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Diabetic Retinopathy Standard Of Care

Retinal Physician - Landmark Laser Trials Continue To Govern Standard Of Care In Diabetic Retinopathy

Retinal Physician - Landmark Laser Trials Continue To Govern Standard Of Care In Diabetic Retinopathy

Landmark Laser Trials Continue to Govern Standard of Care in Diabetic Retinopathy Landmark Laser Trials Continue to Govern Standard of Care in Diabetic Retinopathy Vision loss is one of the many devastating complications of diabetes. People with diabetes are 25 times more likely to go blind than the average person, and each year ~25,000 new cases of diabetes-related blindness occur in the United States. These cases may involve vision loss caused by cataracts, glaucoma, opticneuropathy/papillopathy, or diabetic retinopathy, and most are preventable. Diabetic retinopathy is the most serious eye condition associated with diabetes. It can be particularly severe in persons who have insulin-dependent diabetes mellitus and also occurs frequently with chronicnoninsulin-dependent diabetes mellitus. About 25% of persons with diabetes have at least some form of diabetic retinopathy, and the incidence increases with the duration of diabetes. At 10 years, the prevalence of retinopathy in patients with diabetes is 7%; after 25 years, it is >90%. Diabetic retinopathy can also accelerate during puberty and pregnancy. Figure 1. Cumulative event rates of visual acuity less than 5/200 at 2 or more visits for patients in each treatment group. Reprinted with permission.3 Diabetes causes microvascular abnormalities that lead to retinal vascular pericyte loss and endothelial damage, which cause microvascular occlusion and alterations in retinal vascular permeability. The result is often ischemia and retinal edema. The 2 types of diabetic retinopathy, nonproliferative andproliferative, encompass the spectrum of diabetes-related disease that affects the retina. Nonproliferative retinopathy, also known as background diabetic retinopathy, involves microvascular abnormalities that are apparent du Continue reading >>

Treatment Of Diabetic Retinopathy: Recent Advances And Unresolved Challenges

Treatment Of Diabetic Retinopathy: Recent Advances And Unresolved Challenges

Go to: Diabetic retinopathy (DR) is the leading cause of blindness in industrialized countries. Remarkable advances in the diagnosis and treatment of DR have been made during the past 30 years, but several important management questions and treatment deficiencies remain unanswered. The global diabetes epidemic threatens to overwhelm resources and increase the incidence of blindness, necessitating the development of innovative programs to diagnose and treat patients. The introduction and rapid adoption of intravitreal pharmacologic agents, particularly drugs that block the actions of vascular endothelial growth factor (VEGF) and corticosteroids, have changed the goal of DR treatment from stabilization of vision to improvement. Anti-VEGF injections improve visual acuity in patients with diabetic macular edema (DME) from 8-12 letters and improvements with corticosteroids are only slightly less. Unfortunately, a third of patients have an incomplete response to anti-VEGF therapy, but the best second-line therapy remains unknown. Current first-line therapy requires monthly visits and injections; longer acting therapies are needed to free up healthcare resources and improve patient compliance. VEGF suppression may be as effective as panretinal photocoagulation (PRP) for proliferative diabetic retinopathy, but more studies are needed before PRP is abandoned. For over 30 years laser was the mainstay for the treatment of DME, but recent studies question its role in the pharmacologic era. Aggressive treatment improves vision in most patients, but many still do not achieve reading and driving vision. New drugs are needed to add to gains achieved with available therapies. Keywords: Aflibercept, Bevacizumab, Dexamethasone delivery system, Diabetic macular edema, Ranibizumab, Macular Continue reading >>

