We found 52 results for Ophthalmology in video, leadership & webinar
Inferior Oblique Myectomyvideo
Inferior oblique myectomy is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by transecting it. The patient is a four old with a history of inferior oblique overaction and vertical strabismus, which can be corrected by resection of the inferior oblique muscle. The ointment was applied to the cornea. Forced ductions were performed and identified restriction of the inferior oblique. A conjunctival incision is made in the fornix. Tenon's capsule is dissected to expose the Inferior Oblique. The inferior oblique muscle is isolated using a Stevens tenotomy hook followed by Jameson muscle hooks. The inferior rectus was identified on a steven’s hook medially to the inferior oblique. The lateral rectus was then identified on a steven’s hook laterally to the inferior oblique. This was done to ensure that neither muscle was incorporated with the portions of the inferior oblique muscle to be cut. Wescott scissors were used to cut both ends of the muscle. Bipolar cautery forceps were used to cauterize the resected proximal and distal ends of the inferior oblique muscle. The two ends were released and the remaining muscle ends were allowed to retract into the orbit. The conjunctiva was closed using a plain gut suture. No complications arose during the procedure. Postoperatively, the patient had a subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the one follow-up, the redness and pain had resolved. Inferior oblique myectomy effectively treats inferior oblique overaction and vertical strabismus associated with this condition.
Phacoemulsification and IOL Implantation in an Iris Coloboma Casevideo
We present a case of cataract extraction and intraocular lens implantation in an eye with a congenital iris coloboma.
Thermal Punctal Cautery for Chronic Ocular Surface Diseasevideo
In this video, permanent punctal occlusion is performed with high-temperature thermal cautery for the treatment of refractory ocular surface dryness, in this case due to graft-versus-host disease.
Lower Lid Internal Blepharoplastyvideo
The procedure in this video demonstrates a cosmetic lower lid internal blepharoplasty.
Glabellar Flap Reconstruction After Mohs Surgeryvideo
The procedure in this video demonstrates a bi-lobed glabellar flap reconstruction after Mohs micrographic excision of a basal cell carcinoma in the medial canthus of the eyelids.
Upper Lid Retraction Repair with Platinum Weightvideo
The procedure shown in this video is an upper lid retraction repair with platinum weight.
Dermis Fat Graft Implantation into Anophthalmic Socketvideo
Dermis fat graft implantation has been used for decades to augment orbital volume and surface area in patients with congenital anophthalmia as well as those suffering complications of secondary anophthalmia following enucleation. It is most commonly performed as a means of socket reconstruction in patients with an exposed or extruded orbital implant and to prevent socket contracture. In this video, a dermis fat graft is harvested from the buttock and implanted into an anophthalmic socket for treatment of exposure of orbital implant in the right socket of a patient who was status post enucleation in both eyes for painful blind eyes. Suzanne K. Freitag, MD Victoria Starks, MD Zujaja Tauqeer Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School
Superior Rectus Recessionvideo
Introduction Muscle recession is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by adjusting its insertion posteriorly closer to its origin. The patient is a 14-year-old with dissociated vertical deviation, which can be corrected with recession of the superior rectus muscle. Methods A conjunctival incision is made in the fornix. Tenon's capsule is dissected to expose the superior rectus muscle. The superior rectus muscle is isolated using a Stevens tenotomy hook followed by a Jameson muscle hook. After the remaining Tenon's attachments are cleared, the muscle is secured at both poles with a double-armed 6-0 VicrylTM suture and double-locking bites. The muscle is then disinserted from the sclera with Manson-Aebli scissors. A caliper is used to mark the predetermined distance of muscle reinsertion. Next, the muscle is reattached to the sclera with partial thickness bites and then tied down to its new location. The conjunctival incision is closed with 6-0 plain gut sutures. Results No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the three-month follow up, the redness had resolved. The dissociated vertical deviation had improved. Conclusion Superior rectus recession is a safe procedure that can effectively treat vertical strabismus. By: Michelle Huynh College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA firstname.lastname@example.org Surgeons: Brita Rook, MD Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA BSRook@uams.edu Joseph Fong, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA JFong@uams.edu Video was performed at Arkansas Children’s Hospital, Little Rock, AR, USA.
Ptosis Repair, Mullerectomyvideo
Suzanne Freitag MD Juan Carlos Jimenez Perez, MD Benjamin Jastrzembski, MD Harvard Medical School, Massachusetts Eye and Ear
Pars Plana Vitrectomy and Endolaservideo
This video shows the basic steps in evacuating a vitreous hemorrhage due to a retinal vein occlusion. Surgeon & Editing: Sean Tsao M.D.
Bilateral Dacryocystoceles Resectionvideo
Contributor: Tyler McElwee Congenital dacryocystocele describe the distended lacrimal sac in neonates with or without associated intranasal cyst. The prevalence is about 0.1% of infants with congenital nasolacrimal duct obstruction and a slight prevalence in female infants. It refers to cystic distention of the lacrimal sac as a consequence of the nasolacrimal drainage system obstruction. It typically presents as a bluish swelling inferomedial to the medial canthus in the neonates. Unilateral congenital dacryocystocele is more common but 12-25% of patients affected have bilateral lesions. Ultrasound, CT scan or MRI can be used for diagnosis. About half of the patient with acute dacryocystitis can be management with conservative management such as digital massage of lacrimal sac or in-office lacrimal duct probing. The other half of patients will require surgery under general anesthesia for removal of the dacryocystocele. Endoscopic excision of the intranasal cysts has been used successfully as a treatment option with Crawford stent placement. Post-operatively patients are treated empirically with antibiotics and nasal saline. No second look is usually planned unless patients develop significant nasal obstrctuion. Editor Recruited By: Sanjay Parikh, MD, FACS DOI: http://dx.doi.org/10.17797/16rnuq8n0y
Metallic Intraocular Foreign Body removed from the retinavideo
This is an eye from a young man who was working with metal and a piece of metal shot into his eye, through his cornea and lens and landed on the retina causing a crater. In this surgery we remove the metal and repair the retina. DOI: https://doi.org/10.17797/40cgy368y1
Endoscopic DCR and Dacryolith Removalvideo
Contributors: Nicolas Biro This video displays a left sided Endoscopic DCR with lit pipette assistance for a 25 year old patient with severe epiphora and pain from chronic dacrocystitis and dacryolith. DOI: http://dx.doi.org/10.17797/r6p89jf9in
Endoscopic Excision of Nasolacrimal Duct Cystvideo
The patient is a 4 week old female infant with right sided epiphora and complete right sided nasal obstruction resulting in respiratory and feeding difficulty. Physical exam demonstrated a right medial canthal mass consistent with a dacrocystocele. Flexible fiberoptic nasal endoscopy demonstrated an anterior nasal mass below the inferior turbinate occluding the entire right nasal cavity consistent with a nasolacrimal cyst. The etiology is obstruction at the level of Hassner's valve.
