Inferior Oblique Myokymia

Inferior oblique myokymia is a rare eye movement disorder where a small muscle under the eye (the inferior oblique muscle) twitches by itself without you wanting it to. “Inferior” means it is the lower muscle, “oblique” means it runs at an angle, and “myokymia” means “muscle quiver” or “twitch.” When this muscle twitches, you may feel brief jumps or wobbles in your vision. Myokymia does not usually harm your eye permanently, but it can be annoying and make tasks like reading or driving hard.

Inferior Oblique Myokymia is a rare, benign eye movement disorder in which the inferior oblique muscle of one eye contracts in fast, fine bursts. Patients typically describe brief episodes—lasting seconds to minutes—of vertical or torsional “shimmering” of vision, often triggered by looking up and out EyeWiki. The exact cause is unknown (idiopathic), but it’s thought to result from spontaneous, excessive firing of the muscle’s motor units, rather than nerve compression EyeWiki. Although frightening, most cases improve on their own, and serious complications are exceedingly rare.

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Anatomy

The inferior oblique muscle is one of six muscles that move your eyeball. It sits under the eye and helps you look upward and rotate your eye outward (toward your temple). When this muscle fires, it pulls the bottom of your eye back and up.

• Muscle: soft tissue that can tighten (contract) and relax to move parts of your body.

• Eyeball movement: how your eye turns in different directions.

When the inferior oblique muscle twitches, you see small, fast jumps. Imagine looking through a camera that keeps shaking — that’s what your vision feels like.

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Types of Inferior Oblique Myokymia

Health experts often divide this condition into a few simple groups based on why it happens.

1. Idiopathic Myokymia

   • Idiopathic means “we do not know why.”

   • This is the most common type. The muscle twitches without any clear disease or injury behind it.

2. Secondary Myokymia

   • Secondary means it happens because of another problem.

   • For example, a nerve injury, an infection, or a growth near the eye can trigger twitches.

3. Drug‐Induced Myokymia

   • Certain medicines or substances can make muscles twitch more.

   • If you start a new drug and then the twitching begins, that drug may be the cause.

4. Stress‐Related Myokymia

   • High stress or anxiety can make muscles tighten and twitch.

   • When you are very tired or worried, your body may react by extra muscle activity.

Each type uses the same muscle but has a different trigger. Identifying the type helps doctors decide how to treat it.

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Possible Causes

Below are twenty different things that can make the inferior oblique muscle twitch. Each cause is a simple idea you can understand.

1. Unknown Origin (Idiopathic)

   • No clear reason. Muscles sometimes twitch for no known cause.

2. Multiple Sclerosis

   • A disease where the body’s own defenses harm nerves. Damaged nerves may fire on their own.

3. Brainstem Tumor

   • A growth in the base of the brain can press on nerves serving the eye, causing twitches.

4. Aneurysm

   • A bulge in a blood vessel near the eye can press on nerves and cause irritation.

5. Stroke or Ischemia

   • When blood flow to part of the brain is blocked, the nerve may misfire.

6. Neurosarcoidosis

   • A rare condition where lumps of immune cells form in nerves, triggering twitches.

7. Diabetes‐Related Neuropathy

   • High blood sugar can damage nerves, making them fire unexpectedly.

8. High Blood Pressure (Hypertension)

   • Stresses small blood vessels around nerves, causing irritability.

9. Thyroid Problems

   • An overactive or underactive thyroid can upset body chemistry, leading to muscle twitching.

10. Electrolyte Imbalance

    • Low minerals like magnesium or potassium can make muscles twitch more.

11. Caffeine Overuse

    • Too much coffee or energy drinks overstimulates nerves and muscles.

12. Alcohol Withdrawal

    • Stopping heavy drinking can make nerves fire more than usual.

13. Sleep Deprivation

    • Lack of sleep makes nerves and muscles more irritable.

14. Stress and Anxiety

    • Heightened stress triggers muscle tension and spontaneous twitching.

