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JURNAL BIOMEDIKA DAN KESEHATAN
(JOURNAL OF BIOMEDIKA AND HEALTH )
Vol. 5 No. 3 (2022) pp. 203-213
e-ISSN: 2621-5470
203
ORIGINAL ARTICLE
Degree of Myopia was Associated with Central Corneal Thickness
in 18-40 Years Old
Derajat Miopia Berhubungan dengan Ketebalan Kornea Sentral pada Usia 18-40 Tahun
Elizabeth Ravinka Rossabel ER1, Kartini2
1 Medical Undergraduate Program, Faculty of Medicine, Universitas Trisakti, Jakarta, Indonesia
2 Histology Department, Fakultas Kedokteran Universitas Trisakti, Jakarta, Indonesia
kartiniedwin@trisakti.ac.id
https://doi.org/10.18051/JBiomedKes.2022.v5.203-213
ABSTRACT
Background
The central corneal thickness (CCT) is important in assessing the cornea’s condition and correlates
with refractive errors in which myopic eyes have the thinnest central cornea. Based on the 2018
Riskesdas, 2,133,017 people suffer from severe low vision, of which 42% were connected to refractive
errors. One of the treatments for myopia is to perform LASIK surgery, but complications may occur
during its process. One of the risk factors for post-LASIK complications is a CCT of less than 500
microns. This study aimed to assess the association between the degree of myopia and CCT at 18-40
years old.
Methods
This study was a cross-sectional design with data taken from 124 medical records from the Gading
Laser Eye Center with subjects aged 18-40 years consisting of 88 males and 36 females. Variables
collected were initials, age, gender, CCT, and degree of myopia. Data analysis was carried out using
the Chi-Square test with a significance level of p<0.05.
Results
The age category was 18-28 (87.9%), dominated by males (71.0%). Most degrees of myopia were mild
(48.4%), and CCT was dominated by thinning corneas (63.7%). Data analysis based on the Chi-Square
test regarding the degree of myopia and CCT showed a significant association (p=0.001).
Conclusions
This study showed an association between the degree of myopia and CCT at the age of 18-40 years.
Keywords: central corneal thickness; degree of miopia; refractive errors
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ABSTRAK
Latar Belakang
Ketebalan kornea sentral merupakan parameter penting dalam menilai keadaan kornea dan memiliki
korelasi dengan kelainan refraksi di mana mata miopia memiliki ketebalan kornea sentral yang paling
tipis. Menurut Riskesdas tahun 2018, terdapat 2.133.017 orang yang mengalami penurunan
penglihatan dan 42% disebabkan oleh gangguan refraksi. Salah satu penanganan miopia adalah
dengan melakukan tindakan bedah LASIK namun dalam prosesnya dapat terjadi komplikasi. Salah
satu faktor risiko terjadinya komplikasi pasca LASIK adalah ketebalan kornea sentral yang kurang dari
500 mikron. Tujuan penelitian adalah menilai hubungan derajat miopia dan ketebalan kornea sentral
pada usia 18-40 tahun.
Metode
Desain studi adalah potong lintang yang datanya diambil dari 124 rekam medis dari Gading Laser Eye
Center dengan subjek berusia 18-40 tahun, terdiri dari 88 laki-laki dan 36 perempuan. Variabel yang
dikumpulkan adalah inisial nama, usia, jenis kelamin, ketebalan kornea sentral, dan derajat miopia.
Analisis data dilakukan menggunakan uji Chi-Square dengan tingkat kemaknaan p<0.05.
Hasil
Karakteristik responden terbanyak berusia 18-28 tahun (87.9%), didominasi oleh laki-laki (71.0%).
Untuk derajat miopia paling banyak adalah derajat ringan (48.4%) dan ketebalan kornea sentral
didominasi oleh menipis (63.7%).
Hasil analisis data berdasarkan uji Chi-square mengenai derajat miopia dengan ketebalan kornea
sentral pada usia 18-40 tahun menunjukkan terdapat hubungan yang bermakna (p=0.001).
Kesimpulan
Terdapat hubungan antara derajat miopia dengan ketebalan kornea sentral pada usia 18-40 tahun.
