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    3 views10 pages

    Dengue Asociado A Maculopatia

    Uploaded by

    marco_5109
    dengue

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    © All Rights Reserved
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    ee ___ Dengue-Associated Maculopathy Kristine Envile Bacsal, MD, DPBO; Soon-Phaik Chee, FRCOphth, FRCS(G): Ching-Li Cheng, FRCOphth, FRCS(Ed); John Vincent Policarpio Flores, MD, MSei Objective: To describe the clinical spectrum of fundus ‘manifestations and angiographic and optical coherence tomographic features of dengue-associated maculopa- thy in a lange series, Methods: We reviewed clinical records of patients di- agnosed as having dengue maculopathy at the Sin- gapore National Eye Centre between January 1, 2002, and December 31, 2005, Results: We identified 41 patients with serological evi- dence of dengue fever who had ocular signs and symp- toms not attributable to other diseases within 1 month after onset of symptoms of dengue. Seventy-one eyes hhad maculopathy. Mean best-corrected visual acuity in the affected eye was 20/40 (range, hand motions to 20/20). Intraretinal hemorrhages were seen in 45% of, eyes, usually in association with venous sheathing, Fun- dus fluorescein angiography demonstrated venular occlusion in 25% oF arteriolar and/or venular leakage in 3% and 13%, respectively. Yellow subretinal dots were fan unusual finding in 28%, OF these, 50% showed cor- responding hypofluorescent spots on indocyanine green angiography. Central or paracentral scotomas were observed in 03%. Twenty-eight patients received steroid treatment, Mean visual acuily showed significant improvement hetween weeks 2 and 4, with an increas- {ing proportion of eyes achieving a best-corrected vistal acuity of 20/40 or better across time. Coneluston: Fundus fluorescein and indocyanine green angiography, optical coherence tomography, and visual field testing are useful tools in the diagnosis of dengue ‘maculopathy. Arch Ophthalmol, 2007:125:501-510 Author Affiliations: Department of Ocular Inflammation and immunology. Singapore National Eye Centre (Drs Bacsal, Chee, and Cheng) Scientific Committee, Singapore Eye Research Institute (Dr Chee); Department of Ophthalmology, National University Hospital (Dr Chee) and Deparment of Ophthalmology, Yong Loo Lin School of Medicine (Dr Chee), National University of Singapore; and Quality Management Department, Singapore Health Services (Dr Flores) (aepniyreo) ARCH ORTTTAIATOLVOL ISS, APR DOOT ENGUE FEVER, THE MOST common mosquito- borne viral disease in hu ‘mans, is a multisystemic disease with known com- plications." Ithas also been found to affect the eye.*" The report of Wen et al on the ‘ocular complications of dengute in 24 pa- tents is the largest series thus far. Com- mon findings include retinal hemor- shages, retinal edema, optic dise swelling, and vitritis. Pundus fluorescein angiogrs- phy (FFA) showed leakage at optic dise and retinal vessels, macular nonperlu- sion, and retinal pigment epithelium (RPE) defects, suggesting that the retina and RPE. were the primary sites of involvement. Poor choroidal flushing suggested cho- roidal involvement as well, supported by Lim etal,” who also performed indocys- nine green angiography (ICG) in their small series years alter that by Wen etal Despiteall these reports, the pathophysi- logic mechanism of dengue fe elfect on the eye is still unclear. We pre- senta large, comprehensive series that de- scribes not only FFA and visual field re- sults but also optical coherence tomography (OCT) and ICG findings associated with dengue fever to further our understanding of the ocular sequelae of this condition, rand its Ls} Tie study involved patients who were seen at the Singapore National Eye Centre beeen Jan ary 1, 2002, and December 31,2005, and were ‘iagnosed shaving