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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 108  |  Issue : 3  |  Page : 140-147

Combined cross-linking with femtosecond laser myoring implantation versus combined cross-linking with femtosecond laser keraring implantation in the treatment of keratoconus


Department of Ophthalmology, Sohag University Hospital, Sohag University, Sohag, Egypt

Date of Submission04-May-2015
Date of Acceptance15-May-2015
Date of Web Publication30-Oct-2015

Correspondence Address:
Mohammed Iqbal H Ahmed Saleem
Department of Ophthalmology, Sohag University Hospital, Sohag University, 82425 Sohag
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.168716

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  Abstract 

Purpose
The aim of this study was to compare the results as regards efficacy, safety, and patient satisfaction between two combined procedures. The first is combined femtosecond laser myoring implantation with cross-linking (CXL) and the second is combined femtosecond laser keraring implantation with CXL for the treatment of keratoconus.
Setting
The study was conducted in Sohag University Hospital, Sohag University, Egypt.
Design
This was a prospective nonrandomized clinical comparative study.
Patients and methods
A total of 46 eyes of 30 patients with keratoconus were included in this study. Group A included 27 eyes of 17 patients that were subjected to combined cross-linking with femtosecond laser myoring implantation, whereas group B included 19 eyes of 13 patients that were subjected to combined cross-linking with femtosecond laser keraring implantation. All eyes were subjected to preoperative and postoperative uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), manifest refraction, slit-lamp examination of the anterior segment, intraocular pressure, fundus examination, and keratometry and pachymetry assessed with Pentacam corneal topographies at 3 and 6 months of follow-up period.
Results
In group A, the preoperative mean UCVA was 1.30 ± 0.28 (logMAR ± SD), whereas the postoperative mean UCVA was 0.90 ± 0.12. The preoperative mean BCVA was 0.70 ± 0.23, whereas the postoperative mean BCVA was 0.30 ± 0.17. The preoperative K average was 53.27 ± 0.62 (D ± SD), whereas the postoperative K average was 45.83 ± 0.64. The postoperative astigmatic correction was 1.51 ± 0.42 (D ± SD). In group B, the preoperative mean UCVA was 1.30 ± 0.33, whereas the postoperative mean UCVA was 1 ± 0.16. The preoperative mean BCVA was 0.90 ± 0.46, whereas the postoperative mean BCVA was 0.60 ± 0.32. The preoperative K average was 50.97 ± 0.48, whereas the postoperative K average was 49.01 ± 0.32. The postoperative astigmatic correction was 3.07 ± 0.15.
Conclusion
This study proved that combined CXL with myoring implantation is effective in the correction of the myopic component of keratoconus. Combined CXL with keraring implantation is effective in the correction of the astigmatic component in keratoconus. The type and the site of keratoconus cone together with the K readings can help in the preoperative decision as to which type of ring is best in each keratoconus case. This study proved that there is a synergistic action when CXL is combined with intracorneal rings (myoring of keraring).

Keywords: Cross-Linking, femtosecond laser, keraring, myoring, keratoconus, combined procedures


How to cite this article:
Ahmed Saleem MH. Combined cross-linking with femtosecond laser myoring implantation versus combined cross-linking with femtosecond laser keraring implantation in the treatment of keratoconus. J Egypt Ophthalmol Soc 2015;108:140-7

How to cite this URL:
Ahmed Saleem MH. Combined cross-linking with femtosecond laser myoring implantation versus combined cross-linking with femtosecond laser keraring implantation in the treatment of keratoconus. J Egypt Ophthalmol Soc [serial online] 2015 [cited 2022 Sep 28];108:140-7. Available from: http://www.jeos.eg.net/text.asp?2015/108/3/140/168716


  Introduction Top


Keratoconus is an asymmetric, bilateral, progressive, and noninflammatory ectasia due to gradual biomechanical instability of the cornea. Its reported frequency is approximately one in 2000 in the general population. The condition usually begins at puberty and progresses in ∼20% of patients to such an extent that penetrating keratoplasty becomes necessary to preserve vision [1].