Diabetic Retinopathytreatment & Management

Diabetic Retinopathytreatment & Management

Diabetic RetinopathyTreatment & Management Author: Abdhish R Bhavsar, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP more... Controlling diabetes and maintaining the HbA1c level in the 6-7% range are the goals in the optimal management of diabetes and diabetic retinopathy. If the levels are maintained, then the progression of diabetic retinopathy is reduced substantially, according to The Diabetes Control and Complications Trial. [ 11 ] The Early Treatment for Diabetic Retinopathy Study [ 21 ] has found that laser surgery for macular edema reduces the incidence of moderate visual loss (doubling of visual angle or roughly a 2-line visual loss) from 30% to 15% over a 3-year period. Two-year results from the Diabetic Retinopathy Clinical Research network (DRCR.net) Randomized Trial Evaluating Ranibizumab Plus Prompt or Deferred Laser or Triamcinolone Plus Prompt Laser for Diabetic Macular Edema, known as the Laser-Ranibizumab-Triamcinolone for DME Study,demonstrated that ranibizumab paired with prompt or deferred focal/grid laser treatment achieved superior visual acuity and optical coherence tomography (OCT) outcomes compared with focal/grid laser treatment alone. In the ranibizumab groups, approximately 50% of eyes had substantial improvement (10 or more letters) and 30% gained 15 or more letters. Intravitreal triamcinolone combined with focal/grid laser did not result in superior visual acuity outcomes compared with laser alone, but did appear to have a visual acuity benefit similar to ranibizumab in pseudophakic eyes. [ 26 ] The Diabetic Retinopathy Study has found that adequate scatter laser panretinal photocoagulation reduces the risk of severe visual loss (< 5/200) by more than 50%. [ 22 ] The Diabetes Control and Complications Trial has found that intensive gluc Continue reading >>

A Review Of Ranibizumab For The Treatment Of Diabetic Retinopathy

A Review Of Ranibizumab For The Treatment Of Diabetic Retinopathy

A Review of Ranibizumab for the Treatment of Diabetic Retinopathy Laser photocoagulation has been the standard treatment for diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) for several decades. The discovery of vascular endothelial growth factor (VEGF) and the subsequent determination of its critical role in the development DME and PDR has led to the development of VEGF inhibitory drugs. Ranibizumab was the first anti-VEGF drug approved for the treatment of both DME and diabetic retinopathy in eyes with DME. Medline searches with the keywords "ranibizumab," "diabetic macular edema," and "proliferative diabetic retinopathy" were performed to identify pertinent pre-clinical studies and clinical trials. Top-line data, with emphasis on pivotal trials, was identified and incorporated into this manuscript. Findings from small uncontrolled trials were generally not used unless they filled important gaps in our understanding of anti-VEGF therapy. Ranibizumab is a recombinant humanized antibody fragment that binds all isoforms of VEGF-A with high affinity. Three parallel lines of clinical research have produced level I evidence supporting the superiority of ranibizumab over laser photocoagulation for the treatment of DME. Regular injections also lead to improvement in diabetic retinopathy severity scores in a large minority of eyes. Ranibizumab is effective for PDR and produces less visual field loss than laser photocoagulation. It has an excellent safety profile, with low incidence of ocular and systemic adverse events. Ranibizumab has become a frequently used first-line therapy for the treatment of DME. Emerging data suggest that it may become an important treatment for DR and PDR. Anti-VEGFDiabetic macular edemaDiabetic retinopathyProliferative diab Continue reading >>

Patients Perspectives On Noncompliance With Diabetic Retinopathy Standard Of Care Guidelines - Sciencedirect

Patients Perspectives On Noncompliance With Diabetic Retinopathy Standard Of Care Guidelines - Sciencedirect

Volume 75, Issue 11 , November 2004, Pages 709-716 Get rights and content Periodic dilated eye examinations are recommended by the American Optometric Association, American Academy of Ophthalmology, and American Diabetes Association to detect sight-threatening conditions in diabetic patients. However, many patients with diabetes do not receive this recommended eye care and there is limited research to explain why. The objective of this study was to determine reasons some diabetic patients do not receive a dilated eye examination at least every year. A chart review identified patients at The Ohio State University College of Optometry who had not been examined for more than a year, but less than two years. A telephone interview was attempted for all subjects. Of 100 eligible subjects, 43 completed the telephone interview. The reasons patients with diabetes did not return for a recommended dilated eye examination included transfer of care to another eye doctor, limited personal mobility due to poor overall health, last examination at a homeless clinic, self-reported lack of insurance, and self-reported apathy. Strategies to improve compliance of patients with diabetes should include reaching patients of low socioeconomic status and those institutionalized for poor overall health. Improved compliance may also come by encouraging patients to use medical insurance for eye examinations and using patient recall systems. Continue reading >>

