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Bilateral BRVO | Unusual Case and Lucky Patient

Over the past few months,  I have been following a patient who was unlucky to have bilateral (both eyes) branch vein occlusions, but lucky that neither has affected her vision.

How can that be?

Bilateral Vein Occlusion

Branch Vein Occlusion

Most of the time, a healthy patient may notice sudden vision loss in one eye.  Vision loss due to a BRVO is painless and occurs all of the sudden.

There are two types of retinal vein occlusions:

The mechanism is the same and the two differ mainly by the amount of retina involved.  The CRVO affects the entire retina whereas the BRVO affects half the retina or less.

Vision Loss in Vein Occlusions

Vision loss depends depends upon whether or not the macula is involved.  If the macula, the functional center of the retina, is involved, then there is usually noticeable vision loss.

In most cases, patients can no longer read when the macula is involved in cases of BRVO.

Though I don’t want to get into too much detail, patients with CRVO have much worse vision and the prognosis is not nearly as good compared to BRVO with regard to visual recovery.

Bilateral BRVO

As you look at the image, the areas involved are limited to the areas with the streaks of blood.  The blood leeches due to the corresponding vein becoming occluded.

Think of stepping on a garden hose.  Your foot is the point of occlusion and water will leak out between the spigot and your foot.

If this area of involvement includes the macular (which neither does), then significant vision loss is noticed.

Look carefully and notice that neither macula is involved.  The macula is normally darker as in these pictures.  The blood is just outside of the macula….explaining why there is no vision loss and, in fact, the patient is completely unaware of anything wrong.

Treatments are available if macular edema develops from a BRVO.

This does not happen very often.

Randall Wong, M.D.
Retina Specialist
Fairfax, Virginia, USA

 

Laser Vision Correction Turns 30

First Laser Vision Correction Performed 30 Years Ago

Laser Vision Correction Started 30 Years AgoThe first laser vision correction patient had PRK performed on one eye 30 years ago on March 25, 1988.  Vision correction procedures have been performed since the mid 1950s, but never before using a laser.

PRK (photorefractive keratectomy) is still performed today though LASIK has become the modern favorite, at least in the United States.

Innovative Idea

The idea to use a laser on human tissue began in 1983 with the publishing of a scientific paper proposing the idea.  The excimer laser had been already developed, but was used for industrial purposes to manufacture microelectronic devices and semi-conductors.

What if the precision of the excimer laser could be used to reshape the cornea, and hence, change the refractive power of the eye?

The team of researchers practiced and practiced, first on plastic blocks then on cadaver animal and human eyes.  Finally, the “procedure” was ready for live human testing.

How would they go about getting permission?

Mrs. Cassady Had Cancer

The first patient, Mrs. Cassady, to have laser vision correction had cancer of the eye socket.  Treatment for the cancer behind her eye was to include removal of the healthy eye.

Mrs. Cassady gave her permission to have PRK performed to her eye before the eye was to be removed.  The FDA agreed.

The laser surgery was successful and paved the way for eventual clinical trials for the excimer to be used clinically.

All thanks to the bravery of Mrs. Cassady.

PRK Develops into LASIK

PRK and LASIK (laser-assisted in situ keratomileusis) are very similar.  Both use the excimer laser to reshape the cornea to accurately change the refractive power of the eye.

The curvature of the cornea, along with a healthy tear film, is responsible for about 75% of the total focusing power of the eye.  Changes in the curvature are responsible for the “correction” using the laser.

While the visual results are essentially identical, LASIK requires formation of a corneal flap, whereas PRK does not.  The hinged flap, like a man hole cover is moved out of the way during the laser reshaping and then replaced.  In PRK the surface tissue is ablated and not replaced.  The corneal surface will heal by itself.

The corneal flap:

  • Allows for faster healing
  • Improves vision faster
  • Causes less discomfort

On the other hand…not all patients can have LASIK.   Patients who are considering LASIK must have a thick enough cornea for a flap to be created, that is, some patients with insufficient corneal thickness or too high a prescription can only consider PRK.

Randall Wong, M.D.
Retina Specialist
Fairfax, Virginia, USA

Pre-Retinal Boat Hemorrhage Proliferative Diabetic Retinopathy | Randall Wong, MD Retina Specialist

Vitreous Hemorrhage in a Patient with Diabetes

This a vitreous hemorrhage.  The patient has a 30+ year history of Type 1 diabetes, has had cataract surgery in both eyes and never had laser or vitreo-retinal surgery for treatment of her diabetic retinopathy.

