Eent

Front 1

It consists of a group of ocular diseases characterized by changes in the optic disk, loss of visual sensitivity, and loss of visual field.

Back 1

glaucoma

Hint 1

g

Front 2

In galucoma, Aqueous humor is initially produced by the ________ epithelial cells in the posterior chamber.

It then flows through the pupil between the posterior surface of the iris and the lens to enter the anterior chamber.

After circulating within the anterior chamber, the aqueous humor leaves through the _____________ of the anterior chamber angle to enter the canal of _______.

Back 2

ciliary body, trabecular meshwork, schlemm

Hint 2

c b, t m, s

Front 3

occurs as a result of closure of pre-existing narrow anterior chamber angle, when dilation of the pupil causes the iris to touch the lens.

This obstructs the flow of aqueous humor from the posterior chamber through the pupil and into the anterior chamber.

The ciliary body in the posterior chamber continues to produce aqueous humor, which leads to rapid rise in the intraocular pressure (IOP).

Back 3

primary acute closed angle glaucoma

Hint 3

p a c a g

Front 4

occurs in elderly persons (owing to physiologic enlargement of the lens), those who suffer from hyperopia, and Asians.

Angle closure may be precipitated by pupillary dilation, and thus can occur from sitting in a darkened theater, at times of stress, or, rarely, from pharmacologic mydriasis.

Back 4

acute closed angle glaucoma

Hint 4

a c a g

Front 5

may be observed with anterior uveitis or dislocation of the lens.

Symptoms are the same as in primary acute closed-angle glaucoma, but differentiation is necessary because of differences in management.

Back 5

secondary acute closed angle glaucoma

Hint 5

s a c a g

Front 6

Patients with ____________ usually seek treatment immediately, because of extreme pain, headache (or brow ache), photophobia, and blurred vision, though there are subacute cases.

The blurred vision is associated with rainbow-colored halos around lights.

Back 6

acute closed angle glaucoma

Hint 6

a c a g

Front 7

The patient often looks very sick.

Nausea, vomiting, and abdominal pain may occur, and acute glaucoma must be remembered in the differential diagnosis of an acute abdomen (something that will require surgery, inflammation)

Back 7

acute closed angle glaucoma

Hint 7

a c a g

Front 8

The eye is red with peri-limbal (“ciliary”) injection.

The cornea is hazy and steamy (because of corneal edema).

The pupil is moderately dilated and non-reactive to light.

Back 8

acute closed angle glaucoma

Hint 8

a c a g

Front 9

The globe will be “rock hard”.

The visual acuity will be decreased.

Tonometry reveals elevated intraocular pressure - IOP is often > 50 mm Hg (normal IOP: 10 to 24 mm Hg).

Back 9

acute closed angle glaucoma

Hint 9

a c a g

Front 10

the anterior chamber is shallow.

This is demonstrated by a penlight held laterally and directed nasally.

In an eye with a normal anterior chamber, the entire iris will be illuminated by the penlight.

In an eye with a narrow angle or shallow anterior chamber, a shadow is cast on the nasal side of the iris secondary to the forward bowing of the iris (crescent shadow).

Back 10

acute closed angle glaucoma

Hint 10

a c a g

Front 11

Initial treatment in _______________ is control of intraocular pressure by decreasing the production of aqueous humor and increasing its outflow.

Back 11

primary closed-angle glaucoma

Hint 11

p c a g

Front 12

A topical beta-blocker such as timolol solution (Timoptic) 0.5%, 1 to 2 drops q 10 to 15 minutes for 3 doses, then 1 drop q 12 hours may be used.

Back 12

primary closed-angle glaucoma

Hint 12

p c a g

Front 13

Additionally, a single 500 mg IV dose of acetazolamide (Diamox), followed by 250 mg PO qid, is usually sufficient.

Osmotic diuretics such as IV mannitol, 1 to 2 grams/kg, can also be used.

Once the intraocular pressure is reduced below 40 mm Hg, topical 4% pilocarpine (Pilocar), 1 drop q 15 minutes for 1 hour, then qid, is used to constrict the iris and relieve the obstruction to the flow of aqueous humor, thereby increasing aqueous humor outflow.

Back 13

acute closed angle glaucoma

Hint 13

a c a g

Front 14

The IOP should be checked hourly after treatment is initiated until an emergent ophthalmology consult can be obtained and definitive treatment can be initiated.

