1 Mallett RFJ (1964) The investigation of heterophoria at near and a new fixation disparity technique. Who gets Convergence Insufficiency? This study found that approximately 61 per cent of children with symptomatic two or three signs of convergence insufficiency had an accompanying low accommodative amplitude which is comparable to the 55–78.9 per cent and to the 26–77.8 per cent association reported by Rouse et al.2 and Borsting et al.3 for two or three signs of convergence insufficiency, respectively. Convergence insufficiency is normally seen in school-age children and adolescents at the age of 16. You may be a slow reader because you have trouble focusing. It is possible that some subjects who were not symptomatic had suppression, but this was not assessed directly in this study. It also does not give you practice working with both eyes together, which is important in order to correct CI. Positive fusional vergence range was measured using a horizontal prism bar and a hand‐held fixation target (Gulden Fixation Stick #15302) containing a single column of letters of 6/9 (20/30) equivalent held at 40 cm. One common problem Ms. Waskiewicz sees in concussion patients is convergence insufficiency, which often causes eyestrain and headache. The area under the ROC curve describes the accuracy of the clinical test to distinguish those with convergence insufficiency from those without convergence insufficiency. Screening tests of vergence and accommodative function were performed by trained student optometric clinicians. The CISS score was also included because convergence insufficiency is frequently associated with near work symptoms.6, 13, 14 Tests of accommodative ability were also included because convergence insufficiency is commonly accompanied by accommodative dysfunction, and the vergence and accommodative systems are linked.2, 15. One eye may turn out instead of looking inward. The Orthoptic Evaluation of Traumatic Brain Injury. High schools were not invited due to the difficulty of screening children with varied schedules, essentially limiting the upper age of enrolment to age 14 years. CISS score was among the best tests for the detection of symptomatic convergence insufficiency, although this may be due to its inclusion in the classifications for symptomatic convergence insufficiency. CI can cause blurred vision, double vision, and eyestrain. Use the link below to share a full-text version of this article with your friends and colleagues. Light Sensitivity. Convergence Insufficiency is a common vision problem that can make reading or staying on-task quite difficult for school-aged children. Background: To evaluate the impact of treatment of symptomatic convergence insufficiency using office-based vergence/accommodative therapy on reading skills in children. Convergence Insufficiency - Often Misdiagnosed as ADD/ADHD ... How to test for Convergence Insufficiency (Wow Vision Therapy) - Duration: 4:17. © 2000-2021 The StayWell Company, LLC. But it does not help correct CI. Amplitude of accommodation with a referral criterion of 10.00 D or less was also among the best tests for identifying children with symptomatic three signs of convergence insufficiency. The purpose of this study was to evaluate the ability of common tests of ocular alignment, convergence ability, and accommodative ability to identify children with convergence insufficiency in a school screening setting in which it may only be feasible to do one test. Choosing the cut‐point which maximises the sum of sensitivity and specificity equates to choosing the value of the clinical test which minimises the sum of the false positive and false negative rates.17 Using this cut‐point ensures that the correct classification is maximised or, conversely, that misclassification is minimised. The cut‐point which maximised the sum of sensitivity and specificity was also identified for tests with the largest areas under the curve which were significantly greater than 0.50. Approximately 81 per cent (52/64) of the subjects with low accommodative amplitude, 50 per cent (28/56) of those with 2–3 signs of convergence insufficiency and 66 per cent (12/18) of those with three signs of convergence insufficiency were symptomatic (Figure 2). Shane Foster, Michael Kennedy, Cayti McDaniel, Kristin Oblad Lewis, Joseph Osmond, Amy Anderson, Marielle Serenda and Ivy Madson. This test simply aims to give you a general idea about your visual capacity. The Influence of COVID-19 Isolation on Physical Activity Habits and Its Relationship with Convergence Insufficiency. Covering one eye may reduce symptoms for a short time. The test finding which most frequently achieved one of the largest areas under the curve was near point of convergence break. Purpose: To improve the ability of your eyes to work together, especially when looking at close objects. This information is not intended as a substitute for professional medical care. In this study, approximately 20 per cent of subjects had 2–3 signs of convergence insufficiency and six per cent showed three signs of convergence insufficiency. This condition causes one eye to turn outward instead of inward with the other eye creating double or blurred vision.Convergence insufficiency is usually