somatosensory system
▪ Nociceptive pain receptors respond to pain, mechanical, and thermal
▪ Lacrimal secretions regulated by autonomic nervous system
▪ Ocular surface nerves also regulate blinking
▪ DED inflammation & tissue damage impacts innervation!
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
TFOS DEWS II Report
Iatrogenic Dry Eye
▪ Results from drugs, contact lenses, surgery, etc
▪ Alters neural input -> decreased lacrimal and MG function
Diagnostic methodology
▪ Dry eye questionnaire (DEQ-5) or OSDI
▪ Presence of any 1 of following:
▪ Reduced NITBUT
▪ Elevated hyperosmolarity (>308) or inter-eye delta (>8)
▪ Ocular surface staining – cornea or conjunctival
▪ Secondary evaluation
▪ Tear meniscus height
▪ MG assessment
Not Your Typical Dry Eye
Clinical Considerations for Complex CasesTFOS DEWS II Report
Management & Therapy
▪ Restore homeostasis of tear film and ocular surface
▪ Step 1
▪ Patient education – environment, medications, diet
▪ Lid hygiene & hot compresses
▪ AT’s
▪ Step 2
▪ PF AT’s
▪ Punctal occlusion or moisture goggles
▪ In office MG therapy (expression, LipiFlow, IPL Therapy
▪ Topical AB-Steroid, topical immunomodulators, oral AB’s
▪ Step 3
▪ Oral secretogagues, autologous serum gtt, bandage lenses
▪ Step
▪ Amniotic membrane, tarsorrhaphy
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
▪ Establish a treatment hierarchy
All patients
Disease & Medication Modification
Environmental Considerations Uchino, etal JAMA Ophth132(8):2014
Diet & Lifestyle modifications (omega 3’s)
Why omega 3’s and what’s appropriate ?
▪ Gilbard (Opt 2004) – thin meibum & block cytokines (IL 1a&b, Cox-2)
▪ Roncone (Cont Lens Ant Eye 2010 ) - Reduce TNFa in lacrimal gland ->
increased tear production
▪ Wojtowicz (Cornea 2011) – 450mg EPA + 300 mg DHA x 3mth -> 70% of
pts improved Schirmers & fluorophotometry vs 7% controls
▪ Kangari (Ophth 2013) - 360mg EPA & 240 mg DHA x 1 mth ->
Statistically significant improvements in TBUT, OSDI, Schirmers vs
controls
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
▪ Establish a treatment hierarchy – International Task Force
Grade 1 – Symptoms + TBUT + conjunctival stain
Hot compresses, lid hygiene, & artificial tears and gels
▪ Lacroix (2015) – wet washcloth vs commercial masks – 40*c > 5 minutes
Grade 2 – Above + mild corneal staining
Add short term corticosteroids / Restasis / Lifitigrast
Grade 3 – Above + moderate / severe corneal involvement
Punctal plugs / Topical azithromycin / oral doxycycline
Grade 4- Above and persistent
Moisture goggles qhs
Autologous serum gtt or Platelet Rich Plasma gtt
Amniotic membrane, Bandage lenses or Scleral lenses qd
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
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Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
John, etal Ophth 2017
▪ Single application of Prokera in severe DED cohort
▪ Improved DED signs, symptoms, and corneal nerve density & function
McDonald ASCRS Meeting May 2017
▪ Dry Eye Amniotic Membrane Study (DREAMS)
▪ Improved DEWS severity level in 88% of patients in 1 week
Morkin & Hamrah Oc Surf 17:2017
▪ Single application of Prokera in 10 eyes with neuropathic corneal pain
▪ 75% improvement in pain scale within 1 week (persisted after removal)
▪ IVCM demonstrated 37% improvement in corneal nerve density
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
Clinical Case - 63 yof
Ocular History: Long standing successful monovision scl wearer. C/O dryness, blurred vision, and contact lens intolerance. “I think my dryness is due to my medications”
Contact Lens History: Cooper Frequency 55 Torics. ReNu qhs. Replaces q 2 mths.
Systemic History: HTN, hypothyroid, non-smoker’s lung CA.
Medications: Amlodipine, levothroxyine, & Tarceva. NKDA.
Exam: VA OD cc 20/60 & OS cc 20/50
Pupils, motilities, & CVF’s normal OU / IOP’s 14 OU
Not Your Typical Dry Eye
Clinical Considerations for Complex CasesClinical Case - 63 yof
Refraction: OD - 125-075x180 / +225 = 20/25OS - 200-050x170 / +225 = 20/40
Biomicroscopy: Grade 1 mgd, grade 1 injection, grade 2+ SPK, ACd&q, iris normal, grade 1 NS
Tear Osmolarity 308 mOsm/L OD & 319 mOsm/LTBUT 5s
DFE: Disc, macula, vessels, vitreous, and peripheral retina normal.
