Category Archives: Post Lasik Dry Eye

Hope For Post-LASIK Complications

Is There Hope For Post-LASIK Complications?

LASIK has saved millions of people with refractive eye problems around the word. The objective of this procedure is to restore to good vision and never be bothered with wearing contact lenses or eyeglasses. Regrettably, not all people who have undergone this procedure are free from the complications of LASIK.

The reported complications include blurry vision, dry eye, double vision, glare, halos and more. Initially, some of these side effects are experienced during the first few days, or even weeks after the surgery. However, as the months and years progress many are left with these life long side effects.

What Happens Next?

Prolong dry eye disease, blurry vision, double vision and the rest of the complications after LASIK can cause stress and depression. Although, according to reports, only one percent experience serious complications from the procedure, other reports indicate mild-moderate post LASIK complications to be as high as 40%.

If you have experienced the severe or moderate complications of post-LASIK surgery, the good news is, there is hope for you.

Post LASIK Eye Doctor

Seeking another eye doctor to treat the complications of the post eye restoration procedure is a common practice among patients suffering from the complications of the surgery. The fear of having to experience another blow from their previous eye doctor is dreadful, which is why patients are on the go to have their eyes check from one doctor to the another.

There is nothing wrong with this scenario – doctor shopping; second opinions are necessary. Seeing more than one doctor is draining, financially and physically, going to and fro to their respective clinics and be subjected to a series of eye tests again. What is wise and practical is to nail down one reputable eye doctor who specializes in the clinical pathway to treat the complications of the post-LASIK complications.

How to Find These Eye Doctor(s)

A cutting-edge practice that has the experience, knowledge, expertise, and passion defines an expert eye doctor. Global Contact Lens Specialists has affiliated trained doctors for the treatment and management of Post LASIK complications throughout the country:

Baltimore, Maryland Denver, Colorado | Seattle, Washington | Miami, Florida | Charlotte, North Carolina | Chicago, Illinois | Dallas, Texas | Youngstown, Ohio | Phoenix, Arizona | Philadelphia, Pennsylvania | Boston, Massachusetts | New York, New York | Salt Lake City, Utah

Complications After LASIK Surgery

What To Do After Lasik Surgery?

LASIK eye surgery is a procedure to correct refractive errors. This method has become very popular across the globe, making it very accessible to all with a refractive eye problem. LASIK allows the eye to be free from contact lenses and eyeglasses for a very long time. In fact, millions of people in the US have undergone this procedure to correct their vision. However, there are also side effects or complications of this procedure that you need to know.

After LASIK

The common side effects of LASIK surgery include, haze, seeing halos around the eye, dry eyes and fluctuating vision. These side effects are expected to last for a few weeks, and in some cases for more than four month. However, some common side effects can trigger a more serious problem.

The complications of this procedure are a game changer. One might suffer from moderate to severe visual aberrations. Apart from the physical stress,  one has to address the emotional and psychological anxiety caused by the postoperative outcome.

What People Are Commonly Doing

Unfortunately, patients having suffered the complications of the eye procedure would seek another eye doctor to treat their condition.  Eyesight restoration after the LASIK surgery is not for every eye doctor to treat. It takes expert knowledge and skills to restore the damaged cornea caused by LASIK. Often patients will go back  for a LASIK touch-up or enhancement, but unfortunately this can increase the complications.

Expert Eye Doctor

What separates an eye doctor to another eye doctor is their expertise in the field. Second opinions, in this case, are necessary to put an end to one’s vision problem. The main goal here is to seek a treatment that can restore the eyes to its fullest.

There is hope for people with post LASIK complications. There are expert eye doctors who have the experience, invested in acquiring the most modern equipment, continue to advance their knowledge and skills to help those who are not completely free from post LASIK vision problems.

Where To Find The Experts

Hopping from one doctor to the other does not offer a guarantee of a complete treatment. What is vital here is for one to connect with a dependable eye doctor, that is known in the eye industry. A doctor who can help manage and treat the complications of post-LASIK successfully. The post LASIK management and treatment is often a non-surgical intervention with the use of (specialty) contact lenses, scleral lenses, PVR PROSE, EyePrint Pro, and other options. (soft lenses, RGP lenses, hybrids, scleral hybrids)

LASIK surgery is a modern way to correct the eye vision caused by a refractive error, and there are post-surgery complications that some people have suffered. Fortunately, these complications are treatable by doctors who specialize in the restoration of post refractive surgery.

