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Cataract Surgery and Diabetes

This article is a guest post by cataract and refractive specialist, Dr. Gary Foster.  Gary practices in Colorado/Wyoming and writes regularly on his website about laser vision correction and cataract surgery.   – Randy

 

Cataracts Cause Decreased VisionCataract surgery is the most commonly performed surgery in the world and those with diabetes tend to develop their cataracts at a slightly younger age.  If you have diabetes, there are several additional factors to consider as you contemplate your cataract removal.

Careful planning and preparation can increase your chances for a successful cataract removal and restoration of your vision.

Cystoid Macular Edema

Surgery causes inflammation.  If the inflammation from cataract surgery reaches the back of your eye and causes swelling it is called “Cystoid Macular Edema” (CME).  This decreases the quality of your vision.  There are a number of treatments retina specialist can employ if this happens, but it is better to prevent it in the first place.

To help prevent this from happening I have most of my cataract surgery patients use two different anti-inflammatory eye drops.  In those without diabetes I have them start these drops the day before surgery and then use them for six weeks after surgery.

Diabetics have a greater tendency for swelling to reach the back of the eye after cataract surgery.  To provide an extra measure of protection, I have them start the anti-inflammatory drops one week before surgery so more drug is built up in the eye by the time of surgery.  In addition, I usually have them use the drops for two months afterwards.

Diabetic Macular Edema

Some with diabetes develop swelling in their macula even without surgery.  If retinal swelling is already present prior to surgery, it is best to postpone your surgery and have you see a retina specialist to treat the swelling first.

Depending on the status of your retina, I often have my diabetic friends see a retina specialist a month after the cataract surgery to make sure everything in on a perfect track for success

Infection

Eye infection after cataract surgery is a rare complication.  Some with diabetes are more prone to infection.  We use sterile technique during surgery and have you take antibiotic drops to decrease the chances of infection.

If you have an active infection somewhere else in your body, such as a foot ulcer, we will often postpone the surgery until it is clear the infection is well controlled to guard against the infection affecting your eye.

I perform cataract surgery for a number of friends each week that have diabetes.  I hope this education will help you better prepare for your cataract removal and help you obtain and protect your best vision.  If you have any further questions, please contact me or visit with your retinal specialist.

Gary J.L. Foster MD
Cataract and Laser Eye Surgeon
Board Certified Ophthalmologist
Fort Collins, Colorado 80525

What is Anisometropia?

Image size diffence results from anisometropia, a common cause of double vision following scleral buckle surgery. Randall Wong, M.D.Anisometropia is an imbalance in the prescription needed between your two eyes.  There are several causes of anisometropia, but the most common for a retinal surgeon is a result of a scleral buckle used to repair a retinal detachment.

“Double Vision”

When looking at an object, in most people, we see one single object.  In actuality the left eye and right eye each see something slightly different.  Our brain assimilates each image.  If the images between the two eyes are similar, then we “see” one object.  If the images seen between the two eyes are too dissimilar, then we see double.

If one eye requires a much stronger prescription than the other, you might have double vision due to the large difference in prescription.

Induced Myopia

Every scleral buckle causes in increase in nearsightedness (the ability to see closely without glasses).  After scleral buckle surgery for retinal detachment, the eye elongates, causing the eye to become longer, and therefore, more near sighted.  Over every millimeter longer, there is an increase in 3 diopters of nearsightedness.

Although each eye may have the ability to see 20/20 with separate prescriptions, with both eyes open, the difference may be intolerable.

Inherent with a change in prescription is a change in actual size of the object we are viewing.  Our brain can only tolerate about a 3% difference in the size seen by one eye versus the other.

Cataracts Increase Nearsightedness

A second factor causing anisometropia is cataract.  Most cataracts cause an increase in myopia.  Often intraocular gas is used to help repair the retinal detachment in addition to the scleral buckle.  This intraocular gas can increase the rate of cataract formation and, hence, myopia.

What Does this Mean?

I often get questions on this blog about double vision following retinal detachment surgery.  My own experience tells me that anisometropia is a common cause of double vision following successful retinal detachment repair.

