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Yearly Archives: 2012

Happy Holidays

Randall Wong, M.D., Retina Specialist, Fairfax, Virginia holiday message 2012.Happy New Year!

This is likely my last post for 2012.  Thank you all for your participation on this site whether you’ve subscribed or just read occasionally.

Thank You for Your “Comments”

If you follow me at Medical Marketing, you know I preach that a blog (like this) is the purest form of social media.

A special thank you to those who leave comments or ask questions.  The real value of a blog is the transparency displayed when and question is asked (by the reader) …and answered (by me or another reader).

This provides real value to other readers…those who have similar questions and problems.

So thank you for helping make this site so valuable to others.

New “Welcome” Video

I just added a new video to the home page.  You’ll also notice I moved the location of the latest posts to “Articles/Blog.”

The video is simply a way to say hello and to introduce myself and this site to new visitors.  It will be interesting to see if this has any impact by allowing you to “hear” me.  Over the past few years, I discovered the importance of personal transparency for a physician.  It seemed logical to add a video.

Special thanks to my friends Marijo and Foster.  The video was a result of almost 50 attempts.  Speaking perfectly for 1 minute is harder than I thought (not to mention trying not to be too stiff at the same time).

Social Media

I am hoping to improve visibility on various social media platforms for the new year.  Specifically, I’ll be publishing more videos on Youtube and will try to be more diligent about my activity on Facebook.

By the way, “liking” me on Facebook will improve exposure for this site.  I’d appreciate your support.

Special Thanks to Amy

Amy and I have been busy with Medical Marketing Enterprises.  Since August, she has been working with our company full time.  Her efforts allow me to develop this site and maintain its value all the while keeping up with technology and advances in Web 2.0.

What Does This Mean?

It is so easy to remain committed to this website.  It has long been an obvious way to educate and teach patients, but this year has taught me how powerful this site can be to develop relationships, however, it is not a “one way” endeavor.  Yes, my articles may pique interest, but the most powerful aspect of this site is the trust you show by leaving comments and asking questions.

This communal effort is the strength of this blog (and any good social media platform).  Together, I hope we can continue this effort and serve as an example to others.

Happy Holidays, thank you and Happy New Year!


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist
Fairfax, Virginia


Emergency, Elective and Cosmetic Surgery

Elective Eye Surgery.  Randall Wong, M.D., Retina Specialist, Fairfax, VirginiaThere are different types of surgery; emergency, semi-elective, elective and cosmetic.  The differences lie between the timing (immediate), loss of life or function…or cost.  Emergency surgery must be completed immediately to avoid death, loss of a limb or organ providing a specific function.

Emergency Eye Surgery

There are two situations where retina surgery is an emergency; intraocular infection (endophthalmitis) and a retinal detachment where the macula is attached, but the retina immediately above the macula is detached.

Intraocular infection can permanently blind within hours.  A retinal detachment above the macula may spread below and detach the macula, potentially causing permanent loss of (some) vision.  If the macula is re-attached successfully, there is no guarantee full vision will return.  Thus, we try to operate before the macula detaches.

Semi-Elective Retina Surgery

Repair of an old retinal detachment, removal of ERM, closure of a macular hole are examples of semi-elective surgery.  In my opinion, the visual prognosis worsens the longer you wait.  In other words, the longer you wait to have surgery, even if performed successfully, the worse your resultant vision may be.

Cataract Surgery is Elective Eye Surgery

Cataract surgery and removal of floaters are great examples of “elective” surgery.  Elective means the timing of the surgery is up to the patient and is optional.  The timing has no effect on the outcome or results.  In both situations, there is loss of function, that is, patients can not see.

Elective procedures, however, can be covered by insurance.  Elective simply means the timing of the surgery doesn’t matter.  Insurance usually provides coverage for health problems which can be corrected.  In this example, vision is restored.

Elective Surgery is Covered

Cosmetic surgery and elective surgery are both time independent, both are optional, but cosmetic does not involve loss of function.

There is no retinal cosmetic surgery example, but other examples of purely cosmetic surgery include facelifts, breast augmentation, liposuction, etc.

Cosmetic surgery, or aesthetic surgery, does not deal with conditions related to loss of function.  It is elective and in most cases, not covered by insurance.

What Does This Mean?