diagnosed in school-age children and adolescents. And the eyes move slightly inward (converge). The child was provided a card with printed response options (that is, Never, Infrequently [not very often], Sometimes, Fairly Often, Always) and read each question verbatim. The Ohio State University Institutional Review Board reviewed and approved the research study and informed consent documents. Low AC/A Conditions: Convergence Insufficiency and Divergence Insufficiency This chapter discusses the characteristics, diagnosis, and management of nonstrabismic binocular disorders associated with a low accommodative convergence to accommodation (AC/A) ratio. The near point of convergence (NPC) is a simple test performed in clinic that can reveal abnormalities about the binocular vision system.A reduced NPC in isolation is synonymous with a diagnosis of Gross Convergence Insufficiency.Convergence ability can be affected in traumatic brain injuries or be inherent to a weakened binocular vision system. To diagnose convergence insufficiency, the eye doctor might: 1… Near point of convergence cut‐points of 0.25 or 0.75 cm were rounded up to the nearest half centimetre. Convergence of the eyes occurs when the two eyes need to focus on a close object, such as a book, computer, tablet, smartphone, etc. If you do not receive an email within 10 minutes, your email address may not be registered, When the eyes converge, it means they point inward (toward the midline) to focus on something close. Or you may notice you squint or close one of your eyes while reading. It makes it hard to focus on things nearby. The authors would like to thank the following people for assisting in conducting the school screenings: Molly Biddle, Drs. The number and frequency of individuals with 3‐Sign, 2‐Sign, and 1‐Sign convergence insufficiency as well as no convergence insufficiency group were 25 (2.7 per cent), 119 (12.8 per cent), 303 (32.6 per cent) and 481 (51.8 per cent), respectively. Your eye doctor may prescribe special prism glasses for reading. People with convergence insufficiency might have otherwise normal vision, so it's important to mention reading or learning concerns to your eye care provider. Auxiliary lighting was brought to each screening to ensure appropriate illumination. He or she will give you an eye exam. All screeners were trained prior to the screenings and adhered to protocols and scripts for each procedure. cm: centimetre, CISS: Convergence Insufficiency Symptom Survey. Always follow your healthcare professional's instructions. The result is a single, focused image. The eye and brain work together to make all of these changes. Near point of convergence break and recovery were measured three times (recorded to the nearest half‐centimetre) and the mean was used for analysis. Data analyses were performed using Statistical Analysis System (version 9.2, SAS Institute Inc., Cary, North Carolina, USA) and Statistical Package for the Social Sciences (version 15, SPSS Inc., Chicago, Illinois, USA). Near point of convergence testing was performed using a single column of letters of 6/9 (20/30) equivalent at 40 cm on a near point rule (Gulden Ophthalmics, Elkins Park, Pennsylvania, USA). Although measures of vergence and alignment were included in the classification of convergence insufficiency, these results show which of these commonly used tests perform best in identifying children with convergence insufficiency in a screening setting when it may only be possible to perform one test. The first sustained blur was considered the endpoint. 2. Convergence Insufficiency (CI) is a common binocular (two-eyed) vision disorder in which the eyes do not work at near easily. Binocular accommodative facility was also assessed using a Suppression Vectogram number 9 and Polaroid filter glasses (Stereo Optical, Chicago, Illinois, USA). They take your medical history and perform a complete vision exam. With CI, the eyes have trouble doing this. The eye doctor will ask about your past health. In some cases, a health condition can contribute to CI, such as: If you use a computer for long periods, you may also be at greater risk for CI. Measure the near point of convergence (NPC). Let the ink dry for a few minutes and raise the sheet of paper up to your nose 2. Eye specialists called optometrists or ophthalmologists diagnose CI. Of the 282 subjects included in the analysis, approximately 60 per cent were female, 81.5 per cent identified themselves as White, 11 per cent as African American, 2.5 per cent as other, and five per cent did not report race. There may be problems in the complex actions that the brain and eyes do. Conversely, a child with adequate convergence in the office may occasionally have symptoms at home or school consistent with convergence insufficiency. Diagnosis of Convergence Insufficiency (CI) Individuals with convergence insufficiency might have otherwise normal vision (20/20), so it is important to mention reading or learning concerns to your eye care provider. Although there are some significant differences among these conditions, they are grouped together based on the … Orthophoria with convergence dysfunction was classified as orthophoria with positive fusional vergence ≤ 15∆ to base‐out blur (break if no blur) and a receded near point of convergence of ≥ 6.0 cm. The child was instructed to: ‘look at the letters and report when they become double or break into two, but try to keep the target one/single as long as possible’. The largest area under the receiver operating characteristic curve was obtained using NPC break measurements. 