The symptoms are usually ghosting, distortion and double vision.

Contact lens sometimes improve double vision from anisometropia as there is less image size difference with contact lens wear.

True misalignment from the scleral buckle can occur and this needs to be ruled out as a possible cause, too.

My recommendation is to usually see a pediatric ophthalmologist.  These specialists handle all kinds of eye misalignment in both kids and adults.  They are masters at refraction (they refract babies!) and most are well versed in assessing adult cataracts.

Anisometropia due to scleral buckle is a temporary problem.  If, and when, cataract surgery is needed, the intraocular implant (IOL) can be calculated to better match the fellow eye!

 

 

When a Cataract Comes Back

While not a retinal problem, cataracts can “return” and can mimic the symptoms of the original cataract; blurred vision, glare and distortion.  This can usually be remedied by a simple painless laser procedure called a YAG capsulotomy.

Cataract Surgery with Implant

Like grey hair, everyone gets cataracts.  With time, the natural lens of the eye clouds with time.  This clouding decreases vision.  The lens is similar to an “M&M” piece of candy both in size and shape.  An M&M is a core of milk chocolate surrounded by a candy coated shell.

Cataracts Cause Decreased Vision
Cataract

When cataract surgery is performed, the cataract surgeon cuts a hole in the outside candy coating.  The “chocolate”  (core of the lens) is then sucked out leaving the empty candy coated shell.  In the real eye, this shell is actually a clear tissue very similar to plastic wrap used to cover food.  This shell is called the “capsular bag.”

Once the cloudy natural lens material is removed, a clear plastic implant is used to replace the natural lens.  Vision is restored.

Plastic Wrap Gets Dirty

With time, from weeks to years, this clear plastic wrap-like material can get cloudy.  The original symptoms of blurry vision and glare return.  Decreased vision from “posterior capsule opacification” occurs in almost every cataract patient.

Using a “laser” to Restore Vision

A YAG laser is a type of laser that uses its energy to cut.  By focusing the laser beam on the back portion of the candy coating shell, just behind the implant, a small hole is created.  This removes the cloudy/hazy tissue out of the line of sight and vision is restored.

YAG Laser Used for Posterior Capsulotomy
Laser Cut Hole in Posterior Portion of Shell (Capsule)

Does the Implant Fall

Properly performed, a YAG capsulotomy will not cause the implant to move.  While it has happened (and to me!), it is unusual as the implant is usually scarred in place.

In theory, there may be a slight increased risk of a retinal tear that could lead to a retinal detachment.

What Does This Mean?

Many of my patients have had cataract surgery.  It is a relief when we find the cause of the decreased vision is only due to PCO (posterior capsule opacification) and not due to diabetic retinopathy or macular degeneration.

Many people erroneously believe (and perpetuated by some docs) that cataracts “come back.”  They don’t.

This is also why many people believe cataract surgery is performed with laser.  It isn’t, but now you know why, and how, the rumor started.

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Perfect Surgical Outcomes Erode Relationships

Surgical outcomes are never guaranteed, there are risks to surgery.  In fact, nothing in medicine is guaranteed.  One role of doctors is to educate about the benefits and potential risks of a treatment.  On the other hand, if an operation, were successful every time, would we need doctors?

Starting Your Car is Guaranteed

Each time you turn the ignition, your car starts.  It is just about guaranteed.  The outcome is so successful, we have lost an understanding of automobile mechanics (yet in doing so we have become pretty sophisticated in understanding car warranties).  When you buy a car, do you ever question how often the car will start?

Eye Surgery Works Like a Car

Now let’s turn to surgical outcomes.  What if eye surgery were successful each and every time?  By successful I mean each patient saw better immediately after surgery and there were no complications from the surgery.  Each surgical outcome was successful.

If eye surgery were as successful as a car starting; we wouldn’t need discussions about possible complications of surgery, nor would we need counseling about possible visual outcomes after surgery.

Eye surgery would be risk free.  There would be benefits and no need to counsel about possible risks.  Would we need docs?