For more information visit LASIKFailures.com

PVR PROSE Lenses for Post LASIK Side Effects

PVR PROSE Lenses are helpful in a lot of post LASIK complications and side effects including corneal ectasia, irregular astigmatism, dry eyes, etc.

PVR PROSE Lenses don’t come in contact with the cornea of the eye, therefore they’re helpful in patients having sensitive or irregular cornea, where soft and conventional contact lenses can’t be used.

There is a film of tear between the PVR PROSE Lens and the cornea, which provides a cushion as well as helps in uniform refraction while the light rays pass through the lens, cornea and the gap in between.

PVR PROSE Lens for post Lasik ectasia

PVR PROSE Lenses and dry eyes

PVR PROSE Lenses and nearsightedness or farsightedness

PVR PROSE Lenses and irregular astigmatism

PVR PROSE Lenses can be helpful in patients suffering with irregular astigmatism after the LASIK procedure.

If you’re having any complications after LASIK procedure consult our specialist to discuss the post Lasik side effects in your case and the best possible treatment options for you.

Post Lasik Ectasia

Post Lasik ectasia of the cornea is one of the most severe complications of Lasik (Laser in situ Keratomileusis).

The Lasik procedure permanently weakens and thins out the cornea, resulting in progressive changes in the cornea such as steepening or bulging, called ectasia. Corneal ectasia results in the visual deterioration.

Keratoconus vs Ectasia

Keratoconus and post Lasik ectasia (keratectasia) are histologically two different processes. Keratoconus is a corneal disorder that isn’t related to surgery and affects both eyes. It begins usually in late teenage years or around puberty. Keratectasia is a result of corneal manipulation during surgery, like Lasik. If the patient didn’t have keratoconus before surgery and didn’t have any family history of the disease, then the post Lasik weakening of the cornea is probably keratectasia (ectasia).

Risk factors of Post Lasik Ectasia

Most common risk factors of post Lasik Ectasia in order of significance are:

  • Abnormal preoperative topography
  • Low residual stromal bed (RSB) thickness
  • Young age
  • Low perioperative corneal thickness
  • High myopia

Post Lasik Ectasia

Treatment of Post Lasik Ectasia

Treatment options for post Lasik ectasia include:

Contact lenses

Contact lenses are helpful in the rehabilitation of vision in patients with post Lasik ectasia. The types of contact lenses best for the patient can be variable as per the exact symptoms and case along with patient’s personal preference. Some of the options include:

  • Rigid gas permeable contact lenses (RGP)
  • Scleral contact lenses
  • Soft contact lenses (custom wavefront guided)
  • Hybrid contact lenses
  • Tandem soft contact lenses

Preferably scleral lenses and rigid gas permeable contact lenses are chosen for the patients. However if they are intolerant to the rigid gas permeable lenses they can be advised the tandem soft contact lenses, hybrid contact lenses and the scleral contact lenses as the next options.

Intracorneal ring segments

Intracorneal ring segments (ICRS) are used in post Lasik ectasia patients having thin cornea that can’t tolerate the contact lens. The size, symmetry, location and number of segments to use are dependent on the individual case and surgeon’s decision.

Corneal collagen cross-linking

The anterior thin layer of cornea is weakened during the flap creation. Most of the cross linking effect occurs in that almost 200 microns of anterior layer of cornea. Cross linking has been claimed to stop the progress of ectasia therefore corneal collagen cross-linking (CXL) can be used to stop post Lasik ectasia from getting worse.

Combination therapies

Some patients might need and benefit from the combination therapies including intracorneal ring segments or corneal crosslinking or any other combined therapy.

Penetrating keratoplasty

Penetrating keratoplasty (PKP) is used as the last resort in patients with post Lasik estasia.

Global Complex Eye Care was specifically designed, equipped, and staffed to provide patients with nothing but the finest in professional eye care. As Post LASIK specialists, we have successfully treated patients with Post Lasik Ectasia, Keratoconus, LASIK Dry Eye and other side effects, Pellucid Marginal Degeneration, Stevens-Johnson Syndrome, and other irregular corneas. Optometrists and Ophthalmologists from all over Maryland and surrounding states refer patients to Dr. Irwin Azman.