Essentially, she has been doing very well.  I see her at least twice a year to insure there is no diabetic macular edema and no sign of proliferative diabetic retinopathy.

She has been complaining of a “pixelated” change to the vision of the left eye.  (Honestly, as I told her, I have no idea what “pixelated” means.)

Dilated Eye Examination

Her examination started off normally.  The essential information is as follows;

61 Year Old Female
Bilateral Cataract Surgery
Last Recorded A1C: 8.0
AM Sugar:  90

Vision:  20/20 OD (Right Eye)
20/25 OS (Left Eye)

IOP:  17 OD
20 OS

Every patient gets their pupils dilated so I can examine the retina.  Examination of the retina is paramount in patients with diabetes.

Of significance is that her vision was excellent!

Vitreous Hemorrhage

After dilating her pupils, I was able to diagnose a vitreous hemorrhage.  This is the cause for her “pixelated” vision.  For teaching purposes:

  • This is a photograph of the left retina
  • The scalloped areas are “boat hemorrhages” formed by blood trapped between the retina and the posterior vitreous.  Blood is trapped in a “pocket” between the surface of the retina and the posterior vitreous
  • The top areas are horizontal and “level” due to the effect of gravity – hence,  the “boat”
  • In the larger hemorrhage, notice that the underlying normal retinal blood vessel is hidden – gives you an idea of the actual location of the bleeding

Diagnosis of Proliferative Diabetic Retinopathy

There are many causes of vitreous hemorrhage, but the more likely cause is related to diabetic retinopathy, especially in the absence of a tear in the retina.

While almost every patient with diabetes will develop some early degree of diabetic retinopathy, far fewer develop proliferative diabetic retinopathy.

Proliferative diabetic retinopathy (PDR) is defined as the stage of diabetic retinopathy where abnormal blood vessels, aka “neovascularization,” form somewhere on the retina or elsewhere in the eye.

Neovascular blood vessels are extremely fragile and can bleed easily causing a vitreous hemorrhage.

Sometimes the blood mixes throughout the retina and sometimes, as in this case, the blood remains localized and a nice picture can be obtained.

Vitreous Hemorrhage

In this particular case, my job is to insure that the blood is from the diabetic retinopathy.  As I said above, a retinal tear could also cause a vitreous hemorrhage, so in the absence of a retinal tear or other problem, I can safely observe (i.e. do nothing and simply wait) to see if the hemorrhage resolves on it’s own.  If there were a tear, I would need to treat the tear.

I’ll see this patient back in a few weeks.  The best treatment for this stage of the disease is laser treatment (aka panretinal photocoagulation).

Laser may be attempted in the office if enough of the hemorrhage clears on it’s own.  If not, vitrectomy can remove the blood and laser be performed at the same time.

 

Symptoms of Macular Degeneration | Randall Wong MD Retina Specialist

Signs and Symptoms of Macular Degeneration

is the deterioration of the central portion of the retinathe macula, which is the area of the retina that controls visual acuity and color perception. Macular degeneration usually occurs in people over the age of 55 and is more common in people of northern European ancestry.

Symptoms of Macular Degeneration

The most common symptoms of macular degeneration are blurry vision, blind spots, and distortion.  

New distortion should always be examined and can be monitored at home with the use of the Amsler grid.

Blurriness, blind spots, and distortions are also common symptoms in the following eye diseases:

  • macular edema (swelling) from many causes
  • epiretinal membrane
  • macular hole
  • diabetic retinopathy

Distortion is a common symptom of a disease of the macula and is does not signify a particular disease (i.e. get examined).

The Macula

The macula provides our central “20/20” vision.  As you are reading this article, your eyes are moving to keep the text focused on your macula.  When you are staring at an object, you are focusing the object on your macula.

Macular degeneration can be wet or dry and both types progressively affect the central vision causing blurriness, blind spots, and distortions. However, the wet form causes more serious vision loss.

Retinal Degeneration

For reasons yet to be discovered, the macula degenerates with age.  There are probably environmental risk factors, such as smoking, which increases the chances of developing macular degeneration.

