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optho Flashcards

1
Q

Features of horners syndrome

A

Miosis
Ptosis
Enopthalmos - sunken in
Anihidrosis

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2
Q

Causes of optic neuritis

A

MS
Diabetes
Syphilis

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3
Q

Management of optic neuritis

A

High dose steroids

(Recovery 4-6 weeks)

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4
Q

Features of optic neuritis

A

Unilateral decrease in visual acuity - over hours or days
Poor discrimination of colours
Pain worse on eye movement
Relative afferent pupillary defect
Central scotoma

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5
Q

Investigation of optic neuritis

A

MRI of brain with orbits with contrast

Is diagnostic

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6
Q

A 50-year-old woman presents to the emergency department with severe left eye pain over the last 4 hours. She has no changes in her vision, nausea, or vomiting and has a past medical history of rheumatoid arthritis and takes methotrexate. She does not wear any contact lenses.

Her pulse is 92 bpm, her blood pressure is 123/75 mmHg, and she is afebrile. The left eye is deep red and injected throughout. When palpating the eye, the injected vessels do not move and her eye is tender. The right eye is normal and visual fields and acuity are intact.

What is the most likely diagnosis?

A

Scleritis

Main features = extremely painful, deep red injected eye, patient has systemic connective tissue disease, reduced visual acuity, blurred vision

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7
Q

Management of scleritis

A

same day assessment by an ophthalmologist
Oral NSAIDS = 1st
Oral glucocorticoids - more severe
Immunosuppressive drugs for resistant cases

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8
Q

What is orbital cellulitis

A

result of an infection affecting the fat and muscles posterior to the orbital septum - not involving the globe

Usually caused by URTI spreading from sinuses

Is a medical emergency - risk of cavernous sinus thrombosis and intracranial spread

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9
Q

Risk factors of orbital cellulitis

A

Childhood 7-12 years
Previous sinus infection
No Hib vaccine
Recent eyelid infection
Ear or facial infection

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10
Q

Presentation of orbital cellulitis

A

Redness and swelling around the eye
Severe ocular pain
Visual disturbance
Proptosis
Opthalmoplegia
Eyelid oedema and ptosis
Drowsiness +/- nausea and vomiting in meningeal involvement

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11
Q

IVX orbital cellulitis

A

FBC
Clinical examination
CT with contrast
Blood cultures and microbial swab

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12
Q

MXM orbital cellulitis

A

Hospital admission for IV abx

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13
Q

Leading mechanisms for ocular trauma

A

Blunt trauma
Penetrating injury

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14
Q

What type of fracture associated with blunt force

A

Blow out fracture ie fist to the face/squash ball

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15
Q

Structures involved in blow out fracture

A

herniation of the fat
Tethering of inferior recuts
Infraorbital nerve
Inferior nerve get trapped in inferior wall of orbit

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16
Q

What is hyphaema

A

Blood in anterior chamber

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17
Q

What medical condition could show a dislocated lense

A

Marfans

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18
Q

SEIDELS

A

fluoroscein drops into the eye - would show any aqueous damage

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19
Q

Sympathetic opthalmia

A

Exposure to intraocular antigens > due to penetrating injury to one eye > but can get auto-immune reaction in both eyes

Inflammation in both eyes > may lead to penetrating blindness

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20
Q

How to remove small foreign body on cornea

A

slit lamp
Local anaesthetic
Edge of needle > scrape of scoop

Cover with chloramphenicol ointment after

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21
Q

Investigation for intro-ocular foreign body

A

imaging - x-ray or CT

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22
Q

Chemical injury management

A

Quick history
Check toxbase if possible
Check pH
Irrigate +++ (2L saline)
Then assess under slit lamp

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23
Q

Ametropia

A

refractive error present - light focused in front of or behind retina

There are 3 refractive states:
Myopia - before the retina
Emmetropia
Hyperopia - after retina

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24
Q

Emmetropia

A

Normal vision

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25
Q

Anisometropia

A

Significant difference between right and left ametropia

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25
Q

Anisometropia

A

Significant difference between right and left ametropia

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26
Q

Amblyopia

A

Lazy eye

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27
Q

Astigmatism

A

Rugby ball eye shape - blurry vision

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28
Q

Spectacle prescriptions

A

+3.00 / -2.00 x 90

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29
Q

Recommended imaging for optic neuritis

A

MRI brain and orbits with contrast

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30
Q

Steadily worsening loss of vision over the previous few months - followed by a sudden deterioration