The unaffected eye will also have a narrow anterior chamber and should be treated prophylactically with pilocarpine.

Back 14

acute closed angle glaucoma

Hint 14

a c a g

Front 15

The definitive treatment is laser peripheral iridotomy (a transverse division of some of the fibers of the iris, forming an artificial pupil), which should also be performed prophylactically on the fellow eye.

If it is not possible to control the intraocular pressure medically, glaucoma drainage surgery may be required.

Back 15

acute closed angle glaucoma

Hint 15

a c a g

Front 16

In ______________, systemic acetazolamide is also used, with or without osmotic agents.

Further treatment is determined by the cause.

Back 16

secondary acute closed-angle glaucoma

Hint 16

s a c a g

Front 17

characterized by gradually progressive - over a period of months or years - excavation (“cupping”) and pallor of the optic disk with loss of vision varying from slight constriction of the peripheral fields to complete blindness.

Back 17

chronic glaucoma

Hint 17

c g

Front 18

In this, the intraocular pressure is elevated due to abnormal drainage of aqueous humor through the trabecular meshwork. (it drains but it drains poorly)

Back 18

chronic glaucoma

Hint 18

c g

Front 19

In this, the intraocular pressure is elevated due to obstruction of flow of aqueous humor into the anterior chamber angle.

Back 19

chronic glaucoma

Hint 19

c g

Front 20

In this disorder, intraocular pressure is not elevated above the normal range, but the same pattern of optic nerve damage occurs, probably due to vascular insufficiency that may also play a role in primary open-angle glaucoma.

Back 20

normal-tension glaucoma

Hint 20

n t g

Front 21

chronic or acute glaucoma:The cause of the decreased rate of aqueous humor outflow in primary open-angle glaucoma has not been clearly established.

The disease is bilateral, and there is an increased prevalence in first-degree relatives of affected individuals and in diabetics.

Back 21

chronic

Front 22

occurs at an earlier age, is more frequent in blacks, and may result in more severe optic nerve damage.

Back 22

primary open angle glaucoma

Front 23

secondary __________ may result from uveitis or the effects of trauma.

Back 23

open-angle glaucoma

Hint 23

o-a g

Front 24

T or F:Patients with chronic glaucoma have no symptoms initially.

Back 24

T

Front 25

on examination there may be slight cupping of the optic disk, observed as an absolute increase - or an asymmetry between the two eyes - of the ratio of the diameter of the optic cup to the whole optic disk (cup-disc ratio). Increased cup:disc ratio

Back 25

chronic glaucoma

Hint 25

c g

Front 26

The visual fields gradually constrict, but central vision remains good until late in the disease. (peripheral field loss)

Tonometry, ophthalmoscopic visualization of the optic nerve, and central visual field testing are the best studies for diagnosis and follow-up.

The diagnosis depends upon identification of consistent abnormalities in at least two of these parameters.

Back 26

chronic glaucoma

Hint 26

c g

Front 27

The normal range of intraocular pressure is _______.

Back 27

10 to 24 mm Hg

Front 28

Except in acute cases, the diagnosis of glaucoma is not made on the basis of one tonometric measurement, since intraocular pressure is influenced by various factors.

The diagnosis of _______ is not always straightforward, hampering the effectiveness of screening programs.

Back 28

chronic glaucoma

Hint 28

c g

Front 29

Topical ______ such as timolol (Timoptic), 1 drop bid, continue to be popular anti-glaucoma agents.


They are contraindicated in patients with reactive airway disease or heart failure.

Back 29

beta andrenergic blocking agents

Hint 29

b a b a

Front 30

A topical _______ anhydrase inhibitor (such as dorzolamide {Trusopt} 2%) can be used in addition to a beta-blocker, or as initial therapy when beta-blockers are contraindicated.

Oral _________ anhydrase inhibitors (acetazolamide {Diamox}) may be used on a long-term basis if topical therapy is inadequate and surgical or laser therapy is inappropriate.

Back 30

carbonic, carbonic

Hint 30

c c

Front 31

In chronic glaucoma, Laser ____________ (photocoagulation of the trabecular meshwork of the eye with a laser) is used as an adjunct to topical therapy to defer surgery, and is also advocated as primary treatment.