For more information please call, (240) 782-2020
to schedule your complimentary telephone consultation.

 

Scleral lenses related to post Lasik side effects

Scleral contact lenses are specialized lenses that are made of a high oxygen permeable material and are larger in diameter as compared to conventional lenses.

Scleral contact lenses aren’t a contact lens in strict sense, as they don’t have any contact with the cornea of an eye. The lens rests on the sclera of the eye and doesn’t move with the movement of the eyeball.

Scleral lenses for post Lasik complications

Scleral contact lenses are helpful in a lot of post Lasik complications and side effects including corneal ectasia, irregular astigmatism, dry eyes, etc.

Scleral contact lenses don’t come in contact with the cornea of the eye, therefore they’re helpful in patients having sensitive or irregular cornea, where soft and conventional contact lenses can’t be used.

There is a film of tear between the scleral contact lens and the cornea, which provides a cushion as well as helps in uniform refraction while the light rays pass through the lens, cornea and the gap in between.

scleral-contact-lenses-lasik

Scleral contact lens for post Lasik ectasia

Corneal damage in post Lasik patients can lead to corneal ectasia. Conventional and soft lenses that rest on the cornea are useless in this condition as they sit on the cornea and cannot maintain their contour as they adjust with the corneal surface.

Scleral contact lenses rest on the sclera and have no contact with the cornea directly; therefore their shape isn’t affected by cornea irregularities and ectasia, providing unaffected refraction of light from the lens surface.

Scleral contact lenses and dry eyes

As scleral contact lenses don’t come in contact with the cornea of the eye, they are useful in patients who can’t tolerate the contact lenses otherwise due to the dry eyes.

Scleral contact lenses and nearsightedness or farsightedness

Patients left with refractive errors or having an over correction can use scleral contact lenses to correct the myopia or hyperopia in their eyes.

Scleral contact lenses and irregular astigmatism

Scleral contact lenses can be helpful in patients suffering with irregular astigmatism after the Lasik procedure.

If you’re having any complications after Lasik procedure consult a specialist to discuss the post Lasik side effects in your case and the best possible treatment options for you.

Dr. Oz Show Discusses Long-term Side Effects of LASIK

An episode of the Dr. Oz Show, which aired on October 3rd, 2013, featured an investigative report about the potential life-long side effects of LASIK eye surgery.

As a popular elective surgery, nearly 800,000 people get Lasik every year. FDA clinical data trial shows that every modern laser left 1 out of 5 patients seeing worse after LASIK. Side effects include seeing double, seeing halos or starbursts (especially at night), and dry eye pain.

Investigative reporter Elisabeth Leamy has been investigating the harmful side effects of LASIK for over two years. During her undercover consultations with doctors, she discovered that the side effects were minimalized and the procedure was treated like an easy, no-risk procedure.

Morris Waxler, the former FDA official responsible for getting LASIK surgery approved, is now working to get it banned. He says that the side effects of LASIK are actually injuries and that LASIK harms 20% of patients.

lasik problems

LASIK eye surgery works by cutting a flap of the top layer of the cornea and then using a laser to reshape the exposed cornea. Complications can occur when the flap of the cornea is cut too thick, too thin or too far into the cornea. However, even if this cut is perfect, when the flap is put back down it doesn’t necessarily heal perfectly. Years later it can become dislodged and trigger negative side effects. In addition, if there were underlying issues prior to the LASIK surgery that were not treated, LASIK surgery (and enhancement touch-ups) will most likely exacerbate the issues. Unfortunately many post LASIK patients now have life long side effects, ranging from the smallest amount to the most severe.

Dr. Irwin Azman provides treatment for people who underwent LASIK, PRK, and RK sugery but are now experiencing post-surgical side effects and complications.

According to Dr. Azman:

“While LASIK surgery can be successful under optimum eye conditions, unfortunately many patients do experience side effects due to pre-existing conditions. However, there is hope. Utilizing our vast experience and expertise, as well as an array of new technologies, we are able to treat these side effects with non-surgical techniques.”

For more information about treatments for Post LASIK side effects and complications visit www.lasikfailures.com or call (240) 782-2020.

Glasses After RK surgery

Radial Keratotomy (RK) is a procedure to correct nearsightedness. The procedure included manually flattening the corneal surface to reduce the refraction of light rays passing through cornea in myopic eyes.