Examination findings of a central scotoma and red patches

A

Wet age-related macular degeneration

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31
Q

Dendritic corneal ulcer

A

Herpes simplex virus

Tx. - topical acyclovir

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32
Q

MoA of timolol

A

Used in primary open-angle glaucoma by reducing aqueous production

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33
Q

MoA of prostaglandin analogues

A

Increases uveoscleral outflow

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34
Q

MoA sympathomimetics

A

Reduces aqueous production and increases outflow

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35
Q

Carbonic anhydrase inhibitors

A

Reduces aqueous production

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36
Q

MoA miotics

A

Increases uveoscleral outflow

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37
Q

Ptosis + dilated pupil

A

3rd nerve palsy

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38
Q

Ptosis + constricted pupil

A

Horners

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39
Q

What usually causes blow out fractures

A

Direct blow to the central orbit from a fist or a ball

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40
Q

Most common blowout fracture

A

Inferior blowout - orbital fat prolapses into the maxillary sinus and may be joined by prolapse of the inferior recuts muscle resulting in Diplopia

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41
Q

Organs with autonomic innervation

A

Sympathetic innervation of arterioles, sweat glands and arrector muscles

Smooth muscles of iris and ciliary body associated with the lens

Lacrimal glands

Salivary glands

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42
Q

Sympathetic innervation route -

A

originates from autonomic centres
Passes down spinal cord
Exits spinal cord with T1 - L2 spinal nerves
Travel to sympathetic chains running the length of vertebral column
Pass into all spinal nerves
Pass into splanchnic nerves > organs

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43
Q

What is the commonest cause of a red eye

A

conjunctivitis 30% of all primary care cases

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44
Q

Red painful eye and photophobia , fluorescein and slit lamp exam - dendritic ulcer

What is the causative organism

A

HSV

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45
Q

20 year old female presents with red, severely painful eyes - phenylephrine drops > redness does not blanch

What is the mxm for this

A

Oral NSAIDs

For scleritis

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46
Q

What is used to test between episcleritis and scleritis

A

phenylephrine drops - non-blanching is scleritis

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47
Q

Which conditions can cause anterior uveitis

A

UC
Syphilis
Leukaemia
HLA B27

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48
Q

Child has a 1 day history of redness and swelling around the eyes with pain on eye movement and history of a URTI - what is the initial investigation

A

CT scan

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49
Q

65yr old woman complains of sudden, painless loss of vision since this morning - L fundus shows flame haemorrhage and RAPD

What is the diagnosis

A

Central Vein occlusion

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50
Q

67 year old man with T2D, present with visual disturbances for 3 hours - reports black spots obscuring left eye with a red hue

A

Vitreous haemorrhage

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51
Q

What is a risk factor for retinal detachment

A

Myopia

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52
Q

What is seen on fundoscopy of someone with a retinal artery occlusion

A

Pale retina with a cherry red spot

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53
Q

Retinitis pigmentosa

A

bony spicule

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54
Q

What is the main cause of a retinal artery occlusion

A

Giant cell arteritis

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55
Q

3 year old is brought to GP as his mother is concerned about cross-eyes - corneal light reflection tests confirms strabismus .
What is the management ?

A

Opthalmology clinic where they are given an eye patch

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56
Q

Eye changes classically seen in thyroid eye disease / Graves’ disease

A

inability to close the eyelids

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57
Q

Eye is down and out

A

3rd nerve palsy

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58
Q

What in thyroid eye disease would warrant an urgent review by opthalmology

A

Optic disc swelling

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59
Q

A 60 year old diabetic patient has microaneurysms and new blood vessel formation - no changes on the macula

Definitive management ?