Implantation of corneal ring segments into a circular corneal tunnel improves visual acuity and reduces central corneal steepening in keratoconus. A new surgical system referred to as the corneal intrastromal implantation system (CISIS; DIOPTEX GmbH, Linz, Austria), in which the myoring flexible full-ring implant (DIOPTEX GmbH) is inserted into a corneal pocket, proved effective in the treatment of high myopia and keratoconus [2].

Myoring is a 360° continuous full-ring implant that is implanted into a corneal pocket for the treatment of myopia and keratoconus. The internationally patented device combines two a-priori contradictory qualities: rigidity for the modeling and stabilization of the corneal shape after implantation and flexibility (shape memory) for the implantation through a small pocket entry to preserve the corneal biomechanics. The nomogram for the selection of the right myoring dimension for keratoconus is very simple and depends only on the value of the central K average-reading calculation using the formula (SIM K1+SIM K2)/2 [3].

Keraring (Mediphacos Inc., Belo Horizonte, Brazil) is an intracorneal rings (ICRs) that is used to treat keratoconus. It acts by regularizing the anterior corneal surface, thus decreasing the myopia and regular and irregular astigmatism. It is available in different arc lengths and is made of polymethylmethacrylate. It is triangular in cross-section in contrast to other ICRS such as Ferrara rings and has a 600 μm base and an apical diameter of 5 mm [4].

Femtosecond laser technology allows a surgeon to program a corneal stromal dissection at a predetermined depth with an extremely high degree of accuracy, thus avoiding the potential inaccuracies of a mechanical dissection that is dependent on the surgeon's manual skills [5].

Corneal collagen cross-linking strengthens the stromal collagen fibrillae of the cornea by halting and stabilizing the evolution of keratoconus with a long-term increase in corneal biomechanical rigidity. CXL stiffens the human cornea by ∼300%, increases the collagen fiber diameter by 12.2%, and induces the formation of high-molecular-weight collagen polymers with a remarkable chemical stability [1].


  Patients and methods Top


The aim of this study was to compare combined cross-linking with femtosecond laser myoring implantation and combined cross-linking with femtosecond laser keraring implantation for the treatment of keratoconus to understand as to which ring is suitable in which keratoconus stage and cone properties.

The design of this study was a prospective nonrandomized comparative clinical trial that was performed in Sohag University Hospital, Egypt, after the approval of the ethical committee and written consent was taken from the patients after full explanation of this procedure for the treatment of keratoconus and the nature their disease.

A total of 46 eyes of 30 patients with keratoconus were treated with intracorneal ring implantation (myoring or keraring) combined with CXL to correct the refractive components (myopic or astigmatic) of keratoconus. The study eyes were divided into two groups:

  1. Group A included 27 eyes of 17 patients that were subjected to combined cross-linking with femtosecond laser myoring implantation.
  2. Group B included 19 eyes of 13 patients that were subjected to combined cross-linking with femtosecond laser keraring implantation.


All eyes were subjected to the following preoperative and postoperative measures:

  1. Uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA).
  2. Manifest and cycloplegic refraction.
  3. Slit-lamp examination of anterior segment.
  4. Intraocular pressure and fundus examination.
  5. Pentacam: keratometry and pachymetry assessed by means of corneal topographies at 3 and 6 months of follow-up period.


Surgical procedure

The following devices were used in this study:

  1. The KXL System (Avedro Inc., MA, USA) accelerated CXL [Figure 1]a. [Figure 1]b shows Vibex rapid riboflavin.
  2. Advanced femtosecond laser (iFS; Abbott) [Figure 2]a. [Figure 2]b shows the appearance of the femtosecond laser during the descend of the patient interface (PI or the cone) on to the suction ring.
Figure 1: The KXL System (Avedro).

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Figure 2: (a) Advanced femtosecond laser (iFS; Abbott); (b) application of the patient interface or cone of the femtosecond laser onto the suction ring.