Pars Plana Vitrectomy and Membrane Peelingvideo
This video shows the fundamental steps of removing an epiretinal membrane. Surgeon: Mitul Mehta M.D. M.S. Video: Sean Tsao M.D. Gavin Herbert Eye Institute, University of California Irvine
Lower eyelid ectropion repair with lateral tarsal strip and medial spindle procedurevideo
One of the most common causes of lower lid ectropion is horizontal lid laxity, the incidence of which increases with age. This condition induces poor ocular surface tear film coverage which leads to irritation, tearing, and keratopathy. Lateral tarsal strip fixation is the technique which is widely used to repair involutional ectropion due to horizontal lid laxity. Medial spindle procedure is the well-known technique for puntal ectropion correction. Both surgeries are minimally invasive, simple and effective. Contributors Suzanne K. Freitag, MD, Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School Thidarat Tanking, MD, Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School
Vitrectomy for Retinal Detachment Repairvideo
This is a short video listing out the fundamental steps and maneuvers in performing vitrectomy for retinal detachment repair. Vitrectomy is currently the most commonly employed surgical technique in repairing retinal detachment. In this case, the patient had cataract surgery performed one year prior and developed painless loss of vision over the course of one week. On examination he had an inferior macula involving bullous nasal and inferior retinal detachment. The retinal break identified during surgery was located in the the anterior portion of the eye and considered fairly small in size when compared to other types of retinal breaks. This is typical of "pseudophakic" retinal breaks, a type of small anterior retinal break thought due to traction at the vitreous base as a consequence of energy transmitted from the phacoemulsification probe used for cataract surgery. During the surgery, note how the retinal detachment pools inferiorly while the break itself is situated in the superior portion of the eye. (The surgeon sits at the head of the bed, and thus the bottom portion of the eye seen in the video corresponds to the superior portion/top portion of the eye). This is owed to the fact that liquefied vitreous humor passes through the retinal break and, as a consequence of gravity, pools at the inferior portion of the eye. At the conclusion of the video, gas is injected to fill the eye. The gas exerts an upward force on the retina and prevents it from detaching. In certain cases, the patient must position his or her head (e.g. face down, right side down, left side down) to take advantage of the upward rise of the gas bubble against any retinal breaks. In this particular case, the break was located superiorly and thus the patient was asked to maintain an upright position for the better part of two weeks to allow the retinal break to seal with the endolaser scars.
Lower Eyelid Entropion Repair with Lateral Tarsal Strip and Infraciliary Rotationvideo
This combined procedure addresses multiple anatomic factors causing involutional entropion: the lateral tarsal strip is suspended to reduce horizontal laxity, and infraciliary rotation sutures are placed to stabilize the tarsus, evert the lower eyelid, and decrease orbicularis override. This approach is both efficient and effective, with a low risk of complications.
Pars Plana Vitrectomy for Macular Holevideo
Surgeons: Deepam Rusia, M.D., Mitul Mehta, M.D. Video: Jeffrey Yu Gavin Herbert Eye Institute, University of California Irvine Macular hole is a tear in the macula, located in the center of the retina. The most common cause of macular hole is shrinking of the vitreous and subsequent pulling on the retina. Treatment involves vitrectomy, peeling of the internal limiting membrane, and infusion of gas into the eye. This patient is a 51-year-old female with a macular hole of the right eye.
Upper and Lower Lid Internal Recession with Tarsal Graft Posterior Spacervideo
This video shows a combined upper lid internal recession and lower lid internal recession with placement of a tarsus posterior spacer graft in a patient with eyelid retraction due to thyroid eye disease.
Frontalis Suspension Blepharoptosis Repairvideo
Frontalis suspension blepharoptosis repair is the procedure of choice for the repair of blepharoptosis in the context of poor levator function (< 4mm). Numerous sling materials have been described for this procedure, however, preferred materials include banked, Tutoplast or autologous fascia lata, or silicone rods. This video demonstrates frontalis suspension utilizing silicone rods. Authors: Jay C. Wang, MD (Massachusetts Eye and Ear) Suzanne K. Freitag, MD (Massachusetts Eye and Ear)
Orbital Decompression through Conjuctival and Lynch Incisionsvideo
Surgical orbital decompression for proptosis secondary to Graves' Disease.