Kata Kunci: derajat miopia, kelainan refraksi, ketebalan kornea sentral
INTRODUCTION
Myopia is one of the most common eyes refractive errors. Myopia occurs because parallel light
rays from far shadows are focused on a point in front of the retina, and this condition is a burden
to public health worldwide.1 The World Health Organization (WHO) stated in 2015 that untreated
refractive errors rank first as a cause of visual impairment in the world; it is estima ted that more
than 285 million people in the world have a visual impairment, and 42% of them are caused by
refractive errors that are not corrected.2 The latest data for 2020 states that around 28.3% of the
global population suffers from myopia and 4 % have a high degree of myopia. If this condition is not
handled correctly, myopia cases are expected to increase in 2050 to 49.8% of the global population
and those with high-degree myopia are estimated to be around 9.8%.3
In Indonesia, the prevalence of refractive errors is relatively high, 24.7% and ranks first for eye
diseases.4,5 As many as 48.1% of young adults over 21 years have myopia with a lens power of more
than -0.5 Diopters.5 Myopia can also affect children; around 10% of 66 million Indonesian children
suffer from refractive errors.4 Myopia has become a public health and socio-economic problem
globally.3 This visual disorder can hinder a person from carrying out daily activities.4
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Myopia that occurs in adults is very likely to experience pathological changes which can cause
blindness because it is accompanied by degenerative changes in the posterior segment of the
eyeball associated with elongation of the anteroposterior diameter of the eyeball.6,7 Patients with
high degrees of myopia are at high risk of developing cataracts posterior subcapsular, glaucoma,
and chorioretinal abnormalities.8 In cases of high myopia, a decrease in corneal thickness is
generally found.
The cornea is a transparent structure in the anterior one-sixth of the eyeball, is avascular and
is composed of 5 layers, namely: the corneal epithelium, Bowman's membrane, stroma, Descemet's
membrane, and endothelium.9-11 The cornea is a barrier and protects other structures within the
ball. Eye in fighting infection as well as with the tear curtain layer contributing to two-thirds of the
eye's refractive power.10 The cornea's refractive power ranges from 40-44 Diopters or about 70% of
the total refraction with a refractive index of 1,376.10 From the central part of the cornea occurs
gradually increasing in thickness to the periphery. Under normal circumstances, the central part of
the cornea has an average thickness of 540.4 µm (ranging from 520 µm to 565 µm), while in the
peripheral parts, the thickness ranges from 612-670 µm.7,11,12 Corneal thickness will decrease with
age.10 In myopic eyes, there is an eyeball enlargement associated with the cornea's thinning, in
which the myopic eye thins approximately 0.018 mm compared to a normal eye.7 The horizontal
diameter of the cornea is 11-12 mm and 9-11 mm vertically with an average corneal diameter of
11.77±0.42 mm, slightly different between males and females (male 11.77±0.37 mm; female
11.64±0.47 mm).10
Figure 1. Central and peripheral corneal regions
The management of myopia cases includes the use of glasses and contact lenses, and in the
last decade, the technique of refractive surgery has been increasingly developed.13 One of the most
frequently performed refractive surgery techniques is LASIK (Laser-Assisted In Situ
Keratomileusis). Corneal thickness is important for diagnostic purposes (for example, tonometry)
and therapy in refractive surgery to determine whether a patient with refractive errors can undergo
LASIK surgery.9 In the procedure, corneal thickness is an important factor because to correct the
disorder, The refractive procedure is to reduce the thickness of the central cornea with a laser. The
LASIK surgical technique provides satisfactory results, but the procedure can cause some
complications. The most feared complication by refractive surgeons is corneal ectasia15 which is the
progressive thinning of the cornea and is associated with a decrease in visual acuity that cannot be
corrected.12,16 Therefore, central corneal thickness is an important determinant for preventing
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corneal ectasia after LASIK. Besides being a risk factor for post-LASIK ectasia, central corneal
thickness is also associated with an increased risk factor for glaucoma, which is visual impairment
due to damage to the optic nerve and can lead to blindness.17 Cornea thickness that is less or more
than normal can lead to errors in assessing intraocular pressure, which results in delays in
diagnosing and treating glaucoma.9
