LASIK Laser Eye Surgery

LASIK Laser Eye Surgery: Procedure, Recovery, and Side Effects

LASIK or Laser, In-Situ Keratomileusis is a common surgery used for correcting vision in those suffering from nearsightedness, farsightedness or astigmatism. LASIK implies the use of a laser surgery to reshape the cornea. The laser beam is applied in situ beneath the corneal flap. The procedure utilizes a specialized laser known as the excimer laser to correct refractive errors. This surgery also improves vision and checks the need for glasses or contact lenses. It changes the shape of the cornea, which is the transparent front covering of the human eye. The excimer laser has been used for many decades now. The LASIK surgery was specifically credited to Ioannis Pallikaris, a Greek inventor around 1991.

Procedure

Before: How to Prepare

Before the LASIK eye surgery is carried out, you generally meet a coordinator or the surgeon to agree regarding the procedure. Following this, your medical history is assessed, and the eyes are completely examined. Initial tests include refraction, corneal thickness, air pressure, corneal mapping, and pupil dilating. Once the initial assessment is completed, the surgeon will ask for any queries you may have. If rigid permeable contact lenses are worn, they should be left out at least three weeks prior to the evaluation. Other kinds of lenses should not be donned three days before the evaluation. Check with the surgeon by showing your glass prescription for review.

On the appointed surgery day, a light meal should be consumed before going to the doctor and taking prescribed medications. Eye makeup should not be worn. Neither should there be bulky accessories in the hair that interfere with head positioning.

What Happens During the Surgery?

During a LASIK process, a trained and skilled eye surgeon performance the surgery by creating a precise, corneal flap through the use of a micro-keratose. The flap is pulled back to reach the underlying corneal tissue and the reshaping of the cornea in a pre-specified unique pattern for each individual. The gentle repositioning of the flap follows onto the cornea. No sutures are needed.

The micro-keratome (also known as the femtosecond laser) creates a thin flap in the cornea. Once the cornea is reshaped, it can focus light onto the retina. Once the flap is positioned back, the surgery is over. The LASIK surgery does not require general anesthesia– local will do. Patients may also need mild sedatives and support after surgery.

Kinds of Surgery for Correcting Refractive Error

Wavefront Optimized LASIK

Kinds of Surgery for Correcting Refractive Error
Photo By: Peretz Partensky/ CC BY

Wavefront-optimized LASIK refers to the type of laser surgery which uses wavelength laser. The surgery is carried out based on factors like:

  • Glass prescription
  • Corneal Curvature
  • Thickness

This form of refractive surgery applies energy in a unique fashion to the corneal periphery. Laser reduces complications such as glares, halos and night based vision problems characteristic of conventional treatments. This type of LASIK surgery is also referred as custom or wavefront LASIK. The advantage of this variant is that not only is the basic refractive error of the patient corrected, higher order visual problems can also be treated. In wavefront-guided LASIK, a special mapping is needed prior to surgery for irregularities in the optical system of the patient. The factors can impact:

  • Night vision
  • Contrast Sensitivity
  • Vision Quality

Significant irregularities in the wavefront mapping can be corrected using this type of LASIK surgery. Treatment is on the basis of generation of the wavefront map.

Other types of refractive surgeries include advanced surface ablation, phakic intraocular lenses, conductive keratoplasty, inter corneal ring segments. These laser vision correction surgeries work by reshaping the cornea. LASIK is one of many refractive surgeries to correct the shape of the cornea.

Advantages of LASIK Surgery

The first and primary consideration is that LASIK surgery works really well to correct vision. Close to 96% of the patients get their desired vision following LASIK. LASIK surgery is also extremely pain-free. Vision is corrected immediately or the day following LASIK. No bandage or stitches are required once LASIK is completed.

Adjustments can be carried out after LASIK to further correct vision, with changes in age. Once LASIK surgery is carried out, patients may even no longer need eyeglasses or contact lenses. Though LASIK surgery is technically complex, very few risks are associated with it.

 

Recovery & Side Effects

Recovering from LASIK surgery in the first 1 day to 2 days is sometimes associated with discomfort. Side effects, if any, are extremely rare. These include glare, seeing halos around images, difficulty at driving in the night, fluctuation in vision and dry eyes.