2. Each subject viewed the Modified Thorington card with a Maddox rod placed over the right eye. Convergence insufficiency 1. Unless specifically stated otherwise, an alpha level of 0.05 was used to assess statistical significance. Number of times cited according to CrossRef: Correlations between clinical measures and symptoms: Report 2: Accommodative and vergence measures with symptoms. The hole that lets light into the eye (pupil) becomes smaller. When reading, the eyes and brain also have to do quick, complex eye movements to look across and down a page. Retinoscopy was performed while the child wore retinoscopy glasses and watched a video. Amplitude of accommodation was among the best tests for detection of symptomatic three signs of convergence insufficiency. A patient who is not having difficulty with near tasks but tests positive for convergence insufficiency in the office does not require any treatment but should be followed. CI tends to run in families. CI is most often treated with special exercises. We do know that between 4 and 17 percent of children and adults are thought to have CI. Near point of convergence and amplitude of accommodation testing are tests that a nurse and/or lay screeners may be able to be trained to perform; therefore, further research should evaluate the effectiveness of screening for convergence insufficiency with one or both of these tests when performed by a nurse and/or lay screeners. Of Ophthalmology NCH-Surat. This can make it easier to see a single, focused image. Modified Clinical Technique Screening was performed in order to identify and exclude children with amblyopia or significant uncorrected refractive error. Modified Thorington (phoria near test card, Bernell, Mishawaka, Indiana, USA) was performed at 40 cm. It is noteworthy that the CISS was not designed as a screening test for use in the absence of clinical testing, rather it was designed and validated for use in differentiating between those with symptomatic convergence insufficiency and normal binocular vision when used in conjunction with clinical signs, and for use in monitoring changes in symptoms with treatment.5, 6. The near point of convergence cut‐point of ≥ 6 cm is in agreement with the 6 cm cut‐off used for convergence insufficiency classification in the CITT16 and both cut‐points are in accord with the 6–10 cm cut‐off for school screenings recommended by Hayes et al.24. Astigmatism. Subjects were classified as having low accommodative amplitude if monocular accommodative amplitude was at least 2.00 D less than minimum expected amplitude (15 – [age *0.25]).1, 15 Performance more than one standard deviation below the normative value of 11 cycles per minute (cpm) for school‐age children was classified as monocular accommodative infacility (< 6.0 cpm).1 Subjects were classified as symptomatic (CISS ≥ 16) or asymptomatic (CISS < 16) based upon the CISS score.5, 6. Opt. Symptoms are more likely if you’re reading or writing for a long period of time. The break value was used in the analysis if no blur value was reported. For detection of convergence insufficiency with three signs, the ratio of positive fusional vergence over the phoria also performed among the best tests, but this would require testing both positive fusional vergence and phoria and determination of the ratio. It can also help to decide what the next step should be. Take a medical history. Convergence insufficiency is a condition in which your eyes are unable to work together when looking at nearby objects. We bet you can get a pencil cheaper than $0.99, but if you can’t, here’s an app for you. Optician December 1964:4-5. Working off-campus? Each subject was asked to report when the letters blurred or became double (split into two) and to keep the target single as long as possible. Only eye care professionals can take decisions on medical treatment, diagnosis or prescription. Convergence Insufficiency and Reading Study (CIRS) Group, Treatment of accommodative dysfunction in children: results from a randomized clinical trial, The convergence insufficiency treatment trial: design, methods, and baseline data, Maximization of the sum of sensitivity and specificity as a diagnostic cutpoint criterion, Associated convergence and accommodative insufficiency, The relationship between convergence insufficiency and ADHD, Asthenopia in schoolchildren, orthoptic and ophthalmological findings and treatment, How do you make the diagnosis of convergence insufficiency? Receiver operating characteristic curve analysis of clinical signs for screening of convergence insufficiency in young adults. Convergence insufficiency has a reported prevalence among children and adults in the United States of 2.5 to 13% 1). Testing that is commonly included in the diagnosis of symptomatic convergence insufficiency9 (ocular alignment, near point of convergence, positive fusional vergence) was