denguemaculopathybased tothe following criteria (1) clinical diagnosis, fof dengue fever according othe criteria set by the World Health Organization" and 2) pres- ence of fundus lstons that were not attrib able to other conditions with known ocular in volvement, sch as diabetes mellitus, within 1 ‘month alter onset of=ymptoms of dengue fever. Asenior ophthalmologist (S-P.C.) confirmed the presence of maculopathy. Patients whosat- ‘sled both erteriawere included in this series, Patients diagnosed as having macilopathy based on fundus examination underwent the fol- lowing baseline ancillary teste: FFA and ICG (Topcon 501A retina camera: Topcon, Tokyo, J pan), automated perimetry (Zeiss Humphrey Field Analyzer 750, Carl Zeiss Ophthalmic Sys- tems, Dublin, Calif) or Amsler grid testing, and OCT Geiss OCT 3 version 4; Carl Zeiss Oph- thalmic Systems). In eases of abnormal base- line results, field testing was performed at ev xy visit to assess progression or resolution of disease. Although Humphrey visual field (HVE) testing was preferred, Amsler pid esting was per- formed if patients rlased to give consent forthe siutomated test. Institutional review board ap- proval was obtained before data were collected Medical records were reviewed for demo- graphic data (age, sex, and race), ocular symp- (©2007 American Medical Association. AI rights reserved, ‘Downloaded From: http:/larchopht.jamanetwork.com/ by Marco Adolfo Talledo Vallejo on 05/04/2016 ow smal vious hemorrhage ithe ight and, Opal eahaange tomogrphy toms, ocular finding me. Angiographi the consensus of 3 ma C-LC), The size and sed based om ou m ma. Intervention Stud lected to study only the rows ofeach hemifield, The number of adjacent depre nellen visual T indi od investigators (KEB teal field, compe luding the blinds (and. Funds tho Pc oma on HVE te system. We arbitrarily se ofthe inner 2 and nasal el ons in the central field was 007 American Medical Assoc » Talledo Vallejo on 05 velar and atrlarsheathng inthe pst ear verlr an arta lelage ave th en pos tnt forthe den- rarded based on system, The final counted using a reference tem ity of the scotoma, additional the Advanced Glaucoma Intervention Std core; elletive ofthe size and density ofthe ferred to asthe dot score autoimmune-mediated dis vuble-standed DN C4. and une mi bse slemie sercening to excl orders (including antinuclear antibodie antibodies, anticytoplasmie antibodies, ‘roalbuinin) was performed on the initial patients jon, All rights reserved yoar2016 Figure 2. Eso patient 1 ater 2 weeks of treatment. and 8 undue ores anplogaphy cane recon fvcculr leap. Cand D, Opti hetence tomography shows lating of th retina with reson fsubretnal i quent patients were tested for C3, C4, and urine microalbu thin alone, since only these 3 parameters were found to ‘oceasionally praduce abnormal levels Serial determinations were performed in the event ofbnormal levels on inital testing Plate [evcounts, when available, were abtained from clinical records, Patients were treated with corticosteroids based on the pos- tulated immione-mediated pathogenesis of disease, In general, we treated patients who were symptomatic or had visual acuity fof 20/40 or worse in the allected eye and subjectively had per sistent or progressive deterioration of vision, Unless contrain dicated, patients with bilateral disease received daily oral pred nicolone, 1 mg/kg, tapered according to ocular response ar de velopment of adverse drug reactions visual acuity was severely depressed (20/200 or worse) and/or in the absence of improve ‘ment after 3 daysof inital treatment, intravenous methylpred: nisolone, | g/d for 3 days, was given followed by oral predniso- lone. Additional reatment with intravenous immunoglobulins, 4400 mg/kg, was given for 5 daysin cases in which no clinical im provement vas noted after 3 days of intravenous methylpred: risolone. Unilateral disease