I wrote this due to the many questions I receive about insurance coverage.  Emergency and Semi-Elective surgery seem pretty intuitive, but I found the differences between elective and cosmetic surgery were less clear.

If you classify surgery by the function intended to cure, you’ll have a much easier time understanding the utility, purpose and insurance ramifications.

Ocriplasmin Approved for VMT and Macular Holes


A Posterior Vitreous Detachment May Cure VMT
Posterior Vitreous Detachment “Separates” from the Retinal Surface

Ocriplasmin, or Jetrea,  has been FDA approved.  The drug is approved only for a retinal condition called vitreomacular traction (VMT) or vitreomacular adhesion (VMA).  The VMT may or may not be associated with a macular hole.

What is VMT?

VMT is basically an incomplete, or partial, PVD (posterior vitreous detachment) with subsequent “pulling” on the macula.  This “pulling” is also known as traction and can cause microscopic elevation on the macula and may lead to macular hole formation.

Ocriplasmin (previously known as microplasmin) may be an effective way to complete this PVD and chemically cleave the adhesion between the vitreous and macula.

Current treatment for vitreomacular traction and macular hole is surgical vitrectomy.

Intraocular Injection

Ocriplasmin is given as an intravitreal injection.  The medicine is injected directly into the eye as are other intraocular injections of Avastin, Lucentis and Ozurdex.

Ocriplasmin is a proteolytic enzyme which may chemically cause a more complete separation of the vitreous and surface of the retina.  Cleaving the adhesion between the vitreous and macular surface may improve vision and the macular hole, if present.

Results of Study

In the study presented to the FDA, patients received one injection of ocriplasmin.

  • Jetrea caused resolution of VMT in about 26% of patients and caused a complete PVD in about 13%.
  • Vision improved in a selected group; 25% of those with decreased vision of 20/50 or worse.
  • Macular holes “closed” (i.e. fixed) in 40% of patients.

What Does This Mean?

This is a novel drug to chemically separate the vitreous from the retina.  It has the potential to be an alternative to vitrectomy, the present accepted method for treating VMT and macular hole.

Intravitreal injections are delivered routinely in the office, thus, there is virtually no technique for physicians to “learn.”

The results, however, to not compare with the efficacy of vitrectomy eye surgery.  VMT is “cured” almost all of the time and macular holes are repaired at least 90% of the time with a single surgical attempt.

We really don’t know if the safety of this particular injection is similar to other eye injections. Historically, other eye injections compare equally with vitrectomy with respect to intraocular infection and retinal detachment.

Lastly, for the floater community, I don’t believe this to be a substitute for surgery, but may be used as an adjunct to create a PVD before considering “floater only vitrectomy (FOV)”.  Creating a PVD may make the floaters worse by changing the location +/- causing additional floaters.

As the use of Ocriplasmin becomes adopted by retinal physicians, it will be exciting to see if the efficacy of the drug can be improved and whether or not there will be other indications.  For instance, will the results improve with repeated injections?


Your First "Post-Operative" Eye Exam After Retinal Surgery

Eye Examination after your retinal surgery, Randall V. Wong, M.D., Retinal Specialist, Fairfax, VirginiaI routinely examine patients the first day after retinal surgery. It’s the shortest visit you’ll ever have at my office.  Surprisingly, there are very, very few things for me to check the first day after surgery.

Whether you have had retinal surgery for removal of an ERM (macular pucker), repair of a macular hole, a vitrectomy for vitreous hemorrhage, floater only vitrectomy (FOV) or retinal detachment surgery; the post-operative exam is brief.

Removal of the Eye Patch

Removing the eye patch can be intimidating.  The cotton patch, affixed with paper tape (my favorite due to its’ stickiness), comes off the next morning and stays off.  It is usually a bit moist and bloody.

Though a little unsightly, the blood is expected, but insignificant.  Also, the eye patch has little therapeutic value.

Especially in cases of a scleral buckle, I like to use a “pressure patch” as it eliminates any lid swelling the next day and facilitates a nice easy exam (sometimes it’s difficult to examine an eye with the lids swollen shut).

Checking the Vision

I expect your vision to be lousy immediately after removing the patch.  There are so many reasons why you shouldn’t see, I don’t bother wasting time having you read the eye chart.  Simply seeing a strong light is sufficient.