Following LASIK surgery, eyes will dry up though they do not feel that way. Prescription eye drops will be needed to counter infection and inflammation. Eyedrops should keep your eyes filled with the right amount of moisture. Drugs may cause slight blurring or burn when used. Only use eye drops prescribed by your eye doctor. Rapid healing takes place after LASIK eye surgery. For a few days following the surgery, the vision may be hazy and blurry. Follow-ups will be based on the decision of your surgeon, though generally the doctor is revisited for evaluation 24-48 hrs after the surgery. The surgeon also reviews the situation within the beginning 6 months at regular intervals.

Advantages of LASIK Surgery
Photo By: Rogermommaert/ CC BY

LASIK along with PRK and LASEK has high success rate and assured safety. Treating myopia, hypermetropia and astigmatism are now easy. Live without glasses or contacts with LASIK surgery to see you through. Loss of vision from this surgery is extremely rare. Side effects and surgery complications, if any, can be resolved with extra surgery or medical care.

There are potential risks and side effects you should be aware of, though. Choose a skilled and experienced LASIK eye surgery expert for the best outcomes. He/she should perform the evaluation carefully including checking the shape and thickness of the cornea to check for dry eyes. General health and medical history, as well as medications being taken, are considered. But not every person is a suitable candidate for LASIK eye surgery. Specific conditions and anatomical factors can raise the risk of unwanted outcomes or limited LASIK results. This can range from thinness and irregularity of cornea to large pupils. High refractive error, unable vision, and dryness in the eyes can also be deterrents. Complications are more likely with advanced age, pregnancy and certain autoimmune disorders like lupus.

LASIK eye surgery was introduced more than 2 decades ago. It is one of the safest eye procedures with serious complications below 1 percent. The top candidates are those with mild to moderate vision problems and adequate corneal thickness. It takes 10 minutes per eye and results in 20/20 vision without glasses or contact lenses. Recovery time is a few weeks to several days for the stability of vision.

Side Effects and Risks

Slight, short-lived discomfort and vision problems may result. Discomfort may occur post surgery such as mild irritation and light problems. This is normal and expected. Halos, star-bursts, and glares in low lit environments, dryness of the eye and hazy vision ,as well as reduced sharpness of visual acuity, may be noted. Such problems generally go away by 3-6 months.

Flap difficulties can result if the LASIK is not performed correctly. It can fail to stick to the surface of the eye or striae; fine wrinkles could also develop in the flap. These flap complications cause optical aberrations and distortions in vision. Flap problems impact less than 0.3 to around five percent of all such procedures.

Irregular astigmatic vision may result, caused by lack of equality in the curved corneal surface. This occurs from laser correction not centered effectively or from the wrong type of healing. Re-treatment or additional surgery may be needed in such cases. Another problem that can take place is the ingrowth of the epithelium. This ingrowth is self-restricted and causes no discomfort generally. But, blurred vision can be occurring, and surgery may be needed to lift the flap, removing the epithelial cells.

Photo By: Rogermommaert/ CC BY

Diffuse lamellar keratitis or DLK results when swelling that is uncontrolled occurs after surgery. This can even lead to vision loss. It may require the use of steroids and antibiotics to cure. The flap may also need to be surgically cured.

Keratoconus may also result, from the uncommon bulging of the surface of the eye that can take place if the tissue is removed from the cornea before the surgery and it is weak. Post the surgery; it is not a risk factor. Dryness of the eyes can result in temporary dry eye syndrome. Dry eye problems go away once the eye’s healing is complete.

Significant overcorrecting, under correcting or regression can be a rare scenario post surgery. Less than perfect outcomes may include lack of response to laser eye surgery in known ways. Additional laser vision corrections may be needed in such cases.

Post LASIK Surgery Impact

Once the LASIK procedure completes, your surgeon will rest you for some time. You may experience temporary burning or itching following a specific process. Once a postoperative exam is over, you can be driven home. After LASIK, you cannot drive till the eye doctor sees you in the following day and confirms your uncorrected vision is following the legal standards for driving.

Some haziness and blurry vision may be expected immediately post the surgery; clarity should improve within 12 hours. Your eyesight should continue to strengthen and stabilize within a couple of days. In rare cases, it takes several weeks or longer. For most individuals, vision improves quickly. You may be able to attend work the next day, but some doctors advise a minimum of one day of rest at least.

