ocular trauma - LifeBridge Health

✦✦✦✦✦✦✦✦✦✦✦✦✦✦
Krieger Eye Institute at Sinai Hospital
✦✦✦✦✦✦✦✦✦✦✦✦✦✦
✦✦✦✦✦✦✦✦✦✦✦✦✦✦
✦✦✦✦✦✦✦✦✦✦✦✦✦✦
✦✦✦✦✦✦✦✦✦✦✦✦✦✦
✦✦✦✦✦✦✦✦✦✦✦✦✦✦
eyelights
Spring 2006
OCULAR TRAUMA
EYE INJURY
Eye injury occurs frequently in the United States where nearly
two million individuals require treatment in the hospital (60%)
or doctor’s office (40%) every year. Males are four times more
likely than females to have ocular injuries, and eye injuries occur
mostly among persons in their 20s or younger. However, as the
population ages, we are seeing an increasing number of eye
injuries in the elderly.
Most injuries occur in the home, are sports-related or workrelated or are the result of an assault or result from a motor
vehicle accident. The most common objects
to strike the eye are fists, thrown objects
(e.g., stones, balls), BBs, pellets and sticks.
Older individuals often suffer ocular trauma
after falling down. Assault and motor vehicle injuries are usually the most severe and
may cause so much damage that the eye
must be removed.
TYPES OF INJURY
Contusions and abrasions are the most common types of
injury. The injured eye may present as a black eye due to bleeding
under the skin and into the
soft tissues that surround
the eye. The eye may be
painful, particularly if the
cornea has been scratched
or has a foreign body in it.
Vision may be reduced if
there is bleeding into the
eye or from damage to the
retina. Double vision may
Contusion
occur due to a fracture of
the bones that support the eyeball or due to hemorrhage around
the eye.
Penetrating eye injury requires immediate referral because of
the risk of devastating ocular infection. Such injuries are most
commonly seen in children at play with sharp objects. This type
of injury can occur from a shattered windschield in road traffic
accidents and from high velocity missiles at the workplace.
Foreign bodies are most
frequently found on the cornea and under the eyelid where they
can be easily removed.
We have seen a progressive increase in eye trauma resulting
from automobile accidents in the past seven years. Frontal air
bag deployment was associated with a statistically significant,
two-fold increased risk of eye injury, whereas seat belt use was
associated with a two-fold reduced eye injury risk. Seat belt use
is the most effective means of occupant protection against automobile accident-related eye injury.
Older age, being female, passenger seat position and collision
severity were also associated with eye injury risk.
EYE PROTECTION
Many cases of ocular injury can be prevented by wearing
protective eyeglasses. Many sports-related and occupational
injuries can be prevented if appropriate, properly fitted, taskspecific eye protection is worn. Sports injuries account for
approximately 100,000 eye injuries each year. These are so
common because millions of Americans play sports, but few
wear the appropriate eye protection. Eye and head protection
should be worn by persons playing lacrosse, football, squash,
racquetball or paint ball war games.
CONCLUSION
One can reduce the risk of ocular injury by being aware of
those activities that increase the risk of injury and by taking the
necessary precautions to minimize or eliminate that risk.
CORNEAL INJURIES
The cornea is the clear covering of the eye. It is a very delicate structure that must remain smooth and clear for perfect
vision. Because of the external location of the cornea, when the
eyelids are open, the cornea is subject to many different types of
trauma. The cornea contains more nerve endings than nearly
any other part of the body. This means that when a healthy
cornea is injured—even a tiny scratch—it hurts!
Three main categories of corneal trauma include corneal
abrasions, corneal lacerations and corneal infections.
continued on page 2
eyelights
page 2
CORNEAL ABRASIONS
The cornea has three layers. The outside layer of the cornea,
the layer closest to the outside environment, is made up of clear
epithelium, or skin. When this epithelium gets scratched, it is
called a corneal abrasion. Accidental injury of the cornea (e.g., a
small baby reaches up with his or her fingernail; a coat hanger
or the edge of a piece of paper is moved quickly in front of the
eye) is very common. When this occurs, symptoms include eye
pain, blurry vision, redness, tearing and the “feeling” that something is in the eye. The pain is often more noticeable when the
eye is open, and subsides, somewhat, when the eye is closed.
