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 Table of Contents  
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 160-167

Eyelid malpositions: An overview

1 Department of Orbit, Oculoplasty and Trauma, Giridhar Eye Institute, Kadavanthra, Kochi, India
2 Department of Ophthalmology, Giridhar Eye Institute, Kadavanthra, Kochi, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Marian Pauly
Senior Consultant and Head, Department of Orbit, Oculoplasty and Trauma, Giridhar Eye Institute, Kadavanthra, Kochi - 682 020
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_112_17

Rights and Permissions

Eyelid malpositions are the result of forces acting upon the eyelid margin. A normal eyelid should have a quick return snap to the eyeball. Frequently, tendon laxity at the medial and lateral canthi will render the eyelid margin unstable making it susceptible to contractile forces. Based on the contractile forces either entropion, ectropion, retraction or lagophthalmos can occur. The goal in treating a given eyelid malposition is to reposition the eyelid so that the new healing forces will overcome the pathologic forces. The common approaches include eyelid and canthal tendon tightening, eyelid retractor advancement or recession and skin grafting or transposition flaps. This review article briefly describes the various aspects of lid malpositions in detail.

Keywords: Entropion, gross eyelid distortion, ptosis

How to cite this article:
Pauly M, Maya T J. Eyelid malpositions: An overview. Kerala J Ophthalmol 2017;29:160-7

How to cite this URL:
Pauly M, Maya T J. Eyelid malpositions: An overview. Kerala J Ophthalmol [serial online] 2017 [cited 2023 Feb 6];29:160-7. Available from: http://www.kjophthal.com/text.asp?2017/29/3/160/224290

  Introduction Top

Malpostions of the eyelid can result from a host of causes, the consequences of which, can range from mild discomfort to the patient, to even causing potential threat to ocular surface. This article reviews the types, etiology, and management of the common eyelid malpositions except ptosis, encountered in clinical practice.

Eyelid malpositions in general are entropion, ectropion, eyelid retraction, and lagophthalmos.


It is useful to conceptualize the eyelid as comprising of two lamellae [Figure 1] and [Figure 2]:
Figure 1: Anatomy

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Figure 2: Lower lid retractors

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  1. Anterior – skin and orbicularis muscle
  2. Posterior – tarsus and conjunctiva.

  Entropion Top

Causes of entropion may be congenital or acquired. There are three types of acquired entropion, namely involutional, cicatricial, and spastic.

The presenting symptoms can be varying from redness and pain around the eye, sensitivity to light and wind, sagging skin around the eye, excessive tears, and decreased vision, especially if the cornea is damaged.

Kemp and Collin grading of entropion[1]


Apparent posterior migration of  Meibomian gland More Detailss

Conjunctivalization of eyelid margin + eyelash/globe contact on upgaze


Features of minimal entropion + eyelashes touching the globe in the primary position with or without thickening of the tarsal plate


Gross eyelid distortion + metaplastic eyelashes + presence of keratin plaques + eyelid retraction causing incomplete trichiasis.

  Congenital Entropion Top

Upper eyelid entropion occurs secondary to the mechanical effects of microphthalmos and enophthalmos [Figure 3].
Figure 3: System for epiblepharon/congenital entropion

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Lower eyelid entropion is caused by maldevelopment of the inferior retractor aponeurosis.

Differential diagnosis:

  • Epiblepharon – Epiblepharon comprises an extra horizontal fold of skin stretching across the anterior eyelid margin [2]
  • Tarsal kink is a rare congenital eyelid anomaly manifesting with severe entropion, which may lead to corneal opacity and consequent [3] amblyopia. Modified temporary eyelid margin suture for tarsal kink correction provides better mechanical traction on the tarsal plate by drawing the upper eyelid down to the lower eyelid.

Treatment involves excision of a strip of skin and muscle and fixation of the skin crease to the tarsal plate (Hotz procedure).[4]

  Involutional Entropion Top

Predisposing factors:

  1. Horizontal eyelid laxity
  2. Vertical eyelid laxity due to weak lower eyelid retractor/disinsertion of lower eyelid retractors: Normally, they pull at the lower edge of tarsus inferiorly and posteriorly, thus preventing the inward turning of the eyelid margin. When laxed, it allows the eyelid margin to invert
  3. Overriding of preseptal over pretarsal orbicularis muscle: Rounded eyelid margin and occurrence of entropion on forceful eyelid closure and relative enophthalmos with deep superior sulcus point toward the overriding of preseptal over pretarsal orbicularis
  4. Involution of the soft tissues of the orbit, particularly the orbital fat, may lead to involutional enophthalmos, which in turn can lead to unstable eyelid position with entropion.

