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Tag Archives: Ophthalmology

Retinal Tears and Vitreous Hemorrhage

Vitrectomy for Retinal Tear to Remove Vitreous HemorrhageA vitreous hemorrhage may be caused by a retinal tear.  Sometimes there is so much blood in the eye that direct examination is impossible and we can only guess at the most likely cause.  It is the most difficult situation for me to handle as a doctor.

Patients lose significant vision as the blood in the middle of the eye physically blocks all light from hitting the retina.  While this is usually not permanent visual loss, the blood makes it difficult to make a definitive diagnosis as it can be impossible to see the retina.

Normally, without blood in the eye, a retinal tear may be easily diagnosed and treated with laser.

While there are other causes of vitreous hemorrhage, such as diabetic retinopathy, retinal vascular disease and others.  Still, a retinal tear causing the vitreous bleeding is quite likely.

Retinal Tears Cause Retinal Detachments

A retinal tear can cause a retinal detachment.  A retinal detachment is potentially blinding.

In cases of vitreous hemorrhage, the patient cant’ see “out” and I can’t see “in.”  My ability to examine the eye is hindered.

Options at this point are to observe (i.e. do nothing).  Observing the eye is okay as the blood is doing no harm.  But what if there is a retinal tear?  A retinal detachment could occur if there is an undiagnosed retinal tear.

Other tests, such as an ultrasound can often detect a large tear, but it is not as good as directly examining the eye.  Operating to remove the blood to facilitate proper examination is an option, too.

What Does This Mean?

I am getting older, more aggressive, but smarter.

As I have aged, i.e. gained more experience, I have become more comfortable operating in these cases.  When I was younger, I would often hesitate because I was uncomfortable offering surgery in a situation where surgery might not be necessary, but I’ve learned (through experience) that watching a waiting can be more problematic.

Most of the time I recommend operating to at least remove the blood and confirm a diagnosis.  The risks of modern vitrectomy are quite low, while the risk of a retinal detachment occurring while we are waiting is quite possible.

Vitrectomy surgery is usually performed as an outpatient.  If a tear is indeed present, it can be treated simultaneously.

At the very least, a diagnosis can be made and a potentially blinding condition avoided.

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Vitrectomy Eye Surgery for Macular Pucker

This is my first patient education video.  I uploaded this last evening to YouTube.  It is one of the best I’ve seen for a super niche like eye surgery.

Vitrectomy Surgery

As I state in the video, vitrectomy surgery is performed by retina specialists.  I completed extra training to specialize and to perform retinal surgery.

A vitrectomy is the core operation for many of the surgical diseases we treat.  For instance, a vitrectomy is used to remove an epiretinal membrane (ERM), fix a macular hole or repair a retinal detachment.  A vitrectomy can remove floaters.

It is very similar to arthroscopic surgery or laparoscopic surgery in that all the systems are “closed.”

Patient is Awake and Comfortable

Most of my procedures are performed while the patient is awake.  Before surgery, the patient receives a sedative, putting them to sleep for a few minutes while the entire eye is numbed.

This “IV sedation” or “twilight” form of anesthesia is quite popular in most outpatient surgical settings.  It avoids the rigors of general anesthesia.

By the way, the operation is completely painless!  I am usually able to talk to my patients while operating.

25 Gauge Instrumentation:  No Stitches!

The instruments used have revolutionized vitrectomy surgery.  The instruments are so thin, that we no longer have to take time to stitch the eye.  This improves efficiency (shortens operating times), but also causes less tissue damage and greatly speeds up healing time (fewer office visits).

What Does This Mean?

You’ve probably noticed that you see more and more video.  It’s a great medium, it captures your attention via audio and video, the costs of equipment are miniscule and the video quality is exeptional.

I produced this entire video at home using iMovie (Apple).  The operation took about 16 minutes in real time.  Many thanks to Meredith Maclauchlan for her skill in adding the special effects and background!

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Your Eye Treatments

Eye drops are the most common form of medication for your eyes.  There are also ointments (aka salves), pills and injectable medicines.  The eye is unique in the many ways.  It can be treated directly with medicines.  Eye drops and ointments are the most common.  Medications given by mouth or intravenous usually don’t get into the eye well, due to the blood brain barrier.  Direct injection of medicine into the eye is probably the best for treating problems inside the eye (e.g. the retina).