To diagnose a corneal abrasion, an ophthalmologist will
often use a numbing drop, to temporarily relieve the pain and
allow for an examination under the microscope. A yellow-colored drop is also often used to temporarily stain the cornea and
allow for the correct diagnosis. It should be noted that the
numbing drop used in the office should never be given to a
patient for pain relief because continued use of such a drop will
slow down the healing process. Although the discomfort of a
corneal abrasion is significant, inappropriate use of the diagnostic numbing drops can result in permanent and severe vision
loss. Because the cornea has so many nerve endings, it heals
quickly.
Common treatments of corneal abrasions include antibiotic
eye drops or ointments to protect the eye from infection; patching the eye closed if the original scratch was not caused by
something dirty; or use of a “bandage” contact lens, in more
severe cases.
CORNEA LACERATIONS
A cornea can become lacerated if a foreign object cuts into
the substance of the cornea. If there is a high velocity sharp
object (e.g., a nail, broken glass, a small rock), the object may
tear through the cornea and enter the eye. A corneal laceration
is a medical emergency and usually requires immediate medical
care and possibly surgery by an ophthalmologist. If corneal
trauma is witnessed, and an object is seen “stuck” to the
cornea, never attempt to remove the object yourself. Doing so
may cause more damage to the eye. Emergency medical care
should be sought and only an eye care professional should
remove the object.
CORNEAL INFECTIONS
If a cornea is injured by something “dirty,” it is not uncommon for the cornea to become infected. Common causes of
corneal infection after trauma include eye injuries by plants,
leaves, sticks or thorns; scratches by the paws of pets; scratches
that occur while sleeping in or swimming in contact lenses; or
clean scratches that took a long time to heal, and became
infected later. Corneal infections are very serious and can cause
permanent visual loss if not appropriately diagnosed or treated.
It is common for the cornea to become injured in the setting
of trauma. Corneal injuries should be evaluated promptly and
treated by your ophthalmologist.
GLAUCOMA CAUSED BY TRAUMA TO THE EYE
Ocular trauma may cause problems that can usually be corrected during the post-traumatic period. These include removal
of a foreign body from the cornea or eyelid, repair of any lacerations or damage to the eye and tissues around it, treatment for
intraocular bleeding, and warm compresses to help the black
and contused eye look and feel better. However, damage may
occur to the delicate channels that regulate the flow of normal
intraocular fluids. These channels, called trabecular meshwork,
are important because they let fluid escape from the eye as fast
as new fluid is produced, thereby keeping the intraocular pressure at a normal level. Anything that damages or clogs this trabecular meshwork will cause the intraocular pressure to rise
and produce glaucoma. In time, the glaucoma may cause loss of
vision and lead to blindness.
INFLAMMATION
Trauma to the eye is likely to stimulate inflammation in and
around the eye, a natural process that ordinarily helps the eye
to heal. But in some cases, the inflammatory white cells may be
so numerous that they clog the channels
(trabecular meshwork) and lead to a
buildup of intraocular pressure and glaucoma.
HEMORRHAGE
Blunt trauma to the eye can occur if it Hyphema, blood in the
is hit by a hand or fist, when the eye is
lower part of the anterior
chamber
struck by a flying object or missile, or
when the eye is struck during a fall. This
sudden blow can cause bleeding around the eye (contusion) or in
the eye (hyph-ema, hemorrhage). This mass of red blood cells
can then clog the trabecular meshwork (channels) and block the
flow of the natural fluids in the eye. This can cause a rapid rise
in intraocular pressure and glaucoma. In many cases, the blood
will resorb and disappear in days to weeks. If the eye pressure
climbs too high or the blood fails to resorb, then it may be necessary to remove the blood clot in the eye.
DAMAGE TO THE OUTFLOW CHANNELS (TRABECULAR MESHWORK)
Even when there is no hemorrhage, trauma to the eye can
cause permanent damage to the trabecular meshwork. This can
produce a gradual rise in the intraocular pressure that may take
weeks, months or years to develop. For that reason, it is important to be regularly checked, at least yearly, following trauma to
the eye.
TREATMENT
Inflammation in and around the eye can be effectively treated
with warm compresses and eye drops that decrease the intraocucontinued on page 3
eyelights
page 3
lar inflammation. Elevated intraocular pressure and glaucoma can
be effectively treated with conventional glaucoma eye drops. In
some cases, the intraocular pressure may be so high that it cannot
be reduced by glaucoma eye drops or other medication, and surgical intervention may be required. However, the best treatment is
prevention of the ocular trauma before it happens.