Surgery is generally undertaken when intraocular pressure is inadequately controlled by medical and laser therapy, but it may also be used as primary treatment.

Back 31

trabeculoplasty

Hint 31

t

Front 32

In chronic glaucoma, _________ (surgical opening of the canal of Schlemm) remains the standard procedure.

Back 32

trabeculotomy

Hint 32

t

Front 33

___________ and deep sclerectomy with collagen implant are two alternative procedures that avoid a full-thickness incision into the eye, and may prove to be as effective as trabeculotomy.

Back 33

viscocanalostomy

Hint 33

v

Front 34

Untreated chronic glaucoma that begins at age 40 to 45 will probably cause complete blindness by age 60 to 65.

Early diagnosis and treatment can preserve useful vision throughout life.

In primary open-angle glaucoma, the aim is to reduce ___________ to a level that will adequately reduce progression of visual field loss.

Back 34

intraocular pressure

Hint 34

i p

Front 35

In the most serious cases, intraocular pressure must be reduced to less than ____ mm Hg.

In normal-tension glaucoma, it may be necessary to achieve even lower intraocular pressure.

Surgery is nonetheless generally required.

Back 35

16

Front 36

The _________ tract consists of the iris, the ciliary body, and the choroid

Back 36

uveal

Hint 36

u

Front 37

Inflammation of the iris is referred to as iritis.

Inflammation of the ciliary body is referred to as cyclitis.

Inflammation of the choroid is referred to as choroiditis.

Any combination of iritis, cyclitis, or choroiditis is referred to as _____(inflammation of the uveal tract).

Back 37

uveitis

Hint 37

u

Front 38

characterized by ciliary injection (limbal flush), pupil constriction, decreased visual acuity, and tearing.

Back 38

iritis

Hint 38

i

Front 39

Inflammation of the uveal tract causes protein and white blood cells to escape into the aqueous humor.

Slitlamp examination reveals “flare” and “cells” in the anterior chamber.

This is manifested clinically as ________________.

Back 39

blurred vision

Hint 39

b v

Front 40

light scatter from the slitlamp beam secondary to inflammatory cells and proteins circulating within the aqueous humor, and has the appearance of a “headlight-in- fog”.

Back 40

flare

Hint 40

f

Front 41

refers to the finding of inflammatory cells in the anterior chamber, having the appearance of “dust-in-a- movie-projector-light”.

Back 41

cells

Hint 41

c

Front 42

A common symptom with ______ is pain with accommodation, which has been shown to be highly specific for iritis.

Back 42

iritis

Hint 42

i

Front 43

Other symptoms include photophobia (which is a main symptom), headache, and pain with consensual light reflex

Back 43

iritis

Hint 43

i

Front 44

Photophobia occurs secondary to spasm of the ciliary body with pupillary constriction.

A simple way to detect this spasm is to cover the affected eye, and shine a light in the unaffected eye.

If this causes pain in the covered eye, _____ and ciliary spasm should be suspected.

Back 44

iritis

Hint 44

i

Front 45

pain with accomodation,
photophobia,
headache,
pain with consensual light reflex, and ciliary spasm with unreactive pupils

Back 45

uveitis

Hint 45

u

Front 46

the presence of _______ requires a search for associated systemic illness such as arthritis, Sjogren’s syndrome, herpes simplex virus, and herpes zoster virus.

Back 46

uveitis

Hint 46

u

Front 47

_____ can be precipitated by trauma to the orbit (traumatic ______).

Back 47

iritis, iritis

Hint 47

i, i

Front 48

Topical analgesics (DO OR DO NOT) significantly reduce the pain of uveitis or iritis.

Topical cycloplegics and corticosteroids are prescribed.

Prompt ophthalmology follow-up is important.



(If pain not reduced w/topicals, it is indicative of a deeper problem)

Back 48

do not

Front 49

is any opacity of the lens of the eye.

It may involve a small part of the lens, or the entire lens.

The degree of opacification is variable.

Back 49

cataract

Hint 49

c

Front 50

Cataracts may develop secondary to the natural aging process, trauma, congenital causes, or medication use.

__________ is by far the most common type.

Most persons over the age of 60 have some degree of lens opacity.

Excessive sun exposure and cigarette smoking predispose to cataract development.

Back 50

senile cataract

Hint 50

s c

Front 51

insidious onset of decreased vision is the main clinical feature.