It is recommended to desist from physical exertion for at least one week, as this impacts healing and traumatizes the eye and impacts healing. Generally, the eye doctor or LASIK surgeon will be visited a day post-surgery. Following this initial check-up, visual acuity is to be measured to ensure it is safe for one to drive sans glasses or contact lenses. In many states, this needs visual acuity of 20/40 or more.

As with any other surgery, it is critical to follow doctor instructions and take the medication prescribed. Avoid rubbing your eyes, so there is a small chance you could dislodge the flap of the cornea if you rub the eyes too much, before the flap is secured to the corneal stroma.

Benefits of LASIK Surgery

Lasik eye surgery offers multiple benefits and can impact the quality of life. Most individuals achieve 20/20 vision or better post the operation, but LASIK results do vary. Some individuals make 20/40 vision or less. One may still need to wear glasses or contact lenses post-laser vision correction, though prescription levels will be lower than before. If you have mild refractive error post LASIK and you seek a sharper vision for specific activities like night driving, prescription lenses with anti-reflective coating can be helpful. If you are sensitive to sunlight post LASIK, eyeglasses with lenses that are photochromatic can clear photophobia and render more precise vision. While LASIK operation has a bonafide safety profile, LASIK complications can also take place. These range across infection, night glares, starbursts or even halos.

A small percentage of individuals may even need LASIK enhancement or touch-up procedure. This is generally a few months after primary eye surgery to attain good visual acuity. One may still need reading glasses in the 40s, on account of age-related near-vision or presbyopia. While LASIK surgery has a massive success rate, discuss with your eye doctor or surgeon before consenting to surgery.

Temporarily, the eyes will be dry. Prescription drops may be recommended to prevent swelling, infection, and keep your eyes moist. Healing post LASIK eye surgery occurs rapidly. Vision can be blurry and hazy on the first day. But within a few days of operation, the view improves!

Follow-ups post-surgery vary from one surgeon to another. Revisit the doctor for an evaluation 24 to 48 hours post LASIK eye surgery, along with regular intervals in the first six months. LASIK surgery has been around for 2.5 decades since it was invented.

It serves to correct vision with a high success rate. Close to 96% of patients will experience their desired vision post LASIK; Enhancements can further increase the number.

LASIK is linked to little pain, on account of the numbing drops used. Vision is corrected close to a day post LASIK, and no stitches or bandages are needed. Adjustments to further adjust the vision change, as people age, can easily be made post LASIK surgery.

Infographic

LASIK Surgery: Can It Work for You?

LASIK eye surgery may eliminate the need for corrective lenses. But it does not work for everyone. Learn if you are a right candidate and whether to consider this, as you weigh the decision. If you don't want to wear contact lenses or eyeglasses, you may wonder if LASIK surgery is the most suitable option for you. It is a type of eye surgery that is refractive. Most people undergoing this type of surgery achieve vision of 20/25 or higher, which is suitable for many activities. Most people will eventually need glasses for driving at night or reading, as they get older. LASIK surgery comes with a good record. Complications ensuing in vision loss are rare, and most people are satisfied with these results. Specific side effects like temporary visual disturbances and dry eyes are common. These clear up in a few weeks or months and are rarely considered a problem in the long run.

Results and outcomes of the surgery depend on refractive error, besides other factors. Those with mild nearsightedness have more success with refractive surgery. Those with a high degree of farsightedness or nearsightedness, in conjunction with astigmatism, have less predictable results. To understand if LASIK surgery is suited to you, consider the following information:

What is LASIK Surgery?

There are many variations of laser refractive surgery. LASIK is the most commonly known and best performed. The term LASIK is used to refer to different types of laser eye surgery. Usually, the retinal wall is where images form. With conditions like myopia/nearsightedness, hyperopia/farsightedness or astigmatism end up resulting in blurred vision.

Poor vision is corrected by bending or refracting light rays using eyeglasses or contact lenses. But reshaping the cornea provides the necessary vision correction and refraction. Before LASIK procedure, the eye surgeon assesses detailed eye measurements. Then, a special cutting laser is used to alter the corneal curvature. With each pulse of a laser beam, the tiny corneal tissue amount is removed, permitting eye surgeons to flatten the corneal curve or making it steeper.