However, the problems with the procedure are more than its benefits in many patients. The procedure was widely used before the advent of more technical options that are available today. The patients who went through the RK surgery usually experience visual disturbances and need management of the complications caused by RK surgery. The correction of side effects caused by RK requires the patients to use glasses, lenses with eye drops, and medication too depending upon their individual case.

rk-surgery

Glasses for post RK complications

Patients undergoing RK procedure frequently complain of pain, glare, visual disturbances etc. They might be temporary in some cases, but are reported to be long standing in many cases.

Glasses for under correction after RK

In under corrected cases, the myopia persists and the glasses for fixing nearsightedness are required. Although they’ll be less diverging than the one used prior to the procedure as the nearsightedness will be partially fixed by the RK procedure.

Glasses for over correction after RK

Over-correction means that the condition which was once nearsightedness is now on the side of farsightedness. These patients need converging lens glasses to have a clear vision of far objects.

Glasses for astigmatism after RK

As the RK procedure is a manual, chances of error and irregularities on cornea caused during the surgery are high. These irregularities can result in astigmatism.

The astigmatism correction needs glasses with cylindrical lens to correct the astigmatism along with spherical lens for nearsightedness or farsightedness in the patient’s eye.

Different pair of glasses for different times of day

The RK incisions can swell at a given time in day or can be flat. Depending upon the condition of cornea, the refraction may differ and thus the vision too. Although this might be temporary in most patients during the healing phase only, they still need assistance through eyeglasses in that phase.

Different pair of glasses for each time of day is ideal for such patients so that they can carry on normal routines during all times of the day.

If you had RK surgery and are now suffering from post RK complications, consult with Dr. Irwin Azman, Post RK Specialist, for a complimentary telephone consultation.

Dr. Irwin Azman is one of the pioneers of the Post RK | LASIK | PRK patient. With over 25 years of experience in the management and treatment of the Post RK patient. Together with his knowledge and experience Dr. Azman is able to prescribe each patient with the proper solution in resolving their Post RK complications, including starburst, glare, dry eye, and other RK complications.

Serving the following areas since 1975:

MARYLAND: Annapolis, Baltimore, Bel Air, Bowie, Carney, Cockeysville, Crofton, Elkton, Essex, Fallston, Fredrick, Glenwood, Hampstead, Havre De Grace, Jarrettsville, Kingsville, Laurel, Lutherville, Manchester, Monkton, Parkton, Parkville, Phoenix, Pikesville, Randallstown, Reisterstown, Severn, Severna Park, Silver Spring, Sparks-Glencoe, Sparrows Point, Towson, Westminster, and Perry Hall
PENNSYLVANIA: Harrisburg, Hershey, Middleton,  Shrewsbury,  and York.
VIRGINIA:  Alexandria, Fairfax, Tysons Corner, and Vienna WASHINGTION DC.

LASIK Complications, What to do?

Not Happy After LASIK, What To Do?

The LASIK procedure is said to have a fair success rate and most patients are said to be satisfied with the outcomes. However there are many patients who aren’t just satisfied, but in fact develop one or more post LASIK complications.

What to do if you’re not happy with LASIK results?

Well this is a debatable topic and exact plan of actions depends from case to case and the reason of not being satisfied and / or complications developed due to LASIK.

First step:

The first step to do once you find yourself unhappy with LASIK results is NOT to panic. Relax, panicking isn’t going to solve anything and might drain your valuable energy that you should be focusing on finding the right solution. You’re not alone and luckily most of the post LASIK complications can be managed effectively.

Consult the Doctor

The ideal way to get an explanation to unexpected results or complications is to consult, question and discuss in detail with the doctor who performed the surgery. If he’s not able to satisfy you and even if he does, consult another eye specialist, or a Post LASIK expert and discuss your case with them. Ideally consult three doctors, which you should have done prior to surgery too in fact.

Revision or enhancement procedures

Depending upon the complication and patient’s specific case, some patients might benefit from revision or enhancement procedure following LASIK. Details of which procedure would be best should be discussed with the specialist. However, a LASIK enhancement is not always the best solution. Further surgery may exacerbate the complications.

Manage Lasik Complications

The complications and side effects caused by LASIK surgery are not only disabling but also irritating. You are not only unable to see properly at night, but also what you see is irritating, glare, blurred and so on. Most of the complications following LASIK surgery are manageable therefore you should consult a specialist to get opinion regarding your case and situation.