Eye Drops

The skin is the only other organ in the body where the medication is placed directly upon it.  We use lotions and creams to treat ailments and diseases of the skin.

Eye drops, too, are placed right where we want them.  These drops commonly treat infections, fight glaucoma, lubricate, reduce inflammation, etc.  Eye drops are best suited for problems that develop outside, that is, on the surface, of the eye.  They aren’t so useful for treating diseases in side the eye as the drops do not penetrate the eye very well.

Each eye drop has a volume of about 32 microliters.  The volume of the surface of the eye is about 28 microliters.  These are approximations, but my point is that for most eye drop medications, the volume of one drop exceeds the amount of liquid that can be “held” by the surface of the eye.

This means that whatever the medication, never use more than one drop, or, the excess will roll down your cheek…it is a waste.  I have always recommended that if the directions recommend the use of more than one drop at a time, don’t buy it.  The manufacturer knowingly advises you waste a portion of the product.

A  more practical view?  Often patients are directed to use more than one different type of eye drop.  Separate the drops by a minute or two to prevent the first being washed away (and down your cheek) by the second drop.  Give the first drop time to be absorbed.


There are fewer medications available in ointment form.  The advantage of an ointment, or salve, is the effects may last a bit longer.  Once applied, the ointment heats up.  As it nears body temperature, the ointment melts and releases the medicine over the ocular surface.

Ointments; however, are somewhat greasy, difficult to apply and, most of all, generally blur the vision.  Patients don’t like to use them, they are messy and they can’t see.

Eye ointments are great for eye lid problems and for cases where lubricating the eye requires more than just drops (e.g. just before you go to bed).

Intravenous Medications

Rarely used in the office setting, intravenous medications can be used when there are eye and systemic complications that need to be treated.  Beyond the scope of this article, intravenous medications may be used to treat certain infections, bacterial and viral, that are out of control (e.g. herpes, CMV, syphilis).  Still not much drug finds its way into the eye even whe given I.V.  The “blood-brain-barrier” prevents many drugs from getting inside the eye.  This is a unique problem of the eye and the brain.


Tablets and pills are sometimes used to treat certain types of inflammation, occasionally eye pressure and only a few types of infections.  This route, too, fails to get large quantities of medicine inside the eye, again, due to the blood brain barrier.

Intravitreal Eye  Injections

Most of the advances in treatment for macular degeneration and diabetic retinopathy involve intravitreal injections.  Injecting anti-VEGF medications and steroids have given us new ways to treat these two common retinal diseases.  This circumvents the the “blood brain barrier.”

Sustained Release Drug Delivery

This category is really a subset of intravitreal injections.  These devices will be injected into the eye and release drug over many months (bypasses the blood brain barrier).  Right now, Ozurdex, is the only FDA approved system.  It releases steroid for the treatment of retinal vascular occlusions.  Other sustained release systems are in the pipeline.

What Does This Mean?

Depending on the malady, topical eye drops and ointments are probably best suited to treat disease outside the eye.  They have the advantage of being applied directly to the target tissue.

Similarly, by directly injecting medicine into the eye to treat retinal disease, intravitreal injections share the same advantage; namely, directly applying the medication to the target.

While the main thrust of this web site focuses on retinal disease, don’t forget that eye drops were really the first time we could apply medicine directly to the eye.  History has taught us that this is a very effective method.  This makes for an exciting future for the treatment of retinal disease.

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Eye Drops to Help You Heal

After eye surgery, there are several eye drops to help you recuperate, and heal, quickly.  These eye drops usually include an antibiotic, anti-inflammatory, and sometimes, an eye drop to keep  you dilated for comfort.

There are many types of eye surgery; cataract, glaucoma, corneal, retina, etc.  In general, the post-operative medications/drops that we use are about the same.


These usually come packaged in a bottle with a tan colored top.  It may be used 4 times a day.  The drop is clear and may be prescribed to be used 4 times per day.

Remember that eye drops do not penetrate the eye very well, so it is probable that the antibiotics really help the outside of the eye and the actual incision (i.e. place where your surgeon “cut” into your eye) from becoming infected.

One of the unfortunate complications of any intraocular surgery is endophthalmitis, an infection of the contents of the eye.  I doubt the topical drops actually fight any infection inside the eye per se.

