Foggy vision post SMILE

Hi VSRN,

I would just like to post my experience so far post ReLex SMILE. I had this procedure performed 9 days ago. I had moderate myopia, with corrected visual acuity of approximately 6/3 both eyes. Following surgery I have taken my eye drops religiously. Day 1 post-op I had 6/5 vision in right eye, and 6/6 vision in left eye. There was a lot of foggy vision. Since then, my visual acuity has decreased, and fogginess persists, but has improved slightly. I have daily headaches from straining my eyes trying to read things. I saw my optometrist for a review, and I was told that I have -0.05 of astigmatism in my left eye. No need for refractive correction. My vision was blurry partly because of the astigmatism, and partly because of spottiness of the cornea. I was shown a photo of what my corneas looked like. They were not completely clear but had little spots, which I was told was just the healing process, but honestly I have no idea what they are. I also have some oedema (swelling) of the left cornea. I have been trying to hydrate my eyes as much as possible to help with the healing process.

I am posting this because I am worried that the fogginess won't go away, as this is the main reason that I can't read things. I am not sure why fogginess occurs at all. It is quite disabling not being able to read easily. One reason I struggle is because my left eye will be blurry, then it will clear up and my right eye will be blurry, and the pattern continues. I'm sure that confuses my brain and makes my eyes strain more. Any comments will be welcomed, and I will continue to post my progress.
Original Post
Update.

Day 10 post SMILE. Vision is a little less foggy (5/10 subjectively compared to 6/10 yesterday). It's hard to drive in daylight without sunglasses as it's so bright that my eyes start to ache. I expect that will improve.
I have found that vision becomes quite blurry unless I am in a very bright setting indoors or in natural light.
It is hard to focus on anything. I can look at an object and initially it is blurry. After 5 seconds or so it will clear up a little, and then become blurry again. I suspect that is due to my eye focusing muscles (ciliary muscles) not having had to do much work for so many years because of my spectacles and suddenly they have to deal with blurry objects close up and in the distance (my best uncorrected vision now is probably 6/6 compared to 6/3 previously, so my eyes are trying to get that clarity again but can't). I hydrated my eyes excessively yesterday to determine whether dryness was contributing to the frequent blurriness, but it made no difference. At nighttime, when my ciliary muscles are tired and there is low light, blurriness is at its worst.

Thanks.
Day 13 post SMILE.

I saw my surgeon who performed an eye check. My left corneal oedema is improving. I have read that it can take a month or so to disappear. Vision is worse in the left eye, and I am hoping that is due to corneal oedema only. 6/6 in both eyes with great difficulty due to every letter on the Snellen chart from top to bottom being blurry. It's therefore just barely 6/6, but probably an improvement. Blurriness is worse at night. Fogginess is improving slightly. Fewer headaches when trying to focus now. I went to work, which involves reading a computer screen at times, and this was difficult and I developed a sore neck trying to lean forward to read the screen.
In conclusion, slight improvements are occurring, but vision is still far off where I want to be.
Day 17 post SMILE.

My blurred vision became very bad a few days ago. In low light conditions, my vision was very poor. I had very large haloes around lights. I was travelling, so I made an appointment to see a different practice that does Relex SMILE, and I had a comprehensive assessment. The outcome was firstly that I had very dry eyes, with dry spots all over my cornea. It took a lot of consecutive eye drops before the cornea was hydrated enough to be assessed. It was difficult to determine the cause of the blurred vision, but it could have been dry eyes, steroid-induced glaucoma, or something else. Two weeks of dexamethasone was what I had been prescribed, and that can be enough to cause glaucoma in sensitive individuals. My eye pressure assessment revealed a normal eye pressure, but after corneal surgery the results are unreliable and always underestimate the true pressure. I was told that since dexamethasone was due to cease that day, that any blurred vision from dexamethasone will subside. My left eye had +1.00 power, the right eye had +0.50 power, and I had -0.50 of astigmatism in the left eye. I am not sure how reliable that assessment really is in the presence of blurred vision from another cause. The surgeon I spoke to said that most people after two weeks have very clear vision with basically no residual power, so the fact that I had blurred vision plus overcorrection made me feel disheartened. I hydrated my eyes aggressively over the next three days, stopped the dexamethasone as planned, and my vision is less blurry. I was prescribed Genteal eye gel three times per day, and I started using Dura Tears at night time, on top of the ordinary eye drops that I had been using which don't really hydrate much.