What causes the vision to be so bad?

The cornea is warped from the patch, there might be post-operative bleeding, you might have air or gas in your eye…etc.  Therefore, careful measurement is meaningless as it has no bearing on the actual function of your retina (i.e. how well your retina can “read.”)

Checking Your Eye Pressure

This is somewhat important to ensure that the eye is neither too low (not uncommon after 25 gauge sutureless vitrectomy) nor too high (especially with gas injected).

Dilated Exam

At the end of each operation, I prefer to use stronger dilating drops to keep your eye dilated for a few days following surgery.  While it may add to the blurriness after surgery, you will already be dilated for the next morning’s exam…avoiding the need to dilate your eyes again!  It may also keep your eye more comfortable for the first few days.

Once the patch is removed, therefore, I can examine your retina immediately, looking for complications of surgery including retinal detachment or infection.

What Does This Mean?

Checking your vision, pressure and looking at your retina is all that I need to examine you after your retinal surgery.  Most of the time is spent going over your instructions on how to use your drops and…if needed (it is usually not!), any special head positioning.

Complications immediately following retinal surgery are uncommon, but include;  retinal detachment, bleeding, infection and problems with eye pressure.  All can be assessed quickly, and comfortably, after your retinal eye surgery!




Loss of Vision in an Old Friend

Finding the right doctor for diabetic retinopathy involves trust and friendship.I had an old friend visit me this week.  AB and I met when I was a young doctor in Baltimore.  He was referred to me for treatment of his diabetic retinopathy. Eventually, I operated to remove a vitreous hemorrhage resulting from his proliferative diabetic retinopathy.

For several years, we saw each other twice a year.  He retired about 8-10 years ago and moved to Florida.  There are lots of eye doctors there!

I don’t think we have seen each other for 8-10 years.  As you know, I now practice in Virginia.  He found me on the Internet.

70+ YO Male With Progressive Loss of Vision

When I get to the office, I glance over the patient schedule for the day.  I recognized AB’s name instantly and was excited to see him.

He hadn’t changed much.  I recognized him from across the waiting room, talking with some of the other patients.  He is now in his early 70’s and has had diabetes for 40-45 years.

He told me I’ve gained weight.  He looked as I remembered him, that is, I couldn’t return the  “compliment.”

He said he has had slow progressive loss of vision over the past 6 months.  Reading road signs and watching TV had become increasingly difficult.  He also griped about the last retina doc he saw in FL…didn’t like him at all.

Possible Causes

Diabetic retinopathy can not be cured, but we are often successful maintaining status quo…provided regular checkups occur.

AB not liking his docs could have a couple of meanings;  he doesn’t go back as often as he should, and/or perhaps he didn’t like the news he received from the docs.

The top possible causes?  Diabetic retinopathy (specifically diabetic macular edema), poor sugar control, needs new glasses or cataracts.  While there are many more causes of loss of vision, I thought these were the most likely.

After complete dilated exam, I was happy to report to him that he needed cataract surgery and, most importantly, there were no signs of diabetic macular edema nor active proliferative disease.

What Does This Mean?

Find a doctor who you trust.  That’s the definition of the “best doctor.”  It becomes crucial for patients suffering from long-term, or chronic, diseases such as diabetes or diabetic retinopathy.  All diabetic patients need regular eye exams for diabetic retinopathy.

If you don’t like your doctor, you aren’t likely to believe what she has to say and you won’t go as often as you should.  Simple human nature.

I expect AB to return to 20/20 vision after successful cataract surgery despite his age, length of being diabetic and the history of proliferative disease.

I noted his weight was stable, hinting AB is very disciplined and, unlike me, has been able to control his weight over the years.  I am not sure if there is any causal relationship between good vision and stable weight/diabetic control.

My point is that the disease is not certain to cause blindness or even severe loss of vision and I wanted to share a good story of seeing well despite chronic disease…and a trusting friendship.



Treatment for Proliferative Diabetic Retinopathy

VEGF causes proliferative diabetic retinopathyPatients with proliferative diabetic retinopathy can be treated with laser photocoagulation and/or Avastin.  Proliferative diabetic retinopathy, or PDR, is  a specific stage of diabetic retinopathy which may lead to blindness if left untreated.

