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Download MBBS Ophthalmology PPT 24 Congenital Glaucoma Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 24 Congenital Glaucoma Lecture Notes

This post was last modified on 07 April 2022

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and

Congenital Glaucoma

.

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Learning Objectives

? At the end of this class the students shall be

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able to :

? Define and classify glaucoma.
? Define congenital glaucoma.
? Understand the aetio-pathogenesis and clinical

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features of congenital glaucoma.

? Understand the fundamentals of managing

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congenital glaucoma.

2


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Excessive

blinking +/-

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watering

Hazy cornea

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Large corneas

3

Question

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? A child presents with watering , photophobia and an

enlarged cornea with a diameter of 13mm.

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Examination of the eye reveals double contoured

opacities concentric to the limbus. Which of the

following is the most likely diagnosis:

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? Superficial keratitis
? Deep keratitis
? Thyroid eye disease
? Congenital glaucoma

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What is glaucoma ?

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? The term glaucoma is derived

from the Greek word "glaukos"
meaning "gray blue"

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? Second leading cause of

blindness worldwide

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? Third most common cause of

blindness in India

? Not reversible

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Definition of glaucoma

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? Group of disorders characterized by progressive

optic neuropathy resulting in characteristic
morphological changes at the optic disc leading to a
specific pattern of irreversible visual field defects

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(with or without a raised IOP).

6
Classification of glaucoma

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Glaucoma

Primary

Childhood

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Secondary

Glaucoma

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Glaucoma

Glaucoma

Open angle

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Angle

glaucoma

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closure

glaucoma

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Primary glaucoma

? Open angle glaucoma

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? Primary Open angle glaucoma
? Normal Tension glaucoma
? Juvenile Open angle glaucoma
? Secondary Open angle glaucoma

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? Steroid induced glaucoma
? Pigmentary glaucoma

8
Primary glaucoma

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? Angle closure glaucoma

? Primary angle closure glaucoma

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? Secondary angle closure glaucoma

? Swollen lens

? Posterior segment tumours

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? Neovascular glaucoma

? Plateau iris syndrome

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Childhood glaucoma

? Primary congenital glaucoma

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? Glaucoma associated with ocular abnormalities

? Glaucoma associated with systemic abnormalities

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Secondary glaucoma

Glaucomas after ocular surgery

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Steroid induced glaucoma

Traumatic glaucoma

11

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Childhood glaucoma-Introduction

? Diverse group of disorders
? Primary congenital glaucoma-

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Developmental abnormality of angle of anterior chamber
leading to high intraocular pressure(IOP).
? Secondary congenital glaucoma
With associated ocular and systemic anomalies

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ANGLE OF ANTERIOR CHAMBER

- The peripheral recess of anterior chamber is known as the angle of

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anterior chamber.

- It is clinically visualized by gonioscopy.
- Starting at the root of iris & progressing anteriorly towards the

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cornea, the following structures can be identified in a normal

angle in an adult :

1) Ciliary body band (CBB) & root of iris

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2) Scleral spur (SS)
3) Trabecular meshwork (TM)
4) Schwalbe's line (SL)

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Angle of anterior chamber as seen

on gonioscopy

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14
---------
Grade
IV

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II

II

I

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0

15

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Childhood glaucomas

? True congenital glaucomas- At birth or during

intrauterine period.

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? Infantile glaucoma- Upto three years of age.
? Juvenile glaucoma- After three years of age and

upto 35 years of age.

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Prevalence and genetic pattern

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? Sporadic occurrence in most cases (90%)
? Autosomal recessive in 10% of cases
? Loci linked with congenital glaucoma are

2p21(GLC3A), 1p36(GLC3B) and 14q24(GLC3C)

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? 60% diagnosed by the age of 6 months and 80%

diagnosed within the first year of life

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Prevalence and genetic pattern

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? Bilateral (about 70%) but asymmetrical
? Boys are affected slightly more frequently than girls

(65%)

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? Prevalence is 1 in 10,000 births
? Chance of second sibling having disease is 3%
? Chance of third sibling (of two affected siblings) having

disease is 25%

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Pathogenesis

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? Faulty development of angle

of anterior chamber from

neural crest derived cells

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(trabeculodysgenesis)

The normal chamber angle: on the left is a

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? Absence of angle recess with histological cross-section; on the right is a

flat/concave iris insertion.

drawing of the same

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? Impaired aqueous outflow

? Elevated IOP

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An underdeveloped chamber angle

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Clinical presentation

Classic triad of
? Epiphora
? Blepharospasm

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? Photophobia

? Babies rub their eyes
? Enlarged eyes
? Vision impaired

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Corneal signs

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? Corneal oedema
? Corneal enlargement (Corneal diameter>13mm)
? Haab's striae : Descemet's membrane is not very

elastic and stretching may result in small

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linear/circumferential tears that cause a certain

degree of corneal opacification.

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Clinical presentation

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? Buphthalmos: Enlargement of

the globe as a result of
elevated IOP. Al segments of
the outer eye especially the

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cornea and sclera expand
principally at the corneoscleral
junction

? The anatomic landmarks are

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Advanced developmental

displaced.

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glaucoma with extensive

enlargement and scarring of the

? The anterior chamber is deep

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cornea.

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Clinical presentation

? Sclera becomes thin and appears blue (due to

underlying uveal tissue

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? Iris- atrophic in later stages
? Optic disc- variable cupping
? Intraocular pressure(IOP)- raised
? Axial myopia- due to increased axial length of

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eyeball

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Examination under anaesthesia

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? Mandatory in all cases

? Includes :

? Measurement of IOP ?