Usually, far vision acuity is affected more than near.

Back 51

cataract

Hint 51

c

Front 52

On physical examination, there is a translucent yellow discoloration in the center of the lens.

Back 52

cataract

Hint 52

c

Front 53

As the ________ matures, the retina will be increasingly more difficult to visualize, until finally the fundus reflection (red reflex) is absent, and the pupil is white.

Back 53

cataract

Hint 53

c

Front 54

Treatment involves intracapsular (the lens and entire capsule are excised) or extracapsular (the posterior lens capsule is left) extractions of the ________.

Back 54

cataract

Hint 54

c

Front 55

Functional visual impairment is the prime criterion for surgery

Back 55

cataract

Hint 55

c

Front 56

With the development of ultrasonic fragmentation (photoemulsification) of the lens nucleus, it is now possible to perform ________ surgery through a small incision without suturing the wound, thus reducing complications.

Back 56

cataract

Hint 56

c

Front 57

Retinal Disorders Associated With _________ Diseases:

Diabetic Retinopathy
Hypertensive Retinopathy
Cytomegalovirus Retinitis

Back 57

systemic

Hint 57

s

Front 58

In the normal retina, the _________ are smaller and brighter

Back 58

arteries

Front 59

The ___________ retinal area is the most common site of detachment

Back 59

superior temporal

Hint 59

s t

Front 60

Patients often complain of an acute onset of monocular, decreased visual function and may describe a shadow or curtain descending over their eye.

Back 60

retinal detachment

Hint 60

r d

Front 61

Other complaints include cloudy or smoky vision, “floaters”, or “flashes of light”.

Back 61

retinal detachment

Hint 61

r d

Front 62

Funduscopic exam may reveal a billowing or tent-like elevation of the retina compared with adjacent areas.

The elevated retina often appears out-of-focus and gray.

Back 62

retinal detachment

Hint 62

r d

Front 63

A new onset of “floaters” associated with flashing lights indicates a ________ or detachment until proven otherwise.

All cases of __________ must be referred immediately to an ophthalmologist.

Back 63

retinal tear, retinal detachment

Hint 63

r t, r d

Front 64

Patients with ________________ complain of sudden visual loss, or abrupt onset of “floaters” that may progressively increase in severity

Back 64

vitreous hemorrhage

Hint 64

v h

Front 65

The eye is not inflamed, and the clue to diagnosis is the inability to see fundal details clearly despite the presence of a clear lens.

Back 65

Vitreous Hemorrhage

Hint 65

v h

Front 66

Causes include diabetic retinopathy, retinal tears (with or without detachment), retinal vein occlusions, exudative age-related macular degeneration, trauma, and subarachnoid hemorrhage.

In all cases, examination by an ophthalmologist is essential

Back 66

vitreous hemorrhage

Hint 66

v h

Front 67

is the leading cause of permanent visual loss in the elderly.

It increases in incidence with each decade over age 50

Back 67

age-related macular degeneration

Hint 67

a r m d

Front 68

The exact cause of age-related macular degeneration is unknown, but macular degeneration may be secondary to the toxic effects of some drugs.

Degeneration of the macula may be evidenced by the accumulation of retinal _________.

Back 68

drusen

Hint 68

d

Front 69

In age-related macular degeneration, _________ appear on funduscopic exam as small, discrete, round, yellow punctate deposits, usually in the macular region.

Back 69

hard drusen

Hint 69

h d

Front 70

In age-related macular degeneration, _________ are larger, paler, and without discrete margins.

Back 70

soft drusen

Hint 70

s d

Front 71

In age-related macular degeneration, most patients with _______ have good vision, although there may be decreased visual acuity and distortion of vision.

Back 71

drusen

Hint 71

d

Front 72

There is no effective treatment, however, if detected early, ____________ may respond minimally to laser treatment.

Patients with drusen need ophthalmology evaluation every 6 to 12 months, or sooner if visual distortion or decreasing visual acuity develops.

Back 72

macular degeneration

Hint 72

m d

Front 73

characterized by a sudden, painless, and marked unilateral loss of vision.

Back 73

central retinal artery occlusion

Hint 73

c r a o

Front 74

Most of the fundus is pale due to retinal edema, but the fovea does not have the edema, and thus appears as a cherry-red spot.