A

Pan-retinal laser coagulopathy

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60
Q

What is a risk factor for developing glaucoma

A

Steroids

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61
Q

Most common cause for retinal artery occlusion

A

Arteroi-sclerosis related thrombosis

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62
Q

Most common cause for retinal artery occlusion

A

Arteroi-sclerosis related thrombosis

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63
Q

What describes the change in the optic disc seen in glaucoma

A

Increased cup to disc ration - cupping

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64
Q

What isn’t a feature of angle-closure glaucoma

A

Symptoms worse on bright light - patients actually find it worse in dark room due to dilation > putting pressuring on trabecular mesh work or something

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65
Q

Which type of visual field loss is associated with open angle glaucoma

A

nasal stepping - peripheral vision is lost first in open angle glaucoma

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66
Q

Central scotoma

A

macular degeneration

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67
Q

What are the side effects of 1st line for open angle glaucoma

A

Change in eye colour / pigment
Longer eyelashes

Latintaprost

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68
Q

What do you see with a right sided trochlear nerve palsy

A

up and outwards

Trochlear nerve > SO > attaches behind to move it forwards and down so if not working it will start to drift up

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69
Q

Oculomotor nerve palsy

A

CN III - down and out

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70
Q

Ptosis, diplopia and eye that is fixed down and laterally - an aneurysm of which vessel is most commonly implicated

A

Left posterior communicating artery

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71
Q

Which foramen does CN III IV and VI pass through

A

Superior orbital fissure

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72
Q

On visualising the retina of an 88-year old man with increasingly blurred vision and reduced central vision, choroidal neovascularisation

Diagnosis ?

A

Wet macular degeneration

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73
Q

Tx for dry macular degeneration

A

Vit C, E, beta carotene and zinc

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74
Q

Senior woman diagnosed with dry macular degeneration - what is seen on fundoscopy

A

drusen

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75
Q

What is not associated with cataract development

A

Hypertension

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76
Q

What is the most associated risk factors for cataracts

A

Old age
Steroids
DM
Smoking

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77
Q

What is a sign of cataract

A

A defect in the red reflex

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78
Q

75 year old present with left homonymous hemianopia - where is the lesion

A

Right optic tract

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79
Q

55 year old male present with bitemporal hemianopia - has a PMH of pituitary adenoma - where is the lesion

A

Optic chiasm - tunica celiac

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80
Q

Patient presents to A&E after a RTA - left homonymous hemianopia with macular sparing - where is the lesion

A

Occipital cortex - due to macular sparing (further back in the brain)

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81
Q

III nerve palsy

A

Least common in optho

Innervates everything else

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82
Q

IV nerve palsy

A

Superior oblique - to look left and down (R)

And so eye is looking up - patient has vertical double vision

Depression in adduction

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83
Q

VI Nerve Palsy

A

Most common
Most serious

Lateral recuts is not working and so cannot abduct and also turns inward

Causes:
Micro vascular
Raised intracranial pressure
Tumours + congenital

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84
Q

How does raised intracranial pressure cause VI palsy

A

Pressure increases inside cranium - brain gets pushed down - comes over Petrous bone and into the orbit > eyes goes into squint

85
Q

VI nerve palsy symptoms

A

Squint
Diplopsia

86
Q

VI nerve palsy investigation

A

Fundoscopy - papiiloedema

87
Q

IV nerve palsy symptoms

A

Patients can present with a tilt (incyclo-torsion weak)
Vertical double vision

88
Q

IV nerve palsy bilateral symptom

A

Torsion
Chin depressed
Blurry vision - asthenopia

89
Q

Causes of IV palsy

A

Congenital decompensated
Microvascular
Tumours
Bilateral - trauma

90
Q

III nerve palsy symptoms

A

If only IV and VI nerve are working > abducted and looking down = ocular position , down and out (w/ ptosis)

Blown pupil (dilated - sphincter papillae not innervated)

91
Q

Painful III nerve palsy***

A

Aneurysm !

Posterior communicating artery of circle of Willis is compromised = LIFE THREATENING

92
Q

Causes of visual field defects

A

Vascular disease
Space occupying lesions
Demyelination
Trauma

93
Q

How many bones make up the orbit

A

7

94
Q

What is a dendritic ulcer

A

Caused by HSV

95
Q

Causative organism of dendritic ulcer

A

Herpes simplex

96
Q

What treatment should you avoid in dendritic ulcer

A

Do not give a steroid

97
Q

Investigation for III nerve palsy caused by Pcomm artery aneurysm

A

MR angiogram

98
Q

What causes cupping

A

Glaucoma

99
Q

What is Oculo- coherence tomography

A

Non-invasive way to monitor to see in greater detail of the eye

100
Q

What investigation is useful for ARMD

A

OCT scan

101
Q

When would you see a hypopyon

A

Anterior uveitis

102
Q

What is a hyphaema

A

Haemorrhage - blood in the anterior chamber

103
Q

What is the main risk factor for acanthamoeba keratitis

A

Contact lens use

104
Q

What symptom are you most likely to experience with increased intraocular pressure