15. Fatigue

    • General tiredness wears down nerve control, so muscles twitch.

16. Certain Medications

    • Drugs like stimulants, some antidepressants, or anti‐seizure medicines may cause twitches.

17. Ocular Trauma

    • An injury to the eye or eyelid can irritate muscles.

18. Orbital Mass Lesion

    • A benign or malignant growth in the eye socket pressing on muscles or nerves.

19. Post‐Viral Syndrome

    • After a viral illness, nerves may remain irritable for a time.

20. Nutritional Deficiency

    • Lack of vitamins (especially B vitamins) can impair nerve health and cause twitching.

Each of these ideas shows a way that nerves controlling the inferior oblique muscle can become over‐active or irritated.

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Common Symptoms

Symptoms are what you feel or notice. Here are fifteen things people with inferior oblique myokymia often experience.

1. Visual “Jumps”

   • Sudden, tiny shifts or jumps in your sight, as if the image is bouncing.

2. Oscillopsia

   • A fancy word meaning the world looks like it is moving back and forth.

3. Blurred Vision

   • For a few seconds, things may look fuzzy because the eye moved without your control.

4. Intermittent Twitching

   • You feel the muscle twitch quickly on and off in bursts.

5. Eye Fatigue

   • Your eye muscles feel tired and ache after Twitching episodes.

6. Diplopia (Double Vision)

   • Seeing two of the same object when the muscle movement shifts your eye slightly.

7. Headache

   • A mild headache can come from extra muscle strain around the eye.

8. Brow Ache

   • Discomfort above the eye or near the eyebrow from muscle tension.

9. Nausea

   • If your vision jumps too much, you may feel queasy as your brain tries to keep up.

10. Photophobia

    • Bright light bothers you more when your eye is twitching.

11. Difficulty Reading

    • Small print moves around, making it hard to follow lines of text.

12. Eye Discomfort

    • A general sense of unease or pressure around the twitching muscle.

13. Stress and Worry

    • Knowing your eye is twitching may make you anxious, which can worsen symptoms.

14. Interference with Driving

    • Twitches can happen when you look at a moving road, making you feel unsafe.

15. Trouble with Fine Tasks

    • Activities like threading a needle or detailed crafts become harder as your vision jitters.

People may have just a few of these signs, or they may have many at once. Doctors ask about which symptoms bother you most.

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Diagnostic Tests

To find out if you have inferior oblique myokymia and what might be causing it, doctors use different tests. They check your eyes, your nerves, your blood, and even take pictures of your brain and eye socket. Here are twenty tests divided into five groups.

1. Physical Exam

1. Visual Acuity Test

   • You read letters on a chart. This checks how well you see sharp details.

2. Eye Movement Exam

   • The doctor asks you to follow a moving target. This shows any uncontrolled twitching.

3. Cover/Uncover Test

   • Cover one eye and then uncover it. This finds small eye misalignments.

4. Pupillary Light Reflex

   • A light shines into your eye to see how your pupil (black circle) constricts. This tests nerve function.

2. Manual Tests

5. Forced Duction Test

   • The doctor gently moves your eye with a tool to see if the muscle is tight or stuck.

6. Hess Screen Test (Hess Charting)

   • You look at dots on a screen with each eye separately. This maps eye muscle strength.

7. Subjective Perimetry

   • You press a button when you see small lights in different parts of your vision. This checks visual fields.

8. Bielschowsky Head Tilt Test

   • Tilting your head can reveal subtle over‐action or under‐action in certain eye muscles.

3. Laboratory and Pathological Tests

9. Blood Sugar (Glucose) Test

   • Measures sugar in your blood. High or low levels can harm nerves.

10. Thyroid Function Panel

    • Checks hormones from your thyroid gland. Imbalance can cause twitching.

11. Electrolyte Panel

    • Measures minerals like magnesium and potassium that keep nerves stable.

12. Autoimmune Panel

    • Tests for antibodies that might attack nerves (e.g., in multiple sclerosis or neurosarcoidosis).