Aqueous humor is drained from the eye via the trabecular meshwork or the uveoscleral pathway. Trabeculectomy is performed to lower intraocular pressure in glaucoma patients by means of creating an ostium in the anterior chamber connected to a partial thickness scleral flap covered by conjunctiva. This allows aqueous humor to be filtered into the subconjunctival space and out of the eye via the venous system. Procedure First, a partial thickness traction suture using a 6-0 Vicryl is passed through the superior cornea to rotate the eye inferiorly and expose the superior quadrant. Sharp curved Vannas scissors and 0.12 forceps are used to create a conjunctival limbal peritomy superiorly at the 3 o’clock hour position. The peritomy may be placed near the limbus or fornix. Mini Westcott scissors are then used to bluntly dissect and undermine the conjunctiva and Tenon’s layer to expose the sclera posteriorly, nasally, and temporally. Hemostasis can be achieved with light cautery. Three instrument wipe sponges are soaked with 0.4 mg/m of mitomycin C and then placed underneath the conjunctiva and Tenon’s layer and superior to the sclera nasally and temporally. They are left for 90 seconds and subsequently removed. Any remaining mitomycin C is irrigated with BSS. Next, the eye is rotated inferiorly, and a #67 blade is used to create a 3.5 mm x 3 mm triangular scleral flap hinged at the limbus of about 50 to 75% thickness. Various shapes of the scleral flap can be made depending on surgeon preference (rectangular, trapezoidal etc.). Straight tying forceps are used to lift the apex while a #67 blade is used to dissect beneath the flap anteriorly until the blue-gray zone of the limbus is exposed. At this point, a crescent blade is used to create a tunnel beneath the flap into the peripheral clear cornea. An anterior chamber paracentesis is created. An MVR blade is used to enter the anterior chamber through the tunnel and the sides of the blade are used to enlarge the opening. A Kelley-Descemet punch is used to excise a corneal/trabecular block at the posterior lip of the wound until a clear ostium is observed under the flap. Colibri forceps are used to grasp and prolapse the peripheral iris tissue. An iridotomy is then performed using curved Vannas scissors. The anterior chamber is re-inflated with BSS. A 10-0 nylon suture is then used to close the scleral flap with one suture at the apex and another at each base of the flap. The flap should be closed tightly enough to ensure the anterior chamber remains formed but loose enough to allow for drainage. Only the apical suture should be sealed most tightly to allow easier suture removal if the flap is too tight. Although not featured here, BSS can be injected through the paracentesis, and the flap confirmed to be watertight. 10-0 Vicryl is then used to close the conjunctiva against the limbus, forming a tight seal. The traction suture is then removed. At the conclusion of the case, subconjunctival injection of antibiotic and/or steroid can be given inferiorly. The anterior chamber should be formed and intraocular pressure appropriate. Wound leakage should be inspected with digital palpation. Indications Trabulectomy is indicated in glaucoma with uncontrolled intraocular pressures and progressive nerve injury refractory to maximal or tolerable medication management that is causing visual disability. Cost, compliance, side effects, inconvenience, and other factors should be considered when weighing the risks and benefits of trabeculectomy. Consideration should be made when glaucoma is moderate to advanced in severity, rapidly progressive, or failed prior laser surgery. Contraindications Contraindications to trabulectomy are limited life expectancy, medical comorbidities that enhance the risks of undergoing surgery, and scarring of the superior conjunctiva. Benefits should outweigh risks of the procedure. Setup Patient is prepared and draped in the usual sterile fashion for cataract surgery. Retrobulbar block can be administered. Preoperative Workup The patient’s glaucoma stage and type are identified. History taking should involve asking patients about trauma, prior eye surgeries, bleeding disorders, intake of blood thinners or aspirin, and inflammation or infection. A complete ophthalmic examination is performed, including intraocular pressure and assessment of the angles under gonioscopy. Nerve OCTs and Humphrey visual fields are also obtained. No bloodwork, EKG, or imaging are required. Anesthesia questionnaire is completed prior to the procedure. Anatomy and Landmarks The following anatomic structures should be identified: conjunctiva, Tenon’s, sclera, and iris. It is important that the flap consist of 50-75% scleral thickness. The traction suture should be placed in the superior cornea and the peritomy created at the 3 o’clock hour position. Advantages/Disadvantages IOP control, defined as IOP < 21 mmHg and reduction at least 20% from baseline, was maintained over 5 years on average after surgery . Failure rates in a study that followed patients for 3 years were 13.9% at 1 year, 28.2% at 2 years, and 30.7% at 3 years . Failure was defined as persistent hypotony or uncontrolled IOP. Complications/Risks Risk factors for trabeculectomy failure include previous eye surgeries, neovascular or uveitic glaucoma, African American ethnicity, and young age . Early problems in the post-op period are elevated IOP or hypotony. Complications include bleb leak (6-11%), iris prolapse obstructing flow (1.1%), encapsulated bleb (6-12%), shallow anterior chamber (13%), ptosis (12%), serous choroidal detachment (11%), choroidal effusion (4%), new synechiae formation (5%), corneal edema (6%), endophthalmitis (3%), and suprachoroidal hemorrhage (0.7%) [2,4].
Retroseptal Transconjunctival Approach to Orbital Floor Blowout Fracturevideo
The transconjunctival approach was first described by Bourquet in 1924 and then modified by Tessier in 1973 for exposure of the orbital floor and maxilla for the treatment of facial trauma. This approach can be carried out either in a preseptal plane by separating the orbital septum from within the eyelid (preseptal approach) or posterior to the septum and eyelid (retroseptal approach) by making an incision through the bulbar conjunctiva directly above the orbital rim. The main advantage of the retroseptal approach is that it does not involve dissection and disruption of the eyelid itself, therefore, reducing the incidence of post-operative lid laxity and position abnormalities. This video will show a retroseptal approach to an orbital floor blowout fracture. A lateral inferior cantholysis is performed to facilitate eversion and retraction of the lower eyelid.
Eyelid Cicatricial Entropion Repair with Oral Mucous Membrane Graftvideo
The procedure in this video demonstrates repair of an eyelid cicatricial entropion with an oral mucous membrane graft in a patient with cicatricial entropion secondary to radiation therapy for uveal melanoma.
