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Chinese Journal of Optometry Ophthalmology and Visual science
 
2020 Vol.22 Issue.12
Published 2020-12-25
Orignal Article
Case Report
Review
Orignal Article
881  Evaluation of the Correlation between Vessel Density and Visual Field Loss in High Myopic Patients with Primary Open-Angle Glaucoma Using OCTA
Fen Nie1,Junyi Ouyang2, 3, Lijia Luo2, 3, Jinxiang Luo2, 3, Xiaoyu Chen1,Xuanchu Duan1, 2, 3
 Objective: To evaluate the vessel density and optic disc morphological characteristics in high myopic (HM) patients with primary open-angle glaucoma (POAG), and to investigate the association between vessel density and visual field loss. Methods: This was a cross-sectional study. A total of 24 HM patients (44 eyes) with POAG and 37 HM patients (50 eyes) without POAG (control group) were enrolled in this study. The glaucoma patients were additionally classified into a mild POAG group (13 patients, 20 eyes) and moderate and severe POAG group (15 patients, 24 eyes) according to the visual field mean deviation (MD). All patients underwent imaging using optical coherence tomography angiography (OCTA) to measure vessel density and structural parameters of the optic disc and macula, fudus photography to calculate the optic disc ovality index, and standard automated perimetry. The differences in vessel density, structural parameters and visual field variables between the groups were compared by one-way analysis and the correlation between MD and the optic disc ovality index was performed by Pearson correlation or Spearman correlation analysis. Results: Compared with the control group, the HM patients with POAG showed reduced peripapillary capillary density, deep foveal vessel density and superficial parafoveal vessel density (F=86.340, 18.620, 42.757, all P<0.001), which aggravated the progression of glaucoma. There was no significant difference in the optic disc ovality index between the mild POAG group and control group (P=0.077), while the moderate and severe POAG group showed a decreased optic disc ovality compared to the control group and mild POAG group, and the difference was significant (P<0.001, P=0.028 respectively). The parameter with the highest correlation coefficient to visual field MD was average retinal nerve fiber layer (RNFL) thickness (r=0.782, P<0.001), followed by average ganglion cell complex (GCC) thickness (r=0.621, P<0.001), superficial parafoveal vessel density (r=0.621, P<0.001), peripapillary capillary density (r=0.599, P<0.001) and deep parafoveal vessel density (r=0.420, P=0.002). The disc ovality index was positively associated with the peripapillary capillary density (r=0.318, P=0.002), disc area (r=0.405, P<0.001), average RNFL thickness (r=0.476, P<0.001) and average GCC thickness (r=0.375, P<0.001). Conclusions: In contrast to average RNFL thickness and GCC thickness, decreased vessel density in HM patients with POAG is associated less with visual field loss. The disc ovality index is correlated with a decrease in vessel density and structural damage. The OCTA can be used for early diagnosis of HM with POAG.