My plan is to continue aggressive hydration, and have another assessment of my refractive power in a few weeks' time.
Day 19 post SMILE.

After being 5 days off of dexamethasone, and after 5 days of aggressive eye lubrication, I had a follow up optometry assessment. My vision is a lot clearer, and I have the following prescription:
Left eye: +0.50 sphere, -0.50 cylinder, 0 axis.
Right eye: 0.00 sphere, 0.00 cylinder, 0 axis.

My right eye has lost a line of visual acuity that couldn't be corrected with lenses, so hopefully this is just a manifestation of something like dry eye, and won't be permanent. It has been there from the beginning though, which makes me a little pessimistic.

Given that it has been almost three weeks post surgery, I am not expecting too much more in terms of refractive changes. Full refractive stabilisation will take 3 months, although from my reading it appears that there is usually not much change after the first week.

I have been having a lot of headaches and eye strain when doing my work, so I am fitting some spectacle lenses in temporarily with the above prescription to help reduce eye strain when I am in front of the computer. I may well be needing a different prescription in a few weeks' time. I am not used to the lack of clarity in my vision, and doing simple things like shopping require concentration because I have to concentrate a lot to see things.

In conclusion, I was overcorrected in my left eye and have some astigmatism, and now my eyes are no longer "balanced". I have had to deal with a lot of eye strain and I'm not going to fight it anymore, but wear spectacles for the time being when I need them (just for working). Hopefully my eyes will continue to improve, and any improvement from now on is a bonus.
6 weeks post Relex Smile. I saw my surgeon today.

* I currently have blurry vision in dim light, halos and starbursts when driving at night, and sensitivity to light. I still have headaches and excessive tiredness during the day from focusing.
The surgeon does not know why I have blurry vision in dim light, but he said that when the pupil dilates it creates "effective myopia". From reading these and other internet forums it seems like this is a common issue post SMILE (and Lasik) and perhaps it's due to ablation zone/pupil size mismatch or loss of contrast sensitivity. My dim light vision is improving a little with time.

* My dry spots on the cornea have disappeared. My surgeon thinks that maybe my light sensitivity is due to dry eye and suggested a temporary punctal occlusion, which I will hold off doing for now. In broad daylight I get pain and must wear sunglasses. I read that this can be due to ciliary body inflammation if bubbles track down to the ciliary body, and typically occurs a few weeks after surgery but I had light sensitivity from the beginning, so I doubt that is the issue.

* I get headaches and excessive tiredness from focusing. This has improved a little over the 6 weeks.

* My visual acuity is much better today than last time. My visual acuity today was 6/4.5 in both eyes (20/15). That was a surprise. The letters were blurry but legible.


I have two conclusions. Firstly, my vision is slowly improving, but I have a lot of symptoms still (headaches, light sensitivity, tiredness, and frustration). Secondly, we at VSRN need to accumulate more patient experiences with Relex SMILE because it's not clear what is normal and what is abnormal in terms of healing patterns and visual outcomes post Relex SMILE. What do people think? I'd love to read other people's thoughts.
I'm now almost 2 months post SMILE.

I have a new issue which is a small internal stye in the lower right eyelid. I've never had one before. My symptoms have been blurred vision in that eye, including double vision when looking at green lights (eg. green traffic lights), pain on blinking, and watery eyes. The stye looks much better than it was initially and those symptoms have settled except for the blurred vision/double vision issue. My ophthalmologist said that it is due to astigmatism from the stye pressing on the eyeball as well as watery eyes. My concern is that the blurred/double vision hasn't improved while everything else has (it's day 6 since stye onset). I can't imaging that such as small stye could be pressing that much on my eyeball. Can anyone comment on how long restoration of normal vision takes with a stye? I had tremendous headaches from eye strain all day today, so it may be that the blurred vision is actually getting worse.
An internal hordeolum can, in fact, press on the corneal surface and distort it, creating astigmatism. However, in my experience, lower lids will not do this. An actual stye along the edge of the lower lid could disrupt the tear film and disturb vision. Tear film disturbances could linger following an internal hordeolum, in spite of the major symptoms being abated. Watery eyes will certainly disturb your vision as well.