While most patients (if not all) develop some degree of diabetic retinopathy, most patients will not progress to the proliferative stage.

“Proliferative” Means Growth of Abnormal Blood Vessels

Diabetes is a disease which affects blood vessels.  The retina may lose blood supply resulting in “retinal ischemia,” a condition where insufficient oxygen gets to the tissues (“angina” is another ischemic condition, chest pain develops due to lack of oxygen).

In response to chronic ischemia (poor oxygenation), the eye secretes VEGF (vascular endothelial growth factor).  VEGF acts as a fertilizer to grow abnormal vessels somewhere in the eye.  These abnormal vessels are called neovascularization.

Neovascular tissue may cause a diabetic retinal detachment or neovascular glaucoma.  Either can blind.

Treatments Neutralize VEGF

Avastin, a common anti-VEGF, when used in the eye, can treat wet macular degeneration and macular edema.  Over the last few years, Avastin has also been used to chemically treat PDR.

Avastin works by chemically neutralizing VEGF circulating in the eye.

Laser treatment, called pan-retinal photocoagulation (PRP), indirectly reduces VEGF by killing retinal cells.  By reducing the number of retinal cells (we don’t really need them for vision by the way), the overall demand for oxygen is reduced.  At some point, the reduced oxygen supply becomes adequate and VEGF is no longer produced.

Avastin is Only Temporary Treatment

Avastin, in my opinion and experience, is a quick and immediate treatment for PDR.  It needs to be repeated as it does not fix the actual problem…the ischemia.

I have found that repeating the injections every 90 days or so can keep the neovascularization under control.

PRP, the laser photocoagulation, is a more permanent therapy as it remedies the actual problem…it cures the relative ischemia.  Ischemia is inadequate supply of blood flow/oxygen.  While the laser does not improve supply, it reduces demand and cures the oxygen problem.

What Does this Mean?

I don’t really know how long laser treatment takes to work on patients.  There are several reasons why PRP is not immediately effective; severity of disease, amount of laser, etc.

Avastin works almost immediately and usually within 24-48 hours.  It gives me a great clue as to the likely success of the eventual PRP.

I can often “stop” the disease with the Avastin and perform the more curative treatment at a later date.


What is the Macula?: Macular Diseases

Macular Diseases May be classified by the layer of the retina they affect.The macula is the most sensitive portion of the retina.  The retina is the inside lining of the eye capturing light and sending to our brain to give us vision.  Like a sandwich, the retina has several layers.

Diseases of the macula may be classified by the layer of the retina they affect.

Symptoms of Macular Diseases

Macular diseases, such as epiretinal membranes, macular holes, macular edema and macular degeneration, affect central vision.  Symptoms can include decreased vision and/or distortion and you can’t distinguish (or at least I can’t) one disease from another based on symptoms…they are all the same.

Diseases on the Surface of tbe Macula

The more common is the macular pucker, aka epiretinal membrane (ERM).  This is a sheet of protein which forms on the surface of the retina.  Imagine the retina is the hamburger paddy.  The epiretinal membrane would be the cheese on top of the paddy.

The ERM can microscopically wrinkle the underlying macula causing changes in the vision.

Removal of the membrane with vitrectomy often remedies the situation.  The underlying retina is healthy.

Macular Diseases Involving the Retina

Often the macular tissue itself is affected.  In our sandwich analogy, the retina is the meat itself.

Anything causing macular edema affects the actual retinal tissue (meat patty) and therefore vision.  Common causes of macular edema?  Vascular occlusions (BRVO and CRVO) and diabetic retinopathy.

A macular hole develops after the retina is stretched.  There is actually an absence of tissue causing the hole. (If you took a piece of balloon, poked it with a pin and then stretched the balloon apart, you’d see the resultant pinhole…enlarged by the stretching.  Same thing happens with macular holes).

Macular edema may be treated with medicines or laser.  Macular holes are treated with surgery.

Diseases Underneath the Macula

The most common are wet and dry macular degeneration.  Macular degeneration affects the layer of cells feeding the rods and cones.  Without functioning rods and cones (the two types of cells allowing us to “see” light and color) we have no vision.

Macular degeneration principally attacks the RPE layer by permanently damaging theses cells.  This would be the lower layer of cheese underneath the patty.