Impression: Combined etiology dry eye
Plan: ▪ Environment, hydration, & omega 3s▪ Hot compress qd x 5 minutes▪ Systane Balance PF qid,▪ Lotemax gel bid,▪ Clariti 1-Day toric OD / no lens OS
Not Your Typical Dry Eye
Clinical Considerations for Complex CasesClinical Case - 63 yof
2 week follow-up:
Ocular History: Compliant with all treatments. Right eye feels much better and is much clearer. Left eye still symptomatic.
VA: OD scl 20/25 (D) & OS sc 20/40 (N)
Biomicroscopy: Grade 1 MGD OU,
trace injection OS > OD,
trace SPK OD & grade 1+ SPK OS,
ac d&q, iris normal, grade 1 NS
Plan:
▪ Hydration and omega 3s
▪ Hot compress qd x 5 minutes
▪ Systane Balance PF qid
▪ Clariti 1-Day toric OD & Clariti 1-Day +025 OS
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
Clinical Case - 63 yof
Questions for consideration …
Just what is Tarceva?
▪ Erlotonib is a kinase inhibitor approved for pancreatic cancer and metastatic non-small cell lung cancer
▪ Inhibits epidermal growth factor receptor activity in cancer cells
▪ Stevens Johnson Syndrome among side effects
▪ Ocular side effects: Reduced tear secretion, ocular surface disease, and corneal edema
What are reasonable adjunct treatments?
▪ Amniotic membrane
▪ Punctal plugs
▪ Cyclosporin or lifitigrast
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
Case – 68 yof
cc: Red, irritated eyes x 6 months. +fb sensation. +grittiness.
+photophobia. + variable vision. Moderate intensity. No significant
discharge. Oc hx: Pseudophakia OU Amblyopia OS.
Systemic hx: +asthma. +arthritis. +hypothyroid. +Sjogren’s. +depression.
+ seasonal allergies. No recent uri.
Medications: Advair, glucosamine/chondroitin, levothyroxine, & sertraline
qd. Claritin-D prn. NKDA.
Family hx: Father – AMD.
Social hx: No smoking. Minimal alcohol. Medical receptionist.
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Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
Case 68 yof
VA OD +0.75-1.00x 100 / +2.50 = 20/60
OS +0.50-1.25x80 / +2.50 = 20/80-
Externals: Pupils, EOM’s, and CVF’s normal. No adenopathy.
IOPs: 14 OD & 14 OS
DFE: Healthy disc, macula, vasculature, posterior pole. Vitreous floaters.
Biomicroscopy:
▪ Gr 1+ MGD
▪ Gr 2 conj LG stain
▪ Tear meniscus < 0.25mm
▪ TBUT < 5 seconds.
▪ Coalesced SPK, filaments & ABMD
▪ PCIOL
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
Case 68 yof
Impression:
▪ Aqueous deficient & evaporative dry eye
▪ MGD ou
▪ ABMD ou
▪ Filamentary keratitis ou
Plan:
▪ In office removal of filaments ou
▪ Tobradex ung ou qid
▪ Systane Balance PF ou q2h
▪ Hot compress, hydration, & omega 3s
▪ Follow-up 1 week
Not Your Typical Dry Eye
Clinical Considerations for Complex CasesCase 68 yof - 1 week f/u
Cc: ‘eyes feel about 50% better.’ Complying with all tx. c/o ung blurring va.
No change in systemic health or meds.
VA: Rx OD 20/30 & OS 20/40-
Biomicroscopy:
Gr 1+ mgd, Gr 1 conjunctival LG staining ou
Tear prism < 0.25mm & TBUT < 5 secs
No filaments, gr 1 exposure keratitis, gr 1 abmd ou
Plan:
▪ Tobradex ung ou qhs x 2 wks then d/c
▪ Hot compress qd, good hydration, & omega 3s
▪ Systane Balance PF qid
▪ Xiidra bid
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Case 68 yof - 4 week f/u
Cc: ‘eyes feel no better.’ Complying with all tx. c/o blurring va. No change
in systemic health or meds.
Va: Rx – OD 20/30- & OS 20/50-
Biomicroscopy:Gr 1+ mgdGr 1+ conjunctival LG staining Tear prism < 0.25 mm & TBUT < 5 secGr1 abmd ou … with recurrence of corneal filaments osGr 1 exposure keratitis ou
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Case 68 yof – 4 week f/u
Impression:
▪ MGD ou
▪ Aqueous deficient and evaporative dry eye ou
▪ abmd ou
▪ Filamentary keratitis ou
Plan:
▪ Continue hydration, omega 3s, and hot compresses qd
▪ Parasol punctal plug LL ou
▪ Systane Balance PF q2h
▪ Xiidra bid
▪ BioTrue daily disposable OS prn
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Case 68 yof – Questions for consideration
Would have upper lid punctal occlusion been a better option?▪ Doane Ophth 98(8):1981 - Upper lid occusion slows “Krehbiel flow”
Would you consider ultimately tapering Xiidra?