External Ptosis Repairvideo
This video shows an external levator advancement ptosis repair in a patient with involutional eyelid ptosis. Authors: Justin D. Pennington, BS Suzanne K. Freitag, MD
Amniotic Membrane Graft with Fibrin Glue to Ocular Surfacevideo
The procedure in the video demonstrates repair of the bulbar conjunctiva post Mohs Micrographic surgery with an amniotic membrane graft and fibrin glue
DALK with Femtosecond Zig-zag Incisionsvideo
Deep Anterior Lamellar Kertaoplasty with a femtosecond assisted zig-zag cut
Phacoemulsification of Nuclear Cataract and Intraocular Lens Implantationvideo
Cataract surgery is an appropriate option to consider when a patient’s visual function is no longer able to support their desired activities or when it becomes a detriment to their health and quality of life. Phacoemulsification with intraocular lens implantation is the most common procedure used to restore vision in patients with cataracts; it has been shown to restore vision to 20/40 or better in over 95% of cases  . The procedure uses an ultrasonic handpiece to fragment, emulsify, and aspirate an opacified lens all through a small incision in the cornea. A new intraocular lens made of acrylic is inserted into the remaining lens capsule and replaces the cataract. This outpatient surgery is typically sutureless and completed in 10-20 minutes. This case highlights a patient with a nuclear sclerotic cataract who elected for phacoemulsification extraction with intraocular lens implantation. The video showcases the proper placement of cataract removal instruments and phaco handpiece, completion of the most critical step of the procedure—the capsulorhexis and highlights proper placement of the intraocular lens. Authors Adam Neuhouser, Medical Student, University of Arkansas for Medical Sciences, email@example.com. Victoria Ly, Medical Student, University of Arkansas for Medical Sciences, firstname.lastname@example.org. Ahmed A. Sallam, M.D., Ph.D. Department of Ophthalmology, Jones Eye Institute. email@example.com
Lateral Rectus Plicationvideo
Introduction Muscle plication is a type of strabismus surgery that aims to tighten an extraocular muscle by partially folding the muscle under or over itself without disinsertion. The patient is a 14-year-old with alternating esotropia, who previously had a medial rectus recession. Therefore, she underwent plication of the lateral rectus muscle for this procedure. Methods A conjunctival incision is made in the fornix. Tenon's capsule is dissected to expose the lateral rectus muscle. The lateral rectus muscle is isolated using a Stevens tenotomy hook followed by a Jameson muscle hook. A Stevens tenotomy hook is used to sweep around the muscle to confirm the location of the muscle pole. A caliper is used to mark the predetermined amount of plication, starting at the muscle insertion and marking further posteriorly on the muscle. The muscle is then secured at the location marked by the caliper with a double-armed 6-0 VicrylTM suture with a central bite and double-locking bites at each pole of the muscle. Plication is achieved by bringing the muscle anteriorly and attaching it to the sclera adjacent to the muscle insertion with half-scleral depth bites in crossed-swords fashion. The muscle is tied down to its new location and 6-0 plain gut sutures are used to close the conjunctival incision. Results No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the three-month follow up, the redness had resolved. The alternating esotropia had improved. Conclusion Lateral rectus plication is a safe procedure that can effectively treat esotropia. By: Michelle Huynh College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA firstname.lastname@example.org Surgeons: Brita Rook, MD Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA BSRook@uams.edu Joseph Fong, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA JFong@uams.edu Video was performed at Arkansas Children’s Hospital, Little Rock, AR, USA.
Scleral Fixation of Intraocular Lens Using Gore-Tex Suturevideo
This video demonstrates scleral-fixation of an intraocular lens with GoreTex suture. The surgery was performed by Dr. Ahmed Sallam MD, PhD at the Jones Eye Institute at the University of Arkansas for Medical Sciences. The authors of the video are Victoria Ly, Adam Neuhouser, and Ahmed Sallam MD, PhD.
This is a trabectome procedure performed on a patient with moderate severity open angle glaucoma. Trabectome is a minimally invasive glaucoma surgery (MIGS) developed by Baerdveldt and Chuck where the trabecular meshwork is electrocauterized, irrigated, and aspirated under gonioscopy to improve the drainage of aqueous humor and reduce intraocular pressures. Procedure Topical TetraVisc is first administered to the eye. The patient’s head is rotated 30 degrees away from the surgeon and the microscope tilted 30 degrees toward the surgeon. The patient’s axial core can be rotated if turning the neck proves difficult. The gonioscope lens is used to visualize the trabecular meshwork, the pigmented line between Schwalbe’s line and the scleral spur. A 1.7 mm temporal clear corneal and uniplanar incision is made 2 mm anterior to the limbus. While applying continuous irrigation to deepen the angle, the Trabectome handpiece is introduced into the anterior chamber under gonioscopic visualization, and the end of the device was inserted into the inferonasal trabecular meshwork. When properly inserted, the trabecular meshwork should enter between the electrode tip and the footplate, causing the footplate to be obscured by the trabecular meshwork. The handpiece is used to ablate trabecular meshwork at a setting of flow 3 and 0.7 mW. It is rotated superiorly to create a 120 degree cleft, exposing the outer white wall of Schlemm’s canal. Care must be taken to prevent outward push on Schlemm’s canal by applying a slight inward pull during ablation. The handpiece may need to be readjusted as it is rotated in a counter-clockwise fashion. The handpiece is removed from the anterior chamber. The patient’s head is returned to a neutral position, and BSS was used to exchange viscoelastic from the anterior chamber through the temporal wound. BSS is to irrigate red blood cells from the Schlemm’s canal collector channels. The gonioscope is used to verify the cleft. At the conclusion of the case, the intraocular chamber is formed and pressure checked to be appropriate via digital palpation. Indications Trabectome is indicated for narrow-angle , open-angle, and secondary glaucoma with uncontrolled intraocular pressures and progressive nerve injury refractory to maximal or tolerable medication management . As a MIGS, trabecome can be considered in initial stages of glaucoma due to its safety and quick routine recovery. Reduction of drops due to side effects, costs, or poor compliance are reasons to offer this procedure to patients . Trabectome surgery can also be performed in conjunction with cataract surgery, in pseudophakic and phakic eyes, and after trauma, scleral buckle , laser trabeculoplasty , or failed trabeculectomy or tube shunt [6,7]. Contraindications Contraindications are few but the most common is pathology that limits gonioscopic view of the angle (active neovascular glaucoma, uveitis, corneal edema etc). Setup Patient’s head is rotated 30 degrees away from the surgeon and the microscope rotated 30 degrees toward the surgeon to provide optimal surgical approach. Preoperative Workup The patient’s glaucoma stage and type are identified. History taking should involve asking patients about trauma and prior eye surgeries. A complete ophthalmic examination is performed, including intraocular pressure and assessment of the angles under gonioscopy. Nerve OCTs and Humphrey visual fields are also obtained. No bloodwork, EKG, or imaging are required. Anesthesia questionnaire is completed prior to the procedure. Anatomy and Landmark Trabecular meshwork should be identified as the pigmented line between Schwalbe’s line and the scleral spur. Care must be taken to not ablate the ciliary body band. Blood reflux from Schelmm’s canal collector channels to confirm the ablation target can be induced by burping the main incision. After ablation, the cleft should be verified. The pigmented line from the trabecular meshwork should no longer be visible and only the outer wall of Schlemm’s canal seen. Advantages/Disadvantages Numerous studies have looked at the efficacy of trabectome surgery. Intraocular pressure drops to the mid-teens and decreasing the number of medications in most cases . Unlike trabeculectomy or tube shunts, there is little scarring, the conjunctiva is preserved, the recovery is predictable, and there are less complications . Patients with higher IOPs stand to benefit with greater reductions in IOPs than those with lower IOPs. There is limited data on the long-term success rate of trabectome surgeries. Studies following patients after surgery show that trabectome alone has a 70% success rate at 1 year but only 22% at 2 years [9,10,11]. Complications/Risks The most common complications are transient hyphema, peripheral anterior synechiae, corneal injury, and transient IOP spikes of 10 mmHg or higher. Surgical failure can be due to incomplete or improper removal of the trabecular meshwork as well as damage to the ciliary body band or surrounding tissues . The rate of serious vision-threatening complications, such as hypotony, cyclodialysis cleft, choroidal hemorrhage, and endophthalmitis, is <1% .