was treated with periocular steroids tunless contraindicated (low platelet counts), No treatment ss given ifthe initial visual seuity was better than 20/40 or if the patient reported subjective improvement from the initial decrease {nvision. Deseripivesaistics were generated using Ep Infosta Uistieal software, version 6,040 (Centers for Disease Control and Prevention, Atlanta, Ga) Both x tests and analysis of variance were sed whereappropriate, Resultsarepresented aemeanSD. PATIENT 1 A.33-year-old Chinese woman was hospitalized for dengue fe ver. On the second day of admission (@ days alter fever onset), she complained of an acute decrease in vision in both eyes and was reletred for ophthalmic evaluation Herbest-corrected visual acuity (BCVA) anita examination was 20/400 OU. Pupillay responses and intraocular pressure were rnormal, Anterior chamber cell were occasionally fund in both «yes Shehad bilateral swollen and hyperemicopticdses and ven lirand arteriolar sheathing in the poverior pole small vitreous hemorrhage was found in the right eye (Figure TA and B). Arm sler grid testing detected bilateral large, dense central scotomas ‘We found early segmental leakage ofthe retinal arterioles and venules over the entite macula, which later leaked flordly fon PFA (Figure 1C and D). The ICG findings were unremark- able. The OCT showed exudative detachment over the fovea in both eyes (Figure LE and F). he had a low platelet count (26% 107i.) and C4 level (18 mg/mL) and an clevated urine smicroalbumin level (34 mg/L.) atthe time of examination, The patient was treated with intravenous methylpredniso- lone, 1 gd for 3 days. On day 2 of treatment, vision decreased to counting fingers OD despite a marked decrease in subret- nal fluid on OCT. Visual acuity in the left eye was unchanged. Tn view of progressive eye disease, immunoglobulin therapy was given for 5 days, The BCVA was 20/200 on day 7. Intravenous Steroid were shifted to 1 mg/kg daily of oral prednisolone and tapered. On day 9, visual acuity improved to 20/100 OD and 20/200 0, Vision improved to 20/25 OD and 20/30 OS at 10 ‘weeks and remained stable throughout follow-up. By week 2, vascular leakage and neutosensory retinal detachment had re solved (Figure 24-D). The HVF hada dot score of 8 OD and 15 05, At month 12, the visual acuity was unchanged, and a small central scotoma remained in the right eye despite com- plete resolution in the left eye PATIENT 2 4 16-year-old gil was referred for ophthalmic evaluation when she complained of blurring of vision (7 days alter fever onset) (©2007 American Medical Association. AI rights reserved, ‘Downloaded From: http:/larchopht.jamanetwork.com/ by Marco Adolfo Talledo Vallejo on 05/04/2016 Figure 3. yes of pation 2at ital examination. A and 8, Mull sal, ylowish ubrtial macular dts in bth ayes. Cad D Fund Shows area of eal ypertuorescones that oot den tr ages. and, Hypouoroscert spats the md lat phases are een angiography during her hospitalization for dengue fever. On examination, BCVA was 20/40 OD and 20/50 0S, Mild anterior segment in. Alamnmation was found in both eyes, with vitritis of + OD and 14-05. she had swollen, byperemic optic discs. Several small yellowish subretinal macular dots were found in both eyes igure 34 and B), which corresponded to areas of early hy- perfluorescence that did not fade in later images on EFA (Figure 3C and D), and bypolluorescent spots in the middle to late phases of the ICG (Figure 3D and E). Additional areas of choroidal involvement that were not clinically evident were detected on ICG. The HVF test findings were unremarkable, The patient received a course of oral prednisolone for 2 ronths. Visual acuity had improved to 20/30 OD and 20/2 (Osby week 2A month 2, BCVA was 20/20 OD and 20/25 OS, (aepnuyreD) ARGH OMTTINOL VOL resin anglogaphy on inderyanine EE OCULAR CHARACTERISTICS Forty-one patients who