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2020 Vol. 22 (12): 881-888 [Abstract] ( 299 ) [HTML 1KB] [ PDF 2829KB] ( 2627 )
889  Comparison of Cyclopentolate, Compound Tropicamide and Atropine on Cycloplegiain Children
Yanfang Meng1,Lianhong Zhou1,Xuewei Xiong1,Xuemin Hu1,Wenyan Zhao2,Meihong Ye1,Beixi Yi1
 Objective: To investigate and compare the cycloplegic effect of cyclopentolate, compound topicamide and atropine in children with different ages, refractive status and accommodative esotropia. Methods: This prospective clinical study had been conducted at Renmin Hospital of Wuhan University between September 2018 and September 2019 in 283 children (566 eyes) of 3-12 years old with refractive error. All the children were given 1% atropine to obtain the refractive diopter, and they were randomly divided into group A and group B. The two group are divided into 3-<6 years old group and 6-<12 years old group according to age. The 3-<6 years old group and the 6-<12 years old group are divided into three subgroups: The myopia group without esotropia, the hyperopia group without esotropia and the esotropia group. After 5 weeks, pupil size and light reflex back to normal. Group A received 1% cyclopentolate hydrochloride eye drops for computer optometry, and group B received 0.5% compound tropicamide eye drops for computer optometry. The Wilcoxon signed rank sum test was used to statistically analyze the difference of spherical equivalent of computer optometry before and after 1% atropine, and the difference of computer optometry after different cycloplegia. Results: The SE after 1% atropine was greater than before 1% atropine, the difference of SE was 1.75(1.00-2.75)D, and the difference was statistically significant (Z=-20.62, P<0.001). The difference was more obvious children with aged 3 to 6, children with hyperopia and children with esotropia (P<0.001). In group A, the SE after using 1% atropine was greater than that after using 1% cyclopentolate, and the difference of SE was 0.25(0.13-0.50)D (Z=-11.49, P<0.001). The difference of SE in 3-<6 years old group after using 1% atropine and 1% cyclopentolate in the myopia group without esotropia, hyperopia group without esotropia and esotropia group were 0.25(0.25-0.25)D, 0.38(0.25-0.50)D, 0.50(0.38-0.75)D (Z=-3.34, -7.36, -4.95, all P<0.001). The difference of SE of that 3 subgroups in the 6-<12 years group were 0(0-0.12)D, 0.25(0.12-0.25)D, 0.44(0.28-0.69)D (Z=-0.83, P=0.405; Z=-5.30, P<0.001; Z=-3.53, P<0.001). In group B, the SE after using 1% atropine was greater than that after using 0.5% compound tropicamide, and the difference of SE was 0.25(0.13-0.50)D (Z=-15.46, P<0.001). The difference of SE in 3-<6 years old group after using 1% atropine and 0.5% compound tropicamide in the myopia group without esotropia, hyperopia group without esotropia and esotropia group were 0.25(0.19- 0.25)D, 0.38(0.25-0.75)D, 0.69(0.30-1.03)D (Z=-3.15, P=0.002; Z=-9.89, P<0.001; Z=-4.79, P<0.001). The difference of SE of that 3 subgroups in the 6-<12 years group were 0(0-0.12)D, 0.32(0.13-0.38)D, 0.50(0.41-0.50)D (Z=-1.37, P=0.171; Z=-7.15, P<0.001; Z=-4.37, P<0.001). Conclusions: The spherical equivalent of mydriasis refraction with 1% cyclopentolate eye drops or 0.5% compound tropicamide eye drops is similar to that with 1% atropine in myopic children aged 6 to 12 years without esotropia, and it is different from that with 1% atropine in 3-<6 years old children and children with hyperopia and esotropia at 6-<12 years old.

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2020 Vol. 22 (12): 889-894 [Abstract] ( 336 ) [HTML 1KB] [ PDF 1075KB] ( 3015 )
895  Effect of a Visual Perceptual Evaluation System on Predicting Stereopsis Function Rehabilitation after Concomitant Exotropia Surgery
Ronghan Zhang1, 3, Jing Fu1,Bowen Zhao1,Zhaojun Meng1,Nan Ma1,Li Yan4,Jinghui Wang1,Juanjuan Cheng1,Kai Cao2
 Objective: To evaluate the accuracy, sensitivity and specificity of the plasticity score in examinations of visual perception and training systems in the clinical application for predicting the recovery of stereopsis in patients with concomitant exotropia. Methods: This was a prospective clinical study. A total of 136 patients with concomitant exotropia were continuously recruited and underwent surgery in Beijing Tongren Hospital from January 2017 to September 2017. Of these, there were 109(80.2%) cases of intermittent exotropia and 27(19.9%) cases of constant exotropia. One week after the surgery, all patients underwent visual perception plasticity testing. Spearman correlation was used to analyze the correlation between the type of exotropia, age at surgery, duration of strabismus, deviation angle of preoperative strabismus, deviation angle of strabismus one week after surgery, and plasticity score. All patients underwent visual perception training one week after surgery for 6 months. The far stereopsis and near stereopsis acuity tests were performed 1 month, 3 months, and 6 months after surgery, and the ROC curve was plotted to evaluate the accuracy, sensitivity and specificity of the plasticity score in predicting stereopsis after concomitant exotropia surgery. The Delong test was used to compare the predictive efficacy of the plasticity score and traditional clinical indicators on the recovery of stereopsis function 6 months after surgery. Results: The plasticity score was correlated with age preoperative deviation angle, the course of strabismus, strabismus type and deviation angle one week after surgery (r was -0.3, -0.2, -0.3, 0.4, -0.3, P<0.05, respectively). The plasticity score can predict far and near stereopsis at different time points during the 6 month interval after surgery. There was a moderate predictive significance for both far and near stereopsis six months after surgery (AUC>0.7, P<0.001). For the traditional clinical indicators, preoperative near stereopsis had a low degree of predictive significance for near stereopsis 6 months after surgery (AUC=0.63<0.7, P=0.009), but there was no significant difference when compared with the plasticity score (Z=1.2, P=0.06). The preoperative far deviation angle had a low predictive significance for the complete recovery of both near and far stereopsis 6 months after surgery (AUC=0.66<0.7, P=0.02), but there was no significant difference of degree of predictive significance between the deviation angle and plasticity score (Z=1.4, P=0.15). Conclusions: The plasticity score can effectively predict the recovery of far and near stereopsis in patients with concomitant exotropia after surgery, and provide the basis for further diagnosis and treatment strategies for patients after surgery.