4. Electrodiagnostic Tests

13. Electromyography (EMG)

    • Small needles record electrical activity in the inferior oblique muscle to see if it is firing on its own.

14. Nerve Conduction Study

    • Measures how fast electrical signals travel along the oculomotor nerve that controls the inferior oblique muscle.

15. Visual Evoked Potential (VEP)

    • Sensors on your scalp record brain responses to visual patterns, checking the path from eye to brain.

16. Blink Reflex Test

    • A small shock near the eye triggers blinking; sensors measure nerve reflex speed.

5. Imaging Tests

17. Magnetic Resonance Imaging (MRI) of Brain and Orbit

    • Uses magnets and radio waves to take detailed pictures of your brainstem and eye socket.

18. Computed Tomography (CT) Scan

    • X‐rays create cross‐section images of bone and soft tissue around the eye.

19. Magnetic Resonance Angiography (MRA)

    • A special MRI that looks at blood vessels near the eye for aneurysms or blockages.

20. Orbital Ultrasound (B‐Scan)

    • High‐frequency sound waves create a real‐time picture of the eye and muscles.

Non-Pharmacological Treatments

Therapies and other interventions that relieve symptoms without drugs

1. Warm Compress Therapy

   • Description: Place a clean, warm (not hot) cloth over closed eyelids for 10–15 minutes.

   • Purpose: Relaxes extraocular muscles and improves local blood flow.

   • Mechanism: Heat dilates small blood vessels and reduces muscle tension Zeiss.

2. Cold Compress Therapy

   • Description: Apply a cool gel mask or chilled cloth for 5–10 minutes.

   • Purpose: Temporarily numbs muscle spasm and reduces inflammation.

   • Mechanism: Cold constricts blood vessels, decreasing nerve excitability.

3. Stress Management & Relaxation

   • Description: Techniques such as deep breathing, progressive muscle relaxation, or guided imagery.

   • Purpose: Lowers overall nervous system arousal, reducing muscle hyperexcitability.

   • Mechanism: Activates parasympathetic (“rest-and-digest”) pathways, dampening involuntary muscle firing.

4. Biofeedback

   • Description: Using sensors to monitor eye-muscle activity and learning to control it.

   • Purpose: Empowers patients to consciously suppress twitch onset.

   • Mechanism: Neurofeedback modulates cortical control over ocular motor neurons.

5. Cognitive Behavioral Therapy (CBT)

   • Description: Psychotherapy focusing on stress and trigger identification.

   • Purpose: Teaches coping strategies to minimize episodes.

   • Mechanism: Alters stress response circuitry to reduce sympathetic overdrive.

6. Acupuncture

   • Description: Fine needles placed around the orbit and forehead.

   • Purpose: May reduce frequency of muscle contractions.

   • Mechanism: Stimulates endorphin release and modulates neurotransmitter balance.

7. Acupressure

   • Description: Manual pressure on periocular points (e.g., “Taiyang” point).

   • Purpose: Provides temporary relief of spasm.

   • Mechanism: Mechanical stimulation may interrupt aberrant nerve signals.

8. Yoga & Meditation

   • Description: Regular practice of gentle yoga poses and mindfulness meditation.

   • Purpose: Improves overall stress resilience.

   • Mechanism: Reduces cortisol levels and sympathetic tone.

9. Orthoptic (Eye-Muscle) Exercises

   • Description: Guided saccades and convergence/divergence drills.

   • Purpose: Strengthens and co-ordinates extraocular muscle function.

   • Mechanism: Promotes balanced motor unit recruitment.

10. Gentle Ocular Massage

    • Description: Light circular massage over closed lids and around the orbital bone.

    • Purpose: Relaxes superficial muscles and fascia.

    • Mechanism: Mechanical relaxation of myofascial tension.

11. Vision Therapy with Saccadic Training

    • Description: Computer-guided rapid eye-movement tasks.

    • Purpose: Trains neural circuits to suppress involuntary oscillations.