Anti-Inflammatory Drops

These usually come in a white or pink capped bottle.  I prefer a steroid called prednisolone acetate 1% (e.g. Pred Forte, Omni Pred).  It is milky white.  This drop must be shaken prior to instillation.  It is really a suspension, that is, the drop contains microscopic particles of drug that settle out.

Other anti-inflammatories included Xibrom or Acular.  These are not steroids and probably not as strong.

Anti-inflammatory drops help the eye keep comfortable during the healing.  If we limit the post-operative inflammation, there should be less discomfort.

Dilating Drops

Some operations and some docs require dilating drops after the operation.  These are in a bright red topped dropper.  These are very similar to what is used in the office to dilate your eyes for examination.

Occasionally, it is helpful to keep the pupil dilated during the recovery period.  I like to use these drops at the end of an operation.  The drops I use will keep the pupil dilated for a day or two, but I don’t have to wait for dilation the next day for the follow-up exam.

Certain dilating drops can also cause “cycloplegia” in addition to simple pupillary dilation.  One of muscles inside the eye, the ciliary muscle, can sometimes spasm, causing severe pain and discomfort.  “Cycloplegia” prevents this from occurring and helps keep the eye comfortable.  The ciliary muscle also helps focus, so vision become blurry.

What Does This Mean? Most of the post-operative medicines we use are topical drops.  Oral medicines usually aren’t necessary.   Most of the drops are really used to promote smooth, comfortable healing, the antibiotics being the exception.

Oral pain relievers generally are not required.  I rarely have to prescribe anything by mouth regardless of the procedures I performed.  The operation I perform requiring the most tissue manipulation is a scleral buckle.  Even with this procedure, oral pain relievers are not necessary.  (Of course, this is surgeon dependent and reflects the way I practice only.)

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Gas Injection for Retinal Detachments

Injecting gas into the eye, called pneumatic retinopexy, is the fourth way to fix retinal detachments.  Other methods include

Gas Injection

This procedure is performed in the office.  Similar to other intraocular injections, except gas is introduced into the eye instead of anti-VEGF medications or steroids.

The gas is usually injected at 100% concentration and will expand a bit over the first day or so.  This allows us to inject a small amount of gas that will enlarge and cover more retinal surface area.

Gases used are usually SF6 (sulfur hexafluoride), C2F6 (hexafluoroethane) and C3F8 (octafluoropropane).  These are large molecules, are inert (don’t react with tissue) and can expand at given concentrations.

Their large size means that they will be slowly absorbed after injection, giving us plenty of time to use them as a tool.  In comparison, air, if injected into the eye, does not expand and will be absorbed within 24 hours.

Advantages of Gas Injection

No “operation” is the biggest advantage.  The procedure can be completed within hours of diagnosis.  There are no issues with scheduling an operation at the hospital, pre-operative clearance and coordinating schedules.

Quick Healing – no actual cutting, so tissue healing is very quick.

No Change in Glasses – as the eye remains the same shape (in contrast to scleral buckle), there is no change in glasses prescription.

Disadvantages to Pneumatic Retinopexy

Lower Success Rate – not all retinal detachments can be treated with gas injection.  The forces within the vitreous are NOT changed.

After gas is injected, the head must be positioned so that the gas abuts the retinal tear.  For instance, if the tear is at the “12 o’clock” position of the eye, the head must be held upright, or erect.  Similaryly, if the retinal tear is located at “9 o’clock” as you are looking at the patient, the head must be tilted over to the left to position the gas “bubble” appropriately.

Retinal Detachments and Retinal Tear
A Retinal Tear Can Lead to a Retinal Detachment

For example, in the illustration above, the tear is located at 10 o’clock.  The head should be tilted to the patient’s left, so the gas, as it rises in the eye, will abut the retinal tear.

Usually, only retinal detachments with tears from 8-4 o’clock can be treated with gas.  It is not possible to treat tears occurring at 6 o’clock.

In both scleral buckle surgery and vitrectomy eye surgery, forces are reduced in the vitreous.  This does not occur with pneumatic retinopexy (gas injection).  Therefore, redetachment occurs more often.  The success rate is lower, perhaps around 85% for this procedure.  Scleral buckle and/or vitrectomy procedures are slightly more successful.

Whenever gas is used, there is a higher rate of cataract formation after the operation.  As with any procedure, there is a chance of infection that can cause blindness.