Diabetic Retinopathy

Diabetic Retinopathy

NATURAL HISTORY OF DIABETIC RETINOPATHY Diabetic retinopathy progresses from mild nonproliferative abnormalities, characterized by increased vascular permeability, to moderate and severe nonproliferative diabetic retinopathy (NPDR), characterized by vascular closure, to proliferative diabetic retinopathy (PDR), characterized by the growth of new blood vessels on the retina and posterior surface of the vitreous. Macular edema, characterized by retinal thickening from leaky blood vessels, can develop at all stages of retinopathy. Pregnancy, puberty, blood glucose control, hypertension, and cataract surgery can accelerate these changes. Vision-threatening retinopathy is rare in type 1 diabetic patients in the first 3–5 years of diabetes or before puberty. During the next two decades, nearly all type 1 diabetic patients develop retinopathy. Up to 21% of patients with type 2 diabetes have retinopathy at the time of first diagnosis of diabetes, and most develop some degree of retinopathy over time. Vision loss due to diabetic retinopathy results from several mechanisms. Central vision may be impaired by macular edema or capillary nonperfusion. New blood vessels of PDR and contraction of the accompanying fibrous tissue can distort the retina and lead to tractional retinal detachment, producing severe and often irreversible vision loss. In addition, the new blood vessels may bleed, adding the further complication of preretinal or vitreous hemorrhage. Finally, neovascular glaucoma associated with PDR can be a cause of visual loss. RISK FACTORS AND TREATMENTS Duration of disease The duration of diabetes is probably the strongest predictor for development and progression of retinopathy. Among younger-onset patients with diabetes in the WESDR, the prevalence of any retinopathy wa Continue reading >>

Diabetic Retinopathy And Diabetic Eye Problems

Diabetic Retinopathy And Diabetic Eye Problems

Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Pre-diabetes (Impaired Glucose Tolerance) article more useful, or one of our other health articles. Diabetic retinopathy (DR) is a chronic progressive, potentially sight-threatening disease of the retinal microvasculature, associated with the prolonged hyperglycaemia of diabetes mellitus and with other diabetes mellitus-linked conditions, such as hypertension. Diabetes mellitus can cause a variety of eye problems, the most common being DR, which is the most common cause of severe sight impairment among people of working age in England, Wales and Scotland.[1] Other conditions associated with diabetes and the eye include: Cataracts. Rubeosis iridis and glaucoma. Ocular motor nerve palsies. Diabetic retinopathy The exact mechanism by which diabetes leads to DR is not fully understood. Microvascular occlusion causes retinal ischaemia leading to arteriovenous shunts and neovascularisation. Leakage results in intraretinal haemorrhages and localised or diffuse oedema. These processes result in the characteristic features seen at various stages of DR: Microaneurysms - physical weakening of the capillary walls which predisposes them to leakages. Hard exudates - precipitates of lipoproteins/other proteins leaking from retinal blood vessels. Haemorrhages - rupture of weakened capillaries, appearing as small dots/larger blots or 'flame' haemorrhages that track along nerve-fibre bundles in superficial retinal layers (the haemorrhage arises from larger and more superficial arterioles). Cotton wool spots - build-up of axonal debris due to poor axonal metabolism at the margins of ischaemic infarcts. Continue reading >>

Diabetic Retinopathy: Current And New Treatment Options

Diabetic Retinopathy: Current And New Treatment Options

Diabetic Retinopathy: Current and New Treatment Options Author(s): Gian P. Giuliari . Av. Francisco de Miranda, Torre Cavendes, Piso 6, Ofic. 6-04, Altamira, Caracas, Venezuela. Diabetes mellitus has become a major health concern worldwide and its incidence is projected to increase. Diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) are considered the most sight-threatening ocular complications in these patients. Pivotal studies, such as the Early Treatment Diabetic Retinopathy Study (ETDRS) and the Diabetic Retinopathy Study (DRS), have established macular and pan-retinal laser as the gold-standard of treatment for these complications. The recent discovery of the vascular endothelial growth factor (VEGF) and its role in the development of proliferative disease, has led to a movement towards treating PDR and DME with anti-angiogenic medications alone or in conjunction with the gold-standard of care. Due to the severity of the diabetic ocular complications and the rising incidence of diabetes worldwide, it is important for the non-ophthalmologist care provider to be informed of the new treatments available for these conditions in an effort to better guide their patients. In this review, I will discuss the importance of these new methods of treatment as well as the significance of systemic glucose control, vitreous surgery and laser photocoagulation. Keywords: Diabetic retinopathy, diabetic ocular complications, diabetic eye, proliferative diabetic retinopathy, diabetic macular edema, retinal photocoagulation, angiogenesis, neovascularization, ranibizumab, bevacizuamb, pegaptanib, VEGF inhibitors Title: Diabetic Retinopathy: Current and New Treatment Options Affiliation:Av. Francisco de Miranda, Torre Cavendes, Piso 6, Ofic. 6-04, Altamira, Caracas Continue reading >>