Certain management options include:

  • Management of dry eyes, this might be the leading issue precipitating other complications too.
  • Using glasses or lenses for glare and blurred vision.

Most patients experience complications following the LASIK procedure are temporary and improve over time. They can benefit from supportive management during this recovery phase too. However if the symptoms persist for a longer period of time, and you’re not happy after Lasik, instead of giving up, contact Dr. Irwin Azman, Post LASIK Specialist and get expert opinion specific to your condition.

Dr. Irwin Azman is one of the pioneers of the Post LASIK | PRK | RK patient. With over 25 years of experience in the management and treatment of the Post LASIK patient. Together with his knowledge and experience Dr. Azman is able to prescribe each patient with the proper solution in resolving their Post LASIK complications, including starburst, glare, dry eye, and other LASIK complications.

Serving the following areas since 1975:

MARYLAND: Annapolis, Baltimore, Bel Air, Bowie, Carney, Cockeysville, Crofton, Elkton, Essex, Fallston, Fredrick, Glenwood, Hampstead, Havre De Grace, Jarrettsville, Kingsville, Laurel, Lutherville, Manchester, Monkton, Parkton, Parkville, Phoenix, Pikesville, Randallstown, Reisterstown, Severn, Severna Park, Silver Spring, Sparks-Glencoe, Sparrows Point, Towson, Westminster, and Perry Hall
PENNSYLVANIA: Harrisburg, Hershey, Middleton,  Shrewsbury,  and York.
VIRGINIA:  Alexandria, Fairfax, Tysons Corner, and Vienna WASHINGTION DC.

 

High Order Aberrations (HOA) Related To Refractive Surgery/LASIK

High order aberrations (HOA) refer to complex imperfections of the optical system and are normally present in all eyes in minor unnoticeable amounts. However as a result of optical refractive surgeries such as LASIK, unnatural and irregular shape of the cornea can result in increase in HOA and thus result in halos, double vision, smears and other visual disturbances.

Measuring and Diagnosing High Order Aberrations

High order aberrations are measured using a wavefront aberrometer. The wavefront aberrometer measures the distortions of light as they pass through the patient’s cornea.

Wavefront aberrometry helps in diagnosing both lower order and higher order vision errors based on how the light passing through eye focuses or refracts.

High order vs. Low order aberrations

Lower order aberrations are common vision errors like nearsightedness, farsightedness and astigmatism.

Higher order aberrations are coma, spherical aberration and trefoil. These aberrations result in visual disturbances like glare, halos, starbursts, blurring, double vision, etc.

HOA after refractive surgeries like LASIK

As discussed above, HOA are present in normal un-operated eyes too, however usually they’re too low to be noticed or to cause any visual disturbances to the normal eye.

As a result of manipulation of the cornea or structures of eye involved in refraction of light entering the eye, the HOA are increased.

HOA in LASIK

In conventional LASIK surgeries, the HOA usually increase to an extent that they’re noticeable and cause visual disturbances especially at night when the pupils are dilated. This is due to the change and irregularity of corneal surface induced during the LASIK procedure.

HOA in wavefront-guided LASIK

Although wavefront-guided LASIK was introduced to reduce the total aberrations of the eye (both higher order and lower order) during the procedure, they still tend to result in increased HOA after the surgery, but reportedly less than conventional method.

The increase in HOA as a result of corneal manipulation in procedures like LASIK is one of the main reasons for visual disturbances like halos, glare, starbursts, double vision, blurring of vision, disturbed night vision, etc.

Treatment of increased HOA

HOA POST LASIK High Order Aberrations (HOA)

Before and After Treatment of POST LASIK High Order Aberrations (HOA)

 

 

If the corneal surface is manipulated and significant increase in HOA has occurred to cause visual disturbances, contact Dr. Irwin Azman to discuss the condition in detail, to understand your issue and best options for your specific case. Options to solve the visual complications due to irregular corneal surface or other related option may include the following: rigid gas lenses (RGP), scleral contact lenses, soft contact lenses, hybrid lenses, and other options.

If you’re experiencing HOA disturbances (halos, glare, starbursts, double vision, blurring of vision, disturbed night vision, etc.) consult with Dr. Irwin Azman, Post LASIK HOA Specialist, for a complimentary telephone consultation.