Phacoemulsification of a cataractvideo
Phacoemulsification of a cataract Samia Nawaz, John Chancellor, and Ahmed Sallam Introduction A cataract can be simply defined as clouding of the lens of the eye. As the proteins that make up the lens of the eye harden and aggregate, a cataract forms. Cataracts are attributed to cause half of vision loss in the population and are most commonly related to age, although trauma, radiation exposure, and genetics have also been implicated. Cataracts can cause visual disturbance such as faded color perception, blurry vision, reduced night vision, and the perception of seeing halos around lights. Due to these hindrances, surgery is a common approach to alleviate the problems they cause. Phacoemulsification is a technique that uses ultrasonic waves to emulsify the dysfunctional lens, and we may then replace it with a synthetic one, clarifying vision. A 55 year old patient presented with reduced visual acuity due to a cataract in their left eye. A phacoemulsification of the cataract with implantation of an intraocular lens was performed here. Methods First, the patient’s eye was anesthetized using topical anesthetic. The patient was prepped and draped using sterile technique. A knife was then inserted into the cornea 90 degrees to the presumed incision site. This is known as the primary port incision. After this, incisions are placed 45 degrees to the presumed incision site, known as the secondary port incision. Viscoelastic was then inserted into the anterior chamber. Continuous curvilinear capsulorrhexis was performed using capsulorrhexis forceps to open the anterior capsule of the eye. We began with a central linear cut, then pulled the needle in the direction of the desired tear, allowing the capsule to fold over. We had created a flap we used to gain entry to the lens. We injected salt solution under the anterior capsule in a step called hydrodissection, allowing the fluid to decompress the anterior capsule by compressing the central part of the lens. Nuclear rotation, a step which mobilizes the nucleus and minimizes the possibility of damage to the zonular fibers or posterior capsule, was then performed. Phacoemulsification was begun after this, where ultrasonic waves broke up the nucleus of the lens into smaller pieces, thereby fragmenting the cataract and emulsifying it into a mixture to be irrigated and aspirated. We then inserted an irrigation/aspiration instrument to remove residual pieces of lens cortex. The last step was insertion of the pre-folded synthetic lens. We reformed the anterior chamber with viscoelastic, and then loaded the lens in with a cartridge. It will unfold and settle into the eye with our adjustments. We then irrigated the wound to decrease leakage by swelling up the wound edges. Results The patient was discharged the same day and followed up in clinic 1 week later. The incisions were healing well with no indications of infection or wound dehiscence. Conclusion Phacoemulsification of a cataract is a successful and widely used way of alleviating reduced visual acuity as a result of cataract formation in the eye.
Cataract Phacoemulsification and Intraocular Lens Implantation in a Small Pupil Casevideo
Intro Phacoemulsification and intraocular lens implantation is the gold standard procedure for removing cataracts in developed countries. The patient is an elderly adult who underwent the surgery to alleviate visual impairment from a significant age-related mixed cataract. Before the surgery, his visual acuity in the operative eye was 20/60. Methods This video highlights the steps of cataract phacoemulsification and intraocular lens implantation in a small pupil case, including paracentesis, epinephrine-lidocaine (epi-Shugarcaine) injection for extra dilation and anesthesia, viscoelastic injection into the anterior chamber, capsulorrhexis, hydrodissection, phacoemulsification featuring a divide and conquer technique, cortical irrigation and aspiration, intraocular lens insertion, and wound sealing by hydration. Results No complications arose during the procedure. At the two-week postoperative follow-up, the patient’s visual acuity in the operative eye was 20/30. He denied any pain or discomfort. The visual acuity at four weeks was 20/20. The patient was pleased with results of the surgery. Conclusion Phacoemulsification and intraocular lens implantation is a safe and effective surgery for the management of cataracts. In the setting of a small pupil, intracameral epinephrine-lidocaine mix (epi-Shugarcaine) can be administered for extra dilation. Authors Michelle L. Huynh, BA College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA Joseph G. Chacko, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA Surgeon Joseph G. Chacko, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA Music Royalty Free Music from Bensound
Chalazion Incision and Curettagevideo
Intro A chalazion is a lipogranulomatous inflammation of a meibomian gland in the eyelid that presents as a painless eyelid nodule or swelling. This pediatric patient presented with a chalazion that caused symptoms of eye irritation. The lesion had persisted for many months without improvement in response to warm compresses and eyelid scrubs with baby shampoo. Therefore, she underwent chalazion incision and curettage under sedation. Methods This video highlights the steps of chalazion incision and curettage. With a chalazion clamp tightened over the lesion, the eyelid is everted and an incision is made into the tarsus. A curette is used to scrape the walls of the cyst to remove the chalazion contents. At the conclusion of the procedure, the clamp is removed and pressure is applied to the area of the lesion for hemostasis. Conclusion Incision and curettage is a safe, relatively quick, and effective procedure for the management of persistent chalazia. Authors Michelle L. Huynh, BA College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA Muhammad Shamim, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA Christian Ponder, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA A. Paula Grigorian, MD Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA The procedure was performed at Arkansas Children’s Hospital, Little Rock, AR, USA. Music by bensound.com.