Cataract Surgery is Intuitive and Highly Successful

The technical complication rate of cataract surgery is somewhere around < 0.1%, that is, rarely are there problems with removing a cataract and inserting an implant.  Visual outcomes in cataract are very high and, for the sake of this article, most patients see better after cataract surgery.

Cataract surgery is also intuitive.  You have an operation and you see better.   “Successful” cataract surgery means improved vsion.

There Are No Blogs About Cataract Surgery

Patients with retinal disease, such as diabetic reitnopathy and macular degeneration, have non-intuitive eye problems.  There are fairly complex discussions that each individual must face.  Hence, the success of this blog is based upon the complexity and confusion of having retinal disease.

Cataract surgery, by comparison, has far fewer variables and takes less understanding.  It takes less counseling.  There aren’t many reasons to have a web-based information site, because almost all the time, surgery is “successful.”

What Does This Mean? I say this all the time.  “If something were successful all of the time, a doctor would never have to speak to a patient.”

Cataract surgery and retinal disease are at opposite ends of the spectrum.  Chances are you know more about cataract surgery than you do about retinal disease.

Retinal disease is pretty complex, the vision is often compromised and the surgical outcomes are somewhat “blurry.”

It is pretty disheartening for a patient to undergo a retinal operation, eye injections, laser, etc. and be left with decreased vision, yet the procedure has been deemed “successful.”

Keeping a patient’s perspective optimistic despite vision loss can be trying.  I have found the best way for patients to accept their outcomes is by giving them truthful knowledge, and if we are lucky, an understanding about their disease.  Hence, a reason for this blog.

“Randy”

Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

When You Need Cataract Surgery

Cataract surgery is needed when your vision is not as good as you’d like, and, your eye doctor feels that the elective procedure would help.  In cases of diabetic retinopathy and macular degeneration, there may be other factors that weigh in to the decision of having cataract surgery.

Cataracts are usually elective surgery.  While insurance does cover most cataract surgery, there are a few criteria for having the operation.  Most of the criteria are based on certain vision measurements taken at your eye doctor’s office.  Your visual acuity, with or without glasses, may simply be bad enough to qualify you for surgery.  Sometimes your daylight vision is fine, but you may suffer from significant glare when driving at night with oncoming headlights.  In addition to vision, your doctor simply needs to affirm the presence of a cataract and likelihood of improvement with surgery.

There is no hurry to having surgery.  Unlike a piece of overripe fruit, you really have lots of time.  Choose a time when you are ready for surgery and is convenient for the rest of your friends or family; whoever may be helping you.

There is no strain on the other eye.  Don’t worry about overworking the other eye while waiting for cataract surgery.  There really is not such thing.

Patients with diabetes have some additional concerns regarding the timing of their surgery.  If you have a history of diabetic retinopathy, make sure that the diabetic retinopathy is stable at the time of surgery.  The only way to assess stability is with a dilated eye exam with your doctor or retina specialist.

While the timing is not that crucial in cases of macular degeneration, the expectations of the operation should be reviewed with the doctor.  By definition, patients with macular degeneration already have decreased vision from their retinal disease.  Make sure you and your doctor are on par with your expectations after surgery.

What Does This Mean? Cataract surgery can be a life changing event.  In most cases, there is likely to be full restoration of vision.  The timing of cataract surgery is basically up to you, based upon your own tolerance, or intolerance, of blurry vision.

If you have cataracts, or suspect that you do, I would recommend an examination soon with your eye doctor.  Use this visit as a fact finding mission, you’ll be surprised how much there is to learn about cataract surgery.  You don’t have to commit to surgery.

Take your time to schedule the surgery.  Make sure you are ready.

If you have retinal disease, such as diabetic retinopathy or macular degeneration, make sure you and your doctor are “on the same page” about the timing and expectations of the surgery.

“Randy”

Randall V. Wong, M.D.

Retina Specialist, Ophthalmologist
Fairfax, Virginia

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Dilated Pupils: Those Drops Are So Annoying

Dilating drops are useful tools for examining the eye.  A dilated pupil exam provides direct visualization and is the best way to examine the retina and is second to none.  The dilating drops are annoying, but are necessary.  Any and every time your doctor needs to look at your retina (or other structures such as the optic nerve), your pupils should be dilated.