RETINAL DETACHMENT AFTER EYE TRAUMA
Eye injuries can happen just about any time and in every conceivable setting. One of the most significant factors in the severity of the injury is whether or not eye protection (safety glasses,
sports goggles) is present. Other important factors include the
energy involved in the injury and the mechanism of impact. A
high-energy, high-velocity impact with a sharp object will generally mean a worse prognosis for the eye than a low-energy
impact with a blunt object. Common settings in which eye
injuries occur are sporting/leisure activities, working with lawn
or shop equipment, military combat, and physical assault.
Injury to the retina is more likely to occur with high-risk, highenergy impact injuries. The retina is an extremely delicate and
sensitive layer of nerve tissue that lines the inside of the eyeball,
receiving light and images that are focused through the lens of
the eye. Like film inside a camera, the retina records images and
Sadie
Feldman
T
he department of
Ophthalmology at
Sinai and all of the members of the Krieger Eye Institute (KEI)
will miss Sadie Feldman who died last September. She was a great
friend of the KEI and left behind a legacy for which her entire
family will be remembered and admired. Her death marks the
end of an era when she, her brother, and her sister, Rossetta
Feldman Glashofer, were all part of the KEI family.
Sadie’s brother was a native of Virginia, although he was
reared and educated in Baltimore, where he attended the Johns
Hopkins University and the Maryland Institute College of Art. In
his early years he practiced his artistic skills by submitting several
political cartoons to the local newspapers. He started a successful
advertising firm that was located in downtown Baltimore. But his
real love was collecting Americana, specializing in furniture and
decorative arts relating to Baltimore and to Maryland. His collection was installed in his home, a century-old house built on the
original John Eager Howard estate. He shared many of the treasures in his collection by placing them on indefinite loan to the
local museums.
sends the information back to the brain, where higher order
visual processing occurs, leading to our subjective perceptions of
the world around us. The retina is essentially the gateway that
turns light into sight by sending images to the brain.
Blunt impact injuries can briefly deform the eye ball, changing
its shape much like a tennis ball when it strikes a firm surface.
This traumatic “squeezing” of the eye ball can create tears in the
delicate retinal lining of the eye, leading to bleeding and detachment of the retina from its normal position snug against the
eyewall. If untreated, this can
lead to permanent blindness.
Retinal injury can also occur
with sharp penetrating objects
like nails, glass and chips of
metal.
Common symptoms of retiTraumatic retinal detachment
nal tear and bleeding include
new floaters, flashes of light and blurry vision. In cases of early
retinal detachment, a dark shadow can be seen in the side vision.
It is very important to receive a full eye examination after eye
injury. Early detection of traumatic retinal injury and bleeding
can be the deciding factor in restoring vision and avoiding permanent visual loss.
Sadie graduated from the Johns Hopkins University and the
Maryland Institute of Art and received a master’s degree in psychology at the George Washington University. She returned to
Baltimore where she and her brother, Samson, maintained an active
interest in art and collecting Americana. They inherited their
father’s penchant for collecting rare Americana, leading to an outstanding collection of furniture and decorative arts.
Sadie Feldman, like her brother and sister, was devoted to the
arts and took an active interest in those Baltimore institutions
that preserved them. Her philanthropy rewarded not only the
Baltimore Museum of Art and the Walters Art Gallery, but also
other institutions and programs such as the Jewish Historical
Society and the Department of Art in Medicine at the Johns
Hopkins Hospital.
But most important, Sadie, with her sister, endowed the
Samson Feldman Library, one of the largest collections of ophthalmology texts and journals in Baltimore and used by community medical personnel, ophthalmology residents and staff. Sadie
also provided for the Feldman Family Lectureship at the Krieger
Eye Institute. She attended each program and personally greeted
each Feldman lecturer. This lectureship serves as a memorative
tribute to this wonderful family.
Sadie was a person with a multitude of interests and she
excelled in everything she tried. She was a gentle, kind and generous person. We shall remember her because of the many wonderful and important contributions that she made to this department
and the art community of Baltimore.
eyelights
page 4
Donald Abrams, M.D.