How the Gas Bubble Works

Basically, the gas, when positioned properly, blocks the transmission of fluid through the retinal tear or retinal hole.  The retina reattaches.  By using either laser or freezing (cryotherapy), the tear is treated to induce scarring that will eventually “seal” the retina and prevent re-detachment.  It does NOT “push” the retina back per se.

What Does This Mean? Depending upon the circumstances, there are a variety of ways to operate to fix a retinal detachment.  Gas injection has many advantages, and is a successful way to proceed.

My personal feeling is that gas injection used to be a great time saver, however, the success rate is lower.  As technology as advanced (e.g. 25  gauge vitrectomy), operating room procedures have become easier, and quicker, to perform.  The advantages to pneumatic retinopexy, or gas injection, have become…well, er, “blurry.”

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Steroids Likely to Help Diabetes

Ok, maybe a bit dramatic, but another article was recently published stating that intravitreal injections were used with success to treat diabetic macular edema.   These effects lasted at least 5 years, the duration of the study.

This was a small study where two groups were compared.  One group received intravitreal injections of triamcinalone (a steroid) for the treatment of diabetic macular edema.  The second group received a placebo.

After two years, the second group then started receiving the steroid.  The first group continued.  Occasionally, laser was used in either group.

The results were that vision improved and swelling decreased in the first group.  In the second group, the vision improved and swelling decreased, but only after receiving the steroids.

What Does This Mean? The other day, I reviewed a small study (Eye Injections Challenge Eye Laser for Diabetic Retinopathy) and had a few criticisms.  This study, too, has the same pitfalls.  Don’t take away that all small studies are worthless, they are not.

A few months ago, there was some discussion regarding a couple of emerging new drug delivery systems available for ophthalmic use.  Iluvien® (Alimera) is an injectable sustained release system that will release steroid (fluocinalone) for the treatment of diabetic macular edema.  Clinical trials are underway.

Ozurdex™ (Allergan) is the first sustained drug delivery system to hit the market.  It was approved last June 2009 by the FDA for treatment of macular edema caused by retinal vein occlusions.  Though not approved directly for the treatment of macular edema found in diabetic retinopathy, my prediction is that it will be used “off-label” in the near future.

I think, slowly, we are moving to the point where intravitreal injections are going to replace laser therapy for the treatment of diabetic macular edema.  I am using the term “injections” rather loosely as I also am including the use of sustained release systems.  These, too, will be delivered by an injection method, similar to intraocular injections.  The only difference is that the sustained release systems will deliver the pharmaceutical over a much longer period, thus, requiring fewer “treatments.”

The full article is referenced here;  Ophthalmology. 2009;116(11):2182-2187.  There is no link as viewing may require a subscription.


Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

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You Only Need Good Vision in One Eye to Keep Driving!

In most states, you only need one eye to maintain a driver’s license.  Most states require one eye to have at least  20/40.  In addition, a certain degree of peripheral vision, or continuous field of vision, is required to qualify for an unrestricted license.  A restricted license may still be obtained with slightly lower requirements.  Please check your own state laws.

Can I Drive? Obviously, loss of independence is one of the biggest concerns a patient has after being told of permanent vision loss.  While many eye doctors may not be comfortable with this conversation, most retina specialists, dealing with diabetic retinopathy and macular degeneration, have to be well versed.

Professional Driving Fortunately, in most circumstances where there may be significant vision loss in one eye, the fellow eye is still in good shape.  I am usually quick to point out that one eye is all that is required to maintain a driver’s license.  There are a few professional exceptions; those with commercial driver’s license (CDL), pilots and locomotive engineers require both eyes to see well.  I am sure there are a few others, but my point is that loss of vision in one eye does NOT usually cause a change in careers.

Failing the Vision Test When you take the vision test at the motor vehicle department, keep in mind that these are screening tests.  Patients that do not see well out of both eyes will fail, but this does not mean loss of the driver’s license.  Screening tests are designed to make sure that “one-eyed” patients are seen by an eye doctor.

Most states have a separate form that must be completed by an eye doctor upon failing the screening test.  Completion of this form ensures passing or failing the vision requirements of the driver’s license exam.