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Combined cross-linking with femtosecond laser myoring implantation

The intraoperative parameters of the devices were as follows:

  1. Pocket CXL: Injection of riboflavin (Vibex Xtra) in the pocket every 1 minute for 5 min, followed by 8 min accelerated CXL using the pulsed mode with 30 mW/CC power.
  2. Femtosecond laser parameters for the corneal pocket were as follows: diameter, 9 mm; depth, 300 μm; incision site, at the temporal side of the eye; and incision diameter, 5 or 6 mm according to the ring.


The first step to start with was the application of the suction ring onto the cornea [Figure 3]a. A corneal pocket was created with femtosecond laser [Figure 3]b, followed by creation of the opening incision site of the pocket at the temporal side [Figure 3]cThe corneal pocket was gently opened with a spatula [Figure 3]d to ensure complete opening of the pocket [Figure 3]e. Riboflavin (Vibex Xtra) was injected into the pocket [Figure 3]f using accelerated pulsed mode [Figure 3]g. The remaining riboflavin was washed from the pocket with balanced salt saline (BSS) [Figure 3]h.
Figure 3: Combined CXL with femtosecond laser myoring implantation: (a) application of the suction ring; (b) creation of the corneal pocket with femtosecond laser; (c) creation of the opening incision site of the pocket at the temporal side; (d) gentle opening of the corneal pocket with a spatula; (e) ascertainment of complete opening of the pocket using a spatula; (f) injection of ribofl avin (Vibex Xtra) into the pocket; (g) pocket CXL using accelerated pulsed mode; (h) washing the remaining ribofl avin from the pocket with BSS.

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The correct position of the myoring was ensured [Figure 4]a and the myoring was introduced into the pocket [Figure 4]b pushing the myoring centrally [Figure 4]c. The correct position of the myoring inside the pocket was examined [Figure 4]d. The myoring was centrally adjusted within the corneal pocket [Figure 4]e and contact lens was applied [Figure 4]f.
Figure 4: Combined CXL with femtosecond laser myoring implantation: (a) ascertainment of the correct position of the myoring; (b) introduction of the myoring into the pocket; (c) pushing the myoring centrally; (d) examination of the correct position of the myoring inside the pocket; (e) adjustment of the myoring centrally within the corneal pocket; and (f) application of contact lens.

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Combined cross-linking with femtosecond laser keraring implantation

The intraoperative parameters of the devices were as follows:

  1. Epithelium-on CXL: Instillation of riboflavin (ParaCel) on the cornea every 1.5 min for 4.5 min, followed by instillation of riboflavin (Vibex Xtra) every 1.5 min for 6 min, followed by 5.20 min accelerated CXL using the pulsed mode with 45 mW/CC power.
  2. Femtosecond laser parameters for the corneal tunnel were as follows: inner diameter, 5 mm; outer diameter, 5.9 mm; depth, 75% of thinnest central corneal thickness; and incision site, at the axis of K2 (the steepest) corneal meridian.


The first step was marking of the corneal center by asking the patient to look at the flashing light point coming from the microscope head. This was followed by marking of the center of the cornea at the point of flashing light image [Figure 5]a. Thereafter, the suction ring was applied [Figure 5]b. The central blue mark of the corneal center was identified [Figure 5]c. The corneal tunnel was created with femtosecond laser [Figure 5]d ensuring the patency of the opening incision site of the tunnel [Figure 5]e, and a spatula was passed through the nasal limb of the tunnel [Figure 5]f.
Figure 5: Combined CXL with femtosecond laser keraring implantation: (a) marking of the center of the cornea at the point of flashing light image; (b) application of the suction ring; (c) identification of the central blue mark of the corneal center; (d) creation of the corneal tunnel with femtosecond laser; (e) ascertainment of the patency of opening incision site of the tunnel; (f) passing of a spatula through the nasal limb of the tunnel.