You should be refracted, regularly, at your follow-up visits to monitor the course of your recovery and especially now that you are noticing this development. There may be no glasses that will relieve the blur, but it's still important to assess any vision changes.

Are you using hot compresses?
Thanks Dr Hartzok.

I have noticed blink to blink variation in my visual clarity since SMILE. I'll blink and it's clear, then I'll blink and it's a little blurry. I'm not sure what I can do about this. I'll tell you a bit more about what is happening, and I hope that you can help me.

When the right lower eyelid stye started, I noticed blurry vision in that eye. I have been using warm compresses and it has reduced significantly in size. It now day 7. The double vision and blurry vision probably peaked yesterday actually. When I am driving what I see is that when there is a green light or green arrow, there is a another green light or arrow diagonally below it. I had to do computer work all day yesterday and I had debilitating headaches all day, despite pain relief including ibuprofen and codeine. This morning when I drove to work there was no double vision. After another day of computer work with headaches not quite as bad (but still terrible), I had the green light double vision again and overall the vision is a little blurry in my right eye. Surprisingly, I also had a mild amount of that double vision in my left eye too, eg. a small amount of green light appearing diagonally below the light but not quite double vision. My thoughts are that my ciliary muscles are fatigued from a day of focusing, and actually the left eye has a bit of induced astigmatism from trying to compensate for the right eye.

Logically though, could all of this be caused by a small stye? It's no longer producing watery eye, is no longer painful and is mostly healed.
I have made an appointment to see my optometrist in 5 days time so that the stye is completely healed by then. I could make it earlier of course.
My laser eye surgeon doesn't do refraction at his post-op visits.
I am planning to get a second ophthalmological opinion after my optometry review if the issue doesn't resolve itself quickly. If I have developed a problem that is correctable with lenses it's not so bad. If this is not the case then I' m a little stuck because I can't do my work effectively right now with these tremendous headaches.
Your ciliary muscles are not fatigued. What's fatigued are the extraocular muscles attempting to align and coordinate the two eyes while the image from the right eye does not match the image from the left eye. Dissimilarity (disparate images) causes a lot of eye discomfort. Refraction is critical to look for any imbalance and to reduce any disparity... but, or course, refractive surgery is all about NOT wearing glasses.
Thanks Dr Hartzok.

I went to my optometrist. I have some astigmatism in both eyes, with sphere of 0.00 in my left eye and -0.25 in my right eye. My optometrist demonstrated that when I focusing on a near object, my right eye is becoming a little "cross-eyed", and that's why I am having significant headaches. I have been prescribed lenses for my specs, just for use when doing near work, ie computer work, with a +0.75 extra in each eye.

My uncorrected distance vision is pretty good, so the decision was made to not prescribe lenses for distance vision at all, but just for reading where I'm going cross-eyed and getting severe headaches. I will pick up the frames in 2 days' time, and see the effect.

On another note, my optometrist thinks that the double vision in my right eye is due to my slight myopia.

Not that I'm blaming myself, but can excessive computer work after laser eye surgery increase the risk of myopia? You hear people say things like "I am avoiding screens as much as I can post SMILE/LASIK to avoid inducing myopia". Is that just a myth in an adult with stable vision? Actually, myopic regression in general in a person with stable refraction doesn't even seem logical to me. There would be certain behavioral changes I could modify, like the time I spend looking at my phone, if it were a preventive strategy.
quote:
Not that I'm blaming myself, but can excessive computer work after laser eye surgery increase the risk of myopia? You hear people say things like "I am avoiding screens as much as I can post SMILE/LASIK to avoid inducing myopia". Is that just a myth in an adult with stable vision? Actually, myopic regression in general in a person with stable refraction doesn't even seem logical to me. There would be certain behavioral changes I could modify, like the time I spend looking at my phone, if it were a preventive strategy.