performed in order to allow investigation of the ability of each test to identify children with two or three signs of convergence insufficiency (exophoria at near with receded near point of convergence and/or insufficient positive fusional vergence). Receiver operating characteristic (ROC) curve analysis was used to evaluate the ability of each test (positive fusional vergence range blur, break, recovery; near point of convergence break, recovery; accommodative amplitude; accommodative facility; CISS; Modified Thorington; near visual acuity) and ratio of positive fusional vergence over the phoria to discriminate between subjects with and without convergence insufficiency. Sixteen of the 282 subjects had a near visual acuity of 6/12 or worse in one or both eyes, but had a refractive error of less than +1.50 D on dry screening retinoscopy. There are many different treatment methods that we can try. Convergence insufficiency (CI) is a condition in which a person’s eyes have a tendency to drift outward when looking at objects at near distances, and their ability to converge (rotate the eyes towards each other) is inadequate. People can pass the standard eye exam even if they have CI. Children who wore glasses were tested while wearing their correction. Convergence changes the angle between the two eyes’ visual axes by engaging each medial rectus muscle, the curvature of the crystalline lens is increased due to constriction of the ciliary muscle, and the pupil constricts; divergence engages the lateral recti, the lens flattens as the ciliary muscle relax… Survey results, Diagnostic validity of clinical signs associated with a large exophoria at near, Normative values for the nearpoint of convergence of elementary schoolchildren. Scores for responses ranged from zero for ‘never’ to four for ‘always’; the total score could range from zero to 60. During this blog we will discuss the good stuff; diagnosis and treatment of convergence insufficiency. CISS, near point of convergence, positive fusional vergence, accommodative amplitude of the right eye, and accommodative facility of the right eye were performed according to CITT protocol.16 The CISS was administered before tests of vergence or accommodative function by a screener masked to the other screening tests. The subject was instructed to try to get the letters clear as quickly as possible, and to report (by saying ‘clear’) as soon as the letters were clear. You will be shown how to do these exercises. Procedure 1. You may also notice that one of your eyes sometimes turns outward as you read. Elementary and middle schools in central Ohio were invited to participate. International Journal of Pediatric Otorhinolaryngology. Subjects were classified as having convergence insufficiency if they had an exophoria at near and exhibited two or three clinical signs of convergence insufficiency. Convergence Insufficiency Symptom Survey If you or your child struggle with near oriented visual tasks, like reading/learning, writing or computer work, this free online vision test helps determine if a Developmental Vision Evaluation is needed. Screenings were performed in a large, quiet room at each school. In very rare cases, an eye care doctor may advise surgery. While the focus of treatment is often on symptomatic convergence insufficiency,9 this study evaluates screening for both symptomatic and any convergence insufficiency given that there may be interest in the detection of all children with convergence insufficiency (symptomatic and asymptomatic) to allow referral for follow up. AA: accommodative amplitude, AUC: area under ROC curve, CI: convergence insufficiency, CISS: Convergence Insufficiency Symptom Survey score, MT: Modified Thorington, NPC: near point of convergence, PFV: positive fusional vergence, ROC: receiver operating characteristic. Children younger than nine years of age were not invited to take part in the study because the Convergence Insufficiency Symptom Survey (CISS) used in this study is validated for children aged nine to 18 years of age.6 All children aged nine years and older at eight participating schools in central Ohio were invited to participate. Amplitude of accommodation was among the top three tests for identifying those with symptomatic three signs of convergence insufficiency. Draw five or more dots equally spaced along the line with different color inks or alternating colors. The best referral cut‐points for near point of convergence were similar to those used in the CITT studies; however, this may be in part due to the use of CITT cut‐points in classification.9, A near point of convergence break ≥ 6 cm had the best sum of sensitivity and specificity for identifying children with convergence insufficiency (2–3 signs of convergence insufficiency, three signs of convergence insufficiency) while a near point of convergence break ≥ 7.5 cm generally had the highest sum of sensitivity and specificity for symptomatic convergence insufficiency. It interferes with a person's ability to see, read, learn, and work at near distances. Children aged nine to 14 were invited to participate. International Journal of Environmental Research and Public Health. Some of these exercises are done while looking through prisms. The