  Spastic Entropion Top

Spastic closure of the eyelids allows the orbicularis oculi muscle to overwhelm the oppositional action of the lower eyelid retractors, resulting in an inturning of the eyelid margin and further irritation of the ocular surface from the inturned eyelashes. This occurs when there is spasm of muscle of Riolan (due to irritation) and lack of support of eyelid by the globe. It can be precipitated by intraocular surgeries.[5]

  Cicatricial Entropion Top

Cicatricial entropion occurs due to cicatrization of palpebral conjunctiva. Patients with cicatricial entropion usually display scar tissue of the conjunctiva, usually a result of trauma, chemical burns, Stevens–Johnson syndrome, ocular cicatricial pemphigoid, infections, or local response to topical medication.

Examination of the tarsus and palpebral conjunctiva usually points to the diagnosis in these cases.

system for acquired lower lid entropion - see [Figure 4].
Figure 4: System for acquired lower eyelid entropion (courtesy: Collin JR. A manual of systematic eyelid surgery)

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Sutures are passed to correct the lamellar dissociation as follows:(a) transverse sutures prevent upward movement of preseptal muscle and (b) everting sutures tighten the lower eyelid retractors and evert the eyelid.

Wies procedure

Transverse eyelid split + everting sutures – eyelid is split transversely to create fibrous tissue scar barrier which prevents the upward movement of preseptal muscle. Everting sutures shorten the lower eyelid retractors.[6]

Quickert procedure

Transverse eyelid split + everting sutures + horizontal eyelid shortening – lower eyelid retractors are mechanically tightened and double armed sutures are passed full thickness through the eyelid, entering the conjunctiva posteriorly low in the fornix and exiting on the anterior surface of the eyelid just inferior to the eyelashes. Sutures are tied tightly to give a slight overcorrection, which are left to dissolve over 10 days, and scar tissue holds the retractors in place. The scar forms a barrier for the overriding preseptal orbicularis.[7]

Jones procedure

Plication of lower eyelid retractors [Figure 5]a and [Figure 5]b creates a barrier to the upward movement of preseptal muscles:[8].
Figure 5: (a) Right eye lower lid showing involutional entropion, (b) entropion corrected after lateral tarsal strip with retractor reinsertion in right eye

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  • Treatment of cicatricial entropion – lengthening of the posterior lamella

    1. Mild – tarsal fracture operation is done
    2. Moderate to severe – lysis of the scar tissue and lengthening of the posterior lamella using mucous membrane grafts.[9],[10]

  • Treatment of spastic entropion – Quickert procedure.

  Ectropion Top

Eyelid falls away or is pulled away from its normal apposition to the globe.

  • Sequelae:

    • Inadequate corneal protection
    • Tear drainage dysfunction
    • Chronic inflammation
    • Surface keratinization and metaplasia

  • Contributing factors are similar to entropion.

Clinical approach [11]

  • Horizontal eyelid laxity is tested as follows:

    1. Eyelid distraction test: manually pulling the eyelid away from the eyeball. Normally, lower eyelid should not move more than 6 mm off the eyeball
    2. Snap backtest: pulling the lower eyelid inferiorly toward the inferior orbital rim. Normally, eyelid will spring back into position without a blink. If laxed, eyelid will remain away from the eye for a period of time

  • Medial canthal tendon (MCT) laxity: eyelid is pulled laterally and a lateral excursion of inferior punctum more than 2 mm denotes MCT laxity
  • Lateral canthal tendon (LCT) laxity: identified grossly by a rounded contour of the lateral canthus. Lateral part of the eyelid is moved medially and displacement of the lateral canthus is noted. Displacement more than 2 mm denotes LCT laxity
  • Punctal eversion: examined under the slit lamp
  • Lower eyelid retractor disinsertion/laxity: eyelid is completely everted
  • Cicatricial changes: pull the eyelid upward
  • Eyelid position during mouth opening
  • Palpebral fissure height
  • Skin and conjunctiva: scars and tumors
  • Orbicularis tone: tested by forced closure of eyes, compared with other side also.


Causes of ectropion may be congenital or acquired. There are five types of acquired ectropion, namely involutional, cicatricial, paralytic, mechanical, and congenital.