Named New Chief of Ophthalmology
Dr. Donald A. Abrams becomes the third
Zanvyl Krieger chairman of Ophthalmology and
the latest ophthalmologist-in-chief at Sinai. He follows Dr. Irvin Pollack who was the first director
of the KEI and served for 15 years before stepping
down. Dr. James Karesh was the second director
and left the position in June 2005. Dr. Abrams
assumes the mantle at a time of rapid change within the department
(see articles about Residency and about Faculty). Before 1983,
Ophthalmology at Sinai was a division of the Department of Surgery
when Dr. Herman Krieger Goldberg was chief.
No stranger to the department, Dr. Abrams served as an
Ophthalmology resident at Sinai before coming onto the full-time staff
in 1989. He received fellowship training in glaucoma at the Doheny
Eye Institute, the University of Southern California School of
Medicine. After joining the Sinai faculty, he became director of the
M arc Hirschbein M.D.
Named Associate Chairman of KEI
Dr. Donald Abrams, ophthalmologistin-chief and Zanvyl Krieger chairman of
Ophthalmology appointed Dr. Marc Hirschbein as
associate chairman of Ophthalmology. Dr.
Hirschbein is a Baltimore native who graduated
with general honors from the University of
Maryland and received his M.D. from
Hahnemann University School of Medicine in Philadelphia. He served
as both intern and resident in Ophthalmology at the Krieger Eye
Institute (KEI) of Sinai Hospital during which time he became interested in oculoplastics. He had his fellowship in Oculoplastic Surgery at
Glaucoma Service and received national recognition as a glaucoma
specialist and surgeon. He is assistant professor of Ophthalmology at
the Johns Hopkins University School of Medicine, an outstanding lecturer and has over 30 publications in peer-reviewed journals.
Dr. Abrams has devoted much of his career to teaching and resident
education. He has served as director of Graduate Medical Education
at Sinai, the Departmental Committee and the Medical
Records/Health Information Management Committee. For many
years, he served on the Residency Selection Committee and
Ophthalmology Residency Integration Committee. Among his teaching awards are the Wilmer-Sinai-GBMC Resident Advocate Award
and the Golden Globe Teaching Award.
As chief of Ophthalmology, Dr. Abrams plans to move the department forward by expanding opportunities for the Institute. “I hope to
expand the Krieger Eye Institute’s coverage area by looking into
opportunities for growth at Northwest Hospital Center and other
areas in Pikesville, Mount Washington and Owings Mills, Maryland.”
Albany Eye Physicians and Surgeons and Albany Medical Center
before coming to Sinai. Since 1999 he has been a member of the oculoplastic surgery team at the KEI and has taken an active role in the
continued development and expansion of the department.
Dr. Hirschbein has developed a keen interest in all aspects of ophthalmic plastic and reconstructive surgery, but has a particular interest
in laser research and its use and benefits in plastic surgery around the
eye. He is a member of the National CyberKnife Protocol Steering
Committee and is secretary of the Maryland Society of Eye Physicians
and Surgeons. He has published more than 18 book chapters and
papers in peer-reviewed journals. His major research interest includes
studies with the Cyberknife, eyelid retraction repair with a new
porcine dermal implant and use of mitomycin-C for punctoplasty.
New KEI Ophthalmology
Residents
Dr. Anthony Castelbuone, KEI’s program director, noted that
resident education is not a new activity of the Krieger Eye
Institute. After a wonderful 10 years participating as a sponsoring institution in a combined residency with the Johns Hopkins
n December, the Krieger Eye Institute met with more than
Wilmer Eye Institute and the GBMC Department of
40 medical students from around the country who were
Ophthalmology, Krieger re-formed its own residency this past
each competing for one of two spots in the newly re-formed
fall. “It was the first Accreditation Council for Graduate
Sinai Hospital Ophthalmology Residency Program. The
Medical Education approved new residency program in many
applicants were chosen from over 100 highly qualified medyears,” according to Dr. Castelbuono, “and we are honored to
ical students who applied for the chance to interview. They
Dr. Anthony
have received support from the ACGME. The Sinai Hospital
spent their day meeting the faculty and touring the twoCastelbuono
Department of Ophthalmology has had a legacy of resident edufloor Ophthalmology department. In addition, they got a
cation for more than 50 years and we have renewed excitement for our
chance to see the main hospital and ER-7 and even got to see Sinai’s
free-standing training program.