Dilating drops cause mydriasis (pupillary dilation) and cycloplegia (see below).  They really have no medicinal purpose, though in certain types of inflammation, they may relieve pain.  Atropine, or bella donna, was used in ancient times to dilate the pupil as a way to accentuate beauty.  In modern times, atropine, or atropine-like medicines, are used to facilitate retinal examination, paralyze focusing ability and allow intraocular surgery.-

Retinal examination for conditions such as diabetic retinopathy and macular degeneration should be performed regularly.  The best, cheapest and most efficient way to exam treat these disease is by looking directly at the retina.  Two types of drops are usually used to effectively dilate the pupil.  Actually, the “pupil” is the opening in the iris.  One drop activates a muscle (alpha-adrenergic muscles) that runs radially (like spokes on a wheel) on the iris.  A second drop, inhibits constriction of a circular muscle (it closes the pupil like a purse-string) on the edge of the iris, thereby allowing dilation to occur, that is, in normally opposes the action of the radial muscle.

With a widely dilated pupil, a cataract can be properly identified, the optic nerve inspected for disease such as glaucoma, the retinal veins and arteries are revealed, not to mention detailed examination of the macula and peripheral retina.

Paralysis of Focusing Muscles is a secondary effect of complete dilation.  This is called “cycloplegia.”  The muscles that contract to reshape our natural lens allowing focusing for reading (and focusing at distance for far-sighted people) are paralyzed.  This wipes out close range focusing and distance focusing (for far-sighted people only).

For children, who are usually farsighted at a young age, this is an important step in properly measuring for glasses.  As the eye gets bigger, we become more near-sighted (or less far-sighted).  Thus, most average kids are farsighted and don’t need glasses in most cases.  To properly measure far-sightedness, however,  especially in a kid, the muscles need to be paralyzed.

For adults, this a very annoying part of the dilated exam – there is too much light entering the pupil and everything is fuzzy!

In most cases of intraocular surgery, such as cataract surgery and retinal surgery (aka vitrectomy), the pupil must be widely dilated to see and operate.  Pre-operatively, the same drops are given to dilate the iris/pupil at the operating room as used in the office.  The dilation can last for hours which should be enough time to get the operation done.

What Does This Mean? Dilating the eye is important because the most important structures of the eye; lens, optic nerve and retina, can only be examined by looking directly at them.  Every time a retinal examination is anticipated you should dilated.  Some docs are using non-mydriatic (aka non-dilating) equipment to see in the eye, but these devices are designed for screening purposes and are not considered detailed enough to allow a diagnostic exam.  The point is…get dilated.

There used to be drops that reverse dilation, but I haven’t seen them in a few years.  They are expensive to use and are uncomfortable for the patient.

“Randy”

Randall V. Wong, M.D.

Retina Specialist, Ophthalmologist
Fairfax, Virginia

Eye Surgery Can Blind

There are risks to eye surgery, especially intraocular operations such as cataract removal or vitrectomy.  Cataracts are the most common eye surgery and vitrectomy eye surgery is usually performed by a retina specialist for various problems of the retina and vitreous.  Infection, inside the eye, called endophthalmitis, is uncommon, yet can blind.

There are all sorts of “eye” surgery.  There is cosmetic “eye” surgery to lift the eyelids, there is “eye” muscle surgery to correct strabismus (crooked eyes), laser “eye” surgery to get rid of glasses, etc.  These are all procedures that do not invade the eyeball, and thus, are “extraocular” operations; surgeries that stay outside of the eye.

“Intraocular surgery” is surgery that cuts into the eye.  Cataract surgery, certain glaucoma operations and retina surgery are all invasive and, thus, introduce certain risks not found in other types of “eye” surgery.

Infection is the biggest risk of any intraocular procedure.  As with any surgical procedure, there is a risk of infection.  Intraoculuar infection; however, can be devastating to the vision as it can cause blindness.  Most cases of “endophthalmitis” occur shortly, within days, after intraocular surgery.  The cause is usually due to aggressive bacteria that attack the inside of the eye leading to damage of the retina.