I have been looking back over all your posts in this thread. You were initially about +1.00 in the left eye. Now you are plano, i.e., 0.00. Similarly, you shifted in the myopic direction in the right eye. Is that "myopic regression?" I know what the words mean but I think the idea that patients "regress" is a matter of not understanding what is going on. In many cases of refractive surgery, patients become more difficult to refract. That's because when we ask you which lens is clearer, patients under forty will typically respond to a more myopic (less hyperopic) lens as the clearer one. Looking through the more myopic (or less hyperopic) lens causes these patients to accommodate, which constricts the pupil, which limits light rays entering the eye to those passing through the center of the ablation (refractive) zone, which reduces spherical aberrations, which results in clearer vision. However, the constant need to focus is fatiguing and causes the eyes to converge, which creates problems getting the two eyes to align their fixation. (BTW... well-fitted rigid gas permeable lenses will reduce the spherical aberrations as well, allowing better vision in low light while permitting a full correction of the underlying refractive error.)

This is all a matter of your visual system attempting to function as best it can with an altered refraction. Under most circumstances when we are refracting even non-surgical patients, a one-half diopter over-correction will be rejected - young, old and middle-aged alike. (There are exceptions, of course, as any O.D. reading this will know.) But for otherwise "normal" (myopic) visual systems that suddenly become over-corrected by refractive surgery, the eyes strain to "normalize", that is, adapt to the new circumstances.

In an earlier post you mentioned having to move closer to see your computer. What was happening there was that as your eyes focussed to adjust to the over-correction, your eye over converged, which forced you to move closer to the computer. Your last optometrist prescribed +0.75 over your distance prescription to relieve the eyestrain. Using extra light at near will also help.

So... what does regression really mean? In your case it probably means ADAPTATION to your post-Relex visual system.
Thanks for the detailed explanation Dr Hartzok.
I have been using the prescribed glasses for near work for about a week now. My headaches are getting much better. If this eye strain is a matter of adjusting to a new visual system, then hopefully in a few months' time I can wean myself off of near work glasses, and not need them again for 10 years or so.
I saw my Ophthalmologist for a 3 month review. I told him about the headaches that I have been experiencing, and about my optometrist's diagnosis of overconvergence when looking at near objects. He advised me to do pencil push-ups for 5 mins each day, and explained that this is normally the treatment for underconvergence however it should still be beneficial in training my eyes to converge appropriately.
Does anyone have any experience with rehab options and exercises to do for overconvergence, and is able to provide advice?
Hmm...

If the over convergence is due to an overcorrection the solution is to use "plus" lenses for reading.

If you were to visit an optometrist who specializes in visual-motor issues (a vision therapist) he or she would immediately look for and hope to find that plus lenses solve the problem. Esophoric postures (over convergences) are not particularly amenable to correction with eye exercises, certainly not with pencil pushups. Esotropia (actual crossed-eyes) at distance viewing is corrected with prism or surgery. Esophoria (no double vision but symptomatic eye strain) is corrected with plus lenses and, if severe enough, compensated with prism in glasses. Vision therapists will generally train (apply vision therapy procedures, exercises, etc.) esophoric postures with the patient wearing plus lenses. The goal is to relieve the patient's visual symptoms. If we find that plus lenses do the trick, both the patient and the doctor are pleased.

Refractive surgery, where the sole intention is to eliminate the need for glasses, does not change the long-established fundamentals of vision analysis. The rules remain the same. Refractive surgeons and optometrists who work with refractive surgeons are disinclined to acknowledge those fundamental rules since the "customer" paid them to eliminate their need for glasses.
I got Relex Smile 1 month ago and continue with blurry/foggy vision, specially on one eye I has -3.25 on one eye and -3.50 on the other so the doctor said I was a perfect candidate. According to the doctor eveything is fine and I should be close to 20/20 vision however I feel I was under-corrected since havent noticed an improvement in the last 2 weeks. How long should I wait to know how my vision will improve- stay? Several friends of mine had the same surgery and could see perfect 1 week later. Im starting to get anxious.
One month is not a long time post-Relex Smile, but if your vision is not getting better than you need a few questions answered.

The first question is, "Are you under or over corrected?" This question can only be answered by performing a refraction.

The second question is, "Can you see well with a lens placed before each eye?" If you can, then you may either wear glasses or undergo a surface ablation to fix the refractive error.

The third question is a follow-up to question two: "If you CAN'T see well with a lens placed before both eyes, why?"

If the answers to these questions are not forthcoming from your provider then you need to be examined by a doctor working outside of the surgeon's office, someone who is independent, someone who has no affiliation with the office that did the Relex procedure.