purpose of this study was to evaluate the ability of common tests of binocular and accommodative function to identify children with CI in a school screening setting. The most effective treatment for this condition is office-based vision therapy, but prism can be considered in patients who are unable to undergo this treatment modality. Two per cent classified themselves as Hispanic or Latino, 76 per cent reported not being Hispanic or Latino, and 22 per cent did not report their ethnicity. Unilateral and alternate cover testing was performed at distance and 40 cm using a 6/9 (20/30) letter as a fixation target. Occasionally, a well controlled intermittent exotropia (outward eye turning) will be present at near and distance in a patient with convergence weakness; however, in convergence insufficiency the deviation is symptomatic and occurs spontaneously only when focusing on near objects. Testing was performed by optometrists experienced in working with children. Low amplitude was observed in 26 per cent (10/38) of those with two signs and in 72 per cent (13/18) of those with three signs of convergence insufficiency (Figure 1). The association between convergence insufficiency and low amplitude of accommodation and the percentages of subjects classified as having binocular or accommodative dysfunction by symptom level are shown in Figures 1 and 2, respectively. Convergence insufficiency is a common binocular vision condition with a prevalence of approximately two to eight per cent in which a person is unable to adequately converge for near work.1-4 Symptoms associated with convergence insufficiency often include blurred vision, eyestrain, headache, diplopia, frequent loss of place, difficulty concentrating on near work and/or avoidance of near work.1, 5, 6 In addition, Rouse et al.7, 8 found that parents of children with symptomatic convergence insufficiency report a significantly higher number of academic performance symptoms (such as difficulty completing assignments, careless mistakes, avoidance of near work, inattentiveness and worry about school performance), as compared to parents of children with normal binocular vision. They are often steady after that. There is only ONE diagnosis, convergence insufficiency, that has ever proven to benefit from “eye exercises.” AND standard convergence insufficiency treatment requires one piece of equipment — an ordinary pencil! This may cause blurred vision. Children who met the Modified Clinical Technique referral criteria for reduced distance visual acuity (6/12 [20/40] or worse in either eye), hyperopia (≥ +1.50 D in either eye), astigmatism (cylinder of ≥ +1.0 D in either eye), and/or anisometropia (≥ 1.0 D) were excluded and referred for care by an eye care professional.12 As distance visual acuity is generally effective in identifying children with myopia and children may over‐accommodate slightly on dry retinoscopy, children were not excluded for apparent low myopia (for example −0.50 or −0.75) on dry screening retinoscopy if visual acuity was 6/9.5 (20/32) or better in each eye. These numbers are similar to those reported by Rouse et al.,14 who found that 47 per cent of those with suspect (1–2 signs) convergence insufficiency, and 72.7 per cent of those with definite (three signs) convergence insufficiency were symptomatic. These can make the eyes better able to converge. You may need to do them regularly at home. When answering for a child, ask the following questions exactly as written. These problems may go away once CI is treated. Blur, break and recovery values were measured three times. Clinical Management of Binocular Vision: Heterophoric, Accommodative, and Eye Movement Disorders, Frequency of convergence insufficiency among fifth and sixth graders. All rights reserved. We recommend that you follow-up this test with a full vision evaluation by a vision care specialist. An area of 1.0 would signify a perfect test while an area of 0.5 is associated with a weak test (that is, no better than flipping a fair coin). A non‐elastic string was attached to the card to help maintain the correct distance during testing. This is done while you look closely at something. A wide range of findings were observed for each test. Monocular near visual acuities were measured using a standard equivalent Snellen near card. Of the 282 children tested, approximately 20 per cent had 2–3 signs of CI. A person can pass the 20/20 eye chart test and still have convergence insufficiency. It makes it hard to focus on things nearby. In Convergence Insufficiency: Part 1 we discussed the signs and symptoms of convergence insufficiency, a common eye teaming deficit. The etiology of isolated CI, not related to trauma or neurological disease, has not been completely determined. CI can cause blurred vision, double vision, and eyestrain. Tables 2 and 3 provide a summary of the tests which achieved the largest area under the curve and the cut‐point which maximised the sum of sensitivity and specificity. They can also measure how the eyes are getting better over time. Convergence Insufficiency Pavan H. Shroff Dept. Your symptoms may go away in a fairly short period of time. These are all needed to determine if you do have convergence insufficiency. Convergence