  • Involutional ectropion usually occurs in the lower eyelid because of the effects of gravity on a horizontally lax lower eyelid
  • Cicatricial ectropion of the upper or lower eyelid occurs following loss of skin secondary to thermal or chemical burns, mechanical trauma, surgical trauma, or chronic actinic skin damage leading to shortening of anterior lamella, chronic inflammation of the eyelid from dermatologic conditions such as rosacea, atopic dermatitis, eczematoid dermatitis, or herpes zoster infections [Figure 6]a and [Figure 6]b
  • Paralytic ectropion occurs due to loss of orbicularis tone occurring as a result of paralysis of facial nerve, commonly seen following trauma, Bell's palsy, or following surgery to remove intracranial neoplasms such as acoustic neuroma
  • Mechanical ectropion usually caused by the effect of gravity or mass effect induced by bulky tumors of the eyelid. Fluid accumulation, herniated orbital fat, or poorly fitted spectacles may also be mechanical factors in lower eyelid ectropion
  • Congenital ectropion is rare and occurs usually in the lower eyelid. It occurs due to vertical deficiency of anterior lamella. Congenital ectropion may be isolated or associated with Down syndrome.
Figure 6: (a) Both eyes showing cicatricial ectropion in lower eyelid, (b) Ectropion correction after full thickness skin graft combined with lateral tarsal strip

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  Management Top

Treatment option depends on the predominant component of laxity, whether medial, lateral, or both; accordingly, single procedure or a combination of procedures can be used.

  Horizontal Laxity Top

  1. Lateral tarsal strip [Figure 7]: Lateral canthotomy is followed by lysis of inferior crus of lateral canthal tendon. A thin strip is fashioned from the lateral end of tarsus by removing the overlying skin, orbicularis, and conjunctiva. Depending on the amount of eyelid laxity, excessive redundant tarsus is excised. Lateral edge of the tarsus is then anchored to the periorbita lining the inner part of lateral orbital wall with a nonabsorbable suture-like 6-0 prolene [12]
  2. Bick's procedure: Full-thickness excision of the eyelid is done just medial to the lateral canthal angle. Resection of the eyelid in this location may cause rounding and medial displacement of the lateral canthal angle [13]
  3. Kuhnt–Szymanowski procedure [Figure 8]: This procedure is useful when there is excess of lower eyelid skin in addition to the horizontal laxity. Horizontal eyelid shortening + blepharoplasty: full-thickness pentagon excision is combined with excision of redundant skin [15]
  4. Lateral canthal tendon plication [Figure 9].
Figure 7: Lateral tarsal strip

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Figure 8: Kuhnt- Szymanowski's procedure

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Figure 9: Lateral canthal tendon placation

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  Medial Canthal Tendon Laxity Top

Medial canthal tendon plication

The canalicular part of medial canthal tendon is shortened by suturing the medial end of lower tarsal plate to the main part of medial canthal tendon with a buried nonabsorbable suture.

Punctal ectropion

See [Figure 10] for punctal ectropion.
Figure 10: Medial conjunctivoplasty

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  Paralytic Ectropion – management Top

Medial canthoplasty

See [Figure 11] and [Figure 12]a, [Figure 12]b, [Figure 12]c, [Figure 12]d for medial canthoplasty.
Figure 11: Medial canthoplasty

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Figure 12: (a and b) Right eye paralytic ectropion with lagophthalmos. (c and d) S/P medial canthoplasty with correction of lagophthalmos

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Fascial sling

See [Figure 13] for fascial sling.
Figure 13: Fascial sling

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  • To tackle exposure keratopathy
  • Decreases the visual field
  • Disfiguring.

  Cicatricial Ectropion-Management Top

  • Conservative management

    • Antiscar creams
    • Occlusive dressings: silicone gel sheet

    Cicatricial ectropion of the lower eyelid is usually treated in a three-step procedure:

    1. Vertical cicatricial traction is surgically released
    2. The eyelid is horizontally tightened with a lateral tarsal strip operation
    3. The anterior lamella is vertically lengthened via a midface lift or full-thickness skin graft.

Z-plasty: Done in localized scar. Either single/multiple Z-plasty can be done. Each Z increases the length of wound by 30% and redirects it by relaxing the area under tension [Figure 14].
Figure 14: Z- plasty

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  Eyelid Retraction Top

Normally, upper eyelid lies 1–2 mm below the superior limbus and lower eyelid margin just touches the inferior limbus.

Certain measurements are made to make a diagnosis:

  1. Position of the upper and lower eyelids in relation to the limbus
  2. Vertical palpebral fissure height
  3. Lagophthalmos
  4. Levator muscle function
  5. Exophthalmometry
  6. Assess ocular movements
  7. R/o Marcus Gunn Jaw-Winking phenomenon and Duane's retraction syndrome
  8. R/o pseudoretraction.