Ahmed® Glaucoma Valve for Treatment of Refractory Glaucomavideo
Introduction Intraocular pressure is the single modifiable risk factor resulting in progression of various subtypes of glaucoma. Intraocular pressure control is often achieved with topical medications, outpatient laser procedures, or minimally-invasive glaucoma surgery (MIGS). This patient is a 63-year-old with traumatic glaucoma in the right eye with elevated intraocular pressure sub-optimally controlled despite maximum medical therapy (29 mmHg). His intraocular pressure must be controlled with incisional glaucoma surgery - in this case, with placement of an Ahmed Model FP7 glaucoma valve. An advantage of valved glaucoma shunts is lower risk of postoperative hypotony-related complications compared to non-valved glaucoma shunts. Methods The 10 and 12 o'clock meridians are marked with a marking pen to define the borders of the conjunctival peritomy. A limbal traction 6-0 Vicryl suture is placed superotemporally in the cornea at the limbus. The conjunctival peritomy is then completed using Westcott scissors along the predetermined marks. The peritomy is extended posteriorly with blunt dissection using Stevens tenotomy scissors. Wet field cautery is used to achieve hemostasis of the scleral bed. A Stevens tenotomy hook is used to identify the superior rectus muscle and a marking pen is used to mark its border. The Ahmed Model FP7 tube shunt is then introduced onto the surgical field. Balanced salt solution is injected into the tip of the tube using a 30-gauge cannula to ensure adequate patency of the valve. The Ahmed plate is then sutured to the sclera approximately 8 mm posterior to the limbus using 5-0 Nylon suture. A corneal paracentesis is made at the 8 o'clock position, and viscoelastic is injected to deepen the anterior chamber. A 23-gauge needle attached to the Healon syringe is then used to tunnel from a point 2.0 mm posterior to the limbus into the anterior chamber. The needle tract is anterior and parallel to the plane of the iris and the surgeon must ensure that the tube does not contact the iris or corneal endothelium after insertion. The implant tube is then laid flush with the cornea and shortened with Westcott scissors with an oblique cut, bevel up. Healon is injected as the needle is withdrawn. Non-toothed forceps are then used to insert the tube into the anterior chamber. A single 8-0 Vicryl suture is used to secure the tube to the underlying sclera. A corneal patch graft is cut to fit the site of tube implantation and secured with a single 8-0 Vicryl horizontal cross mattress suture. The conjunctival peritomy is then closed with a running 8-0 Vicryl suture on a BV needle. Anchoring sutures incorporating the conjunctiva and the episclera to firmly secure the corners of the peritomy to the limbus. A 9-0 Nylon suture is used to re-approximate the limbal conjunctiva. At the conclusion of the case, the eye is returned to a neutral position, the traction suture is removed, and satisfactory intraocular pressure is confirmed by palpation. Results No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and mild pain that decreased over the following week. Prednisolone acetate drops were applied six times daily to prevent inflammation and moxifloxacin drops were applied four times daily to prevent infection. At the three-month follow up, the eye was quiet and intraocular pressure was measured to be 9 mmHg. Conclusion Implantation of an Ahmed glaucoma tube shunt is a safe procedure that can effectively treat various subtypes of glaucoma with sub-optimally controlled intraocular pressure despite maximum medical therapy. Joseph W. Fong, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA JFong@uams.edu Ahmed A. Sallam, MD, PhD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA ASallam@uams.edu Surgery was performed at University of Arkansas for Medical Sciences, Little Rock, AR, USA.
Orbitotomy with Lacrimal Gland Biopsyvideo
The procedure in this video demonstrates an orbitotomy with lacrimal gland biopsy.
Temporal Artery Biopsyvideo
Temporal Artery Biopsy - gold standard for the diagnosis of temporal (giant cell) arteritis
Treatment of mild eyelid ptosis with conjunctivo-mullerectomyvideo
Mild eyelid ptosis with good elevator function can be treated with minimally invasive procedures. When Muller's muscle contraction corrects the deficiency (evaluated by phenilefrine test) conjunctivo-mullerectomy is the procedure of choice. This video presents the surgical steps to perform conjunctivo-mullerectomy. Contributors Dov Charles Goldenberg, MD Phd, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School Vania Kharmandayan, MD, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School
Jones Tube Replacement with Endoscopic Endonasal Guidancevideo
The procedure in this video demonstrates the removal and replacement of a malpositioned Jones tube with endoscopic endonasal guidance to ensure proper tube placement within the nose.
Phaco in Phacomorphic Catarcactvideo
Explains tips for performing phaco emulsification in a hyper mature cataract .
A Technique for Corneal Gluing Small Corneal Perforationsvideo
This video, using a simulation eye in a wet lab, demonstrates the preparation and techniques required to perform a corneal glue procedure on a small corneal perforation.