There is presently no accepted treatment for dry macular degeneration.  Eye injections of anti-VEGF are one helpful treatment for the wet form.

What Does This Mean?

The macula is a small 2 mm x 2 mm area of the retina producing our useful vision.  Thus, “macular” becomes an adjective when describing various disease affecting this region.

Only the ERM involves healthy retinal tissue and, hence, the best prognosis.  The retina is the healthiest compared to the other situations.

The treatments available for most of the “macular” diseases are not necessarily successful at fully restoring vision.  When the diseases affect the tissue itself, either the retina or the layer underneath, some degree of permanence may be expected.

Why Vision is Poor with Silicone Oil

Why your vision is poor following silicone oil for retinal detachment surgery.

There are many reasons why you may not see well after silicone oil is used for your retinal detachment eye surgery.  Remember, retinal detachments are potentially blinding conditions and silicone oil is often used for repeated detachments.

Did Your Macula Detach?

One major concern with every retinal detachment is whether or not the macula becomes detached.  The macula is the most sensitive part of your retina.  It provides central vision, reading ability, color vision, etc.

One goal of retinal detachment surgery, if possible, is to fix a retinal detachment before it spreads large enough to detach the macula.

If the macula detaches, you my lose permanent central vision and/or develop distortion regardless if the surgery is successful.  Thus, if the macula detached at any time, there may be some permanent loss of vision.

Was Your Lens/Cataract Removed?

Silicone oil is rarely used during “primary” retinal detachment surgery, meaning we usually don’t use silicone oil unless the retina repeatedly detaches.  So, too, is the necessity to remove the cataract, or your natural lens, during retinal detachment surgery.

If your lens was removed, this might impact your vision, too.

Index of Refraction

This is a fancy term referring to the ability of light to be focused in oil versus water.  Light is focused differently depending upon the medium, or liquid in the eye.  For instance, replacing the natural saline solution and the vitreous (i.e. during a vitrectomy) with oil would change the power of your glasses or contacts.

Too Much Oil

Oil and water focus light differently, therefore, your vision will change simply because the medium (water/vitreous exchanged for oil).

Filling an eye with silicone oil can be tricky.  Eyes come in all sizes and therefore require different volumes of oil.   We have to use our best judgement when filling the eye with oil.

The perfect amount of oil fills the entire back of the eye and stays behind the iris.  In patients where there is no lens, too much oil can move forward through the pupil and decrease the clarity of the cornea.

Too Many Retinal Detachments

Many times eyes lose vision due to damage to the retina or cornea simply from repeated detachments and surgery.  That is, while oil may be used to prevent complete loss of the eye (often the case), there has already been permanent damage to some of the ocular tissues and, thus, poor resulting vision.

What Does This Mean?

Retinal detachments are difficult to understand.  Communication with your doctor is essential, though I realize we doctors vary in our ability communicate effectively.

Silicone oil is often used as a last resort to prevent further operations.  As you can see from the list above, just by putting oil in the eye, the vision is reduced.  This fact, coupled with the necessity for future surgery to remove the oil, prevents most of us from using oil during the initial surgery.

There is a difference between successful surgery, i.e. getting the retina fixed, and seeing well.  They don’t always go hand in hand, especially in cases where there have been repeated retinal detachments….the most common use of oil.

In the end, ask your doctor why she thinks you are not seeing.  If the answer you are receiving does not make sense to you, seek a second opinion.  You have a right to understand.



My 52nd Birthday!

Birthday Post:  What I've learned from this website.I’m 52 years old this past Wednesday (9/5).  As with last year, I want to take my birthday celebration to write about what I’ve learned through this website.

My Practice

Now 3.5 years old and > 450 articles, now has a PR = 3, attracts over 16K visitors per 30 days (and growing).  Honing in on!

This site has taught me alot about transparency and developing relationships with patients.  My practice has grown and I now attract patients from all over the country and a few from overseas.  This is a significant difference compared to one year ago.  This is also a testament as to the importance of communicating via a website.

Websites Different Stages of Development

I’ve learned that a website has different stages of maturity.  Basically, with continued writing, religious answering comments and exhibiting transparency…I have succeeded in building trust and credibility.  This takes time.  One does not simply build a website and get rewarded with trust.