Pseudoretraction may be seen in cases of contralateral eyelid ptosis with a Hering effect. In the presence of unilateral ptosis, equal central nuclear outputs to both levator muscles may result in elevation and retraction of the previously normal opposite eyelid. Pseudoretraction of the elevated eyelid is suggested when on gently lifting the ptotic eyelid, the retracted eyelid returns to its normal resting position. Similarly, digital closure of the retracted eyelid results in elevation of the opposite ptotic eyelid.


Congenital acquired

  1. Neurogenic
  2. Mechanical
  3. Myogenic.

Primary congenital – either upper/lower eyelid or both

  • Diagnosis of exclusion
  • Retraction stable over time
  • Levator muscle fibers tend to extend more anteriorly
  • Management: only observation, surgery is deferred till 4 years of age unless retraction is severe and causing exposure of cornea.


  • Benign transient conjugate downward gaze in preterm infants
  • Pretectal or dorsal midbrain syndrome – collier sign
  • Facial nerve paralysis [14] – unopposed action of levator, following the loss of tone of orbicularis
  • Pinealoma
  • Hydrocephalus
  • Marcus Gunn syndrome
  • Aberrant regeneration of third nerve.
  • Orbital floor fracture/basilar artery disease.


  • Proptosis
  • Craniosynostosis
  • Myopia
  • Buphthalmos
  • Irritation from contact lens
  • Following orbital floor fracture/orbitotomy.


  • Thyroid eye disease [17]

  • Proposed mechanisms: orbital proptosis secondary to enlargement of the rectus muscles, levator and Müller's muscle infiltration with fibrosis, excessive sympathetic innervation, abnormal adhesions between the levator and adjacent tissues

  • Other important myogenic causes are postsurgical complications of vertical rectus muscle recessions, ptosis overcorrection.

  Management Top

Alternatives to surgery

Eyelid retraction associated with Graves' disease may show some improvement following the treatment of dysthyroidism.

  Surgical Top

Surgical correction of eyelid retraction is indicated when it causes exposure keratopathy and for cosmetic indications.

Cosmetic reasons are as follows:

Upper eyelid retraction correction

  1. Muller muscle recession with/without levator recession:After adequate anesthesia is achieved, the eyelid crease is incised and dissection continues through the orbicularis oculi muscle to the septum. The septum is identified and incised 1–2 mm above its insertion into the aponeurosis. Orbital fat can be gently pushed superiorly with cotton-tipped applicators. The inferior attachments of the aponeurosis are freed from the superior border of the tarsus. Dissection under the aponeurosis and above Müller's muscle is continued up to Whitnall's ligament. Müller's muscle is excised from the superior border of the tarsus up to the level of Whitnall's ligament. The position of the eyelid relative to the superior limbus is evaluated. The eyelid should be ptotic, and the procedure now becomes a ptosis repair. The aponeurosis may be advanced to tarsus or sutured directly to conjunctiva so that the eyelid margin lies at the appropriate height. Can be done transconjunctivally also
  2. Placement of spacers to lengthen the upper eyelid: Tarsus, autologous fascia, processed collagen, sclera were used for this purpose. Sclera was the most commonly used initially, but it caused eyelid thickening, cyst formation and had a potential risk of prion disease transmission. Later, Mersilene mesh was used. The primary problem associated with spacers in the upper eyelid is the obvious increased risk of corneal irritation and abrasion
  3. Full-thickness anterior blepharotomy – Koornneef procedure [Figure 15]a and [Figure 15]b:Surgical procedures in cases with thyroid eye disease are not performed until the ophthalmopathy is fully stabilized, which takes about 6–12 months. Until this time, botulinum toxin can be used as a reliable adjunct to the treatment of eyelid retraction. An average drop in the upper eyelid of 2–3 mm can be achieved with a transconjunctival injection of 2.5–5 units for about 3 months.
Figure 15: (a) Left eye congenital eyelid retraction. (b) S/P full-thickness blepharotomy

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Lower eyelid retraction

  1. Involutional lower eyelid retraction-eyelid tightening procedures such as lateral tarsal strip
  2. Cicatricial retraction may need anterior lamellar augmentation with a skin graft
  3. Lower eyelid retraction associated with thyroid-related orbitopathy can be managed by transconjunctival recession of lower eyelid retractors with/without the use of spacer materials.

Mild lower eyelid retraction can also be treated with fillers such as stabilized hyaluronic acid.

  Lagophthalmos Top

Causes of lagophthalmos

  1. Common cause – facial nerve paralysis
  2. Other causes – related to cicatricial changes of the eyelids due to chemical/thermal injury or disorders such as Stevens–Johnson syndrome
  3. Neurogenic eyelid retraction
  4. Exophthalmos in thyroid eye disease
  5. Proptosis of any etiology.