▪ Donnenfeld & Perry Rev Oph 8:2003
How much omega 3’s are necessary?
▪ 500mg EPA+DHA up to 4,000mg EPA+DHA (Lovaza qid)
Would FreshKote be a reasonable option ?
▪ High osmotic pressure
▪ Amisol, lacrophillic aqueous, mucomimetic components
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Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
Clinical Case - 44 yof
Ocular History:
Previously wore soft contact lenses, but d/c due to dryness
Referred by corneal specialist
Has tried Optive, Systane, & TheraTears
Has tried Pred Forte & Alrex
Current eye gtt: Patanol ou bid, Restasis ou bid.
Cc: ‘I get eye hemorrhages monthly.’ I’d like to get back into wearing contact lenses if possible’.
Systemic History: +Anxiety. (-) Thyroid. (-) Arthritis.
(-) Blood dyscrasias / hematology work-up.
Medications: Fluoxetine qd, Fish oil qd.
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
Clinical Case - 44 yof
VA: OD Rx 20/20- & OS Rx 20/20.
Externals: (+) malar flush
Biomicroscopy:Grade 3 mgd ouGrade 2 conjunctival chalasis ouGrade 1 conjunctival LG stain ouCornea clear with TBUT < 10 sec ouTear prism <0.5mm ou
Impression:▪ MGD ou▪ Keratoconjunctivitis sicca ou▪ Rosacea (ocular)▪ Subconjunctival hemorrhage ou
(Menstrual related ?)
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
Clinical Case - 44 yof
Plan:
▪ Spoke with ob-gyn – r/o causes for menorrhagia
▪ Spoke with pcp – doxycycline 50 mg qd
▪ Hot compresses with digital massage ou bid
▪ Nordic Naturals ProOmega – 2 softgels po qd
▪ Lotemax ou bid
▪ Patanol ou qam
▪ Restasis ou bid
▪ F/u 1 month
1 month f/u
Doing much better.
Plan: 1) D/C Lotemax 2) Continue all other tx 3) f/u 2 months
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Clinical Case - 44 yof 3 month
CC: ‘doing great, no hemorrhages in 2 months.’ VA: OD Rx 20/20 & OS Rx 20/20.
Biomicroscopy: Gr 1 mgdGr 1 conjunctival chalasis w/o LG stain ouCornea clear with TBUT ~ 10 sec ou
Plan:▪ Continue hot compress ou qd▪ Continue Restasis ou bid & Patanol ou prn▪ Continue ProOmega qd▪ Doxycycline 50 mg qod x 1 mth, then d/c▪ BioTrue Daily Disposable
Not Your Typical Dry Eye
Clinical Considerations for Complex Cases
Clinical Case - 44 yof
Questions for consideration ….
Is conjunctivoplasty indicated in symptomatic LIPCOF ?Acera, etal Invest Ophth Vis Sci 54(13):2013N = 12 eyes conjunctival resection for conjunctivochalasisImproved pro-MMP-9 levels led to less epithelial defects, epiphora, and symptoms
Yamamoto, etal Eye Cont Lens Aug 12, 2015 (epub)N = 362 pts: CCh + visually demanding tasks = 3+ SCHN = 38 pts conjunctivochalasis (CCh) surgery for SCH80+% no SCH recurrence after surgery
If the ‘menstrual cycle’ subconjunctival hemorrhages return, is a low dose oral contraceptive indicated ?
Dua, etal Ophth Plast Reconstr Surg 30(2):2014Case of ‘vicarious orbital menstruation’ responds favorablyto oral contraceptives
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Clinical Case - 36 yom
▪ Ocular History: Myopia & Astigmatism OU.
Contact lens intolerance secondary to DED.
▪ Systemic History: (+) Depression (+) Anxiety (+) Allergies.
▪ Current Medications: Xanax qd. Claritin prn. NKDA.
▪ Family History: AMD – aunt. POAG – grandmother.
▪ Surgical History: Bilateral advanced surface ablation (PRK).
▪ Chief complaint: Dryness & asthenopia.