A

Reduced peripheral vision

105
Q

Clinical features of wet age related macular degeneration

A

A reduction in visual acuity - particularly for near field objects = subacute
Difficulties seeing in the dark
Fluctuation in visual disturbances
Photopsia /glare around objects

Positive AMSLER grid testing
New blood vessels > choroidal neovascularisation

106
Q

What are the investigation for ARMD

A

Slit - lamp microscopy

Fluorescein angiography

Ocular coherence tomography

107
Q

Treatment of ARMD

A

Vascular endothelial growth factor (anti-VEGF)
+ laser photocoagulation

108
Q

What is optic neuritis associated with

A

MS, diabetes and syphillis

109
Q

*red desaturation

A

Optic neuritis

110
Q

*horners syndrome + neck pain

A

Carotid artery dissection

111
Q

*teardrop sign on x-ray

A

Due to a blowout fracture

112
Q

What innervates orbicularis oculi

A

Facial nerve - palpebral part gently closes the eye, orbital part tightly closes the eye

113
Q

What is the action of superior tarsal muscle ? (Muellers)

A

Elevating the upper eyelid - affected in Horner’s

(Sympathetic innervation)

114
Q

What type of glands produce meibum ?

A

Tarsal glands / meibomian glands

115
Q

Innervation of the extra-ocular muscles

A

LR6 (lateral rectus - CN VI)
SO4 (superior oblique - CN IV)
AO3 (all else - CN III)

116
Q

Name these

A
117
Q

What produces lacrimal fluid

A

Lacrimal gland - innervated by CN VII (parasympathetic)

Fluid - washes over eye > medial angle > drains through lacrimal punctuation > lacrimal sac > nasal meatus

118
Q

What make up the 3 layers of the eye

A

Fibrous = sclera + cornea
Uvea - vascular layer = ciliary body + iris + choroid
Retina = macula + optic disc + retina

119
Q

Where is the vitreous body found

A

Posterior segment of eye

120
Q

What produces aqueous humour

A

The ciliary body

121
Q

Route of aqueous humour

A

It is produced by the ciliary body
It then circular within the posterior chamber
It then passes through the pupil into the anterior chamber
And is then reabsorbed into scleral venous sinus (Canal of Schlemm) at iridocorneal

122
Q

What makes up the retina

A

Optic disc - only point of entry/exit for blood vessels
Macula - greatest density of cones
Fovea - area of most acute vision

CN II affected

123
Q

Why is the optic disc the ‘blind spot’

A

There are no photoreceptors there

124
Q

Features of rods

A

Contain rhodopsin - activated by light (requires vit. A)

High convergence —> increased sensitivity, reduced acuity

125
Q

Features of cones

A

3 types

Low convergence —-> increased acuity, reduced sensitivity

126
Q

What type of palsy is this ?

A

‘Down and out’

Oculomotor CN III (only superior oblique and lateral rectus are therefor working - SO pushes eye down, LR pulls eye out to the side hence down and out appearance)

127
Q

What nerve palsy is this ?

A

Palsy to CN VI (LR is paralysed > hence eye deviates medially)

128
Q

*double vision looking down

A

Nerve palsy to CN IV

129
Q

Management for conjunctivitis

A

Mild viral = hypromellose + if still angry topic antiviral + Cold compressses

Bacterial = topical chloramphenicol

Allergic = avoidance of triggers

130
Q

What is keratitis

A

Inflammation of the cornea

Contact lens related

Herpes Simplex is the commonest causative organism

Presents as a dendritic lesion with fluorescein stain, severe ocular pain associated with foreign body sensation, watery eye, photophobia and reduced visual acuity

131
Q

Investigations of keratitis

A

Examination with fluorescein
Corneal swab
Slit lamp

If hypopyon seen > immediate specialist referral + culture

132
Q

Management of keratitis

A

Viral = topical antiviral
Bacterial = ofloxacin + chloramphenicol
Fungal = topical anti fungals

133
Q

Main causes for anterior uveitis

A

Autoimmune - reiters, UC, ankylosing spondylitis, sarcoidosis

134
Q

Management of anterior uveitis

A

Topical steroids
Mydriatics

135
Q

*gritty eyes, foreign body sensation, mild discharge

A

Blepharitis

Management = warm compress, tear drops, oral doxycycline

136
Q

Which eye is shown in the image of a normal retina

A

RIGHT EYE - the optic disc is present on the nasal side of the retina

137
Q

How to perform the relative afferent pupillary defect ?