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The temporal keraring segment was implanted [Figure 6]a and was pushed towards its position [Figure 6]b. The nasal keraring segment was implanted [Figure 6]c and was pushed towards its position [Figure 6]d. Transepithelial riboflavin was instilled onto the cornea [Figure 6]e. Epithelium-on CXL was carried out using accelerated pulsed mode [Figure 6]f.
Figure 6: Combined CXL with femtosecond laser keraring implantation; (a) implantation of the temporal keraring segment; (b) pushing the keraring segment towards its position; (c) implantation of the nasal keraring segment; (d) pushing the nasal keraring segment towards its position; (e) instillation of the transepithelial riboflavin onto the cornea; (f) epithelium-on CXL using accelerated pulsed mode.

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  Results Top


A total of 46 eyes of 30 patients (18 male and 12 female) were included in the study. The male-to-female ratio was 3 : 2. The mean age was 18.45 ± 6.70 years. The preoperative data of patients and the postoperative data at sixth postoperative month for both groups are summarized in [Table 1] and [Table 2].
Table 1: Summary of the preoperative and postoperative data of group A eyes with combined CXL with femtosecond laser
myoring implantation


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Table 2: Summary of the preoperative and postoperative data of group B eyes with combined CXL with femtosecond laser
keraring implantation


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As regards postoperative visual acuity in group A, the UCVA and BCVA showed excellent improvement (two lines or more). What was amazing is that the postoperative K average showed huge reduction in the myopic component of keratoconus, reaching up to 8 D or more (ranging from 4.5 to 10.5 D). However, the improvement in the astigmatic component of keratoconus was little (ranging from 0.50 to 2.00 D).

Almost all patients in this group expressed their satisfaction and happiness with their newly gained postoperative visual acuity, as more details became clearer postoperatively.

In group B, there results were different from those in group A. There was an excellent improvement in postoperative UCVA and BCVA (two lines or more). The K average showed a good reduction, reaching up to 3 D (ranging from 2 to 4 D) or more in some cases.

The most significant outcome was the excellent effect of keraring in reducing the mean preoperative astigmatism from 0.52 to 4.32 D postoperatively. Postoperative astigmatic correction reached up to 4 D or more in some cases. In contrast, the mean postoperative myopic correction was 1.25 D and did not exceed 2 D in any case.

The difference between the two groups with examples of the preoperative and postoperative data of both groups is shown in [Table 3] and [Table 4].
Table 3: Example of a group A eye: the preoperative and postoperative data of the left eye of one patient with combined CXL and femtosecond laser myoring implantation

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Table 4: Example of a group B eyes: the preoperative and postoperative data of the right eye of one patient with combined CXL and femtosecond laser keraring implantation

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Furthermore, the clinical comparison between the two procedures is shown in [Table 5].
Table 5: The clinical comparison between combined CXL with femtosecond laser myoring implantation and combined CXL with femtosecond laser keraring implantation

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  Discussion Top


A total of 46 eyes of 30 patients (18 male and 12 female) were included in the study. The male-to-female ratio was 3 : 2. The mean age was 18.45 ± 6.70 years.

In all study eyes, the preoperative and postoperative mean UCVA and BCVA increased two lines or more. In group A, the mean postoperative myopic correction was 8.24 D, whereas the mean postoperative astigmatic correction was 1.51 D. This highlights the great success of the combined CXL with myoring implantation in effectively reducing the myopic component of keratoconus with limited effect on the astigmatic component of keratoconus. The myoring succeeded in flattening all meridians of the cornea nearly symmetrically, which explains its high success in correcting the myopic component of keratoconus to a greater extent compared with the astigmatic components.

Meanwhile, in group B the mean postoperative myopic correction was 1.45 D, whereas the mean postoperative astigmatic correction was 3.07 D. This highlights the great success of the combined CXL with keraring implantation in effectively reducing the astigmatic component of keratoconus with limited effect on the myopic component of keratoconus. This study showed that keraring succeeded in mainly flattening the steeper corneal meridians with little influence on the flatter corneal meridians, which explains why keraring mainly corrects the astigmatic component.