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Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Clinical case – 36 yom
▪ Unaided VA: OD 20/40 OS 20/70
▪ Externals: Pupils, EOM’s, and CVF’s normal OU
▪ IOP: 15 OU
▪ DFE: Normal posterior pole OU
Biomicroscopy:
▪ Grade 1+ Blepharitis & MGD
▪ Weak tear prism OU
▪ TBUT 5-7 s
▪ Arcuate haze OD
▪ Central haze OS
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Clinical Case – 36 yom
Pre-operative Rx
OD -7.50 -0.50 x 165 = 20/15
OS -7.00 -0.75 x 180 = 20/15
Postoperative Rx
OD +1.50 -1.25 x 21 = 20/20=
OS -1.25 -1.00 x 142 = 20/20-
Keratometry
OD 37.78 x 39.32 D
OS 39.87 x 40.95 D
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Clinical Case – 36 yom
Treatment:
▪ Hydration, reduced caffeine, and omega 3’s
▪ Hot compress and eyelid hygiene qd
▪ Blink gtt tid & gel qhs
▪ Bilateral lower lid punctal plugs
Contact Lenses:
▪ OD B&L PureVision 2 8.9 +1.50 -1.25 x 20 = 20/25+
▪ OS B&L PureVision 2 8.9 -1.25 -0.75 x 140 = 20/25+
▪ Clear Care qhs
▪ Wears contact lenses ~ 5 days per week.
▪ Uses Pataday prn for overlying ocular allergy symptoms.
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Clinical Case: 36 yom
Questions for consideration ….
Is there a relationship between depression and dry eye ?▪ vanderVart, etal AJO 159(3):2015▪ 7,200 DED, 20,000 anxiety, and 30,100 depression▪ Adjusted odds ratio of 2.8 DED/anxiety and 2.9 DED/depression
Does vitamin C play a role in mitigating post PRK haze?▪ Stojanovic, etal J Ref Surg 19(3):2003▪ 500 mg bid x 1 mth -> significantly lessens haze (n=500 eyes)
Would ‘mini-PRK’ have been a better surgical option ?▪ Mini- PRK (Scott MacRae, MD URMC Flaum Eye Institute)
▪ 7 mm vs 8.5 mm = 34% reduction in epithelial defect size
▪ Bandage lens Rx -1.00 D Rx for 1-2 weeks
What is our game plan going forward?▪ Leccisotti J Cat Ref Surg 35(4):2008.▪ Mitomycin C improved H-PRK haze, predictability, and efficacy
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Case - 56 yof
Cc: c/o extreme dry eye and diplopia ou. Hx of MVA with bilateral 7th CN
‘crush’ injury. Bell’s palsy -> corneal ulceration -> tarsorraphy -> punctal
cauterization Meds: saline gtt ou q15 minutes, bland ung ou qhs, Pred
Forte ou bid.
Systemic hx: Osteopenia. Boniva q1mth. NKDA.
Family Hx: non-contributory.
Social Hx: No nicotine. No alcohol. Office administration.
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Case – 56 yof
VA: OD +3.25 - 2.00 x 4 = 20/100
OS +1.50 – 3.50 x 120 = 20/400.
Externals: Perrla (no apd), EOM – constant OS 20pd et, cvf – full ou.
IOP’s: 15 OD & 14 OS goldmann @ 10 am.
DFE: Healthy posterior pole OU.
Biomicroscopy:
Grade 1 MGD and lower lid punctal cautery OU
Stromal scarring with neovascularization OU
Incipient cataract OS > OD
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Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Case – 56 yof
Impression:
▪ Mild MGD OU
▪ Neurotrophic dry eye OU
▪ Corneal neovascularization & scar OU
▪ Esotropia OS
▪ Incipient cataract OS > OD
Plan:
▪ Continue with sterile saline OU prn
▪ Hot compress OU qd
▪ Pataday ou qam & Alrex OU qhs
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Case - 56 yof – 2 week f/u
OD SynergEyes Duette 7.80 14.5 -1.50 MED
Central, acceptable movement,
VA cc Rx = 20/20-
OS Clariti 1-Day 8.6 +4.00
Central, optimal movement,
VA = < 20/400
Plan:
▪ Initiate contact lens wear
▪ ClearCare qhs & SE saline qam
▪ Pataday OU qam & Alrex OU qhs
▪ Sterile saline gtt OU prn
Not Your Typical Dry Eye Clinical Considerations for Complex Cases
Case – 56 yof – Questions for consideration
Is cyclosporine or Lifitigrast indicated here?
▪ Neurotrophic vs inflammatory
Are there other options for neuroparalytic keratitis ?
▪ Turkoglu, etal Semin Ophthal 29(3):2014
▪ Both autologous serum and amniotic membrane effective for acute care
▪ Amniotic membrane slightly better in deep stromal ulcers
Would a scleral lens be a better option (given extensive neo)?
▪ Compan, etal IOVS 55(10):2014
▪ DK > 120 + Thk <200u + Vault < 150u = No edema!
Michael DePaolis, OD, FAAO
Flaum Eye Institute / URMedicine
Rochester, NY
Thank you for attending!
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