Pachymetry is a procedure for measuring central corneal thickness that can be performed
through contact (e.g. ultrasound) and non-contact (optical biometry) methods.9 The acceptable
limit value for corneal thickness for safe refractive surgery is 500 µm. Corneas thinner than this size
are at risk of corneal ectasia in the LASIK procedure.11 Mohammed et al. state that central corneal
thickness correlates with refractive errors, in which myopic eyes have the thinnest central corneal
thickness, followed by emmetropia and hypermetropia.9 Research by Das et al. concluded that
there is a significant correlation between central corneal thickness and the incidence of myopia
where there is a decrease in central corneal thickness in cases of myopia. 7 Another study by Chen
et al. concluded that there was no correlation between central corneal thickness and the incidence
of myopia in adult subjects in Taiwan. According to this study, it is possible that in cases of myopia,
the cornea does not thin in the same way as the sclera.18 The study of Kobayashi et al. concluded
that the corneal thickness had no significant difference between low, moderate and severe myopia
on each axis. Still, the pachymetry map (a simple test to assess corneal thickness) showed a thinner
cornea in the inferior meridians than in the superior meridians in mild and moderate myopia. 19
The effect of myopia on central corneal thickness has been widely reported, but the results are
conflicting. Several studies have found myopic subjects with thicker central corneas, but others
have found otherwise.7 This study assessed the relationship between demographic characteristics
(age, sex) and degree of myopia with central corneal thickness in adults aged 18 -40 years.
METHODS
This study is an observational analytic study with a cross-sectional approach to assessing the
relationship between myopia degree and central corneal thickness at 18-40 years old. The data was
taken from the medical records of patients treated in the June-December 2020 period at the Gading
Laser Eye Center Clinic, North Jakarta. The data collection period is September – October 2021. One
hundred twenty-four respondents aged 18-40 comprised 88 men and 38 women. The inclusion
criteria for this study were patients with mild, moderate, or severe degrees of myopia. They had
complete medical record data, especially the results of an examination of central corneal thickness
and degree of myopia. The exclusion criteria for this study were having a history of glaucoma,
corneal disease, and a history of eye surgery or trauma to the eye. The sampling technique was a
non-random consecutive sampling technique from the medical records of patients who met the
inclusion and exclusion criteria. Central corneal thickness at the clinic was measured using a
pachymetry measuring instrument, and myopia refractive errors were measured using a Snellen
chart measuring instrument with negative spheres by optical refractionist and An ophthalmologist
analyzed the examination results.
Statistical analysis used the IBM SPSS (Statistical product and service solution) program
version 24 with the Chi-Square test, and the significance value was p<0.05. This research has
obtained an ethical permit from the Research Ethics Commission of the Faculty of Medicine,
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Jurnal Biomedika dan Kesehatan 207
University of Trisakti number 98//KER-FK/IX/2021 and received a research permit from the local
clinic.
RESULTS
From the research results, it was found that 109 subjects (87.9%) were in the age range of 18-
28 years, with the median (maximum-minimum) age being 19 (18-40) years. The results of the
Kolmogorov-Smirnov normality test showed that the data distribution was not normal (p=0.000).
The majority of subjects were male, namely 88 subjects (71.0%).
Research on myopia is divided into 3 degrees, namely mild degrees (<3 Diopters/D), moderate
degrees (3-6 Diopters), and severe degrees (> 6 Diopters). As many as 60 subjects (48.4%) suffered
from mild degrees of myopia. Variable central corneal thickness is classified into thin (< 540 μm)
and normal (540-550 μm). The study found that as many as 79 subjects (63.7%) had thin central
corneal thickness. (Table 1)
Table 1. Distribution of subject characteristics
Variable
Frequency (n)
Percentage (%)
Age
18-28 years old
109
87.9
29-40 years old
15
12.1
Gender
Male
88
71.0
Female
36
29.0
Degree of myopia
Mild
60
48.4
Moderate
48
38.7
Severe
16
12.9
Central corneal thickness
Thinning
79
63.7
Normal
45
36.3
Based on the bivariate analysis results, it was found that 68 (62.4%) of 109 subjects aged 18-28
years had thinning central corneal thickness, and for subjects aged 29-40 years, there were 11
people (73.3%). However, the Chi-square statistical test results between age and central corneal
thickness did not show a significant relationship (p=0.408).