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2020 Vol. 22 (12): 895-901 [Abstract] ( 332 ) [HTML 1KB] [ PDF 807KB] ( 2551 )
902  Observation of Surgical Effects of Slanted Lateral Rectus Recession and Lateral Rectus Recession on Convergence Insufficiency Intermittent Exotropia
Jialu Wang, Xiaoli Kang, Lingyan Dong, Jie Cen, Yan Wei, Junjue Chen, Liuhui Zhang
 Objective: To observe the surgical effects of slanted lateral rectus recession (S-LR) and lateral rectus recession (LR) on convergence insufficiency intermittent exotropia [CIX (T)]. Methods: In this retrospective study, surgery was performed by the same surgeon on 101 patients with CIX (T) in Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine from January 2017 to August 2019. They were divided into 2 groups: A bilateral slanted lateral rectus recession group (S-BLR group, 44 cases) and a bilateral lateral rectus recession group (BLR group, 57 cases). All patients were followed up for 3 months. The postoperative near deviation, distant deviation, and near-distant disparity (NDD) were measured and compared in this retrospective study. Data were analyzed using Mann-Whitney U test, χ2 test, t test. Results: Three months after surgery, the improvement of NDD was 8.0±3.3 PD in the S-BLR group and 6.1±4.0 PD in the BLR group (Z=-1.995, P=0.046). NDD improved more significantly in the S-BLR group than in the BLR group. The near deviation of the S-BLR group (-5.1±5.5 PD) significantly decreased compared with the BLR group (-8.3±5.8 PD) (Z=-2.882, P=0.004). There was no significant difference in distant deviation between the S-BLR group and LR group after 3 months. The success rates after 3 months of follow-up were 82% in the S-BLR group, which was a higher rate than 53% in the BLR group (χ2 =9.34, P=0.002). There was no significant difference between preoperative and postoperative fovea-disc angles and A and V patterns in the S-BLR group. Conclusions: In postoperative near deviation and NDD, S-LR patients improve more significantly than LR patients. S-LR does not cause A and V pattern strabismus or fundus rotation. S-LR patients have a better surgical outcome than LR patients with CIX (T).