Diabetic Retinopathy Screening Standards

Diabetic Retinopathy Screening Standards

Diabetic retinopathy is a common complication of diabetes whichaffects the eyes. It occurs when the small blood vessels in theretina, which is at the back of the eye, become blocked or leak.Untreated diabetic retinopathy is one of the most common causes ofsight loss in Scotland, and the fifth-leading cause of globalblindness. In its early stages, there are no symptoms so people withdiabetes may not realise they have diabetic retinopathy. Screeningis important because if the condition is caught early, treatment iseffective at reducing or preventing visual impairment and sightloss. We have developed standards to supportstaffandensurethe highest standards in diabetic retinopathy screening areachieved. Each standard also details what people, patients andtheir representatives, and the public can expect of these servicesin Scotland. Diabetic Retinopathy Screening Standards - Consultation report: June 2016 (PDF, 764K) This document specifies a minimum set of performance standardsfor diabetic retinopathy screening and can be usedtoreinforcenational consistencyanddriveimprovementindiabetic retinopathyservicesacross Scotland. The 2016 Healthcare Improvement Scotland diabetic retinopathyscreening standards cover the following areas: Continue reading >>

Diagnosis

Diagnosis

Print Diabetic retinopathy is best diagnosed with a dilated eye exam. For this exam, drops placed in your eyes widen (dilate) your pupils to allow your doctor to better view inside your eyes. The drops may cause your close vision to blur until they wear off, several hours later. During the exam, your eye doctor will look for: Abnormal blood vessels Swelling, blood or fatty deposits in the retina Growth of new blood vessels and scar tissue Bleeding in the clear, jelly-like substance that fills the center of the eye (vitreous) Retinal detachment Abnormalities in your optic nerve In addition, your eye doctor may: Test your vision Measure your eye pressure to test for glaucoma Look for evidence of cataracts Fluorescein angiography With your eyes dilated, your doctor takes pictures of the inside of your eyes. Then your doctor will inject a special dye into your arm and take more pictures as the dye circulates through your eyes. Your doctor can use the images to pinpoint blood vessels that are closed, broken down or leaking fluid. Optical coherence tomography Your eye doctor may request an optical coherence tomography (OCT) exam. This imaging test provides cross-sectional images of the retina that show the thickness of the retina, which will help determine whether fluid has leaked into retinal tissue. Later, OCT exams can be used to monitor how treatment is working. Treatment Treatment, which depends largely on the type of diabetic retinopathy you have and how severe it is, is geared to slowing or stopping progression of the condition. Early diabetic retinopathy If you have mild or moderate nonproliferative diabetic retinopathy, you may not need treatment right away. However, your eye doctor will closely monitor your eyes to determine when you might need treatment. Work with Continue reading >>