A

Move the pen torch swiftly between the pupils

138
Q

Name missing

A
139
Q

Bones of the orbit

A
140
Q

What conditions results in acute vision loss

A

Amaurosis fugax
Close angle glaucoma
Vitreous haemorrhage

141
Q

Pathological changes seen on retina with diabetes

A

Cotton wool spots

142
Q

What do you see as hypertensive retinopathy

A

Copper wiring

143
Q

Retinopathy seen with retinal artery occlusion

A

Cherry red spots

144
Q

Shadow that being in lower, inner part of patient’s vision what retinal detachment is this ?

A

Superior temporal retinal detachment

Superior - lower

Temporal - inner

145
Q

‘Phacoemulsification and insertion of an intra-ocular lens into the eye’ describes what procedure

A

Procedure to fix cataracts

146
Q

*absent red reflex + dense opacfication of the lens

A

= cataracts

147
Q

Lesion at the parietal lobe would result in what ?

A

Contralateral homonymous inferior quadrantinopia

148
Q

Lesion at the visual cortex (macula sparing) would result in what ?

A

Contralateral homonymous hemoanopia

149
Q

Lesion in the temporal lobe would result in what visual field change?

A

Contralateral homonymous superior quadrantinopia

150
Q

Optic tract lesion would result in what visual field change

A

Contralateral homonymous hemianopia

151
Q

Management of viral conjunctivitis

A

Conservative management

152
Q

management of bacterial conjunctivitis

A

Chloramphenicol

153
Q

Management of herpetic keratitis / dendritic ulcer

A

Topical acyclovir

154
Q

What investigation is used to differentiate between dry and wet ARMD

A

Optical coherence tomography (OCT)

155
Q

What investigation would be useful in differentiating what level of wet ARMD has occurred ie how much new neovascularisation

A

Fluorescein angiogram

156
Q

*extended contact lens use

A

Infectious keratitis

157
Q

What disease does this retina look like its associated with

A

Hypertension

> this is hypertensive retinopathy

158
Q

What is rhodopsin converted into when it is exposed to light ?

A

> opsin and trans-retinal

159
Q

What does the conversion of rhodopsin lead to ?

A

Conversion into opsin and trans-retinal causes the sodium channels to CLOSE and the membrane is hyper-polarised which results in NO neurotransmitter being released into the synapse

A greater potential is then produced in the bipolar cell, and if it is great enough an action potential is generated in the ganglion cells which is propagated to the brain

160
Q

What is seen on this retina

A

Optic nerve swelling

161
Q

What is seen

A

Dendritic ulcer identified with fluorescein drops

162
Q

What is this ?

A

Keratic precipitates

163
Q

What does a hypopyon look like ?

A
164
Q

What are synechiae?

A

Adhesions between the pupil and iris and can lead to small/irregular pupil

165
Q

*corneal reflections are not symmetrical = what type of squint ?

A

Manifest squint

166
Q

Convergent vs divergent squint

A

When the uncovered eye moves OUT to take up fixation = convergent

167
Q

Mechanical closure of aqueous drainage angle’ describes what disease pathway ?

A

Acute angle closure glaucoma

168
Q

‘T-cell driven inflammation with recruitment of other inflammatory cells such as macrophages’ describes what disease pathway

A

Development of scleritis

169
Q

‘Higher intra-ocular pressure resulting in reduced blood flow to the optic head and subsequent nerve loss’ describes the disease pathway for what ?

A

Proposed mechanism for chronic open angle glaucoma

170
Q

‘Entry of bacteria, fungi, Protozoa via a defect in the corneal epithelium causing an inflammatory response’ describes what disease pathway

A

Infectious keratitis

171
Q

What is the most concerning type of trauma to the eye ?