Based on gender, the results showed that more female subjects had thinner central corneal
thickness than male subjects (75.0% vs 59.1%). The results of the Chi-square statistical test between
gender and central corneal thickness in subjects aged 18-40 also found no significant relationship
(p=0.094). (see table 2)
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Table 2. Relationship between sociodemographic characteristics, degree of myopia, and central
corneal thickness
Variable
Central corneal thickness
p*
Thinning
Normal
Age
18-28 years old
68 (62.4%)
41 (37.6%)
0.408
29-40 years old
11 (73.3%)
4 (26.7%)
Gender
Male
52 (59.1%)
36 (40.9%)
0.094
Female
27 (75.0%)
9 (25.0%)
Degree of myopia
Mild
21 (35.0%)
39 (65.0%)
0.001
Moderate
42 (87.5%)
6 (12.5%)
Severe
16 (100.0%)
0 (0.0%)
* Analysis used the Chi-Square test, (p<0.05) = statistically significant
There were as many as 21 (35%) subjects who had mild degrees of myopia had a thinning central
corneal thickness; subjects with moderate degrees of myopia, as many as 42 subjects (87.5%) had
thinning central corneal thickness; and all subjects with severe myopia had a thinning central
corneal thickness. The results of the Chi-square statistical test between the myopia degree variable
and central corneal thickness showed a significant relationship (p=0.001).
DISCUSSION
This study found that the age of people living with myopia was 18-28 years, dominated by men,
the severity of myopia was mild, and the majority of subjects had a thinning central cornea.
Research by Wang et al. with adult subjects (aged 18-44 years), people with myopia in China who
underwent laser refractive surgery were also dominated by the male sex (63.4%).20 The same thing
was also found in a study by Verkicharia et al. with people with myopia in various age groups, and
as many as 53% were male; most subjects suffered from mild degrees of myopia (65%).21
This study found that the percentage of subjects aged 29-40 who experienced central corneal
thinning was higher than those aged 18-28 (73.3% vs 62.4%). Wang et al.'s study17 concluded that
central corneal thinning increased with age. Sridhar also stated that the thickness of the cornea
would decrease with age.10 Furthermore, this study also found that the percentage of female
subjects with thinning central corneal thickness was higher than that of males (75% vs 59.1%). Wang
S et al.'s study17 found that the average central corneal thickness in women was thinner than that
of men (553.0±40.0 µm vs 554.6±41.0 µm). The same thing was also expressed by Wang Q et al. 20,
who stated that men have a thicker central cornea than women (p <0.001).
This study's results indicate a significant relationship between the degree of myopia and
central corneal thickness. This is in line with the research by Das et al. with a subject of 100 myopia
patients with lens power between -1.00 D to -17.00 D (mean -4.41±3.23 D) concluded that there is a
significant correlation between the degree of myopia and central corneal thickness. According to
this study, the higher a person's degree of myopia, the thinner the central corneal thickness. The
average central corneal thickness is thinner in high-degree myopia than in moderate and low-
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Jurnal Biomedika dan Kesehatan 209
degree myopia. Statistical analysis found a significant difference in mean thickness central cornea
between low and high degrees of myopia and moderate and high degrees of myopia, but not
significant between low and moderate myopia.7
A retrospective study by Mimouni et al. with a subject of 30,245 patients (myopia up to -12.0 D
and cylinders up to 6.0 D) who underwent refractive surgery from January 2000 to December 2014
at Care-Vision Laser Centers, Tel-Aviv, Israel, also obtained the same result, namely a significant
correlation between degrees of myopia and central corneal thickness. The mean central corneal
thickness for various myopia ranges ranged between 528 and 538 µm. This may be related to the
axial elongation of the eyeball that occurs in cases of myopia.22
Research by Mohammed et al. found that the cornea of the central part of the myopic eye is
the thinnest (449.65±39.27µm) compared to emmetropia (542.66±46.35µm) and hypermetropia
(557.67±41.83µm). The study concluded that there is a correlation between central corneal
thickness and refractive errors. Another study by Nemesure et al. also stated that central corneal
thickness is associated with refractive errors. Price et al. stated that a thin central cornea is
associated with myopic eyes, and this may be an explanation for the tendency to develop glaucoma
in myopic cases.9
Research by Wang X et al. 8, who compared 97 subjects with normal eyes and 48 subjects with
high degrees of myopia, concluded that there were significant differences in the cornea's thickness
and the eyeball's axial length between the two groups but not in the thickness of the corneal
epithelium. The study found a group of patients with degrees of myopia significantly increased the