A surgeon creates a corneal flap and raises it before it is reshaped. There are variations in which a thin or no flap is used or built. Each technique comes with its share of pros and cons. Individual eye surgeons can specialize in different types of laser eye procedures. The differences are minor, and none are better than others. Depending on your requirements, you can consider LASIK surgery.

Do You Have Healthy Eyes, Despite Less Vision?

Generally, laser eye surgery is most appropriate for those with a moderate degree of refractive error and no unusual vision problems. The eye surgeon will check with you about eye health and ensure you don't have conditions resulting in poor outcomes or complications.

These include the following:

  1. Eye diseases resulting in progressive vision deterioration and corneal thinning. If conditions like keratoconus run in the family, be wary of eye surgery.
  2. Eye infections like keratitis, herpes simplex impacting the eye, uveitis, etc.
  3. Eye injuries, lid problems.
  4. Dryness of the eyes. Dry eyes can be made worse through LASIK.
  5. Large pupils, especially in dim light. LASIK may not be suitable in such cases as it results in ghost images, halos, glares, and starbursts.
  6. LASIK can make glaucoma worse by raising eye pressure.
  7. Cataracts can also come in the way of LASIK surgery.

Rethink LASIK surgery if you have high refractive error or nearsightedness. The benefit of LASIK surgery may not justify its risks, in such cases. Check if you have a relatively good overall vision. If you are well enough to require minor glasses or low strength contact lenses, an improvement from surgery is not the right option. Moreover, presbyopia or age-related vision changes cannot be cured using LASIK. Additionally, if you participate in contact sports such as boxing or martial arts, LASIK surgery may not be a great idea.

Are You in Optimal Health?

The eye surgeon will also ask about detailed questions regarding general health. Certain medical conditions not related to your eyes can increase the risks linked to LASIK surgery or make outcomes less predictable. This includes diseases or conditions impacting the immune system, and coming in the way of healing or combating infections. This consists of a wide range of autoimmune disorders like lupus, rheumatoid arthritis, and much more. Even if you are taking immunosuppressive medicines, LASIK is not the right choice.

Is There a Possibility of Complications?

 

Depression or certain chronic pain conditions like irritable bowel syndrome, migraine, and fibromyalgia can complicate the outcome of LASIK surgery, by causing dry eyes and postoperative pain.

Is Your Vision Stable Despite Deficits?

If you have myopia, your vision may change across teenage years or more, requiring a change in contact lenses or glasses prescription periodically. People should be over 18 before considering LASIK surgery, for best results. Remember that certain medicines and conditions, including steroid drugs, pregnancy, or nursing, can lead to temporary, short-term  fluctuations in vision. Wait till image stabilizes before considering LASIK eye surgery.

Check the Cost, Side Effects & Implications

Many insurance plans consider laser eye surgery to be an elective procedure and do not cover the cost. Be clear about what the surgery will cost you. Another important consideration is checking of possible side effects and complications. While complications resulting in loss of vision are rare, specific side effects like dry eyes and temporary visual disturbances are common. These generally resolve within a couple of weeks or months; few people consider these conditions as problems that will last in the long run.

Further, LASIK surgery can lead to a temporary decrease in tear production. Within the first six months or so post-surgery, eyes may feel dry as they heal. Even post the healing process, an increase in the dry eye may be experienced. The eye doctor may recommend using eye drops. Special plugs may also be placed in tear ducts to prevent tears from draining from the eye's surface.

Glare, halo, and double vision may also result. You may notice these effects lasting from a couple of days to a few weeks.

Under-correction can also be an outcome of LASIK if laser removes too little tissue from the eye. This is common if the procedure is not correctly performed for nearsighted patients. Under-corrections are likely to require another refractive surgery within a year. Overcorrections are another issue. The laser may remove excess tissue from the eye. Overcorrections can be harder to manage than under corrections.

Astigmatism is due to uneven tissue removal. This can also happen post LASIK surgery and may require new glasses, contact lenses, or surgery. Flap problems during operation can also lead to complications, including excess tears and infection. The corneal tissue layer on the  external side of the epithelium may grow abnormally beneath the flap at the time of healing. While vision losses or changes are rare, in some cases, these can occur.

By their early to mid-40s. All adults lose the capability to focus on nearby objects or presbyopia, which results in problems in reading the small print or performing tasks up close. A possible benefit of myopia is that the condition compensates for presbyopia that develops, as one gets older. A nearsighted eyesight will focus objects on its own, in the absence of reading eyeglasses. LASIK surgery removes this near vision deficit, as myopia has been corrected. As one gets older, there is a need for reading glasses, however.