The vast majority, 90% of cases, are the dry variety, which causes very slow, yet progressive blurry vision.  Wet ARMD causes the development of abnormal blood vessels within the layers of the macula.  These blood vessels cause destruction of the normal retinal tissue and can leak fluid and bleed.

Regardless of the type of macular degeneration, the initial symptoms are the sameblurriness, blind spots, and distortion.  However, wet macular degeneration can destroy vision rapidlyin days or weeks.  

What Can You Do?

If you have symptoms such as persistent blurry vision, blind spots, and/or distortion, make sure you get a complete dilated eye examination. 

While there are many causes of blurry and distorted vision other than macular degeneration, you want to make sure that you get an early diagnosis so whatever eye condition is causing your visual symptoms, the proper treatment can be initiated early in the process.  

Early diagnosis and treatment of eye diseases may prevent or limit permanent vision loss.

 

Drusen and Macular Degeneration

Do Drusen Diagonse Macular Degeneration?

The simply answer is, no, not all patients with drusen have macular degeneration. Drusen can be associated with macular degeneration, but are not diagnostic of the disease.

In other words, a person can have drusen AND macular degeneration which means that the two conditions are associated because they can occur together, but the presence of drusen by themselves without other signs or symptoms does not mean macular degeneration is going to occur or is in the process of occurring.

What are Drusen?

Drusen are spots (lesions) that form in the layers of the retina. There are two types and can be “hard” or “soft.” based upon appearance.   The presence of a few small drusen is normal with advancing age.

Drusen can be found anywhere in the retina.  When they are located outside the macula, they are usually of no consequence and are not related to any disease, especially macular degeneration.  I am only concerned when they are located within the macula.

Unfortunately, most non-retina doctors do not mention that drusen away from the macula are of little consequence and can simply be a family trait.

When Should Macular Degeneration be Diagnosed?

Let’s take the scenario of a patient having only hard drusen and no other signs of macular degeneration such as pigment changes, fluid, or blood.

Is there vision loss?  If there is vision loss, the next thing I do is determine if there are reasons for it other than macular degeneration, such as cataracts.

When a patient has no vision loss or a loss of vision that is explained by something such as cataracts, I do not necessarily diagnose macular degeneration.

I know that many doctors DO diagnose macular degeneration every time they see drusen, and in my opinion, this is not correct or fair. Unnecessarily pronouncing this diagnosis to patients causes many people worry, anguish, and stress as they wait to go blind from a disease they do not have.

Best Test for Macular Degeneration Diagnosis

If there is any question about the diagnosis of macular degeneration, have your doctor order a fluorescein angiogram.

A fluorescein angiogram (FA) is the best test for a definitive diagnosis of  macular degeneration (ARMD).  The test is performed by a retinal specialist and each eye is injected with a dye (not iodine based) called fluorescein.  As the fluorescein dye travels through the retinas, pictures are taken which help the retinal specialist diagnose or rule out macular degeneration.

In cases of a positive diagnosis for macular degeneration, a fluorescein angiogram will also distinguish between wet ARMD and dry ARMD, so that the proper treatments can be undertaken as soon as possible.

All the best,

Randall Wong, M.D.
Retina Specialist
Fairfax, Virginia 22030

Gene Therapy Cures Blindness

Gene Therapy Prevents Blindness

Gene Therapy Cures BlindnessAn FDA panel has unanimously recommended approval of Luxturna, a new gene therapy for the treatment of two inherited retinal diseases which cause blindess.

The FDA will formally meet in January 2018 to officially decide if Luxturna (voretigene neparvovec) will be approved.  This may be the first gene therapy treatment used for eye disease.

Luxturna is manufactured by Spark Therapeutics and is intended to be used to treat patients with Leber’s Congenital Amaurosis (LCA) and retinitis pigmentosa 20.

Mutant Genes Produce Mutant Proteins

Both Leber’s Congenital Amaurosis (LCA) and retinitis pigmentosa 20 develop from a defective gene known as RPE65.

Genes produce proteins.

The defective gene can not produce a functioning protein necessary for the normal “vision cycle” to occur.

The “vision cycle” is the process whereby light is translated by the retina into electrical signals which are understood by the brain.

Both Leber’s Congenital Amaurosis and retinitis pigmentosa 20 can lead to blindness due to non-functioning vision cycles.  There is presently no cure or treatment for either disease.