Cyberknife, the only one in the state. A social event was organized for
Judging from the high quality of our applicants and their excitement
out-of-town visitors in the Inner Harbor, where they had opportunity
to meet our current residents and talk to the faculty. They seemed high- for our program,” Dr. Castelbuono added, “we look forward to working with two new residents who will begin in July 2007. Together with
ly interested in what Krieger had to offer, namely a very high level of
our attendings, we are certain they will continue to provide a high level
on-site training by board certified and fellowship trained specialists in
of patient care for the Northwest Baltimore community.”
all the subspecialty areas of ophthalmology.
I
TAKE NOTE
Congratulations to Dr. Joseph B. Harlan who was selected as one
of Baltimore Top Docs by Baltimore Magazine in November 2005.
Congratulations to Dr. Gerami Seitzman who was awarded the
Sinai Hospital “SuperStar” Award in November 2005.
The Annual Symposium of the Krieger Eye Institute will be held June
23, 2006, at the Sheraton Inner Harbor Hotel. Dr. Alan Robin will speak on
New Medications and Surgical Techniques and will give the Feldman
Family Lecture. Dr. Richard Tipperman will discuss Modern Approaches to
the Management of Complications during Cataract Extraction.
eyelights
page 5
swelling and blurry vision. Double vision is common. Numbness
may extend all the way down to the lips. Children and teenagers
may present with a “white-eyed fracture.” In these patients, there
Marc J. Hirschbein, M.D., F.A.C.S.
is almost no swelling or bruising. There is usually difficulty looking
up. These patients often have severe nausea or loss of
Orbital trauma may occur in the setting of motor vehicle
appetite (a result of an eye muscle being “trapped” by the fracaccidents, sports injuries, physical altercations, falls and the
ture). These fractures must be repaired as soon as possible to
occasional “bizarre mishap.” All orbital trauma requires a thoravoid
permanent muscle damage.
ough ophthalmic evaluation, and those requiring surgery should
All
potential
orbital fractures should be evaluated with a CT
be seen by an oculofacial or similar surgeon specializing in orbital
trauma. Damage may occur to the eyelids (eyelid lacerations), tear scan. Orbital X-rays alone are inadequate to diagnose a suspected
fracture. Not all orbital fractures require surgery. Indications for
drainage system, the eye itself (ruptured globe, lens dislocation,
surgery
are: 1) the eye looking “sunken in,” 2) the eye being
retinal detachment) or to the orbital bones (orbital fractures).
unable
to
move in certain directions, and 3) a large fracture as
The most common type of orbital fracture is the orbital
seen on a CT scan.
“blowout” fracture. In these cases, an object
Orbital fractures can often be repaired via hidlarger than the orbital opening (i.e., a fist
den
incisions on the inside of the eyelids. During
or a baseball) strikes the orbital rim. The force is
surgery,
scar tissue is released, and the fracture
transmitted like a “shock wave” through the
site is covered with an implant. Synthetic
orbit and may result in outward fracturing of the
implants made of porous polyethylene (Medpor),
orbital bones (most often the orbital floor or the
as well as titanium plates and screws, have greatinner wall of the orbit). Other orbital fractures
ly improved surgical outcomes and reduced
result from direct trauma to the bones on the
surgical times.
Double vision caused by deviated eye
outer orbital rim.
Orbital Trauma
Patients typically present complaining of pain,
after trauma
Fireworks Injuries to the Eye
It’s not the Fourth of July yet, but the second most common
time for fireworks injuries is New Year’s Eve. Even though most
states have restricted the types of fireworks available to the general public, there are still 12,000 fireworks-related injuries a
year in the United States. About 20% of these, or about 2,400
injuries, are to the eye. About half of these eye injuries result in
legal blindness, and about 5% result in loss of the eye (or necessitated removal of the eye).
The statistics are grim. About 3/4 of these eye injuries occur in
children. The average age was 15, but 5- to 9-year-olds had the
highest injury rate. Most of the injuries to children under age 5
are from sparklers. According to the United States Eye Injury
Registry, about 3/4 of the injuries occur during the Fourth of July
holiday. More than half of those injured are bystanders, and 3/4
of those injured are male. The bottle rocket (illegal in
Maryland) causes most of the injuries. This is the firework with
the long thin stick attached. It is designed to be placed in a bottle before the fuse is lit.
continued on next page
Papers and Chapters Published:
Hirschbein M, Karesh J, Yassur Y: Ectropion and Entropion in Step by Step Oculoplastic Surgery, ed. A. Agarwal, Slack Inc.