    • Mechanism: Neuroplastic adaptation of oculomotor pathways.

12. Prism Lens Therapy

    • Description: Fresnel prisms applied to spectacles.

    • Purpose: Redirects visual input to reduce torsional perception.

    • Mechanism: Optical compensation masks the perceived oscillopsia.

13. Occlusion Therapy

    • Description: Partial occlusion with Bangerter filters or eye patches during peak episodes.

    • Purpose: Temporarily blocks vision in the affected eye, halting symptoms.

    • Mechanism: Eliminates visual feedback that can trigger or reinforce spasms.

14. Transcutaneous Electrical Nerve Stimulation (TENS)

    • Description: Low-level electrical stimulation near the periorbital area.

    • Purpose: Interrupts hyperactive motor signals.

    • Mechanism: Gate-control of nerve conduction reduces firing.

15. Thermal Contrast (Hot-Cold Alternation)

    • Description: Alternating warm and cool compresses in 2-minute cycles.

    • Purpose: Fluctuates blood flow to discourage sustained muscle overactivity.

    • Mechanism: Repeated vasodilation/constriction modulates nerve excitability.

16. Sleep Hygiene Optimization

    • Description: Regular bedtime routine, blackout shades, no screens before sleep.

    • Purpose: Ensures deep restorative sleep, reducing fatigue-provoked twitching.

    • Mechanism: Minimizes central nervous system irritability.

17. Screen-Time Reduction & 20-20-20 Rule

    • Description: Every 20 minutes, look 20 feet away for 20 seconds.

    • Purpose: Prevents digital eye strain that can precipitate spasms.

    • Mechanism: Relieves continuous near focusing effort on extraocular muscles.

18. Hydration & Electrolyte Balance

    • Description: Drink adequate water and consume electrolyte-rich fluids.

    • Purpose: Optimizes neuromuscular function.

    • Mechanism: Prevents dehydration-induced nerve hyperexcitability.

19. Ergonomic Workstation Setup

    • Description: Proper monitor height, ambient lighting, chair support.

    • Purpose: Reduces neck and eye-muscle strain.

    • Mechanism: Maintains neutral head posture, minimizing compensatory ocular muscle use.

20. Lifestyle Modifications (Caffeine & Alcohol Avoidance)

    • Description: Limit coffee, tea, energy drinks, and alcohol.

    • Purpose: Avoid stimulants that exacerbate muscle twitching.

    • Mechanism: Prevents sympathetic overactivation of motor units Wikipedia.

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Drug Treatments

Evidence-based medications used off-label or by analogy to superior oblique myokymia

Many of these drugs are used off-label for IOM based on similarities to superior oblique myokymia treatments. No single medication works for everyone; choice depends on individual response and side-effect profile.

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Dietary Molecular & Herbal Supplements

Potential supportive agents that modulate neural excitability or reduce inflammation

1. Magnesium Citrate (400 mg/day)

   • Function: Muscle relaxant, reduces neuromuscular hyperexcitability.

   • Mechanism: NMDA receptor antagonism and Ca²⁺ channel blockade Wikipedia.

2. Magnesium L-Threonate (144 mg elemental Mg/day)

   • Function: Crosses blood–brain barrier for central neuroprotection.

   • Mechanism: Stabilizes synaptic membranes, modulates neuronal firing.

3. Riboflavin (Vitamin B₂, 100 mg/day)

   • Function: Supports mitochondrial energy metabolism.

   • Mechanism: Cofactor in electron transport chain, reduces neuronal irritability.

4. Pyridoxine (Vitamin B₆, 50 mg/day)

   • Function: Precursor to GABA.

   • Mechanism: Enhances GABA synthesis, inhibiting motor unit overactivity.

5. Coenzyme Q10 (100 mg/day)

   • Function: Antioxidant, improves mitochondrial function.

   • Mechanism: Scavenges free radicals, preserves neuronal integrity.

6. L-Theanine (200 mg/day)

   • Function: Promotes relaxation without sedation.