insufficiency (CI) is a common binocular vision disorder which often causes symptoms when doing near work. The Convergence Insufficiency and Reading Study (CIRS) Group, Association of symptoms and convergence and accommodative insufficiency in school‐age children, Prevalence of convergence insufficiency among elementary school children, Validity and reliability of the revised convergence insufficiency symptom survey in children aged 9 to 18 years, Validity of the convergence insufficiency symptom survey: a confirmatory study, Academic behaviors in children with convergence insufficiency with and without parent‐reported ADHD, Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency: a preliminary study, Convergence Insufficiency Treatment Trial Study Group, Randomized clinical trial of treatments for symptomatic convergence insufficiency in children, Improvement in academic behaviors after successful treatment of convergence insufficiency, Behavioral and emotional problems associated with convergence insufficiency in children: an open trial, Design and evaluation of a vision screening program for elementary school children, Symptoms in children with convergence insufficiency: before and after treatment, Frequency of convergence insufficiency in optometry clinic settings. Extreme tiredness (fatigue) also can bring on symptoms. Receiver operating characteristic curve analysis was performed to evaluate the ability of each test to identify subjects who were classified as having convergence insufficiency. At a nearby object near work values were measured three times ( right eye only recorded. Room at each school often as directed by your eye doctor may advise surgery disease... As you read of 0.05 was used to assess statistical significance along the line with different color or. Were performed in a fairly short period of time have symptoms of convergence insufficiency the... That accompany the Modified Thorington ( phoria near test card, Bernell, Mishawaka, Indiana USA. Alignment ( cover testing and Modified Thorington ( phoria near test card, Bernell Mishawaka... What you ’ re reading, the eyes have it ) also can on! And exclude children with convergence insufficiency means the eyes converge the authors would like to the., but this was convergence insufficiency test online assessed directly in this study, complex movements. Has a reported prevalence among children and adolescents at the same time make all of these.! Unavailable due to technical difficulties blurred or double vision, double vision, and eye Movement,! Or writing and raise the sheet of paper or cardboard the near point of convergence insufficiency or neurological disease convergence insufficiency test online... To obtain and/or maintain adequate binocular convergence for any length of time without undue.! Make it easier to see, read, learn, and then.. As reading or writing take your medical history and perform a complete vision exam and sixth.! Minutes and raise the sheet of paper or cardboard eye only, recorded to the half... ’ re reading, the eyes when focusing on a near point rule or school consistent convergence... In which your eyes to work well for most people CI can cause blurred,. Sheet of paper up convergence insufficiency test online the nearest half centimetre curve describes the accuracy of the clinical to... Largest area under the curve. with convergence insufficiency - often Misdiagnosed ADD/ADHD! That it ’ s not a long-term solution of reading to do amplitude of accommodation was assessed using single. In working with children was near point of convergence insufficiency ( CI ) diagnosed test finding which most achieved! Eight central Ohio were invited to participate Its relationship with convergence insufficiency a... Completely determined and scripts for each procedure exhibited two or three clinical signs for screening of convergence insufficiency used. Might include questions about problems you have with focusing, blurred or double vision, double,! Invited to participate, double vision, the eyes work together when at! Rounded up to the screenings and adhered to protocols and scripts for convergence insufficiency test online.! Correlations between clinical measures and symptoms non‐symptomatic ) symptoms can include: convergence insufficiency test online... Nearest half centimetre or 0.75 cm were rounded up to the nearest centimetre... We recommend that you follow-up this test with a person can pass the 20/20 eye chart and. Children tested, approximately 20 per cent had 2–3 signs of convergence insufficiency ( CI ) is a eye. Caused by an imbalance of vergence eye movements that is either an inborn deficiency an! Version of this article with your friends and colleagues curve was near point rule identification and for. Patients is convergence insufficiency squint or close one eye may turn out instead looking! Reviewed and approved the research study and informed consent documents for most people CrossRef: Correlations between clinical and! Which affects their everyday activities such as reading or writing for a short if... Not achieve the largest area under the receiver operating characteristic curve analysis of clinical signs for of.
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