satisfied the inclusion criteria were ‘dentfied from January 1, 2002, to December 31, 2005. Of these, 24 (589%) were female and 35 (859%) were Chinese. The mean age was 28.8114 years (range, 11-61 years). Seventy-one eyes had dengue maculopathy. Ocular in- volvement was bilateral but asymmetric in 30 patients (73%); the rest were unilateral. Mean follow-up was 5.44.8 months (range, 1-21 months) (©2007 American Medical Association. AI rights reserved, ‘Downloaded From: http:/larchopht.jamanetwork.com/ by Marco Adolfo Talledo Vallejo on 05/04/2016 Table 1. Posterior Segment Findings of 74 Eyes With Table 2. Anglographie Characteristics of Eyes With Dengue Dengue Maculopathy ‘Maculopathy Fina Fnang| ne. (ot eves Frnaing No.) over Fatal emerge 25) Fan) Venu sheating 218) Bock orescence 21 83) Atle shesting 3) Vena occlsion 16125) Yalow subrati!dote 20,28) Vena leakage 813) ou oes sing 11(15) Vena leakage wth ecluson 36) Disc edema at) aby capilaryhypertuaesconce 843) Opti dsc hyperemia 10(14) ‘terior eeclusion 12) PE matting 12407) Serr eskage 20) Inara precipitates 11) PE window detect 20) Vireus bemerthage 10) PE hypartorascence 640) Capi ranpertuson 12) ‘brvition RPE, etal pigment pha, Indocyanie green anlograpy a =50) any ge ssl yparuorescence 181) Mil tat hypouarescnt spots 17729) Symptoms included generalized blurring of vision in 62 eyes (879%), scotoma in 45 eyes (63%), and floaters in L eye (1%). Symptoms were noted a meansSD of 6.944.0 days (range, 0-30 days) alter the onset of fever There was a mean SD delay in consultation of 8.64 15.6 days (range, 0-90 days) from the onset of symptoms. The summary of fundus and angiographic findings is provided in Table 1 and Table 2. Intraretinal hemor- hages were scen in 32 eyes (45%), usually in association with venous sheathing. Fundus fluorescein angiography demonstrated nonischemic venular occlusion in 16 eyes (25%) or arteriolar and/or venular leakage in 2 eyes (3%) and 1S eyes (13%), respectively. Yellow subretinal dots were an unuisual finding in 20 eyes (289%), usually without cor- responding angiographic findings. In 10 eyes (50%) with yellow dots, the lesions corresponded to hypofluorescent spots in the middle to late phases of ICG and RPE hyper- fluorescence on FFA in 3 eyes (15%). The rest had no cor- responding abnormality on angiography. Anterior cham- ber cells were observed in 12 eyes (17%), vitreous cells in 2 eyes (31%), and anterior chamber and vitreous cells in Beyes (119%). Among the 42 eyes tested, OCT showed ext jure 43) im 11 eyes (2696), and neurosensory retina-RPE atrophy in 1 eye (2%) (Figure 48). A combination of lestons fre- quently occurred in the same eye. Conversely, different le- sions were identified in either eye of the same patient in some cases. The details of ocular characteristics according, dative retinal detachment in 4 eyes (10 sensory relina-RPE thickening at the fovea to predominant involvement are presented in Tables 3, 4,5,6,7.and 8 Among eyes with maculopathy, the initial BCVA was 20/45 (means SD, 0.47 40.42 logMAR equivalent); 37 eyes (5296) had a BCVA of 20/40 (0.30 logMAR equivalent) oF better. Those without maculopathy had a BCVA of 20/25 or better (mean SD, 0.05.0.06 logMAR equivalent), which \was significantly different from maculopathy eyes (analy 001). Among the 04 ey field test results, the mean4SD HVP parameters were as follows: mean deviation of 5.6225.43, pattern standard de- 31 Improvement in mean BCVA was noted in all eyes (Figure 8). A significant improvement in mean BCVA from baseline was noted between weeks 2 and 4 (Tukey mul- sis of variance swith visual Viation of 4.3 194, and dot score of. Abbreviations: FA, funds orescain angiography: APE, rial pigment epithe. Figur 4. Optical coerce tomography of the tasted wes. A, Outer euroeenery retin-a pigmant pall thickening th foes BWarosenzory etna rta pgm ephlal tophy in donque