Letting these questions go unanswered makes your question here (How long should I wait to know if my vision will improve?") somewhat relative since we need to know how over or under-corrected you are, whether there is an imbalance between your eyes and or whether or not your corneal optics are intact.
quote:
Originally posted by Dr. DavOD Hartzok:
One month is not a long time post-Relex Smile, but if your vision is not getting better than you need a few questions answered.

The first question is, "Are you under or over corrected?" This question can only be answered by performing a refraction.

The second question is, "Can you see well with a lens placed before each eye?" If you can, then you may either wear glasses or undergo a surface ablation to fix the refractive error.

The third question is a follow-up to question two: "If you CAN'T see well with a lens placed before both eyes, why?"

If the answers to these questions are not forthcoming from your provider then you need to be examined by a doctor working outside of the surgeon's office, someone who is independent, someone who has no affiliation with the office that did the Relex procedure.

Letting these questions go unanswered makes your question here (How long should I wait to know if my vision will improve?") somewhat relative since we need to know how over or under-corrected you are, whether there is an imbalance between your eyes and or whether or not your corneal optics are intact.


Thanks for your quick response! A refractive test has been done everytime I have went to post surgery check ups, however results have not been shared and I have just been told "eveything is fine".

Just yesterday I tried my brother´s glasses and I could see better so I will go to an independent place to get a refractive surgery.

In your experience can the vision take 3 or more months to improve afer Relex?

If it doesnt improve is a safe enhancement surgery even possible after Relex Smile?
Yes, by all means. if you can see well wearing your brother's glasses then a refraction by an independent examiner is indicated. Examiners at the surgical facility are understandably not hoping to find over or under corrections.

Relex Smile is a relatively new procedure. Relex patients just began posting on VSRN about July 2015. Relex is not available (yet) in the U.S. so we haven't had much experience with recovery times.

Enhancement following Relex is limited to surface ablations like PRK where there is no flap. Enhancement by ablation seems to be safe but, again, we have not had a long history with it.
Hi again.

I have a couple of questions for Dr Hartzok, if that's OK.

I saw my optometrist recently (14 months post-SMILE) who found that I have become more long-sighted since 12 months ago. I was initially found to be slightly myopic post surgery, but had overconvergence so was prescribed plus lenses to correct this.
A recent refraction shows that I am now +0.75 in the left eye and +0.50 in the right eye, indicating a big change in my prescription from being mildly myopic to now mildly hyperopic over the last 12 months. I have noticed that my vision has been slightly blurrier lately, which is consistent with a change. Looking back at my situation, with headaches due to overconvergence relieved by plus lenses, and given that post-laser patients are difficult to refract, I wonder whether I have been hyperopic the whole time since surgery. I have been using my plus lenses for computer work and reading for 12 months now.

Can wearing plus lenses lead to progressive hyperopia? In other words, if I try to use my glasses less frequently, could that help to reduce my hyperopia? Is there anything else that can help with my situation?

Thanks.
Wearing plus lenses will not CAUSE increased hyperopia but it will REVEAL it. The fact that you have been keeping your eyes more relaxed by using reading glasses allows you to accept some plus lens for distance. Adult eyes shift in the hyperopic direction naturally as we age but you are still too young for that to be the case. You were either (1) over-corrected by the actual Relex procedure or (2) possibly your pre-Relex prescription was not accurate (too strong) and so your procedure was based on that Rx.

Refractive surgery ASSUMES that everyone involved in the refractive surgery process is an absolute expert at REFRACTION. This is not the case. Refraction is more than sphere, cylinder and axis; that view that is a very naive understanding of how the visual system functions.
Thank you for that.

My optometrist postulated that my vision hasn't "stabilised" yet since the procedure, given my initial preference for minus lenses and now my current preference for plus lenses. However, you have given explanations for all of the changes that have occurred.
Had another refraction performed. No change since January, meaning that my vision is now stable.
All along, my headaches were due to an undiagnosed overcorrection. It still causes me to have headaches, and reduced/blurry vision at night. Overall, it was a regrettable decision to have SMILE surgery. It seems as though headaches post refractive surgery is common. To others with this symptom, I would suggest trying plus lenses due to the possibility of overcorrection.
Yes I wear them most of the time when I am at work, because there is a lot of near work. I get eyestrain if I am doing a lot of near work and I'm not wearing my glasses. When I am not working, eg. driving, exercising, at social functions, etc, I don't wear them.