axial length of the eyeball (by 16%) compared to the normal group.8 What's interesting about this
study is that the corneal thickness increased (thicker) in myopic eyes. Differences in corneal
thickness may be related to the stages of changes in corneal thickness in myopic eyes (whether it
occurs at an early/middle/advanced stage). Still, there needs to be more research on this. In
addition, the thickness of the cornea also fluctuates within 24 hours, so differences in measurement
times may affect the results. From the results of this study, it was found that the cornea of the high -
degree myopia group was thicker than the normal eye group. Still, from measurements of the
thickness of the corneal epithelium (the outermost layer of the cornea), it was not different
between the two groups. This indicates that changes in the thickness of the cornea mainly occur in
the stroma. Another thing that might affect the results of the study is the difference in the
technique of measuring the thickness of the cornea.8
Research by Krishnan et al. concluded that an increase in the cornea's refractive power is
associated with an increase in myopic refraction. The increased curvature (curvature) of the cornea
is related to the axial length of the eyeball and the thinning of the cornea. The mean central corneal
thickness was 533.87 µm, with a standard deviation of 40.02. According to this study, axial myopia
is associated with increased corneal thickness. This ocular biometric finding has important
implications in refractive surgery.23
Different results were obtained in the study of Solu et al. with a subject of 150 patients
consisting of 66 myopia patients, 33 hypermetropic patients, and 51 emmetropic patients, which
concluded that central corneal thickness did not have a significant relationship with the degree of
myopia, possibly because each individual's central corneal thickness was influenced by genetics so
that the results could be in contrast to other research results.24 Research by Chen et al. with a
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210 Jurnal Biomedika dan Kesehatan
subject of 528 patients who underwent laser refractive surgery for myopia correction from January
2004 to December 2006 found that myopia with an average lens power of -7.27±2.96 D and a mean
central corneal thickness of 560±35 µm, based on the statistical analysis found no relationship
between refractive error with central corneal thickness. The different results may be due to
differences in age, sex, genetics, ethnicity, diurnal variations in measuring central corneal thickness
and the tools used in measuring.18 Several studies have reported a reduction in central corneal
thickness as a person ages due to a decrease in keratinocyte density.9 In addition, the onset of a
person with myopia also affects the progression of the disease; the younger the onset of myopia,
the more likely it is to experience myopia development to a more severe level.25
Wolffsohn et al. stated that the condition of refractive error is an inherited disorder. This was
proven by identifying 150 gene loci related to myopia. However, the development of myopia is
inseparable from the interaction of genetics and environmental factors. Research on students in
China concluded that students with a history of reading at close range and both parents have
myopia have a 26x higher risk of suffering from myopia than students who habitually read at a
distance of more than 20 cm and do not have parents with myopia. This inherited myopia disorder
may be related to certain ocular components, such as the axial length of the eyeball.25 The study of
Wang S et al. found that female gender, advancing age and race were associated with thinning of
the cornea. The Negroid race has a thinner cornea (537.3±39.9 µm) than the Caucasian race
(558.5±40.3 µm), while the Asian and Hispanic races have a cornea in between thicknesses. 17
This study also assessed the relationship between age and central corneal thickness in 124
myopia patients aged 18-40 (divided into two age groups) who underwent central corneal thickness
examination. The results showed that there was no significant relationship between the two
variables. These results are in accordance with the research of Ismail et al. in 60 hyperopic eyes at
Al-Azhar University Hospital, Cairo, Egypt, which were divided into two age groups (20-37 and 42-
56 years). This study found no significant relationship between age and central corneal thickness in
the two age groups.26 A study by Ismaili et al., which was carried out on 80 patients with refractive
eye errors at the Kosovo University Clinic with an age range of 19-38 years, also obtained the same
result, namely that there was no significant relationship between age and central corneal
thickness.27 Meanwhile, Mashige stated that with age, there is a reduction in central corneal
thickness due to decreased keratocyte density.9 This difference in results may occur because the
central corneal thickness is said to be related to genetics, so because there are differences in the
study population, the results obtained may also be different.