The damaged retina, even after the infection is controlled, does not see.

Endophthalmitis following cataract surgery is estimated to be less than 1/2000.  Endophthalmitis from vitrectomy retina surgery is even less common.  I usually give the estimate of about 1/10,000 or lower.  Certain types of glaucoma surgery carry a life long chance of developing an infection.

Symptoms of endophthalmitis are pain and decreased vision, although with advances in technology, these symptoms are sometimes less apparent.  In general, if there are concerns about pain or decreased vision following eye surgery, make sure your doctor is aware.  The results can be devastating.

Early identification of possible infections is really, really key.  Treatment can range from antibiotic injections, intravenous antibiotics and vitrectomy surgery.

Retinal detachment is the second biggest risk of intraocular surgery.  By operating inside the eye, an inadvertent retinal tear can be made in the retina leading to a retinal detachment.  Retinal detachments usually do not lead to blindness, but they can.  Additional retinal surgery could be necessary to repair the retinal detachment, but some visual loss is possible.  The chance of developing a retinal detachment following intraocular surgery is somewhere from 1-3%.  Again, with advances in technology, I believe this rate has decreased over the past decade.

Other risks of intraocular procedures are relatively minor, but can include bleeding, but most bleeding into the eye is usually self-limited, sounds horrible, but usually does no permanent damage.  Cataract formation can be caused or enhanced by retina or glaucoma surgery.  This is not a true risk, per se, but hastened cataract formation following intraocular surgery is common.  Sometimes the intraocular pressure can be too high or low following surgery.  There are many reasons why either can occur.

What Does This Mean? These are the most common, and feared, complications of intraocular eye surgery.  This is not a complete listing, but certainly items that should be considered when contemplating surgery.

Your eye surgeon should be able to comfortably discuss, with you and your family, the risks and benefits of any surgery offered to you.  If not, move on.

Eye surgery, especially in America, is extremely safe.  Don’t get me wrong, cataract surgery enjoys about a 99% technical success rate, that is, over 99% of the time the cataract is removed and replaced with an implant…as planned!  Retina and glaucoma surgery, too, are both very successful and usually performed with a high rate of technical success.  Technical success is defined as the ability to perform the actual surgical task.

Complications are the risks undertaken with surgery despite technical success, and no surgery, however, is without risk.

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Medical Insurance Pays for Your Eyes. Vision Insurance Pays for Glasses. The Difference?

When it comes to eyes and vision, there is often confusion as to what services are covered.  Most companies provide medical insurance; the traditional health insurance guarding against catastrophic medical bills, doctor’s bills, etc.  Many more companies will provide a prescription plan and vision insurance.

Vision vs. Medical Insurance – Vision insurance typically will “pay for”  glasses or contacts and an “eye exam.”  In a nutshell, vision insurance pays for the services and goods required to obtain proper glasses or contact lenses.  It probably does not cover a dilated eye exam.  Check with your eye doctor or your insurance plan to verify.  Vision insurance does not usually pay for any “health related” vision problems such as diabetic retinopathy, macular degeneration, cataracts, glaucoma, etc.

Medical insurance pays for the health services necessary to diagnose and treat health related eye problems.  Patients with medical eye diseases are covered by medical insurance.

Get a Dilated Eye Exam - If you have either macular degeneration or diabetic retinopathy, the only way a complete, and thorough, eye exam can be performed is by having a dilated eye exam.  It is imperative that your eye doctor get the chance to look at your retina with the pupil fully dilated to allow an unimpeded view of your retina.  While there are special cameras allowing a picture of the retina “without dilation,” this does not substitute as a thorough eye exam.

What Does This Mean? Simply put, if you have medical insurance, and have a medical eye problem, you should be able to have a complete, dilated eye exam that is covered by your insurance.  Your eye doctor should be able to fully examine and treat you for any medical eye problem.  Patients with diabetic retinopathy and macular degeneration require routine, dilated eye exams. These are health issues, not “vision.”