Medial Orbital Dermoid Cyst Removalvideo
Dermoid cysts are the most common orbital tumor in childhood. It is a developmental benign choristoma, arising from ectodermal sequestration along the lines of embryonic fusion of mesodermal processes. It is lined by keratinized stratified squamous epithelium and expands slowly due to constant desquamation and dermal glandular elements. They are usually smooth, painless, mobile, or partially mobile lesions mostly present at the fronto-zygomatic suture with proptosis, displacement, ptosis, or diplopia, depending on depth and extent1. Although lateral orbital dermoid cysts are common, medial orbital dermoid cysts are rare2. Our patient had a right medial orbital congenital dermoid cyst since birth. At the presentation, the patient was 2 years old. On CT, the cyst measured 5 mm at the upper lid/medial canthus of the right orbit with subtle bone remodeling. He had a mildly clogged tear duct on the left but was otherwise asymptomatic. The decision was made to surgically remove the dermoid cyst. In this video, we present a case of removal of a medial orbital dermoid cyst in a 2-year-old patient. An incision was planned directly over the lesion. It was marked following the natural skin tension lines of the face to give the most natural esthetic appearance. A small amount of Local anesthetic (0.5 ml of Lidocaine and Epinephrine) was injected under the skin to promote hemostasis and postoperative pain control. A continuous Incision was made with a #15 blade on the skin. Westcott scissors were used to dissect further through the subcutaneous tissue to expose the cyst and slowly dissect it from the normal tissue surrounding it. Extra care was made to protect the integrity and avoid the rupture of the cyst. After the entire cyst was freed from the surrounding tissue, it was carefully removed from its attachments to the periosteum using Westcott scissors. The incision was closed in a two-layer fashion. The deeper layer was closed by 6.0 Vicryl in a vertical mattress fashion with 2 interrupted sutures. Next, wound edge eversion was achieved by placing two interrupted, superficial 5.0 fast-absorbing gut sutures. This will minimize the scar appearance. Dermabond was applied next and the sutures were protected by a small piece of Tegaderm. This will be left in place until it spontaneously falls off.
A Pediatric Case of Levator Palpebrae Resectionvideo
In this video, we present a case of levator palpebrae resection in an 8-year-old patient with right eye ptosis. In the pre-op photo, significant ptosis of the right eye can be appreciated. An incision was planned along the lid crease. 0.1 ml of 1: 100,000 epinephrine was injected. An incision was made by electro-cautery along the lid through the skin and orbicularis. Westcott scissors were used to further dissect horizontally. The septum was identified and opened. The preaponeurotic fat was identified and lifted, and the levator aponeurosis was identified. The levator was then tagged with two 6.0 Vicryle sutures, and isolated from surrounding tissues. Next, three6-0 Mersilene sutures were run from the upper tarsus to the levator. They are tightened with releasable notes. The lid elevation and contour were evaluated and adjustments were made until contour and height were equal and appropriate. The temporary surgical knots were transitioned into permanent surgical knots. Approximately 14 mm of excess levator was then excised. Next, three lid crease formation sutures were placed using 6-0 Vicryl. These were attached to the subcu-skin and levator to recreate the upper eyelid crease. Skin closure was performed with 6-0 fast-absorbing gut sutures. In this one-week post-op photo, the ptosis of his right eye was improved. Thank you for watching!
Lacrimal Probing and Irrigationvideo
This video demonstrates lacrimal probing and irrigation to investigate the anatomy, patency, and functional status of the lacrimal drainage system.
Punctal Dilation and Mini-Monoka Stent Insertionvideo
This video demonstrates punctal dilation and insertion of a Mini-Monoka stent for treatment of epiphora due to punctal/canalicular stenosis.
This video demonstrates an evisceration surgery with placement of a 16mm silicone implant in a patient with a blind, painful eye.
Matthew Wade, MDleadership
University of California, Irvine
- Department of Ophthalmology
- University of California, Irvine
- Gavin Herbert Eye Institute
Dr. Matthew Wade is a fellowship-trained eye surgeon who specializes in LASIK vision correction, complex cataract surgery and cornea transplantation at the Gavin Herbert Eye Institute. Dr. Wade earned his medical degree from the George Washington University School of Medicine and Health Sciences in Washington, D.C. He completed his residency in general ophthalmology at UC Irvine, where he also completed a fellowship in cornea, anterior segment and refractive surgery.
Mitul Mehta, MDleadership
University of California, Irvine
- Clinical Assistant Professor
- Department of Ophthalmology, Retina Division
- University of California, Irvine
- Gavin Herbert Eye Institute
Dr. Mitul C. Mehta, completed his undergraduate degree at the Massachusetts Institute of Technology (MIT), and received a Masters of Science in Physiology & Biophysics from Georgetown University. He earned his medical degree from the Keck School of Medicine of USC in Los Angeles. After completing his ophthalmology residency at the University of Cincinnati College of Medicine in Cincinnati, Ohio, he completed fellowship training in vitreoretinal surgery at the New York Eye & Ear Infirmary of Mount Sinai in New York City.
In addition to the care of patients with vitreoretinal disorders, Mehta teaches medical students, residents and fellows. He also does research on surgical devices and techniques, as well as on vitreoretinal diseases, such as diabetic retinopathy and macular degeneration. His surgical interests include retinal detachment repair, ocular trauma, secondary lens placement, epiretinal membranes, macular holes, and surgery for endophthalmitis (severe eye infections).
Nahyoung Grace Lee, MDleadership
Harvard Medical School
- Massachusetts Eye and Ear Infirmary
Grace Lee, M.D. is an ophthalmologist at Massachusetts Eye and Ear (MEE) with a rigorous clinical practice in ophthalmic plastic surgery. Approximately 80% of her time is devoted to patient care, which is integrated with teaching residents and fellows in the clinic and surgical setting. This component also includes direct instruction in the wet lab and weekly supervision in the MEE emergency room. Twenty percent of Dr. Lee‘s time is spent doing clinical and basic science research.Dr. Lee completed her BA of Neuroscience at Johns Hopkins University followed by a doctorate in Medicine. Upon completing her ophthalmology residency at the University of Southern California, she pursued a fellowship in ocular oncology and pathology at the Casey Eye Institute, at the Oregon Health & Science University. She directly taught residents in the pathology lab as well as through over 15 hours of didactic lectures. Her additional training involved three years of fellowship in oculoplastic surgery at MEE, where she was the recipient of the Fellow of the Year teaching award. During this fellowship, Dr. Lee collaborated with Dr. Leo Kim to produce an animal model of orbital inflammation and investigated angiogenesis in thyroid eye disease, which was published in Ophthalmology. At the culmination of her training, she was inducted into the American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) and is now Assistant Professor of Ophthalmology at Harvard Medical School (HMS).Dr. Lee‘s clinical expertise and innovations have focused on thyroid eye disease and common conditions in ophthalmic plastic surgery. She has expanded her clinical practice to involve anterior segment tumors, building on her fellowship in ocular oncology. In the process, she has trained 4 fellows, 3 of whom have accepted or will be accepting positions at academic institutions. Additionally, she serves as an oral board examiner for the American Board of Ophthalmology.