Eye Injection

Luxturna, a one time treatment, will insert “normal” DNA into the retinal cells.   Luxturna will be injected into the eye to allow direct exposure to the retina.

The normal DNA will contain intact and functioning copies of RPE65 which will produce a normal protein.

Production of the normal protein should restore, or improve, the retina’s “vision cycle” and lead to improved vision.

FDA Fast Track

Spark Therapeutics has been able to achieve “Fast Track” status for Luxturna.  FDA reviews “fast track” applications as they have the potential to significantly impact the treatment of a disease.

In these cases, there is no present treatment.

Results submitted to the FDA include the mobility results of patients with the confirmed inherited retinal diseases.   The patients were subjected to a maze under varying lighting conditions.  The maze would change to prevent memorization.

In most situations, patients vision improved such that successful navigation through the mazes was achieved with only the equivalent of a nightlight.   Most patients have exhibited improvement lasting over a year.  The study includes patients maintaining improvement for 2-4 years.

Inherited retinal diseases are caused by over 220 known defective genes.  Retinitis pigmentosa 20 and LCA are two diseases caused by the same gene.

I should also point out that “retinitis pigmentosa” is a collection of diseases caused by variuos genes.  Luxturna will treat only retinitis pigmentosa 20.

All the best,

Randy

Total Eclipse of the Sun | Protect Your Eyes

Solar Eclipse | What You Need to Know

Total Eclipse of the Sun Can Cause Solar Retinopathy | Randall Wong, M.D. Retina SpecialistThe Great American Solar Eclipse 2017 is just around the corner.   Are you ready?

Here are some quick tips you will need to know to insure that your family and friends can enjoy this “once in a lifetime” event and protect their vision at the same time.

Total Eclipse of the Sun

Bonnie Tyler will sing “Total Eclipse of the Sun” while aboard a Royal Caribbean cruise ship.  The ship leaves from Miami and will be situated within the path of totality as it leaves the coast of South Carolina.

The path of totality starts in Oregon and moves eastward through South Carolina.  The path of totality is about 70 miles wide and will be the only area in the United States where a total eclipse of the sun will be experienced.

For 2 minutes and 4o seconds, those in the path of totality will essentially experience total darkness as the sun is completely blocked by the moon.

Those not within this 11 state swath will experience a partial eclipse.

Protect Your Eyes with ISO Filters

Sunglasses offer no protection from the damaging UV light of the sun.   Only ISO certified filters offer protection from direct sunlight.ISO 12312-2 Filters Protect Against Solar Retinopathy | Randall Wong, MD, Retina Specialist

ISO 12312-2 filters are used in “eclipse glasses” and solar viewers.  These filters are strong enough to allow direct visualization of the eclipse.

ISO filters are the only way to directly visualize the eclipse without risk of solar retinopathy.  Solar retinopathy is caused by the sun’s intense UV radiation causing damage to the rods and cones of your retina.

Symptoms of Solar Retinopathy

While gazing too long at the sun, UV damage to your retina is painless.  Symptoms of solar retinopathy include:

  • Decreased color perception
  • Blind spots in central vision
  • Distortion
  • Pain, especially when looking at bright lights
  • Redness and tearing, especially when looking at bright lights
  • Loss of vision in both eyes

Solar retinopathy can be permanent.  Blindness can occur.

Indirect Viewing is Safest

If you can not find certified ISO eclipse glasses, consider constructing your own pinhole camera.

Using simple materials found around the house (aluminum foil, white paper, tape, scissors), construct an easy to build pinhole camera.

A pinhole camera avoids direct sun light and, therefore, avoids any chance of developing permanent vision loss from solar retinopathy.

All the best,

Randy

 

 

Protect Your Eyes and Vision from Solar Eclipse | Randall Wong MD Retina Specialist

How to Watch the Eclipse Safely | Avoid Blindness

Are your prepared to watch the eclipse safely?

WARNING:  It’s never safe to stare directly at the sun or at an eclipse.

Here’s how you can safely view the upcoming eclipse without causing eye damage or blindness.

The Great American Eclipse 2017

A total eclipse of the sun will occur on August 21, 2017 in North America.  This may be a “once in a lifetime” opportunity to experience the “path of totality” – when the moon completely blocks the sun for about 3 minutes.

The “path of totality” is about 70 miles wide and will sweep eastward from Oregon to South Carolina.  For those viewing within this path, they will experience a total eclipse of the sun.  The sky will become a dark twilight.