If you are an adult who is older than 40, you might want to consider correction of vision for monovision when contemplating LASIK surgery. With monovision, one eye stands corrected for near vision, and the other, for distant vision. Monovision is not easy for everyone. It is essential to carry out trials with contact lenses without opting for permanent surgery.

Can You Go Without Contact Lenses Before Surgery?

While this is not usually the issue, you may have to stop wearing contact lenses and switch to eyeglasses 2-4 weeks before surgery. Contact lenses distort the natural cornea shape, leading to inaccurate measurements and less than the perfect surgical outcome. Doctors will provide specific guidelines based on the situation and how long one has been wearing contact lenses.

What Do You Expect from LASIK Surgery?

Most individuals who undergo LASIK surgery have from good to excellent vision in most cases for years or even decades. You will be able to play sports and swim. Seeing everyday objects like the clock or numerals on a watch dial will be more comfortable. As you get older, in low light conditions, you may still need to wear glasses. Most individuals report massive satisfaction post LASIK surgery. LASIK procedures have been refined over time, and the techniques and technology are continually changing. This makes it harder to conclude the reported data. Even when postoperative follow up is carried out and said vision is measured under optimal testing conditions. Vision in dusky or low light or foggy conditions may also improve.

Have You Chosen a Right Surgeon?

Most individuals lack firsthand idea about LASIK or even an eye surgeon. A good beginning point when choosing an eye surgeon is to approach a professional whom you can trust. Ask for recommendations from known people. Your surgeon will probably work with a team, that helps in initial evaluation, and measurements. It is the surgeon who takes the final responsibility for assessing whether LASIK is right for you. Confirm that who will guide the operative and postoperative procedures. Talk with the eye surgeon regarding questions and concerns about how LASIK will benefit you. Understand the benefits and limitations of surgery, as well.

When it concerns LASIK eye surgery, there are no clear answers. Carefully consider factors, weigh preferences and risk tolerances, and ensure you have realistic ideas. Check with the surgeon in whom you feel a sense of confidence and have all your queries answered. In case this feels right, proceed forward. Don't rush ahead, however.

Frequently Asked Questions/ FAQs

What is LASIK?

LASIK is Laser in Situ Keratomileusis which means a laser has to be used beneath the corneal flap to reshape this part of the eye. This procedure uses a highly specialized laser or excimer laser designed to improve vision, treat refractive errors, and reduce the need for contact lenses and glasses. This laser process changes the corneal shape, which covers the transparent front of the eye. This laser procedure alters the corneal shape, an open front covering of the eye. Though the excimer laser has been used for years before, Ioannis Pallikaris was the one who developed this surgical method in the 90s.

How Does LASIK Work?

At the time of the LASIK surgery, a trained eye surgeon who is a specialist creates a thin, hinged corneal flap via a microkeratome. The surgeon then pulls back the flap for exposing the underlying corneal tissue, and then the excimer laser ablates or reshapes the cornea in a pre-specified pattern for every patient. The flap is repositioned gently onto the underlying cornea in the absence of the sutures.

How Do Contacts or Glasses Improve Vision as Against LASIK?

Glasses or contacts are used to compensate for the refractive error of the eye by bending light rays. In contradistinction to this, LASIK and other refractive surgery correct the refractive error of the eye to prevent the need for visual aids.

What is Refractive Error?

In the eye, the cornea and lens inside the eye form the focal system and focus incoming rays of light onto surface of the retaina, much like camera lenses that focus light onto the film. In perfect optical order, the power of the glass and cornea are perfectly matched with the eye length. Images are centered, and any mismatch in the system is the refractive error, resulting in blurred vision.

How do I Choose the Perfect Eye Doctor?

If you consider refractive surgery, ensure that you compare the levels of risk and benefits. Consider that there may be variance across different procedures, devices, manufacturers, surgeons depending on the level of experience with a specific system. Don't base the decision only on cost and don't settle for the first eye doctor, procedure, or center you come across. Recall that the choices you make about your eyes and surgery can impact you for the remainder of your life.

What is the Refractive Error Types?