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Perkins tonometer/Tonopen

(Normal 10-21 mm Hg)

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? Measurement of corneal diameter ? by

callipers

(Normal 9.5mm-10.5mm)

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Examination under anaesthesia

? Slit lamp examination- with portable slit lamp
? Ophthalmoscopy- to evaluate optic disc

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Asymmetric disc cupping in a child with developmental glaucoma. (A) Note

steep-wal ed cup. This is typical of glaucomatous cupping in the elastic

infant eye. (B) The left eye has no cupping.

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Examination under anaesthesia

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? Direct Gonioscopy ? to examine angle of anterior

chamber

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? Koeppe's gonioscopy
lens is preferable
? Angle is open but
immature in
congenital glaucoma

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Differential Diagnosis

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? Hazy/Cloudy cornea-- -
? STUMPED (Sclerocornea, Trauma, Ulcer, Metabolic

disorders, Peter's anomaly, Endothelial dystrophy)

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? Watering and intolerance to light-- -
Congenital Naso Lacrimal Duct obstruction
keratitis, conjunctivitis
? Optic cupping - - disc coloboma, hypoplasia,

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physiological cupping

? Corneal enlargement -- megalocornea, high myopia
? Descemet's breaks - - Forceps delivery ,birth trauma 28

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Management

? Glaucoma surgery is the primary option

? Medications are not very effective

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? Role of medical management is temporary, till

surgery is taken up.

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? Beta blockers (Timolol), hyperosmotic

agents(Mannitol), carbonic anhydrase inhibitors

(acetazolamide/dorzolamide)

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? Miotics and Alpha-2 agonists are not used in

children.

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Goniotomy/Trabeculotomy

Trabeculectomy with

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trabeculotomy

Modified Trabeculectomy

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Glaucoma drainage implant

Cyclodestructive procedures

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Approach to management

Goniotomy/Trabeculectomy/Combined Trabe-Trab

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Surgical outcome?
EUA after 3-4 weeks

IOP controlled

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IOP not controlled

Evaluation after 3 months

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Add medical therapy

Normal IOP

If IOP not control ed

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repeat Trab ? MMC

Evaluation after 3 months Controled Uncontroled

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FU every 3 months

Poor prognosis

VISUAL

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Record IOP, CDR, VA

REHABILITATION

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Consider

Axial length, VF (if possible)

Drainage implant

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Cyclodestruction31

Goniotomy

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? Safe procedure when performed

skilfully.

? Performed with direct

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visualization of trabecular

meshwork

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? Aims to transect Schlemm's

canal by ab-interno approach

? Incises only superficial

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trabecular tissues, necessary to

cure this disease

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Trabeculotomy

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? Ab-externo trabeculotomy has good success rates.

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Trabeculotomy with trabeculectomy

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? Most commonly performed surgery in India

? Easy adaptability
? Safe and successful

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? Suitable in compromised corneas
? More predictable results

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Steps of Trabeculectomy

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with trabeculotomy

Scleral flap

Ds sDissection upto grey limbus

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Trabecular meshwork cut

Diffuse subconjunctival bl

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Role of antimetabolites in paediatric glaucoma

? Significantly more complications associated with the

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use of Mitomycin(MMC) in paediatric glaucomas

? Thin, avascular filtering blebs
? Wound leakage

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? Choroidal detachment
? Bleb related endophthalmitis

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Options for refractory glaucoma ?

? Glaucoma Drainage Devices

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? Cyclo-destruction

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What is a Glaucoma Drainage Device?

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Glaucoma drainage devices

(GDDs) create an alternate

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aqueous pathway from the

anterior chamber (AC) by

channeling aqueous out of the

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eye through a tube to a

subconjunctival bleb. This tube

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is usually connected to an

equatorial plate under the

conjunctiva.

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Cyclodestructive procedures

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? Cyclocryotherapy



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? Cyclophotocoagulation

?Transscleral
?Transpupillary
?Endoscopic

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CYCLO CRYOTHERAPY

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TREATMENT OF 1950

BIETTI


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Lasers relatively safer energy

? Trans-scleral route

? Direct application to ciliary

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epithelium



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Trans pupillary

Trans-scleral route

diode laser

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810 nm wave length

Penetrates through sclera

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Contact delivery through

fibre optic cable

Diode laser is prefer ed

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Melanin in the ciliary

epithelium bet er absorbs

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this wavelength

Causes more targeted

destruction with

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less inflammation



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VISUAL REHABILITATION

? Correction of refractive error

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? Management of media

opacities

? Amblyopia therapy to achieve

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binocular stereoscopic vision

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VISUAL REHABILITATION

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? Low vision aids
vTelescopes (hand-held or
spectacle-mounted)

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vHand or pocket
magnifiers (2? to 3?)

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CONCLUSIONS

? Glaucoma is a group of disorders characterized by progressive

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optic neuropathy.

? Early diagnosis and prompt treatment can preserve vision.

? All children with suspected childhood glaucoma should be

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examined under anaesthesia.

? Mainstay of management of childhood glaucoma is surgery

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? Visual rehabilitation and counseling of the parents of the child is

as important as IOP control.

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Question

? Identify the abnormality

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marked by arrow.

? Which structure is

involved?

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? What type of slit lamp

illumination is used in

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the photograph?

? Mention one

differential diagnosis of

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the condition

46

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