Diabetic Retinopathy Treatment

Diabetic Retinopathy Treatment

Your treatment is based on what your ophthalmologist sees in your eyes. Treatment options may include: Medical control Controlling your blood sugar and blood pressure can stop vision loss. Carefully follow the diet your nutritionist has recommended. Take the medicine your diabetes doctor prescribed for you. Sometimes, good sugar control can even bring some of your vision back. Controlling your blood pressure keeps your eye’s blood vessels healthy. Medicine One type of medication is called “anti-VEGF” medication. This helps to reduce swelling of the macula, slowing vision loss and perhaps improving vision. This drug is given by injections (shots) in the eye. Steroid medicine is another option to reduce macular swelling. This is also given as injections in the eye. Your doctor will recommend how many medication injections you will need over time. Laser surgery Laser surgery might be used to help seal off leaking blood vessels. This can reduce swelling of the retina. Laser surgery can also help shrink blood vessels and prevent them from growing again. Sometimes more than one treatment is needed. Vitrectomy If you have advanced PDR, your ophthalmologist may recommend surgery called vitrectomy. Your ophthalmologist removes vitreous gel and blood from leaking vessels in the back of your eye. This allows light rays to focus properly on the retina again. Scar tissue also might be removed from the retina. Preventing vision loss from diabetic retinopathy If you have diabetes, talk with your primary care doctor about controlling your blood sugar. High blood sugar damages retinal blood vessels. That causes vision loss. Do you have high blood pressure or kidney problems? Ask your doctor about ways to manage and treat these problems. See your ophthalmologist regularly for dilat Continue reading >>

Diabetic Retinopathy

Diabetic Retinopathy

Diabetic retinopathy, also known as diabetic eye disease, is a medical condition in which damage occurs to the retina due to diabetes and is a leading cause of blindness.[1] It affects up to 80 percent of people who have had diabetes for 20 years or more.[2] At least 90% of new cases could be reduced if there were proper treatment and monitoring of the eyes.[3] The longer a person has diabetes, the higher his or her chances of developing diabetic retinopathy.[4] Each year in the United States, diabetic retinopathy accounts for 12% of all new cases of blindness. It is also the leading cause of blindness for people aged 20 to 64 years.[5] Signs and symptoms[edit] Normal vision The same view with diabetic retinopathy. Emptied retinal venules due to arterial branch occlusion in diabetic retinopathy (fluorescein angiography) Diabetic retinopathy often has no early warning signs. Even macular edema, which can cause rapid vision loss, may not have any warning signs for some time. In general, however, a person with macular edema is likely to have blurred vision, making it hard to do things like read or drive. In some cases, the vision will get better or worse during the day. In the first stage which is called non-proliferative diabetic retinopathy (NPDR) there are no symptoms, the signs are not visible to the eye and patients will have 20/20 vision. The only way to detect NPDR is by fundus photography, in which microaneurysms (microscopic blood-filled bulges in the artery walls) can be seen. If there is reduced vision, fluorescein angiography can be done to see the back of the eye. Narrowing or blocked retinal blood vessels can be seen clearly and this is called retinal ischemia (lack of blood flow). Macular edema in which blood vessels leak their contents into the macular regi Continue reading >>

Comparison Of Dilated Clinical Fundus Exam Using The International Clinical Diabetic Retinopathy Severity (icdrs) Scale With Standard Stereoscopic Seven-field Photography Using The Early Treatment Diabetic Retinopathy Study (etdrs) Scale | Iovs | Arvo Journals

Comparison Of Dilated Clinical Fundus Exam Using The International Clinical Diabetic Retinopathy Severity (icdrs) Scale With Standard Stereoscopic Seven-field Photography Using The Early Treatment Diabetic Retinopathy Study (etdrs) Scale | Iovs | Arvo Journals

ARVO Annual Meeting Abstract| May 2007 Comparison of Dilated Clinical Fundus Exam Using the International Clinical Diabetic Retinopathy Severity (ICDRS) Scale With Standard Stereoscopic Seven-Field Photography Using the Early Treatment Diabetic Retinopathy Study (ETDRS) Scale DECR, National Eye Institute, Bethesda, Maryland Greater Baltimore Medical Center, Baltimore, Maryland DECR, National Eye Institute, Bethesda, Maryland DECR, National Eye Institute, Bethesda, Maryland DECR, National Eye Institute, Bethesda, Maryland Commercial Relationships W.T. Wong, None; C.P. Wilkinson, None; E. Agron, None; K. Glander, None; M. Davis, None; S. Adler, None; R. Rasooly, None; R. Danis, None; E.Y. Chew, None. Investigative Ophthalmology & Visual Science May 2007, Vol.48, 1401. doi: Comparison of Dilated Clinical Fundus Exam Using the International Clinical Diabetic Retinopathy Severity (ICDRS) Scale With Standard Stereoscopic Seven-Field Photography Using the Early Treatment Diabetic Retinopathy Study (ETDRS) Scale You will receive an email whenever this article is corrected, updated, or cited in the literature. You can manage this and all other alerts in My Account W. T. Wong, C. P. Wilkinson, E. Agron, K. Glander, M. Davis, S. Adler, R. Rasooly, R. Danis, E. Y. Chew, FIND Study Group; Comparison of Dilated Clinical Fundus Exam Using the International Clinical Diabetic Retinopathy Severity (ICDRS) Scale With Standard Stereoscopic Seven-Field Photography Using the Early Treatment Diabetic Retinopathy Study (ETDRS) Scale. Invest. Ophthalmol. Vis. Sci. 2007;48(13):1401. ARVO (1962-2015); The Authors (2016-present) Purpose:: To correlate the simplified International Clinical Diabetic Retinopathy Severity (ICDRS) Scale for diabetic retinopathy (DR), to the "gold standard" of stereosc Continue reading >>