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2020 Vol. 22 (12): 902-907 [Abstract] ( 335 ) [HTML 1KB] [ PDF 867KB] ( 2701 )
908  Analysis of Refractive Outcome and Related Factors in PACG Patients after Phacotrabeculectomy
Yanxia Li, Jia Li, Jing Zhao, Yajuan Zheng
 Objective: To study the refractive outcome and related factors in primary angle closure glaucoma (PACG) patients 3 months after phacotrabeculectomy. Methods: This was a prospective clinical study. Fifty-one eyes of 51 patients with PACG and co-existing cataract who underwent phacotrabeculectomy at the Eye Center of the Second Hospital of Jilin University from December 2018 to September 2019 were enrolled. Patients with intraocular pressure (IOP) ≤21 mmHg (1 mmHg=0.133 kPa) were classified as the normal IOP group and patients with IOP >21 mmHg were classified as the high IOP group. Anterior chamber depth (ACD), axial length (AL) and keratometry were measured by AL-scan, and the SRK-T formula of AL-scan software was used to calculate the intraocular lense power and predict the refractive outcome. Subjective refraction was performed at 3 months. According to postoperative refractive error (RE), the patients were divided into a myopia group (RE <-0.5 D), hyperopia group (RE >0.5 D) and no refractive error group (-0.5 D≤RE≤0.5 D). A Chi-square test was used to compare the distribution of refractive errors between the normal and high IOP groups. The preoperative biological parameters of the myopia group and hyperopia group were compared by an independent t-test, and a paired sample t-test was used to compare the biological parameters before and after surgery. Results: In the normal IOP group, there were 4 patients with myopia (17%), 3 patients with hyperopia (12%), and 17 patients without refractive error (71%); in the high IOP group, there were 7 patients with myopia (26%), 16 patients with hyperopia (59%), and 4 patients without refractive error (15%). The reduction of AL in patients with high IOP was greater than that in patients with normal IOP, and the difference was statistically significant (t=-4.308, P<0.001). The preoperative ACD of the hyperopia group was shallower than that of the myopia group, and the preoperative AL was shorter than that of myopia group. The difference was statistically significant (t=3.226, P=0.03; t=4.993, P<0.001). With keratometry, there was no significant difference between the two groups (t=-1.143, P=0.263). There was a negative correlation between postoperative RE and preoperative ACD and AL (r=-0.32, P=0.023; r=-0.52, P<0.001); there was no significant correlation between postoperative RE and keratometry (r=0.15, P=0.101). Conclusions: Compared with normal IOP, PACG patients with high IOP have more RE, and most of them are hyperopic RE. In addition, the shallower the ACD and the shorter the AL were, the refractive outcome of PACG patients after phacotrabeculectomy more likely tends to be hyperopia.

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2020 Vol. 22 (12): 908-913 [Abstract] ( 333 ) [HTML 1KB] [ PDF 814KB] ( 2958 )
914  The Correlation between Retinal Sensitivity and Vessel Density in the Macular Area of Simple High Myopia
Qiu Qiu1,Bo Ye1, 2, Ning Li1,Jie Shi1,Licheng Tang1,Fan Liu1
 Objective: To study the standardized changes in retinal sensitivity and vessel density in the macular area of simple high myopia and to explore their correlations. Methods: This was a descriptive research. A total of 80 patients (80 eyes) who were treated at Nanchang Aier Eye Hospital and volunteers from March 2019 to September 2019 were included, of which 47 cases (47 eyes) were in the simple high myopia group, and 33 cases (33 eyes) were in the control group. Optical coherence tomography angiography (OCTA) was used to measure the retinal superficial vessel density (SVD) and deep vessel density (DVD) in the macular area at 3 mm×3 mm. Macular integrity assessment (MAIA) measured the retinal sensitivity (RS) in a 10° diameter of the macular area. Based on the Early Treatment Diabetic Retinopathy Study, the RS was divided into 6 regions (temporal, superior, nasal, inferior, fovea and parafovea) corresponding to the vessel. Data in each area were compared by an independent t-test between the two groups. Pearson correlation analysis was used for the correlation of RS with axial length (AL), spherical equivalent (SE), SVD and DVD. Results: RS in the high myopia group decreased significantly in all areas except the nasal area (P<0.05). The entire area and the parafoveal, superior and inferior areas of DVD in the high myopia group decreased significantly (P<0.05). Regardless of the entire group of subjects or the high myopia group, RS was positively correlated with SE (r=0.382, P<0.001; r=0.435, P=0.002), and negatively correlated with AL (r=-0.429, P<0.001; r=-0.382, P=0.008), positively correlated with DVD (r=0.286, P=0.010; r=0.344, P=0.018), and had no correlation with SVD. In the high myopia group, RS was positively correlated with SVD in the foveal, parafoveal, temporal and nasal regions (r=0.386, P=0.015; r=0.292, P=0.046; r=0.435, P=0.006; r=0.319, P=0.048). RS and DVD were positively correlated with DVD in the foveal, parafoveal, inferior and inferior regions (r=0.330, P=0.040; r=0.358, P=0.025; r=0.294, P=0.045; r=0.437, P=0.005). Conclusion: Retinal sensitivity and deep vessel density in simple high myopia decreases with regional differences. The decrease in retinal sensitivity may be related to the decrease in deep vessel density.