A

Alkali burn

(Acid burn = coagulative necrosis that is contained before cornea
, alkali - liquefactive necrosis with breakdown of normal cellular barrier > penetrates past the cornea)

172
Q

Describe EXOtropia

A

Uncovered eye moves in to take up fixation

It was in a divergent position = manifest divergent squint

173
Q

What type of squint moves down to take up fixation

A

Hypertropia

174
Q

What type of squint moves up to take fixation

A

Hypotropia

175
Q

What type of squint moves out to take up fixation - having been in a convergent position

A

ESOtropia

176
Q

The clinical sign ‘chemosis’ is seen with what disease

A

Viral conjunctivitis

(It is oedema of the conjunctiva)

177
Q

Episcleritis vs scleritis

A

Episcleritis = self-limiting (can be fixed with some lubricant)

Scleritis = usually comes about due to associated conditions
*purple appearance of sclera + headache , treated with topical steroids/topical anti-inflammatories can if not managed needs to be treated with IV immunosuppression (scleral melt)

178
Q

Tx of viral conjunctivitis

A

Cold compresses / not sharing towels

This is self limiting

179
Q

Main disease that causes a corneal ulcer

A

Rheumatoid arthritis

180
Q

What is the sensation of a corneal ulcer describes as

A

Needle like !

181
Q

Tx of dendritic ulcer (HSV)

A

Gamciclovir
More than acyclovir

182
Q

Tx for bacterial corneal ulcer

A

Ciprofloxacin / ofloxacin

(Chloramphenicol is not very useful)

183
Q

Commonest sign of acute anterior uveitis

A

Keratic precipitates

184
Q

Treatment of acute anterior uveitis

A

Steroids
Mydriatics (dilating drops)

185
Q

Why are mydriatics useful in acute anterior uveitis

A

They dilate your pupils and relive pain by relaxing the muscles in your eye - helps with photophobia

186
Q

Where are elderly people (and also people with hypermetropia) at a higher risk of acute closed angle glaucoma

A

Because of increased development of cataracts - they push on the trabecular mesh work

187
Q

*eye is solid, pupil mid dilated , increased IOP

A

= acute closed angle glaucoma

188
Q

How to treat ACAG

A

Pilocarpine

Acetozolamide (Carbonic anhydrase inhibitors)

189
Q

What is the final management of ACAG

A

Iridectomy

190
Q

Most common cause of eye trauma

A

Corneal foreign body

191
Q

How to manage a corneal foreign body

A

Removal with a needle with referral to opthalmology + chloramphenicol for a few days

192
Q

What are the associated conditions of optic neuritis

A

MS
Syphilis

193
Q

What is amaurosis fugax

A

*curtain coming down on vision
Is transient - lasts a few minutes

Need to assess CVD risk

194
Q

Are occlusions of blood vessels in the eye painful or painless

A

Painless loss of vision best describes main sign of vein/artery occlusion

195
Q

What is the cherry red spot on fundoscopy

A

Seen in retinal artery occlusion

Describes the coroidal vasculature coming through

196
Q

*tortuous blood vessels

A

Central retinal vein occlusion

197
Q

Why can you get a vitreous haemorrhage

A

For whatever reason - perhaps due to diabetic retinopathy - there is proliferation of poor quality blood vessels and they burst

198
Q

Treatment of vitreous haemorrhage

A

Laser cauterisation

199
Q

Treatment of retinal detachment

A

Surgery to reattach

200
Q

Tx for dry armd ?

A

None available

Although some suggestions that vitamin supplementation can help prevent further wear and tear

Most appropriate step is to stop smoking

201
Q

Tx for wet armd

A

Anti-vegf injections (can be done by specialist nurse) - to stop and decrease size of new blood vessels that leak

VEGF responsible for proliferation of new blood vessels in response to wear and tear

202
Q

*disc swelling and loss of vision

A

Ischaemic optic neuropathy

203
Q

Who deals with squints / ocular muscle problems / palsies

A

Orthoptist

204
Q

Who deals with prescription glasses

A

Optometrist

205
Q

Lesion affecting the parietal lobe can lead to what visual field defect

A

Contralateral homonymous inferior quadrantinopia

206
Q

Lesion affecting visual cortex can result in what visual field defect

A

Contralateral homonymous hemianopia (macula sparing)

207
Q

Lesion of optic tract can result in what visual field defect ?

A

Contralateral homonymous hemianopia

208
Q

Investigation to confirm dry armd after fundscopy

A

OCT

209
Q

What is a chalazion

A

A meibomian cyst presenting as a firm painless lump in the eyelid

everything (29 decks)

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