Screening For Diabetic Retinopathy - 2014

Screening For Diabetic Retinopathy - 2014

Summary The American Academy of Ophthalmology recognizes that screening for diabetic retinopathy using validated digital imaging can be a sensitive and effective detection method. Such technology has not been demonstrated to be as effective, however, at detecting and quantifying the spectrum of other ophthalmic pathology that can accompany diabetic retinopathy, including cataract and glaucoma, which are more prevalent in patients with diabetes mellitus. Imaging technology also does not mitigate the need for periodic comprehensive ophthalmic examinations. Background The Preferred Practice Pattern on Diabetic Retinopathy states1: Diabetic retinopathy is a leading cause of visual impairment in working-age adults. While defects in neurosensory function have been demonstrated in patients with diabetes mellitus prior to the onset of vascular lesions, the most common early clinically visible manifestations of diabetic retinopathy would include microaneurysm formation and intraretinal hemorrhages. Microvascular damage leads to retinal capillary nonperfusion, cotton wool spots, increased numbers of hemorrhages, venous abnormalities, and intraretinal microvascular abnormalities (IRMA). During this stage, increased vasopermeability can result in retinal thickening (edema) and/or exudates that may lead to a loss in central visual acuity. The proliferative stage results from closure of arterioles and venules with secondary proliferation of new vessels on the disc, retina, iris, and in the filtration angle. These new vessels then lead to traction retinal detachments and neovascular glaucoma respectively. Vision can be lost in this stage from capillary nonperfusion or edema in the macula, vitreous hemorrhage, and distortion or traction retinal detachment. Diabetic retinopathy can occu Continue reading >>

2017 Ada Position Statement On Diabetic Retinopathy

2017 Ada Position Statement On Diabetic Retinopathy

Home / Specialties / Ophthalmology / 2017 ADA Position Statement on Diabetic Retinopathy 2017 ADA Position Statement on Diabetic Retinopathy This represents the first such update by the American Diabetes Association since 2002, and is notable for inclusion of the latest evidence and recommendations with respect to appropriate eye examination intervals, referral criteria, prevention of incidence and progression of diabetic retinopathy (DR), and treatment strategies with respect to preventing vision loss from vision-threatening diabetes-related retinal disease proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME). Diabetes remains the leading cause of severe vision loss and blindness in Americans of working age, and though improved metabolic control of diabetes and advances in therapy have significantly diminished the probability of poor vision outcomes for individual patients, the increased prevalence of diabetes (despite plateauing incidence) combined with improved longevity of patients serve to sustain the impact of DR on a population level. [1] With respect to prevention of DR and vision loss, the Statement continues to emphasize the importance of good diabetes control (blood glucose, blood pressure and lipids), including the benefits of good, early glycemic control (protective metabolic memory) even in patients with T2DM (based on findings from ACCORD-Eye). It also emphasizes the emerging benefit of fenofibrate therapy to prevent progression of mild to moderate non-proliferative diabetic retinopathy (NPDR) in patients with T2DM (based on findings from two RCTs, FIELD and ACCORD-Eye). In fact, fenofibrate is approved as first-line therapy for adults with T2DM and NPDR in Australia; the number needed to treat to prevent one patient from requiring l Continue reading >>

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