There are three types of refractive errors. The first is myopia or nearsightedness, where there is a mismatch in eye length and focusing power causing distant objects to be blurred and near ones to improve in clarity. The second is farsightedness or hyperopia, where the mismatch is on concentrating power and eye length, causing more adjacent objects to appear blurred and distant objects to be clearer. Finally, there is astigmatism, where the cornea or lens shape is distorted, causing multiple retinal images. This causes objects at different distances to appear blurred. Most people combine myopia or hyperopia with astigmatism.

How Does Vision Change When One Ages?

During young adulthood and teens, the natural lens comes with the capability to change power and shape. This ensures we focus on close objects through the process of accommodation. As you age, the natural lens stiffens and loses the flexibility. This is called presbyopia, which indicates loss of accommodation and the requirement for visual aids, bifocals, or reading glasses to facilitate near work.

What are the Different Kinds of LASIK?

There is an entire range of different types of lasers used in ophthalmology. Each LASIK procedure is performed with a specific type of laser called excimer laser. In one sense, all LASIK procedures are the same. However, there are different laser manufacturers, including Nidek, Bausch & Lomb, Alcon, Visx, and Wavelight, which have specific lasers.

Further, specific types of laser ablation procedures can be carried out, including conventional laser, wavefront-optimized or wavefront-guided treatments. A completely different kind of laser called femtosecond laser is used to create the LASIK flap of the cornea as well.

What Does Conventional LASIK Involve?

Conventional LASIK refers to the ablation pattern on most lasers that treats directly based upon the glass's prescriptions, and there are fixed treatment guidelines for each patient. This laser eye surgery is sufficient for most individuals but can result in glare, night vision issues, halos, and other issues in rare cases.

What Does Wavefront Optimized LASIK Refer to?

Wavefront optimized LASIK is the kind of eye surgery available on the laser for wave light. This treatment is also associated with glass prescriptions but also considers corneal thickness and curvature, uniquely applying laser energy in the corneal periphery. This laser reduces complications such as halos, glares, and other visual aberrations associated with conventional therapies.

What Does Wavefront Guided LASIK Involve?

Wavefront-guided LASIK surgery, also referred to as custom or wavefront LASIK, is akin to conventional LASIK, except that along with the patient's fundamental refractive error, specific eye aberrations can also be cured. In this type of LASIK, accurate mapping is carried out to identify small issues in the optical system of the patient. When irregularities are severe, this impacts contrast sensitivity, night vision, and vision quality. When there are significant irregularities in the wavefront mapping, this type of LASIK can be used, and treatment based on wavefront map generated.

 

How Many Other Types of Refractive Surgery Are Available?

Other kinds of refractive surgery are available, such as advanced surface ablation, phakic intraocular lenses, conductive keratoplasty, and others.

Will LASIK Surgery Work for Me?

Refractive surgery works well for many people. But do ask yourself specific questions before considering LASIK surgery. The right answer depends on the state of your health, the stability of your vision, and the age at which operation is carried out, among other factors. The eye doctor must look out for risk factors before surgery that makes you a less than perfect candidate for surgery and discussing abnormal findings at length. Patients with extreme prescriptions or thin corneas might not get the best outcomes from LASIK.

How Do I Find the Perfect Eye Surgeon?

If you are contemplating refractive surgery, you must compare all the different variables going into your operation. The overall procedural success depends on the kind of surgery conducted, the lasers used, and the level of expertise of the doctor. Don't base your decisions on cost alone. Visit different doctors and clinical centers before zeroing in on the right one. Make sure the surgeon you opt for has a good reputation and appropriate training. Ask your eye doctor to discuss outcomes and know results. It is essential to know your surgeon will be available during postoperative moments when you need support for managing the issue. It is equally important to ensure your surgery is equipped with the skilled staff, advanced technology, and a good reputation you can rely on. Opt for being an educated consumer. This is an important decision, so read as much information as possible. Check with your eye doctor to have an in-depth discussion about appropriate procedures. This can vary from one individual to another.

Eye infections rarely occur post surgery. Medicated eye drops are a must, however. Oversize pupils, haze visual aberrations, irregular flap and dry eyes can be some of the side effects for which further treatment and/or surgery may be needed. If you need any help on LASIK Laser Eye Surgery, please visit Eye7 Hospital.

Leave a Comment

Your email address will not be published. Required fields are marked *

*