Most importantly, it’s not the “MD” that gives me instant trust and credibility.  The most compelling part of this website are the questions/ comments left by other readers and then my answers….the so-called “conversations.”  The articles I write catches attention by providing answers.  It’s the dialogue witnessed in the comments after the articles that are the most engaging.

This is power of social media; finding others with similar interests/problems.

The questions and comments serve as a basis for other readers to find people with similar problems.  Patients finding others with problems to which they can relate.  By answering each and every comment, I show a willingness to engage and participate with my “patients.”

There is a practical aspect, too.  Patients are able to learn a bit about me and how I practice.

Social Media and Medicine and Scarcity Marketing

18 months ago, Amy and I started Medical Marketing Enterprises, LLC, a company to teach doctors, medical practices and administrators how to develop a web presence, market their themselves and educate patients.

Armed with information via the Internet, patients (you) now have information about their health issues.  The era of scarcity marketing is over.  Patients no longer rely on doctors as their sole source for health information and, as a result, are able to be more selective over their health care providers.

What Does This Mean?

We, doctors, that is,  must learn to respond to the needs of our patients.  Foremost we must learn to be  transparent (show human qualities).  Patients are looking for people who are doctors.  Docs who are willing to display themselves as people first and docs second are going to flourish.

It’s the new “bedside manner” and “word of mouth.”

Doctors without a web site no longer exist.  It’s a strong statement that they don’t care to engage their patients.  Patients would rather go elsewhere.



Lucentis Approved for Diabetic Retinopathy

FDA Approves Lucentis for Treatment of Diabetic Macular Edema, Randall Wong, M.D.Lucentis is now FDA approved for the treatment of diabetic macular edema (DME). Diabetic macular edema is the most common “complication” of diabetic retinopathy.

Retinal swelling can now be treated by either laser treatment or intravitreal injection. This is the first time we (doctors, that is) have an FDA approved alternative for the treatment of DME.

Laser Not For Everyone

Laser treatment, the gold standard for DME, has been in use for about 30 years and has been the standard of care. Not all patients; however, are great candidates for laser treatment. Either their swelling doesn’t respond to laser treatment, or the areas of leakage can’t be treated without damaging the central vision.

Intravitreal injections are attractive because they treat the disease by a different mechanism.

Lucentis Limits Swelling

The goal of successful treatment for DME is to decrease the amount of swelling.  Laser treatment works by heating the areas of leakage and/or increasing absorption of the abnormal fluid.

Lucentis, and other anti-VEGF medications, are known to work by chemically stopping the leakage of the normal retinal blood vessels.

Lucentis and Laser for Treating DME

Due to the different mechanisms by which the treatments work, it is plausible that both Lucentis and laser treatments can be used to achieve success.  While not usually applied at the same time, both injections and laser treatment are often used in combination over the course of treatment.

What Does This Mean?

Use of Lucentis for diabetic retinopathy is actually not new.

Retina specialists have been using Lucentis and Avastin (both are similar anti-VEGF medications) for several years to treat diabetic macular edema.  Both have been FDA approved for the treatment of other diseases (macular degeneration and cancer, respectively) and have been used “off-label” for the treatment of macular edema.

Off-label use, that is, prescribing a drug for other than the FDA approved treatment is common practice.  FDA approval is necessary for getting a drug to market, but once on the market, other uses may be determined.

While this approval does validate our “off-label” use of the drug, it now allows the manufacturer to market the drug as a treatment for diabetic retinopathy.  Without FDA approval, a company can not advertise or recommend its use for anything other than the intended treatment.



Currently, I see patients with retinal diseases; macular degeneration, retinal detachment, macular holes, macular pucker within several different's a different arrangement, but it allows more continuous care with many eye specialists. In addition, I am very accessible via the web. To schedule your own appointment, call any of the numbers below.

Virginia Lasik | Office of Anh Nguyen, M.D.
Randall V. Wong, M.D.
Contact: Layla

A: 431 Park Avenue, Suite 103 • Falls Church, Virginia 22046
Ph: 703.534. 4393
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Dressler Ophthalmology Associates, PLC
Randall V. Wong, M.D.
Contact: Ashley (Surgery/Web)
Chrissy Megargee (Web)

A: 3930 Pender Drive, Suite 10 • Fairfax, Virginia 22030
Ph: 703.273.2398
F: 703.273.0239
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