What was remarkable in this study is that there were no signs of postoperative deterioration of any case included in this study. This can be explained on the bases that CXL is the only surgical procedure that can halt the progression of keratoconus. Furthermore, the significant postoperative visual improvement belongs to the mechanical action of the implanted rings.

Daxer [6] reported that there was no significant difference in the results between myoring treatment of central and noncentral cones. In contrast, this study revealed that myoring was best in cases with central or nipple cones.

Furthermore, Daxer [6] showed that, in the central cone, the corrective power of myoring acts mainly concentric around the optical axis with a central flattening effect of 10 D. There were nearly similar results between this study and the study by Daxer, who revealed that myoring reduced the myopic component of keratoconus up to 10.50 D when used to correct the central cone.

In their study, Daxer et al. [2] put forth the question as to whether keratoplasty can be replaced by intracorneal implants in combination with corneal CXL19 in the future treatment of keratoconus. Such a replacement may significantly reduce the rate of complications, as well as the period of discomfort and recovery time for the patient. The corneal intrastromal implantation system provides a new option for keratoconus management. The technique appears to be safe and effective in decreasing myopia, corneal steepness, and decentration of the corneal apex and is also potentially reversible. In addition, Corneal Intrastromal Implantation System can be combined with CXL [2].

Similar results were reported by Jabbarvand et al. [7], who showed that myoring ICR implantation in keratoconus appears to be an acceptable substitute for keratoplasty in advanced keratoconus. Both studies used femtosecond laser for creation of the intrastromal corneal pocket for myoring implantation. Furthermore, Daxer et al. [8] reported that the treatment of keratoconus with myoring intracorneal continuous ring implantation significantly improved visual function.

This study proved that combined CXL with keraring implantation had the best results in cases with oblique or oval cones. In addition, this procedure succeeded in reducing the astigmatic component of keratoconus 4 D or more. Furthermore, this study showed that most of the improvements in keratometry results were in the steep corneal meridians (K 2 or Kmax ) with little influence on the flat corneal meridians.

In agreement with the results of this study, Gharaibeh et al. [9] reported that keraring implantation provided significant improvement in visual acuity, spherical equivalent, and keratometry results. It is an effective treatment for managing keratoconus and might delay or even avoid the need for penetrating keratoplasty.

In this study, advanced femtosecond laser (iFS; Abbott) was used with no recorded intraoperative complications. Similar results were reported by Coimbra et al. [10]., who showed that intrastromal corneal ring implantation with the use of a femtosecond laser was a safe procedure, with low risk of complications and significant improvement in visual acuity and topographic data in this setting of patients with secondary corneal ectasia.

This study showed similar results compared with the study by Hosny et al. [11]., who reported that both complete ring and ring segment implantation are effective for improving corneal and visual parameters in keratoconus and that complete ring implantation may have a greater flattening effect on the anterior corneal surface [11].

Furthermore, they reported that implantation of myorings and kerarings by means of femtosecond technology in cases of keratoconus significantly reduced the myopic spherical error due to central corneal flattening. The Corneal Intrastromal Implantation System provides a new option for keratoconus management. The technique appears to be effective for decreasing myopia, corneal steepness, and decentration of the corneal apex, and it is also potentially reversible. In addition, corneal intrastromal rings can be combined with corneal cross linking. Complete ring implantation may have a more flattening effect on the anterior corneal surface [11].

This study proved that there is a synergistic action when CXL is combined with intracorneal rings (myoring or keraring). This can be attributed to the fact that both procedures have different types of actions on the keratoconic cornea. At a time when CXL succeeded in halting the progression of the keratoconus and in flattening the cornea, the ICRS succeeded in adding more corneal flattening, thus giving the augmented synergistic action by reducing both myopic and astigmatic components of the keratoconus.