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2020 Vol. 22 (12): 914-921 [Abstract] ( 319 ) [HTML 1KB] [ PDF 2902KB] ( 3137 )
922  Clinical Presentation in Contact Lens-Associated Infectious Keratitis: A Study of Twenty Cases
Ju Zhang, Xiaoxiao Li, Mingna Liu, Weiyun Shi, Hua Gao
 Objective: To observe the clinical presentation and outcomes of corneal contact lens-related infectious keratitis, in order to provide a reference for clinical diagnosis and treatment. Methods: Patients who were hospitalized from July 2009 to June 2019 due to contact lens-related infectious keratitis were retrospectively reviewed. The risk factors of lens care, symptoms and signs, characteristics of corneal infection focus, results of etiological examination, treatment process and prognosis of the patients were collected and analyzed. Results: A total of 20 patients (23 eyes) were included in the study, 12 females and 8 males, with an average age of 21.4. Seventy-two percent of high-risk lens care (8/11) were wearing lenses for several days and washing the lenses in tap water. The most common clinical symptoms were foreign body sensation, pain, redness and vision loss. The ulcer in 15 eyes was located in the optic axis and paraoptic areas, and 8 eyes in the peripheral area. The positive rate of etiological examination was 35% (8/23). Acanthamoeba infection was found in 4 eyes, including 2 eyes combined with staphylococcus epidermidis infection, 3 eyes with pseudomonas aeruginosa infection and 1 eye with staphylococcus epidermidis infection. Sixteen eyes were successfully treated with drugs, and 7 eyes were successfully treated by surgery combined with drugs. Treatment outcomes were excellent in 8 eyes (35%), good in 9 eyes (39%), and poor in 6 eyes (26%). Conclusions: Wearing lenses for several days and washing them in tap water are the important risk factors of contact lens infection. Ulcers mainly occur in the optic axis and paraoptic areas. Acanthamoeba and pseudomonas aeruginosa are the most common pathogens. After timely and reasonable drug and surgical treatment, most of the patients can obtain satisfactory results.

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2020 Vol. 22 (12): 922-927 [Abstract] ( 349 ) [HTML 1KB] [ PDF 9964KB] ( 2679 )
928  Retrospective Analysis of Patients with Fungal Keratitis in a Hospital in Wenzhou
Lili Jin, Xiaoyi Qin, Pengfei Chen, Yali Li, Meiqin Zheng
 Objective: To analyze the etiology, drug sensitivity, laboratory examinations and treatment of patients with fungal keratitis in a hospital in Wenzhou, thus providing evidence for the diagnosis and prognosis of fungal keratitis. Methods: This was a retrospective case. Data from 258 patients (258 eyes) who were diagnosed with fungal keratitis at the Eye Hospital,Wenzhou Medical University, from January 2017 to December 2019 were collected. Patients were divided into different groups: Males and females, older and younger patients, farmers and non-farmers, plant injuries and non-plant injuries, fusarium and non-fusarium infections. The respective operation rates were calculated for gender, age, occupation, pathogenic factors and pathogenic bacteria. χ2 analysis was performed for the difference in operation rates in each group. Further, the positive detection rate of the pathogenic examination method was compared and analyzed, and the drug sensitivity of the main pathogenic bacteria was also included. Results: September to November was the highest incidence period for fungal keratitis, accounting for 48.1% for the entire year. Most of the patients (60.5%) were farmers. Plant injury was the leading pathogenic factor while fusarium was the main pathogen accounting for 34.5% and 45.3%, respectively. The positive rate of fungal culture was 68.6%, which was higher than the smear test (χ2 =4.522, P=0.033). Of the 258 patients with fungal keratitis, 44(17.0%) underwent surgery. Further analysis revealed that elderly (≥65 years) patients (χ2 =5.293, P=0.036), plant injury patients (χ2 =11.386, P=0.001), and fusarium infection patients (χ2 =3.939, P=0.044) had a higher probability of surgery. Additionally, the geometric mean values of the minimum inhibitory concentrations (MIC) of fusarium to amphotericin B, itraconazole and voriconazole were 4.283, 17.290 and 1.105 μg/ml, respectively; those of aspergillus were 3.389, 2.661 and 0.125 μg/ml, respectively; those of alternaria were 0.604, 0.531 and 0.258 μg/ml, respectively; and those of candida were 0.317, 0.552 and 0.047 μg/ml. Conclusions: Fusarium is the main pathogen of fungal keratitis in Wenzhou, and plant injury is the main pathogenic factor. Elderly patients, plant injuries, and fungal keratitis caused by fusarium infections are more serious and are more likely to require surgical treatment.