rmaclpaty Uiple comparisons testing continued to improve thereafter, the dilference between sub- sequent follow-up intervals was not significant. Table 9 further illustrates that the proportion of eyes with BCVA 05). Although visual acuity ‘of 20/40 or better increased a every follow’ ps from 37 eyes (52%) at initial examination to OL eyes (869%) at final fllove up. In 3 eyes (494) that had only’ | month of follow-up, BCVA was worse than 20/200 although better than at ini tial examination, The lack of adequate serial HVP obse vations precluded the same analysis for visual fields LABORATORY CHARACTERISTICS Among 19 patients tested, the mean SD C4 level was low (range, 8-38 mg/mL), whereas in 14 patients (©2007 American Medical Association. AI rights reserved, ‘Downloaded From: http:/larchopht.jamanetwork.com/ by Marco Adolfo Talledo Vallejo on 05/04/2016 Table 3. Characteristics of Dengue Maculopathy With Predominant Retinal Vasculopathy oysexy oat ratte vA, nav, rauow-p, Aa6.7 Eye _Shrtng sectona_Sesoma ‘IogAA IoglAR Cleat nage __FFA_——tc_—_eatment™ "a TR A + CD «150 O10 Abel tus seating, Fd AVL Uwonarale UP MIG, or 12 realnenorhaga dst BF erode ing SD on OT Le Rie 1808 ACs tesa Farid VL, Unematal realnenorhaga dst BF ing SD on OT Wawa ROTO —Faltoning.vtnal——_FowalVC_Unaraatie Ol pacar 7 emorage swede Lo mt ting Focal VL Uemable Taek Vo Unenarable Obsenaton 7 CE Ee am _tralmortape ——_V0,8F —_Unemaiatl a a a TT) Vo _Unvenarate Obseraton z cof fps am oa kon wR OWT SAT 000 _Ptrlbanovinge __8F ___Unararatie Galswrads 2 CE urna 0 Feealeheting CWS VOU Mae aay ++ Oe 030 0 Faralbamartage, VO Unrate Poa o hexhg eee Eerode owe Cm COCO Shing cad Vo Uvenaiatle Oalswrass emorhage HW RCD Vain shearing inal —_VO——_Unararatie WP oa 3 emorhage eet Lt 0000 var reratRemarhage VO Unrate stad L aro Ras 0100 —Shonig val Vo Uvenaratle Obseraton 7 emorhage Sewsa Cy Ce OT «OTD Shing van Vo Uvenarable WP oar z Remorhage, NSO on OCT rode Ta Ae) + AT 20) 0 Vii etal namorage, BF RPE —Unenaate WP or % maar ype sro TA cr = O30 Moca inatoctage EMT TH 7 CF dost 060 O18 Vari etatnementage, BF NE rode Aa) ~—~=«SD «AT tradpamrtage —_-8F Unrate Obearaion o MTR + Dee 057010 Sating a Vo Uvenarable WP ot 3 emorhage sro Lo teasing nal BH Uemantle emorhage me RT 0 Sting a VE Uwenaabe Or petoouar 7 emorhage swede ee ee ee ee WL Uvemarable ie = ATR O70 — Fos sening KG! Unenuriatie Galsarads 1 CF ata Foal seating VoL Uvemarable TARR E090 i aig ta —_ KO Tosa emorhage ee ee ee ee ma rey Dec 0100 Reiralbonartage, ——_VO._—_Unonanle TW, wal o hexhng eee Erode Abbraviations: AC, antaror camer. VL, arlar and vr leaps; BF blocked Nurescanc: Bl, bistaimveement; CWS, catten-voo spots De, decrease FF, und urescananiography CG docjnine gran angogranhy, TA, inauirelvameiolane acetonide, VG ravenous immunoglobulin; IVP intavenous matyprdaclee;KCH ody copay Myperfuorescence Le No na dlfeteee; NSD, neursensry ria detachment Hat etd OCT, ata cabrene tomography. gh es, aoc: RPE rial pigment epthalum: RPE hyper, APE hyperfuorescenee Un, uniter invert VA visual acuity: VL. venula kage; VO, venula oecusin: VOL van cclson with ake; +, pesn , ne "Systemic eatant appli abate Laas ndeated oy ayes tha ocaved tan oe eatment high mean SD urine microalbumin level was reported TREATMENT PROFILE at 68.064144.56 mg/L. (range, <11-565 mg/L). The meanaSD C3 level of 86424 mg/mL (range, 47-121 mg/ Twenty-eight (68%) of the 41 patients received treat- mL) was within the reference range. In 37 patients, the ment in the following manner: intravenous methyl- meanaSD platelet count at the time of ocular examina- prednisolone followed by oral prednisolone in tion was 133.47 £117.82 10%pL (range, 11-670% 10%iL). oral prednisolone alone in 11, and intravenous (aepnuret) ARCH OMTITIMOLVOLIGS, ATI NOT WWW ARCOMTTTAIMOLCON (©2007 American Medical Association. AI rights reserved, ‘Downloaded From: http:/larchopht.jamanetwork.com/ by Marco Adolfo Talledo Vallejo on 05/04/2016 Table 4. Characteristics of Dengue Maculopathy With Predominant RPE and/or Choroidal Involvement oysexy nmol fina) ava, atv, Fotew-sp, Aas.7 Eye Stung Seoloma_scotoma_‘igMAupMAR’_lneatFnangs___FFA__—_—¢a_entment” me Braue 0 -APEctanges enable WH Oalswroe 1 ies te) SSSCSCS*SC«tCTO ‘nrenarable UH Peon 7 os a a | 3 maar edema thas Mie maa) CSCC APE window WH Oalaaods ‘ee Ly + ee 20707) mated Unamable WH Orlstecids 2 PE aT FS EO Maesaricaning APE WH Pavocuir 17 t | O_Nofeaigs APEtyper WH steals uM 7 SWOPE aT Oberon 1 t ee eS ee Nr Tose = SMSO Wong RPE wr Tieton 1 t 2m ase 038 Mong RPE ur Abbrvation: lita ivlvement ac, deceased; FA, fundus fluorescein angiography, [C5 ndoeyanne green angiography. WMP, ravenous rethypenisolns let LPHS, a-phase hypoluoescnt pos VK, rg vessel hyporuorasconc, MT, nol etd ght PE, real pigment pul: RPE hyper APE hyparforecens: Un, unatralmeiement VA un acy, pean none ‘Systemic weatant appli a Boh ees. aera sindcata ol in ayes tha caved ada oal eatment Table 5. Characteristics of Dengue Maculopathy With Foveolts insolation or in Combination With Other Findings weysey tat fiat YR Final A, rauow-p "Ade 7 €7e Surin seatama stotoma loth oglAR cinta! Fangs fa eo raatment” ne WMaT-R + Dee 200 0 Rea banorhoge, ound oF TS WMG, 12 “or se, en ‘a Or yw det Peta Lo te 130010 Ratna Remoroge, ound BF ws eras WT ACR «ORD 0 _‘Fealcenig rina! __—_VO.BF Uae Obsovaion 8 emarthage elton oor Lo = = 010 Foz shating aint ———VO,BF ———Unemarale emarthage elton oor mene RCRD ahting al AO Timah WH orl 7 emarthage nal ovots pete onutr erage Le 00> Fatal ahting tial Unrraabe emarthage na ovots onocr Wau R__+ > Dw 030 0 Raundfomalieson, fonobis —Unrmaabe —Unenarable Orage 6 ‘noc Le 10 Randal ein owes Unramable Unemaale ‘noc WERT Aa) + - __~ O18 050 Vie, dscswaling twats Foaleaplay —Unonafable Peicadar 9 ‘nT enpartson, rie Petar Bia ACD «OB low det oundional VOL ry TH wg, sling ovat on OCT ral TA Le me 20045 Shing yo at round VOL we "ova sling ovo oo oor ‘Abbrvition:AVO, aro and vnulareeclusion flaked uoreeceoy Bi, blaralivohamnt De, dearaeed FA, und aorscein angiography. 1c, ndoyanine green angiography rir tramrinelon aestong, VIG, etavinous mminogiabain MP. ravenous metyresioions: Lt [Pinte phaetypofuorercrt pot LVF, atp-vsel hypetvrecones: NT, ot ested OCT, apa eobrene tomogray: Anahi es, sola PE hyper vt amen apteam hypefuorecenes: Un unter vavemer: VA, visual acy VO, veulr eceusen, VOL. wendarecisan ith Iblage presen = none "Sjstemie wearer apis a both es. Lateral is inate oly in ayes that rceveda oa eaten ‘Ab includ i Tal. (aepniyrep) ARCH ORTITAIATOLVOUIGS, APSDOT WWW ARCHONTTTALOL COM (©2007 American Medical Association. AI rights reserved, ‘Downloaded From: http:/larchopht.jamanetwork.com/ by Marco Adolfo Talledo Vallejo on 05/04/2016 Table 6. Characteristics of Dengue Maculopathy With Yellow Dots in Isolation or In Combination With Other Findin ayaa) nat naka VA, Fal A, Fatiow-sp, "Ade 7 6 Shing Seloma Seoloma logMAR ToghAR cinta! Fangs a eo __teatmente tine BRE LB) +e «O70 O10 Soatng.yelow aus KOHLOF OLAS Pocuar 7 enarhage a CTY Ewan Or 7 ‘tec US RS ~C~~SC~*«R CDi Aa yalow cas —_—APEWpar WH LFS Olas 12 Ct Faisal ytow cat: RPEbypxr UH LPS Tara Ue ~«SOD Oi yom ce ak Ta Moa 12 earage, mata ema ‘era, ivi Tare Re ~SC~*C«D «OV yon ae w Ta Pear z tras Teun Rua tsa «ODO yon a RPEhyperUFHS——_—Oosenaton 7 THWSTR + Dez <0 ——«O0_ Vii seating ylow det, _VLF ___Unenaabe Oalstwads 18 atl emorag, L$ + ee 018010 vis stetingyelow dot, VLBF Unrate Peacuar atl mariage ‘tel ares Uy «alow dat eal ovaroge BF a Dalawode 7 TOFS Run) —wT WT 100 0 Vii seaing ylow det, VO.BF___Unenaabe Obsovaion atl mariage. a >> ee 200 05 Ylow do, rune onal vaing, VOLO nF 7 ova on OCT alta LF ee 20005 Seating. yew dt round VOL ove seling ovens on oor Sere TBD ++ —

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