Similar results were reported by El-Raggal [12], who stated that combined keraring insertion and CXL can be performed safely in one or two sessions. However, the same-session procedure appears to be more effective in terms of the improvement in the corneal shape [12]. Furthermore, in another study El-Raggal [13] reported that femtosecond laser channel creation can be performed after CXL; however, the laser power must be modified. Results show that channel dissection and ICRS implantation should be performed before or concurrent with CXL [13].


  Conclusion Top


This study proved that combined CXL with myoring implantation is effective in the correction of the myopic component of keratoconus. Combined CXL with keraring implantation is effective in the correction of the astigmatic component in keratoconus. The type and the site of keratoconus cone together with the K readings can help in the preoperative decision as to which type of ring is best in each keratoconus case. This study proved that there is a synergistic action when CXL is combined with intracorneal rings (myoring or keraring).


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Spoerl E, Hafezi F, Bradley J. Corneal collages cross-linking. SLACK Incorporated 2013; 20 :139-142.  Back to cited text no. 1
    
2.
Daxer A, H Mahmood, RS Venkateswaran. Implantation of a complete corneal ring in an intrastromal pocket for keratoconus. J Refract Surg 2011; 27 :63-68.  Back to cited text no. 2
    
3.
DIOPTEX, CISIS, POCKETMAKER and MYORING. Available at: http://www.dioptex.com/products/myoring-corneal-implant. [Accessed 15 April 2014].  Back to cited text no. 3
    
4.
MEDIPHACOS Ophthalmic Professionals. Available at: http://www.mediphacos.com/en/produtos/cornea/implante-intracorneano-keraring. [Accessed 9 April 2014].  Back to cited text no. 4
    
5.
Coskunseven E, Kymionis GD, Tsiklis NS, Atun S, Arslan E, Jankov MR, Pallikaris IG. One-year results of intrastromal corneal ring segment implantation (KeraRing) using femtosecond laser in patients with keratoconus. Am J Ophthalmol 2008; 145 :775-779.  Back to cited text no. 5
    
6.
Daxer A. Myoring for central and noncentral keratoconus. Int J Keratoconus Ectatic Corneal Dis 2012; 2 :117-119.  Back to cited text no. 6
    
7.
Jabbarvand M, Salamatrad A, Hashemian H, Mazloumi M, Khodaparast M. Continuous intracorneal ring implantation for keratoconus using a femtosecond laser. J Cataract Refract Surg 2013; 39 :1081-1087.  Back to cited text no. 7
    
8.
Daxer A, Mahmoud H, Venkateswaran RS. Intracorneal continuous ring implantation for keratoconus: one-year follow-up. J Cataract Refract Surg 2010; 36 :1296-1302.  Back to cited text no. 8
    
9.
Gharaibeh AM, Muhsen SM, AbuKhader IB, Ababneh OH, Abu-Ameerh MA, Albdour MD. KeraRing intrastromal corneal ring segments for correction of keratoconus. Cornea 2012; 31 :115-120.  Back to cited text no. 9
    
10.
Coimbra CC, Gomes MT, Campos M, FigueiroaJr ES, Barbosa EP, Santos MS. Femtosecond assisted intrastromal corneal ring (ISCR) implantation for the treatment of corneal ectasia. Arq Bras Oftalmol 2012; 75 :126-130.  Back to cited text no. 10
    
11.
Hosny M, El-Mayah E, Sidky MK, Anis M. Femtosecond laser-assisted implantation of complete versus incomplete rings for keratoconus treatment. Clin Ophthalmol 2015; 9 :121-127.   Back to cited text no. 11
    
12.
El-Raggal TM. Sequential versus concurrent KERARINGS insertion and corneal collagen cross-linking for keratoconus. Br J Ophthalmol 2011; 95 :37-41.  Back to cited text no. 12
    
13.
El-Raggal M. Effect of corneal collagen crosslinking on femtosecond laser channel creation for intrastromal corneal ring segment implantation in keratoconus. J Refract Surg. DOI:dx.doi.org/10.1016/j.jcrs.2010.10.048  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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