The rest of the country will experience a partial eclipse – differing amounts of sunlight loss.

Next Total Solar Eclipse

Incidentally, the last total eclipse of the sun occurred on March, 2016 and could be experienced in Indonesia.  The next total eclipse of the sun will occur in South America, 2019.

For most of us, the Great American Eclipse 2017 will be the only practical opportunity to experience this unique astronomical event.

Solar Retinopathy Can Blind

Staring directly at the sun, including an eclipse, can blind you.  The light rays of the sun are strong enough to burn your macula.  The macula is the most sensitive portion of your retina.

Sun damage can permanently destroy your central vision.  This condition is called solar retinopathy.  There is no cure for solar retinopathy.

Never look or photograph the sun without use of special lenses which have been designed specifically for the sun.

Eclipse Glasses Safely Protect Retina

There is only one safe way to view the sun or eclipse.  The American Academy of Ophthalmology and the American Astronomical Society recommend the use of special lens filters, ISO 12312-2, which have been designed for sun viewing.

If your “eclipse glasses” or solar viewers are compliant with the ISO 12312-2 safety standard, you may view the sun or eclipse safely.

These filters are strong enough to block the harmful rays of the sun and are thousands of times stronger than the darkest sunglasses.

The filters are used in “eclipse glasses” and other solar viewers.  I have included a link to known telescope and solar-filter companies that manufacture eclipse glasses and handheld solar viewers.

It may be fun to construct a pinhole camera to indirectly, and safely, view the upcoming eclipse.  A pinhole camera uses simple materials found around the house and can be a fun and inexpensive way to enjoy the total eclipse of the sun.

Fireworks Cause Significant Eye Injuries | Randall Wong MD | Retina Specialist

Happy 4th July | Avoiding Eye Injuries

Fireworks Cause Significant Eye Injuries | Randall Wong MD | Retina Specialist4th of July means BBQs and fireworks.  It can be a fun holiday, but for thousands this year, bodily injury and eye injury will occur.

Injuries occur to both bystanders and the handlers of the celebratory explosives.   Unfortunately, fireworks are marketed as toys – implying safety, but as you read, fireworks can cause serious bodily injury and eye injury.

Here are some tips to avoid eye injuries from fireworks – for both you and your children.

Eye Injuries … Exploding

Significant and permanent damage can occur from a ruptured globe (ruptured eye), retinal detachment, chemical and thermal burns and corneal abrasions.

The American Academy of Ophthalmology reports that nearly 1300 eye injuries caused by fireworks occurred in 2014 as reported by emergency rooms.  There were barely 600 cases reported in 2012.

Spectators and Children Injured

Nearly half the injuries are sustained by spectators.  Of that, 35% are children under the age of 15.

Most eye injuries are caused by bottle rockets, firecrackers and sparklers.  The heat generated by sparklers can exceed 3000 F depending upon the fuel and oxidizer used which can cause significant burns and even ignite clothing.

The American Academy of Ophthalmology (AAO) and the American Optometric Association (AOA) recommend:

  • Discuss firework safety with your children and teens
  • Children should not be unsupervised around fireworks
  • Wear protective eyewear when handling any fireworks
  • Fireworks, matches and lighters should be stored securely away from children
  • Sparklers are dangerous – refrain from purchasing
  • View fireworks from at least 500 feet away, respect barriers
  • Report unexploded fireworks to professionals, do not touch

What to Do for a Fireworks Eye Injury

  • Call 911 or go to Emergency Room
  • Do not rub eyes or apply pressure
  • Do not rinse eyes
  • Do not remove any objects stuck in the eye

Happy fourth of July!  Celebrate responsibly and enjoy the holiday.  I wish you and your family a very safe holiday.

All the best,

Randy

Echo Voice Assistant

“Alexa, Read This” | Personal Voice Assistants Aid Low Vision Patients

amazon alexa | voice assistantThis article has been contributed by Paul Burden.  Paul’s mother suffers from wet macular degeneration.  Paul founded Our Voice after he discovered the advantages of personal voice assistants and how they can help blind or low vision patients such as his mom.  I am impressed with the variety of information and tasks a personal voice assistant, such as Amazon’s Echo, can perform.  Enjoy.  – Randy.