   • Mechanism: Increases brain GABA, dopamine, and serotonin levels.

7. Taurine (500 mg twice daily)

   • Function: Inhibitory neurotransmission support.

   • Mechanism: Modulates GABA_A receptors, stabilizes membrane potentials.

8. N-Acetylcysteine (600 mg twice daily)

   • Function: Antioxidant, reduces excitotoxicity.

   • Mechanism: Precursor to glutathione, modulates glutamate release.

9. Melatonin (3 mg at bedtime)

   • Function: Improves sleep quality.

   • Mechanism: Regulates circadian rhythm, increases relaxation.

10. Valerian Root (600 mg at bedtime)

    • Function: Mild sedative properties.

    • Mechanism: Enhances GABAergic transmission.

11. Passionflower (250 mg twice daily)

    • Function: Reduces anxiety and muscle tension.

    • Mechanism: Modulates GABA_A receptors.

12. Chamomile Extract (500 mg twice daily)

    • Function: Anti-inflammatory, mild relaxant.

    • Mechanism: Flavonoids bind GABA_A receptors.

13. Ashwagandha (Withania somnifera, 300 mg twice daily)

    • Function: Adaptogen, stress modulation.

    • Mechanism: Reduces cortisol, supports GABA activity.

14. Omega-3 Fatty Acids (EPA/DHA, 1000 mg/day)

    • Function: Anti-inflammatory, neuromembrane stabilization.

    • Mechanism: Alters neuronal membrane fluidity and signaling.

15. Curcumin (500 mg twice daily)

    • Function: Potent antioxidant and anti-inflammatory.

    • Mechanism: Inhibits NF-κB and COX-2 pathways.

Note: Always discuss supplements with your healthcare provider to avoid interactions with prescribed medications.

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Regenerative & Stem-Cell-Related Therapies

Experimental or theoretical approaches aimed at neuro-muscular repair

1. Cenegermin (Recombinant Human Nerve Growth Factor)

   • Dosage: 20 µg/ml ophthalmic solution, one drop six times daily for 8 weeks.

   • Function: Promotes survival and regeneration of ocular motor neurons.

   • Mechanism: Binds TrkA receptors, enhancing neurotrophic support.

2. Platelet-Rich Plasma (PRP) Injection

   • Dosage: 1 ml periorbital injection monthly for 3 months.

   • Function: Delivers concentrated growth factors for tissue repair.

   • Mechanism: PDGF, TGF-β, and VEGF release promotes muscle healing.

3. Autologous Mesenchymal Stem Cell (MSC) Therapy

   • Dosage: 5×10⁶ cells per injection, peri-orbital, three injections over 6 weeks.

   • Function: Paracrine secretion of neuroprotective cytokines.

   • Mechanism: MSCs modulate inflammation and secrete BDNF, GDNF.

4. Erythropoietin (EPO)

   • Dosage: 300 IU/kg IV daily for 5 days.

   • Function: Neuroprotective, anti-apoptotic.

   • Mechanism: Activates EPO receptors on neurons, reducing oxidative stress.

5. Insulin-Like Growth Factor 1 (Mecasermin)

   • Dosage: 0.04 mg/kg subcutaneously twice daily.

   • Function: Stimulates muscle and nerve growth.

   • Mechanism: Binds IGF-1 receptor, promoting protein synthesis and axonal repair.

6. 7,8-Dihydroxyflavone (BDNF Mimetic)

   • Dosage: 5 mg/kg orally once daily for 4 weeks.

   • Function: Enhances neurotrophic support.

   • Mechanism: Activates TrkB receptors, supporting neuronal survival.

These regenerative approaches remain investigational; consult a specialist before considering off-label or research protocols.

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Surgical Procedures

Reserved for refractory, severe cases

1. Inferior Oblique Myectomy

   • Procedure: Partial removal of inferior oblique muscle fibers.

   • Why: Weakens muscle to reduce hypercontractions.