Hirschbein M, and Brennar: Stereotactic Radiosurgery of Orbital Disease in Robotic Radiosurgery, ed. R Mould.
Hirschbein M, Garibaldi, Park, Fine: Disorders of the Orbit in Handbook of Ophthalmology, ed. A Agarwal, Slack Inc.
Berkow JW, Fine BS: Arch Ophthalmology, 2005.
Magone MT, Seitzman GD, Nehls S, Margolis TP: Treatment of neurotrophic keratopathy with nasal dilator strips. Br J Ophthalmol., 2005.
Seitzman GD: Cataract surgery in Fuchs’ dystrophy. Curr Opin Ophthalmol., 2005.
Seitzman G, Cevallos V, Margolis T: Rose Bengal and Lissamine Green Inhibit Detection of Herpes Simplex Virus by PCR. Cornea, 2006.
Dr. Donald Abrams and Dr. Anthony Castelbuono attended the annual meeting of the Association of University Professors in Ophthalmology in
Sarasota, Florida.
Nearly all faculty members attended the annual meeting of the American Academy of Ophthalmology in Chicago.
Dr. Marc Hirschbein presented a paper to the Cyberknife Users Society on Stereotactic Radiosurgical Treatment of Orbital Disease.
Dr. Irvin Pollack participated at the Glaucoma Society meeting of the International Congress of Ophthalmology in Vancouver, Canada.
Dr. Joseph Berkow attended the annual Macular Society meeting in Key Biscayne, Florida.
Dr. Joseph Harlan presented Shaken Baby Retinal Injury to the Department of Pediatrics. He also spoke before the South Carroll Senior Center
and Mercy Ridge Assisted Living Facility about macular degeneration.
Dr. Gerami Seitzman attended the American Society for Cataract and Refractive Surgeons in San Francisco. She also discussed “How Your Health
Can Affect Your Eyes” at the Community Center in Augsburg Village.
Even when used “properly,” these rockets
If an eye injury occurs, the recommendation
can fly off in any direction and are considis to place a protective shield over the eye and
ered to be the most dangerous type of firego to the nearest emergency room, and NOT to
work in regard to the number of injuries
apply any medication to the eye. Rubbing the
they cause.
eye or placing any medication or rinsing the
However, even the limited types of fireeye may make the injury worse.
works available for sale to the public still
All of the reports emphasize that the safest way
represent a hazard. Sparklers reach a temperto enjoy fireworks is to attend a professional disature of 1,000+ degrees and can cause severe Playing with a sparkler
play. It is less exciting than setting off your own
burns and set fires. About 37% of sparkler
explosives, but it is also much less risky.
injuries are to the eye. Fireworks with large amounts of
Considering the large number of injuries that continue to occur
pyrotechnic content (greater than 50 mg.) such as cherry
year after year and that most of the victims are children, it is
bombs, M-80s and silver salutes are banned in most states.
prudent to keep all types of fireworks away from children.
Did you know?
1.
A 65-year-old white person has about a 10% chance of having glaucoma. However, an African American of the same age is twice as likely to
have glaucoma.
2.
Nearly half of all people with glaucoma do not know that they have the disease, 65-70% of Hispanics have glaucoma that has not yet been
diagnosed.
3.
4.
5.
6.
7.
Two million people suffer eye injury every year in the United States.
8.
Most eye injuries occur in young men under 20 years of age.
The cornea has more nerve endings than nearly any other part of the body. Therefore, even a tiny scratch in the cornea will cause terrible pain.
Blunt trauma to the eye (such as from a fist or rock) can cause hemorrhage in the eye or retinal detachment and lead to blindness.
Most states in the United States have restricted the types of fireworks available to the general public. Even so, there are 2,400 injuries to the eye from
fireworks every year and 1/2 of these result in blindness.
Three quarters of all firework injuries occur in children.
NONPROFIT
U.S. POSTAGE
Krieger Eye Institute
2411 West Belvedere Avenue
Baltimore, MD 21215-5271
––– PAID –––
BALTIMORE, MD
Permit No. 6721