Personal Voice Assistants have fundamentally changed the way we use technology. A voice assistant can be especially beneficial for the blind and low vision community. It’s difficult to use and keep up with ever changing technology.

Voice Instead of Keyboard

With a voice assistant, there’s no more complicated software to learn and update; no keyboard, users simply speak. Using voice only, users can:

  • have their music played
  • get the latest headlines and weather
  • listen to their favorite radio stations and podcasts
  • have books read to them
  • do their shopping
  • manage their calendars
  • contact family and friends in case of an emergency
  • query the Internet for information
  • make and receive phone calls
  • and much more

Meet Amazon’s “Alexa”

There are several voice assistants on the market, but the Amazon Echo family of products is far and away the most widely used voice assistant with more than 70% market share.

The Echo’s voice is named Alexa.

Once the Echo is connected to your Wi-Fi, you have immediate access to a wide variety of information.  For example,

Just say, “Alexa, what are today’s headlines?”  Headlines are immediately read to you.

“Alexa, what’s the weather look like for tomorrow?” You’ll get tomorrow’s forecast, or the 10 day forecast if you like.

In addition to all the information immediately available, there are lots of Apps available as well. What you think of as an App on your smartphone or computer, is called a “skill” on the Echo. They’re the same thing.   A large number of skills are particularly useful for blind and low vision users. A few examples:

My Buddy Skill

“My Buddy” allows the user to call, text or email any number of designated “buddies” or family members.

If you find yourself in distress and need help, say: “Alexa, my buddy.” Alexa will ask: “Who do you want me to contact?” You reply, “My family.”

Your family can include as many members as you’d like.  Do you have 20 members of your family you’d like contacted?  All at once?  No problem.  The call/email/text goes out to all 20 simultaneously.

Shopping by Voice

You can shop from the comfort of your home, using your voice only. Amazon has nearly 500 million products in stock!

Down to your last roll of paper towels? Say, “Alexa, order paper towels.” Alexa will offer a few options, asking for your permission to place the order.

When you hear what you like and confirm, your order is placed. Your order will arrive in a day or two, frequently your order is delivered on the same day.

Would you like to know when your order will be delivered? Just say, “Alexa, where’s my stuff?”.  Alexa responds with the day and approximate time your order will be delivered.

“Alexa – Read This!”

Alexa will read books on your Kindle.  The books are read to the listener in Alexa’s own computer generated voice.

Amazon owns another electronic book service called Audible.  Audible works very well with the Echo family of products.  The listener can bookmark particular chapters, fast forward/rewind, pause, adjust volume and summon a different book.

Audible books are read by professional voices.  While most Echo skills are free, Audible is not.  Audible requires a monthly subscription of $14.99, allowing 2 books a month.  More books can be added.

What’s the Next Step?

While the Echo is very easy to use, it can be difficult to set up and configure. That’s where Our Voice comes in, we’re Amazon Echo experts. Our Voice is a company dedicated to making voice assistants available to everyone. Our Voice installs and configures the Echo for the specific needs of the customer. We then train the customer to use device so they get the most out of their voice assistant experience. To learn more about Our Voice, visit www.ourvoice.net or call toll free: 844-voice 13 – 844-864-2313.

Our Voice | Personal Voice Assistant ExpertsPaul Burden is the Founder of Our Voice; a company dedicated to bringing voice technology to the blind and low vision community.  Prior to Our Voice, Burden held executive positions at Microsoft, Cyveillance and XAPPmedia.  You may contact Paul at www.ourvoice.net

Randall V. Wong, M.D.

offices

Currently, I see patients with retinal diseases; macular degeneration, retinal detachment, macular holes, macular pucker within several different practices.....it's a different arrangement, but it allows more continuous care with many eye specialists. In addition, I am very accessible via the web. To schedule your own appointment, call any of the numbers below.

Virginia Lasik | Office of Anh Nguyen, M.D.
Randall V. Wong, M.D.
Contact: Layla

A: 431 Park Avenue, Suite 103 • Falls Church, Virginia 22046
Ph: 703.534. 4393
F:703.992.8158
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Dressler Ophthalmology Associates, PLC
Randall V. Wong, M.D.
Contact: Ashley (Surgery/Web)
Chrissy Megargee (Web)

A: 3930 Pender Drive, Suite 10 • Fairfax, Virginia 22030
Ph: 703.273.2398
F: 703.273.0239
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