  • Main aim – to prevent exposure keratitis and reestablish eyelid function
  • Mainstay of treatment – intensive lubrication
  • Medical treatment:

    1. Botulinum toxin chemodenervation to induce a protective ptosis – 7.5 units of botulinum neurotoxin type A is injected into the levator muscle.[18]

  • Surgical procedures;

    1. Tarsorrhaphy and upper eyelid reanimation techniques including eyelid loading with gold weights and palpebral springs and thinner platinum loadings [19]
    2. Prosthetic replacement of the ocular surface ecosystem device provides a liquid bandage to protect the cornea from eyelid interaction and desiccation, in addition to improving vision.[20]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kemp EG, Collin JR. Surgical management of upper lid entropion. Br J Ophthalmol 1986;70:575-9.  Back to cited text no. 1
Jordan R. The lower-lid retractors in congenital entropion and epiblepharon. Ophthalmic Surg 1993;24:494-6.  Back to cited text no. 2
Aziz S, Bhatt PR, Lavy T, Dutton G. A simple correction for congenital tarsal kink associated with distichiasis. J AAPOS 2006;10:281-2.  Back to cited text no. 3
Kakizaki H, Selva D, Leibovitch I. Cilial entropion: Surgical outcome with a new modification of the Hotz procedure. Ophthalmology 2009;116:2224-9.  Back to cited text no. 4
Ahuero AE, Hatton MP. Eyelid malposition after cataract and refractive surgery. Int Ophthalmol Clin 2010;50:25-36.  Back to cited text no. 5
Lance SE, Wilkins RB. Involutional entropion: A retrospective analysis of the Wies procedure alone or combined with a horizontal shortening procedure. Ophthal Plast Reconstr Surg 1991;7:273-7.  Back to cited text no. 6
Quickert MH, Rathbun E. Suture repair of entropion. Arch Ophthalmol 1971;85:304-5.  Back to cited text no. 7
Jones LT. The anatomy of the lower eyelid and its relation to the cause and cure of entropion. Am J Ophthalmol 1960;49:29-36.  Back to cited text no. 8
Kersten RC, Kleiner FP, Kulwin DR. Tarsotomy for the treatment of cicatricial entropion with trichiasis. Arch Ophthalmol 1992;110:714-7.  Back to cited text no. 9
Sodhi PK, Yadava U, Mehta DK. Efficacy of lamellar division for correcting cicatricial lid entropion and its associated features unrectified by the tarsal fracture technique. Orbit 2002;21:9-17.  Back to cited text no. 10
Nerad JA. Techniques in Ophthalmic Plastic Surgery-E-Book: A Personal Tutorial. Elsevier Health Sciences 2012.  Back to cited text no. 11
Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol 1979;97:2192-6.  Back to cited text no. 12
Leone CR Jr. Repair of ectropion using the Bick procedure. Am J Ophthalmol 1970;70:233-5.  Back to cited text no. 13
Choi SJ, Park SH. Surgical treatment of facial paralysis by using static ancillary procedures. J Korean Soc Plast Reconstr Surg 1998;25:1531-9.  Back to cited text no. 14
Fox SA. A medical ectropion procedure. Arch Ophthalmol 1968;80:494-5.  Back to cited text no. 15
Bartley GB. The differential diagnosis and classification of eyelid retraction. Ophthalmology 1996;103:168-76.  Back to cited text no. 16
Wesley RE, Bond JB. Upper eyelid retraction from inferior rectus restriction in dysthyroid orbit disease. Ann Ophthalmol 1987;19:34-6, 40.  Back to cited text no. 17
Yücel OE, Artürk N. Botulinum toxin-A-induced protective ptosis in the treatment of lagophthalmos associated with facial paralysis. Ophthal Plast Reconstr Surg 2012;28:256-60.  Back to cited text no. 18
Silver AL, Lindsay RW, Cheney ML, Hadlock TA. Thin-profile platinum eyelid weighting: A superior option in the paralyzed eye. Plast Reconstr Surg 2009;123:1697-703.  Back to cited text no. 19
Dimit R, Gire A, Pflugfelder SC, Bergmanson JP. Patient ocular conditions and clinical outcomes using a PROSE scleral device. Cont Lens Anterior Eye 2013;36:159-63.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]

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  In this article
Congenital Entropion
Involutional Ent...
Spastic Entropion
Cicatricial Entr...
Horizontal Laxity
Medial Canthal T...
Paralytic Ectrop...
Cicatricial Ectr...
Eyelid Retraction
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