This produces the hallmark on funduscopic exam: a pale retina with a cherry-red colored fovea.

Back 74

central retinal artery occlusion

Hint 74

c r a o

Front 75

History should focus on how long ago the episode occurred.

If the loss of vision occurred recently, attempts to restore blood flow may be beneficial if performed in a very narrow time window after the acute onset.

This may be accomplished by:
1. Laying the patient flat.
2. Administering high concentrations of inhaled oxygen.
3. Decreasing intraocular pressure with topical beta-blocker ophthalmic drops or IV acetazolamide.
4. Ocular massage.

Back 75

central retinal artery occlusion

Hint 75

c r a o

Front 76

temporal arteriits should be strongly considered in all pts presenting w signs and symptoms of

Back 76

central retinal artery occlusion

Hint 76

c r a o

Front 77

Apply direct pressure to the eye with the heel of your hand for 5 to 15 seconds, then release.

Repeat this several times.

The goal is to create a sudden rise and fall of the intraocular pressure that may dislodge the embolus and improve retinal perfusion.

What is this called and when is it indicated?

Back 77

occular massage, central retinal artery occlusion

Hint 77

o m, c r a o

Front 78

Emergency ophthalmology referral is necessary.

Prognosis is poor even with immediate treatment.

A work-up for valvular and atrial thrombus is warranted to prevent further damage.

Back 78

central retinal artery occlusion

Hint 78

c r a o

Front 79

The hallmark of ___________ is a sudden onset of unilateral, painless visual loss (but more gradual than that of central retinal artery occlusion).

Back 79

central retinal vein occlusion (CRVO)

Hint 79

c r v o

Front 80

Funduscopic exam classically reveals multiple hemorrhages of various sizes and shapes around the disk; and dilation and tortuosity of the venous system.

This is called “blood and thunder” fundus.

Back 80

central retinal vein occlusion (CRVO)

Hint 80

c r v o

Front 81

Ocular massage is to be avoided in _______________!

The severity of visual loss is variable.

All patients should be referred urgently to an ophthalmologist.

Back 81

central retinal vein occlusion

Hint 81

c r v o

Front 82

(“fleeting blindness”) is usually caused by retinal emboli from ipsilateral carotid disease.

Back 82

amaurosis fugax

Hint 82

a f

Front 83

Noninvasive evaluation of the carotids can be accomplished using duplex ultrasonography and magnetic resonance angiography (MRA).

Emboli from cardiac sources (such as atrial fibrillation) may also be responsible, therefore EKG and echocardiography may be indicated.
may also be a result of choroidal or retinal vascular spasm, in which case calcium channel blockers may be effective.

Back 83

amaurosis fugax

Hint 83

a f

Front 84

The visual loss is usually described as a curtain passing vertically across the visual field with complete monocular visual loss lasting a few minutes, and a similar curtain effect as the episode passes.

Back 84

amaurosis fugax

Hint 84

a f

Front 85

is the leading cause of new blindness among US adults aged 20 to 65.

It is broadly classified as nonproliferative and proliferative.

Back 85

diabetic retinopathy

Hint 85

d r

Front 86

retinopathy shows dilation of veins, capillary microaneurysms, flame or splinter hemorrhages (located in the superficial nerve fiber layer of the retina), dot and blot hemorrhages (located deeper in the retina), retinal edema, and hard exudates.

Back 86

nonproliferative diabetic retinopathy

Hint 86

n d r

Front 87

tiny, weakened blood vessels which have ballooned out, appearing as small dots in the retina.

They represent the earliest clinical sign of diabetic retinopathy.

Back 87

Microaneurysms

Hint 87

m

Front 88

In diabetic retinopathy, ___________ are caused by proteins and lipids from the blood, leaking into the retina through damaged blood vessels.

Back 88

hard exudates

Hint 88

h e

Front 89

They appear as refractive, creamy or yellowish, often bright lesions with sharp margins, sometimes in a ring-like structure around leaking capillaries.

Back 89

hard exudates

Hint 89

h e

Front 90

is the leading cause of legal blindness in non-insulin dependent diabetes mellitus (NIDDM).

Back 90

nonproliferative retinopathy

Hint 90

n r

Front 91

characterized by soft exudates, intraretinal microvascular abnormalities, and venous beading (neovascularization).

Vitreous hemorrhage is a common sequela.