My experience early post-SMILE was that my optometrist did not specifically find me to be hyperopic based on my refraction, but prescribed plus lenses because of evidence of overconvergence. The symptom relief with plus lenses was ultimately attributable to overcorrection.

Hi,

I recently had Relex smile surgery on both my eyes and would like to share my experience of the same. Before I detail about my post-op experience let me first mention my pre-op lens prescription and the surgery details.

My pre-op lens prescription was,

    Left eye   :  -9.5D + -1D astigmatism

    Right eye :  -7.5D + -1.5D astigmatism

Surgery details

    Left eye   : Relex Smile + Xtra

    Right eye : Relex Smile

    Date         : 25th Feb 2019

I had Smile procedure on the right eye and Smile + Xtra on the left eye as my cornea was a little weak on the left. The Xtra procedure was performed after Smile and took just another 2 minutes or so. Surgery went pretty smooth although I remember moving my eyes when my surgeon was performing the Xtra procedure(left eye) after the Smile and the doctor had asked me to stop moving them. There was no burning or itching sensation immediately after the surgery or infact I never had any burning or itching on either eyes. Doctors had placed a contact lens on both eyes and asked me to visit the next day. The lens on my left eye was very uncomfortable and it was causing an irritation while the right eye never had any issue with the lens. Next day after the check-up lens were removed and I felt immediately relieved. Wore the dark shields for that entire week and didn't strain my eyes much.

For my next check-up a week after the surgery I noticed that right eye was clear while left eye was blurred. Reading was pretty difficult at this point and vision in low light was very bad. Using the mobile phone was also a challenge as I couldn't focus correctly. All these along with glare/halos/starbursts which only became more evident the following week when I resumed work and started using computers on a low light environment. I continued my eye drops regimen religiously for another 3 weeks.

4 weeks past surgery my condition hasn't improved much or at least not so much that is actually evident. Here are my feelings /sensations 1 month post-op.

Feelings/sensations 1 month post-op

1. No trouble using mobile phones.

2. Reading is comfortable.

3. Full visual acuity in bright sunlight.

4. Blurred vision in low/dim lights only in left eye.

5. Glare/halos/starbursts on both eyes but more severe in left.

6. Vision becomes clear for a couple of minutes after applying lubricating drops then becomes blurred again(only in left).

7. Poor lighting in my work environment makes it working on the computer very difficult as I could see halos around any bright objects on the screen.

8. Interestingly the trouble working on computer screen is reduced if I constrict/contract my eyes and then things become clear.

9. Dryness because of excessive computer usage so I apply lubricating drops every hour.

10. Sometimes I have a feeling that something's there in my eye, again only in left eye.

So above mentioned is the state of my eyes and my condition 1 month post-op. Please let me know if these are normal after Smile surgery and will they improve over the course of time. Now I would like to post my queries here in this forum and hope someone could please clarify them for me.

Queries

1. is this Xtra procedure same as "Corneal Collagen Cross-linking with Riboflavin" aka c3r.

2. How is healing different for Smile and Smile + Xtra

3. I remember doctor asking me to stop moving my eye during Xtra. Can it create any complication.

4. Have full visual acuity in both eyes in bright sunlight but getting blur in left eye alone in dim/low light conditions. Why this difference. Is it related to Xtra procedure done on my left eye.

5. Nearby objects are clear(no blurring at all) with left eye while farther objects are blurred. Near and far objects are clear with right eye. Does it mean a residual power in my left eye.

6. Having halos/glare around bright objects in screen while working in low light conditions. Will this improve over time?

7. I don't see any improvement over the period of 1 month. My condition is pretty much the same as it was a week after the surgery. Is this normal.

8. Is it true that people who had higher myopia heal slower. Even so why's my vision in right eye clear however left not so much.

9. Can the blurriness be fixed by a prescription glass until healing is complete.

10. Was travelling on a bus at night. It was pretty dark inside and after a while I noticed that I could read all signboards outside and much farther away very clear using both eyes. Why did that happen.

@mep, Hi

For how many days did you have the blurred vision or reduced vision at night after the surgery? Can you please share how your vision changed over the course of healing from 3 months after surgery. I see that you had posted your updates up until 3 months post-op and then next came 2 years later. How do you feel now? Eagerly waiting for your response...

Thanks

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