If you have vision insurance only, and not medical insurance, you may need a complete dilated eye exam, but check with your doctor to make sure what is covered by insurance.

“Randy”

Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

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Cataracts are Like Grey Hair! Everyone Gets Them.

Everyone gets a cataract.  Just as grey hair, some people get cataracts at an early age and some people get them at a later age.  Patients with diabetic retinopathy and macular degeneration aren’t spared either.

What is a cataract? A cataract is the clouding of the natural lens in the eye.  Very advanced cataracts actually are white, hence the name “cataract” to compare to the whiteness seen in a waterfall.  These days, a “white” cataract is pretty rare as cataract surgery is likely to have been performed much earlier.

Symptoms of Cataract include blurry vision, dim vision requiring more light and glare.  At some point, depending upon your visual acuity and quality of life, cataract surgery may be performed where the actual cloudy lens is replaced with a clear implant.  This is not performed by laser.

Cataracts are Not a Disease and usually occur with advancing age in perfectly healthy individuals.  A cataract forming in a 25 year old probably isn’t that common, but it wouldn’t be too surprising.  It is safe to say that most cataracts, however, occur at a later age.

Other Causes. Congenital cataracts occur at birth.  There are a few congenital syndromes where cataracts are present and require surgery during infancy.  Trauma may also cause cataracts.

There are a few diseases where cataracts are seem more commonly.  Patients with uveitis (arthritis-like inflammation inside the eye) may develop a cataract earlier than usual.

Patients with diabetes often develop cataracts earlier than the general population.

Patients with macular degeneration will develop cataracts, but usually occur with more advanced age.

Visual Loss may occur with progressing cataracts.  In patients with diabetic retinopathy or macular degeneration, it is important to remember that cataract formation can occur in these patients as well.  While a patient with diabetic retinopathy or macular degeneration may experience some loss of vision, regular examinations should be performed to determine if cataracts are an issue.

Diabetic patients should consider cataract surgery at a time with the diabetic retinopathy is stable.  Any macular edema should be resolved as cataract surgery, at times, can worsen the swelling.

Macular degeneration patients may safely consider cataract surgery when their doctor advises.

Remember, there are many reasons for decreased vision and having a retinal disease, such as diabetic retinopathy or macular degeneration, does not preclude you from developing a cataract.

Afterall, vision changes from a cataract are “reversible.”

“Randy”

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

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Cataract Surgery May Worsen Diabetic Retinopathy

This post will be short and is written as follow-up to “Diabetics Get Cataracts”.

There is a study just published in the journal Ophthalmology where patients with diabetes underwent cataract surgery.  The incidence of diabetic retinopathy was then followed for at least 12 months.  Patients with both Type I and Type II diabetes were followed.

Overall, there was an increased incidence of diabetic retinopathy in the eyes of those patients that underwent cataract surgery versus the eyes that did not have cataract surgery.  In addition, in 45 patients where only one eye was operated upon, there was an increased chance of developing diabetic retinopathy in the operated eye.

What does this mean? This seems to underscore the importance of having cataract surgery earlier than later, that is, have cataract surgery when the retinopathy is either not detectable or barely detectable.  Also, this study included patients 65 years or older.  The results did not follow the visual acuity. Lastly, even though the incidence of diabetic retinopathy increased, the results indicate better outcomes than similar studies using older cataract surgery techniques (i.e. newer techniques are better and safer).  The newer “phacoemulsification” techniques are quite common in the U.S. and have been so for about 10-15 years.

The abstract to the article.

“Randy”

Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist
www.TotalRetina.com

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offices

Currently, I see patients with retinal diseases; macular degeneration, retinal detachment, macular holes, macular pucker within several different practices.....it'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.

Capital Eye Consultants
Randall V. Wong, M.D.
Contact: Brigitte O’Brien

A: 3025 Hamaker Court, Suite 101 • Fairfax, Virginia 22031
Ph: 703.876.9630
F: 703.876.0163
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Dressler Ophthalmology Associates, PLC
Randall V. Wong, M.D.
Contact: Andrea Armstrong (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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