A Discussion About Removal of Intraocular Foreign Bodieswebinar
Attendees will learn about the proper procedure to follow when removing foreign bodies from the eye by discussing the process with three expert Vitreoretinal Surgeons.
Mitul Mehta, MD, MS
Fellowship Director of Vitreoretinal Surgery / Health Sciences Clinical Associate Professor
Gavin Herbert Eye Institute / University of California, Irvine
Mitul Mehta MD MS, is a board-certified ophthalmologist with fellowship training in medical and surgical diseases of the retina. He sees patients at the UCI Medical Center in Orange, CA and the Gavin Herbert Eye Institute in Irvine, CA. Dr. Mehta graduated from the Massachusetts Institute of Technology (MIT), he then completed a Master of Science degree in Physiology & Biophysics at Georgetown University and earned his MD degree from the University of Southern California (USC). After completing his ophthalmology residency at the University of Cincinnati, he graduated from fellowship training in vitreoretinal surgery at the New York Eye & Ear Infirmary of Mount Sinai. Dr. Mehta cares for patients with vitreoretinal disorders as the Vitreoretinal Surgery Fellowship Director. He teaches medical students, residents, and fellows, and does research in surgical devices, techniques and vitreoretinal diseases such as retinitis pigmentosa, diabetic retinopathy and macular degeneration.
C. Kiersten Pollard, MD
The Retina Center of Western Colorado
Dr. Pollard completed her undergraduate education at the Massachusetts Institute of Technology, she then went on to earn her MD at the University of Colorado School of Medicine where she also completed her intern year in internal medicine. She completed her Ophthalmology residency at the University of Arizona and her vitreoretinal surgery fellowship at UT Southwestern Medical Center. Dr. Pollard practices at The Retina Center of Western Colorado where she and her partners provide advanced medical and surgical vitreoretinal care to the people of western Colorado, eastern Utah, and southern Wyoming.
Hemang K. Pandya, MD FACS
Vitreoretinal Specialist / President
Dallas Retina Center / American Retina Forum
Dr. Pandya earned his M.D., with Alpha Omega Alpha honors, from the Chicago Medical School. Dr. Pandya completed his Ophthalmology training at the Kresge Eye Institute. Thereafter, Dr. Pandya completed a 2-year fellowship in Vitreoretinal Surgery at the Dean McGee Eye Institute. Dr Pandya practices at Dallas Retina Center and can be reached at DrPandya@DallasRetina.com.
The Ins and Outs of Medical Research & Publicationwebinar
The International Journal of Medical Students and CSurgeries have come together to provide and exclusive inside scoop on the world of medical publications. They will review how to properly research and submit an article along with selecting the best journal to publish through.
Editor in Chief
International Journal of Medical Students
Francisco is the Editor in Chief of the IJMS. He is a physician and has a master's in epidemiology from the Universidad del Valle (Colombia). He is currently finishing a PhD in Clinical Research and Translational Science at the University of Pittsburgh. He is also the CEO of the research foundation Science to Serve the Community, SCISCO (Colombia), and is an Assistant Professor at Universidad del Valle in Colombia teaching research to ophthalmology residents.
Francisco is a researcher of several groups in public health, ophthalmology and visual sciences, injuries, mental health, global surgery, and rehabilitation, and he was ranked as an Associate Researcher by the Colombian Ministry of Science, Innovation & Technology."
Pediatric Otolaryngologist / Assistant Professor
Seattle Children's Hospital / University of Washington
Dr. Bonilla-Velez is a pediatric otolaryngologist at Seattle Children's Hospital and an Assistant Professor in the Department of Otolaryngology - Head and Neck Surgery at the University of Washington. Originally from Cali, Colombia, Dr. Bonilla-Velez completed her medical school in the Universidad del Valle, Colombia. She then did a postdoctoral research year at Massachusetts Eye and Ear Infirmary, after which she started residency at the University of Arkansas for Medical Studies in Otolaryngology, Head and Neck Surgery before coming to Seattle Children’s for fellowship in pediatric otolaryngology. She also serves as a founding editor of the International Journal of Medical Students (IJMS).
Chief of Pediatric Otolaryngology / Professor and Vice Chair of Department of Otolaryngology-Head and Neck Surgery
University of Arkansas for Medical Sciences, Arkansas Children’s Hospital
Gresham Richter, MD, FACS, FAAP is a Professor, Vice Chair, and Chief of Pediatric Otolaryngology in the Department of Otolaryngology-Head and Neck Surgery at the University of Arkansas for Medical Sciences (UAMS) and Arkansas Children’s (AC). Dr. Richter received his undergraduate and medical degrees at the University of Colorado. He completed his residency in Otolaryngology at UAMS and a fellowship in Pediatric Otolaryngology at Cincinnati Children’s Hospital. He returned to Arkansas to join UAMS faculty and founded the Arkansas Vascular Biology Program, a robust laboratory at AC dedicated to understanding and discovering new therapies for complex vascular lesions. Outside of the hospital, Dr. Richter is an entrepreneur and CEO of GDT Innovations.
Professor of Otorhinolaryngology / Director, Pediatric Aerodigestive Center
Baylor College of Medicine / Texas Children's Hospital
Director, Pediatric Aerodigestive Center, Texas Children's Hospital | Professor of Otolaryngology, Baylor College of Medicine. Dr. Mehta's clinical interests are complex airway surgery, pediatric swallowing disorders and head and neck masses,along with general otolaryngology. His research interest includes outcomes of airway surgery, laryngeal cleft management and outcomes of sleep disorders.
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