Back 91

proliferative retinopathy

Hint 91

p r

Front 92

also known as “cotton wool spots”, which are pale white or grayish areas in the retina with soft, fuzzy edges, resulting from infarcted nerve fibers.

Back 92

soft exudates

Hint 92

s e

Front 93

In diabetic retinopathy, these occur where blood vessels have blocked and localized areas of nerves have been damaged.

Back 93

soft exudates

Hint 93

s e

Front 94

Without treatment, the visual prognosis of which is worse: proliferative retinopathy or nonproliferative retinopathy

Back 94

proliferative

Front 95

__________ is occasionally present at the time of diagnosis of type 2 diabetes (NIDDM).

Treatment includes optimizing control of blood glucose and any associated hypertension or hyperlipidemia.

Excellent glucose control is beneficial in any stage of diabetic retinopathy because it delays the onset, and slows the progression of diabetic complications in the eye.

Laser photocoagulation is helpful in the treatment of macular edema.

Back 95

nonproliferative retinopathy

Hint 95

n r

Front 96

In diabetic retinopathy, ___________ must be recognized early and treated by panretinal laser photocoagulation to prevent blindness.

Neovascularization is all too often diagnosed only at the time of vitreous hemorrhage.

Back 96

proliferative retinopathy

Hint 96

p r

Front 97

Patients with diabetes should have _________ ophthalmoscopic examination through dilated pupils.

Examination by an ophthalmologist is recommended in type 1 diabetes (IDDM) of more than 5 years’ duration, at the time of diagnosis in type 2 diabetes (NIDDM), if ocular symptoms develop, or if there are suspicious findings of retinopathy.

Back 97

yearly

Hint 97

y

Front 98

In this disorder, Blurred vision can also occur from acute increases in serum glucose, causing lens swelling and a refractive shift even in the absence of retinopathy.

Back 98

diabetic retinopathy

Hint 98

d r

Front 99

The retinal arteries become more tortuous and narrow and develop abnormal light reflexes (“silver-wiring” and “copper wiring”).

Back 99

hypertensive retinopathy

Hint 99

h r

Front 100

In hypertensive retinopathy, _________occurs when the arteries, especially those close to the disk, become full and somewhat tortuous and develop an increased light reflex with a bright ________ luster.

Back 100

copper wiring, coppery

Hint 100

c w, c

Front 101

In hypertensive retinopathy, __________ occurs when a portion of a narrowed artery develops such an opaque wall that no blood is visible within it.

Back 101

silver wiring

Hint 101

s w

Front 102

In this disorder, there is increased venous compression at the retinal arteriovenous crossings (“arteriovenous nicking”).

Back 102

hypertensive retinopathy

Hint 102

h r

Front 103

Cotton-wool spots, retinal hemorrhages, and microaneurysms are the most common ophthalmoscopic changes seen in AIDS patients.

________________ occurs when CD4 counts are below 50/µL.

Back 103

Cytomegalovirus (CMV) retinitis

Hint 103

c r

Front 104

Patients are often asymptomatic until there is involvement of the fovea or optic nerve, or until retinal detachment develops.

They may complain of the gradual onset of the following visual sensations: floaters, scintillating scotoma (quivering blind spots), decreased peripheral visual field, and metamorphopsia (a wavy distortion of vision).

Back 104

Cytomegalovirus (CMV) retinitis

Hint 104

c r

Front 105

a wavy distortion of vision

Back 105

metamorphopsia

Hint 105

m

Front 106

quivering blind spots

Back 106

scintillating scotoma

Hint 106

s s

Front 107

is a necrotizing virus that is spread hematogenously so that damage is concentrated in the retina adjacent to the major vessels and the optic disk.

Back 107

CMV

Front 108

It is characterized by progressively enlarging yellowish-white patches of retinal opacification, which are accompanied by retinal hemorrhages, giving the characteristic “pizza-pie” or “cheese and ketchup” appearance.

Back 108

Cytomegalovirus (CMV) retinitis

Hint 108

C R

Front 109

The commonly used agents are intravenous or intravitreal ganciclovir, foscarnet, and cidofovir.

Reactivation of disease, and therefore, eventually complete loss of vision, can only be delayed rather than prevented.

Back 109

Cytomegalovirus (CMV) retinitis

Hint 109

c r