An analysis to assess the relationship between gender and central corneal thickness was also
carried out with 124 myopia patients consisting of 88 men and 36 women who examined central
corneal thickness. The findings showed no significant relationship between the two variables. The
same was also found in research by Iyamu et al. in 2012 in Nigeria with 130 subjects consisting of 77
men and 53 women, who said there was no significant relationship between gender and central
corneal thickness.28 The results obtained were also in accordance with research conducted by Hahn
et al., who found that the difference in central corneal thickness between men and women was
very small, only 4.6 μm. This size is smaller than the mean difference in interocular central corneal
thickness (7.7 µm) in normal subjects, so it is concluded that the difference in male and female
central corneal thickness values is statistically significant but not clinically significant.9
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Jurnal Biomedika dan Kesehatan 211
Research Chen et al. with the mean age of the subjects being 34.8±7.3 years and the majority
of women (79.9%) concluded that central corneal thickness was not related to age, and central
corneal thickness was significantly thinner in women than in men.18 Study of Chang et al. stated
that the cornea of myopic eyes tends to be thinner in eyes with increased axial length, but
statistically no relationship was found. Central corneal thickness may decrease with age and female
sex is associated with a thin cornea. According to Chang, different central corneal thickness
measurement techniques might have influenced the results of the study.18 The study of Wang X et
al. compared corneal biometric parameters between groups of normal eyes and high-degree
myopia and assessed factors influencing these parameters such as age and gender. The study found
that age did not correlate with central corneal thickness, axial length of the eyeball or corneal
epithelial thickness in the high-degree myopia group, while gender correlated with axial length of
the eyeball and central corneal thickness, but not with corneal epithelial thickness.8 The effect of
gender on central corneal thickness and axial length of the eyeball may be related to hormonal
differences between males and females because gonadal hormones affect ocular tissue growth.8
Based on this study that the degree of myopia affects the thickness of the central cornea, so
one of the expected practical implications is to open people's minds to pay more attention to eye
health, it is important to identify and treat myopia as early as possible to prevent worsening of eye
refraction, especially for those who are interested in doing LASIK surgery to avoid complications of
corneal ectasia. Further research regarding central corneal thickness may be carried out by paying
attention to the axial length of the eyeball, the time of measurement to minimize diurnal variations,
the stages of myopia development and the length of time suffering from myopia, as well as the
measuring instrument used. With the development of science and technology, it may also be
possible to measure certain layers of the cornea so that the thinning layer can be assessed.
CONCLUSION
Of people with myopia aged 18-40 years who were treated at the Gading Laser Eye Center
Clinic, North Jakarta, in June-December 2020, 63.7% experienced central corneal thinning and 48.4%
suffered from mild degrees of myopia. There is a significant relationship between the degree of
myopia and central corneal thickness at 18-40 years old. However, there is no significant
relationship between age and sex with central corneal thickness at 18-40 years.
ACKNOWLEDGEMENT
Thanks to dr. Magda Siholita Pandjaitan, Sp. M and all staff who have assisted in the process
of retrieving medical record data at the Gading Laser Eye Center, North Jakarta.
AUTHORS CONTRIBUTION
ERR plays a role in preparing research designs, data collection, data analysis, and data
interpretation and is responsible for data collection in the field and preparing manuscripts. K plays
a role in drafting concepts, data analysis, data interpretation, preparing and revising final
manuscripts for publication.
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212 Jurnal Biomedika dan Kesehatan
FUNDING
This research was carried out with the researcher's personal funds
CONFLICT OF INTEREST
There is no conflict of interest between the authors
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