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2020 Vol. 22 (12): 928-933 [Abstract] ( 336 ) [HTML 1KB] [ PDF 780KB] ( 2609 )
934  Correlation between Traditional Chinese Medicine Constitution and Quality of Life in Patients with Acute Anterior Uveitis
Na Tang, Xiaohan Jiang, Yingxi Zhao, Chunjie Lu, Shengjin Xiang
 Objective: To evaluate the correlation between traditional Chinese medicine (TCM) constitution and quality of life in patients with acute anterior uveitis. Methods: This was a cross-sectional study that included a total of 196 patients from the Eye Hospital, Wenzhou Medical University. Pathological constitution was judged by constitutional scores from December 2014 to December 2017. The quality of life score was evaluated by the Chinese Quality of Life Scale. Generalized linear regression and linear regression were used to analyze the correlation between TCM physique and quality of life scores in various fields. A total of 196 patients with pathological constitution were judged by the constitution score, using generalized linear regression and linear regression to analyze the correlation between TCM constitution and quality of life scores. Results: In the 196 patients with acute anterior uveitis, 147 had a simple constitution and 49 had a complex constitution. After generalized linear regression analysis, the patients' different constitution types and constitution scores were significantly correlated with scores on the Chinese Quality of Life Scale. Further analysis found that constitutional scores were significantly correlated with shape and emotion in the Chinese Quality of Life Scale (both P<0.05), without an obvious correlation with the mind. After linear regression analysis, among the different types of TCM constitutions, Qi deficiency constitution, Phlegm-dampness constitution, Blood stasis constitution, Yang deficiency constitution, Yin deficiency constitution and the Chinese Quality of Life Scale have significant correlations (all P<0.05). There was a significant correlation between qi-stagnation constitution and emotions (P=0.001) and there was a significant correlation between damp-heat constitution and shape and emotion (both P<0.001). Conclusions: Different TCM constitutions in patients with acute anterior uveitis are closely related to the Quality of Life of traditional Chinese medicine, and have the greatest impact on the aspect of shape.

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2020 Vol. 22 (12): 934-939 [Abstract] ( 356 ) [HTML 1KB] [ PDF 911KB] ( 2526 )
Case Report
940  
 

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2020 Vol. 22 (12): 940-942 [Abstract] ( 303 ) [HTML 1KB] [ PDF 11210KB] ( 2398 )
943  
 

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2020 Vol. 22 (12): 943-945 [Abstract] ( 306 ) [HTML 1KB] [ PDF 3517KB] ( 2560 )
Review
946  Advances in Rotationally Asymmetric Multifocal Intraocular Lenses
Xiaomin Liu, Yusen Huang
With the continuous development of intraocular lens design technology and the continuous improvement of quality of life for a new generation of aging population, cataract phacoemulsification combined with intraocular lens implantation can achieve better overall vision and higher visual quality. This is the common expectation of the cataract surgeon and the patient. Rotationally asymmetric multifocal intraocular lenses (MIOLs) reduce the incidence of adverse optical phenomena while providing distance, intermediate and near vision, meeting the needs of patients' lives and work. In this paper, the design, clinical effects and research progress of in vitro experiments on rotationally asymmetric MIOLs are reviewed. 

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2020 Vol. 22 (12): 946-950 [Abstract] ( 345 ) [HTML 1KB] [ PDF 1066KB] ( 3151 )
951 Advances in Diabetic Keratopathy
Yang Wang, Yanning Yang
 In recent years, diabetes-related complications have received increasing attention, mainly affecting the cornea and retina in the eye. The popularity of vitrectomy has caused concern of diabetic keratopathy. Hyperglycemia can affect corneal hierarchy by changing corneal morphology, metabolism and physiology, affecting the corneal epithelium, corneal nerve, tear film, and even the normal function of corneal endothelium and conjunctiva, leading to corneal epithelial elongation, persistent edema, recurrent erosion, decreased corneal nerve sensitivity, and tear film changes. This paper mainly discusses the morphological and pathological changes of diabetic keratopathy, the related pathogenesis and the experimental therapeutic agents currently under research, hoping to be helpful for clinical treatment.

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2020 Vol. 22 (12): 951-955 [Abstract] ( 316 ) [HTML 1KB] [ PDF 699KB] ( 2941 )
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