The Visual Requirements One eye must have a visual acuity of at least 20/40 and have a continuous field of vision.  We have mentioned different ways to measure visual acuity in other articles.  The peripheral vision, however, is measured in degrees.  The continuous field of vision pertains to the amount of peripheral vision and is measured in the number of degrees of intact, peripheral vision.

Diabetic retinopathy and macular degeneration involve central vision.  There can be complications from retinal detachment that may affect the peripheral vision, but basically, diabetic retinopathy and macular degeneration would decrease central acuity.  Other diseases such as glaucoma, or certain strokes, might reduce the peripheral vision.  Though patients may have excellent central vision, the peripheral vision may be so compromised (e.g. tunnel vision), that passing the driver’s license requirements are impossible.

What Does This Mean? Remember, in most cases of diabetic retinopathy and macular degeneration, the chance of significant vision loss is low.  Still, in many more instances, the fellow eye may be good enough so that independence is not jeopardized.

Another reason to see your eye doctor……………..early.


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

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Eye Injections Challenge Eye Laser for Diabetic Retinopathy

There is a small study just published in the journal “Ophthalmology” stating that intraocular injections of Lucentis® were superior to laser photocoagulation for the treatment of diabetic macular edema.  As you read this, don’t forget that the “gold-standard” for treatment of diabetic macular edema is still laser photocoagulation.  These “studies” are very small and not of the caliber needed to change the way we practice, but there is still some merit to the findings.

In this study, 126 patients with diabetic macular edema were split into 3 groups;

  1. treated with Lucentis® only
  2. treated with laser only
  3. treated with laser, then Lucentis

Of the 3 groups, the patients receiving Lucentis®, when compared to the laser only group, had the most improved vision and reduced “thickness” or “swelling” of the macula.  The 3rd group, where laser and Lucentis® were combined, was not significantly better in terms of vision, but the swelling was improved more than laser only.

What Does This Mean? The study indicates that intraocular injections of anti-VEGF therapy are better than laser treatment for diabetic macular edema.  If you watch the internet, many “authorities” will start proclaiming that this is a new, and better, treatment for diabetic macular edema.  But we should be cautious.

First, the best studies require that the “studies” are prospective, randomized and double-blinded.  These studies are prospective (vs. retrospective), randomized to treatments options, and basically, no one knows what treatment is administered, including the doctors and patients.  This helps remove bias and placebo effects.  This also means, in a study like this, “fake” lasers would have been performed along with “sham” injections.  After the study, a code would be cracked to disclose which treatments were given to which patients.

Second, the study is too small and too short to have allow any significant meaning.  “Statistical significance” means that an adequate number of patients were studied such that the results could not have occurred by chance.  I don’t know the actual number of patients needed, but most likely would have involved hundreds instead of tens and would have involved more than one testing center.

We also don’t know if the effects are long-lasting.  We only know there was improvement  in the short period of the study.  Now if the effects are still noted 1-2 years after treatment, for example, then maybe we are on to something.

Last, many aspects of the patient selection and treatment are not standardized.  For example, we don’t know if the patient selection was biased in any way that might favor one treatment over another.  For example, perhaps everyone in one group had better sugar control than the other.

My point is, that studies such as this are suspect due to many shortcomings.  Proper prospective, randomized, double-blinded studies take years to develop, perform and analyze.  The AREDS1 Study is an example.  These studies also take large reserves of cash.

The value of these studies is; however, that if similar “small” studies have similar themes, then these may serve as a nidus to create and form much larger, more formidable studies.  Also, for the clinicians (aka yours truly), it also gives us information about alternative treatments that seem viable.


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

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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.


Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

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New Review Section: Diabetic Retinopathy, Signs, Symptoms and Treatment Options

I just completed the new section on diabetic retinopathy.  As with the other sections, it is a comprehensive review of diabetic retinopathy.

The link is located on the left panel under “SECTIONS” or click here.

My next goal will be to complete the various sections (I haven’t decided if I even need extra topics) and then continue posting as usual.  I still need a better way to organize the content of the web site.

Other than the obvious “one stop” reading, the section on diabetic retinopathy and macular degeneration will be a nice and easy way to keep up to date with big news about these subjects.

I believe this is a pretty simple way to develop some more structure to this site.  I would appreciate hearing your thoughts about;

What additional topics, if any, are needed?

Suggestions on easy ways to navigate/find information on the site.

I’d appreciate any “comments.”

Thanks again.


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

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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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