2. Inferior Oblique Recession

   • Procedure: Detach and re-insert muscle further back on the globe.

   • Why: Permanently decreases muscle leverage and excursion.

3. Inferior Oblique Anterior Transposition

   • Procedure: Move muscle insertion anteriorly relative to inferior rectus.

   • Why: Alters muscle vector to reduce torsional pull.

4. Tenotomy

   • Procedure: Surgical cutting of the inferior oblique tendon.

   • Why: Immediately disrupts aberrant contractile force.

5. Orbital Decompression (Rarely used)

   • Procedure: Remove small bone segments to relieve orbital pressure.

   • Why: Indirectly reduces mechanical stress on extraocular muscles.

Surgical success varies; patients often require extensive preoperative counseling.

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Prevention Strategies

1. Limit Caffeine & Stimulants

2. Prioritize Stress Reduction (meditation, therapy)

3. Maintain Good Sleep Hygiene

4. Ensure Proper Hydration

5. Avoid Alcohol & Tobacco

6. Schedule Regular Eye Breaks (20-20-20 rule)

7. Use Ergonomic Workstations

8. Monitor & Manage Triggers (e.g., pyridostigmine)

9. Wear Sunglasses in Bright Light (reduce glare)

10. Have Annual Eye Exams (rule out underlying pathology)

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When to See a Doctor

Seek evaluation if you experience:

• Episodes lasting longer than 1 minute or occurring multiple times daily

• New onset of pain, drooping eyelid, or vision changes

• Associated diplopia (double vision) that affects daily activities

• Lack of improvement after 4–6 weeks of conservative measures Eureka Health.

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Diet: What to Eat & What to Avoid

Eat:

• Leafy greens (spinach, kale) for magnesium and B vitamins

• Nuts & seeds (almonds, sunflower seeds)

• Fatty fish (salmon, mackerel) for omega-3s

• Whole grains (oatmeal, brown rice)

• Lean proteins (chicken, legumes)

• Berries & citrus fruits for antioxidants

Avoid:

• High-caffeine beverages (coffee, energy drinks)

• Excessive sugar and processed foods

• Alcohol and tobacco products

• Monosodium glutamate (MSG)

• Artificial colorings and preservatives

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Frequently Asked Questions

1. What exactly is inferior oblique myokymia?
   A benign condition of fine, rapid contractions of one eye’s inferior oblique muscle, causing momentary “shimmering” vision EyeWiki.

2. Is it dangerous?
   No—most cases resolve spontaneously or with conservative therapy. Serious complications are extremely rare.

3. How long do episodes last?
   Typically seconds to a minute, though some may persist several minutes before stopping.

4. What triggers it?
   Looking up/out, stress, fatigue, caffeine, and eye strain are common triggers Wikipedia.

5. Can stress cause it?
   Yes; emotional or physical stress can heighten nerve excitability and precipitate episodes.

6. Will it go away on its own?
   Many patients experience spontaneous improvement within weeks to months.

7. Are eye exercises helpful?
   Orthoptic and vision-therapy exercises can strengthen muscle co-ordination and reduce spasms.

8. When is surgery needed?
   Only in severe, drug-resistant cases that significantly impair vision and quality of life.

9. Can medications cure it?
   No cure exists, but anticonvulsants and muscle relaxants often reduce frequency and intensity.

10. Do supplements really help?
    Supplements like magnesium and B vitamins may support neuromuscular health, though evidence is anecdotal.

11. Is there a genetic component?
    Currently, no hereditary pattern is known—most cases are idiopathic.

12. Can it lead to permanent vision loss?
    No; there’s no evidence that IOM damages ocular structures or leads to lasting vision impairment.

13. What tests confirm the diagnosis?
    Clinical observation and video-oculography suffice; MRI is usually normal.

14. Should I avoid driving?
    If episodes are frequent or impair vision, refrain until symptoms are controlled.

15. What specialists treat this?
    Neuro-ophthalmologists or strabismus specialists have the most experience managing IOM.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: August 07, 2025.

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