Dr. Irwin Azman is one of the pioneers of the Post LASIK | PRK | RK patient. With over 25 years of experience in the management and treatment of the Post LASIK patient. Together with his knowledge and experience Dr. Azman is able to prescribe each patient with the proper solution in resolving their Post LASIK complications, including starburst, glare, dry eye, and other LASIK complications.

Serving the following areas since 1975:
MARYLAND: Annapolis, Baltimore, Bel Air, Bowie, Carney, Cockeysville, Crofton, Elkton, Essex, Fallston, Fredrick, Glenwood, Hampstead, Havre De Grace, Jarrettsville, Kingsville, Laurel, Lutherville, Manchester, Monkton, Parkton, Parkville, Phoenix, Pikesville, Randallstown, Reisterstown, Severn, Severna Park, Silver Spring, Sparks-Glencoe, Sparrows Point, Towson, Westminster, and Perry Hall
PENNSYLVANIA: Harrisburg, Hershey, Middleton,  Shrewsbury,  and York.
VIRGINIA:  Alexandria, Fairfax, Tysons Corner, and Vienna WASHINGTION DC.

 

Scleral Contact Lenses For Post LASIK

The concept of scleral contact lenses is as old as 100 years, but their use was limited due to various issues such as permeability and material of lens. However with technological advancement, the use of scleral lenses have become wide spread in past few decades for various ocular conditions, including post-LASIK complications like residual refractive error.

Scleral contact lenses for post LASIK complications

In post LASIK cases, the modified cornea may no longer be able to fit well to conventional lenses like toric soft lenses and may add to patient’s irritation and frustration. Scleral contact lenses are advised to those patients to overcome the post LASIK complications such as visual disturbances and dry eyes.

What is a scleral contact lens?

Scleral contact lenses are a type of rigid gas permeable lenses. They are often considered to be the last resort for patients for whom other lenses have failed.

Scleral contact lenses are wider than usual lenses and thus are supported entirely by the sclera, without irritating or getting support from cornea. Therefore they are helpful in preventing corneal irritation and to overcome corneal surface abnormalities easily.

How scleral contact lenses help post LASIK patients

During the LASIK procedure, the cornea is modified and manipulated. Although the procedure is performed to get rid of lenses and glasses, in some cases of LASIK complications, scleral lenses might be the last resort in solving the post LASIK side effects. However, due to corneal changes during the LASIK procedure, conventional lenses are hard to fit on its surface and thus result in more irritation and issues. In those patients, scleral contact lenses are advised to fix post LASIK complications.

The scleral contact lenses provide vision correction without touching the cornea, therefore any irregularity on the surface of cornea has no affect in de-shaping the scleral contact lens surface.

Furthermore, the permeable material used in scleral contact lenses allows easy gas exchange preventing corneal hypoxia.

The scleral contact lenses are helpful in patients with dry eyes and various other visual issues following LASIK surgery.

If you’re not happy after LASIK surgery and are having any post LASIK complications, consult Dr. Irwin Azman, Post LASIK Specialist, for a complimentary telephone consultation. Discuss the possibility and effectiveness of scleral contact lenses and all your options in your case.

Dr. Irwin Azman is one of the pioneers of the Post LASIK | PRK | RK patient. With over 25 years of experience in the management and treatment of the Post LASIK patient. Together with his knowledge and experience Dr. Azman is able to prescribe each patient with the proper solution in resolving their Post LASIK complications, including starburst, glare, dry eye, and other LASIK complications.

Serving the following areas since 1975:
MARYLAND: Annapolis, Baltimore, Bel Air, Bowie, Carney, Cockeysville, Crofton, Elkton, Essex, Fallston, Fredrick, Glenwood, Hampstead, Havre De Grace, Jarrettsville, Kingsville, Laurel, Lutherville, Manchester, Monkton, Parkton, Parkville, Phoenix, Pikesville, Randallstown, Reisterstown, Severn, Severna Park, Silver Spring, Sparks-Glencoe, Sparrows Point, Towson, Westminster, and Perry Hall PENNSYLVANIA: Harrisburg, Hershey, Middleton,  Shrewsbury,  and York. VIRGINIA:  Alexandria, Fairfax, Tysons Corner, and Vienna WASHINGTION DC.