ICMR BULLETIN VOL. 5-No.-10-OCTOBER-1975 8P
Item
- Title
- ICMR BULLETIN VOL. 5-No.-10-OCTOBER-1975 8P
- extracted text
-
mLETI
9B
wmmunffy HEALTH
Main, I Block
CELL
326, V
Vol. 5 No. 10
Korambngala
October 1975
Bangalore-560034 -
India
RESEARCH IN BLINDNESS
Blindness is both a health and a socio
economic problem.
India with the exception of
Egypt is said to have the highest proportion
of blind population in the world.
Early
reports indicated a total of 2 million blind
persons in the country, the figure being based
on information collected from the Census of
1941. This figure continued to be quo ted till
the early sixties even though the population
had increased from 350 million to 460 million.
and later UNICEF.
The project was located at
Aligarh and as a part of its programme of
research, carried out a survey to determine
the prevalence of blindness in the area under
study. Defining economically blind as those
persons who cannot count (with both eyes open)
fingers beyond 2 meter distance,
the total
number in the rural areas was estimated at
nearly 3 million.
VITAMIN A DEFICIENCY & BLINDNESS:
In 1956 the Trachoma Pilot Project of
ICMR assisted by WHO carried out a survey on
the incidence of blindness.
It was estimated
that there were at least 3.5 million blind in
India.
These figures, though not represent
ative of the whole of India as they were
obtained from predeminently rural areas , do
indicate the enormity of the problem.
EARLIER STUDIES
Trachoma Control Project:
With the Council's emphasis on communi
cable diseases,
it is not surprising that the
first major project in the field of blindness
was on trachoma, which was undoubtedly one of
the most important and preventable causes of
blindness in India.
A Trachoma Commission was organised in
1954 with the objective of reviewing the prob
lem of trachoma and recommending the most use
ful approach to the problem.
In 1956 the Trachoma Control Pilot Pro
ject was initiated with the assistance of WHO
Vitamin A deficiency, an important public
health problem in developing countries, is
responsible for a large proportion of cases of
preventable blindness in India.
Studies on vitamin A deficiency have been
in progress for over a decade at the National
Institute of Nutrition.
The earlier studies were carried out
among the preschool children (the high risk
group) in 2 different areas of South India:
one in Coonoor and the other in Hyderabad.
One of the outstanding achievements of
these studies was the demonstration of the
value of a 6 monthly massive oral dose of
vitamin A in preventing the severe form of
vitamin A deficiency (Keratomalacia), a fre
quent cause of blindness. This preventive
therapy was incorporated in the fourth Five
Year Plan by the Government of India and has
been adopted in a nation-wide programme.
The
programme is now in operation in several
states of India and a method for its evalua
tion, even in the absence of baseline data,
has been recently developed.
THE PREVALENCE OF CORNEAL BLINDNESS
GARH AREA:
IN DIBRU-
By the end of 1974, work in 4 rural blocks had
been taken in hand and it was planned to in
clude the remaining 5 blocks in the future
programme. The Contact Lens and the Low Vision
Clinics were well established.
In 1974 the
former was attended by 1716 patients and 67
eyes showed improvement with contact lenses.
Thirty-eight■ persons attended the Low Vision
Clinic and 26 benefited with visual aids.
A study of the prevalence of corneal
blindness in Dibrugarh area was carried out
over a period of two years (1970-72).
A
population of 80,029 persons in 23 wards was
screened. When the 27,758 patients attending
the Eye OPD of the Assam Medical College were
included, a total of 1,07,787 persons had been
covered.
COORDINATED STUDY OF THE PREVALENCE
NESS:
The number of corneal blind was found to
be 1,744 i.e. 1.7 per cent. The prevalence was
higher in the 0-9 years age group and among
males.
Vitamin A deficiency appeared to be a
predominant cause (27.5 per cent) and next in
order was trauma.
Trachoma was not found to
be a common cause of blindness in this area
and was more often seen in migrants from other
On the whole corneal
parts of the country.
blindness was
associated with poor socio
economic conditions.
PREVALENCE
OF TRACHOMA IN
CERTAIN
AREAS IN RAMANATHAPURAM DISTRICT:
OF BLIND
In view of the importance of the problem
of blindness and the lack of precise infor
mation on the prevalence of this disability in
the country, the Council initiated a coordi
nated project in 1970.
Seven centres located
in different parts of India i.e.
Ahmedabad,
Cuttack, Delhi, Indore, Madurai and Varanasi
were organised simultaneously. The main aim
of this project was to carry out studies on
the prevalence and etiology of blindness
in
the country.
ENDEMIC
A brief report on the findings of
the
study is presented. A detailed report is
under preparation and will be published as a
Technical Report Series of the Council.
A study in 1972 on the prevalence of Tra
choma on 4,424 school children in Ramanand
District of Tamil Nadu revealed that 9.3 per
cent of the children (417 cases) were suffer
ing from trachoma.
Definition of Blindness:
For the purpose of the survey a totally
blind person was defined as one who was unable
to count fingers beyond 2 meters
(vision 2/60
or less). A person with a vision 6/60 or less
or when the field of vision was reduced to 20°
or less was taken as economically blind.
The
data presented here pertain to that on eco
nomically blind only.
A PILOT REHABILITATION
CENTRE
AND MOBILE
OPHTHALMOLOGICAL UNIT FOR PERSONS DISABLED BY
EYE DISORDERS:
A project for
the establishment of a
pilot
Rehabilitation
Centre
and
Mobile
OphthaImological Unit for Persons Disabled by
Eye Disorders was started in 1968 at Chandi
garh.
The project was planned to provide ser
vices to the blind in rural areas at their
very door, so as to reintegrate them into
family and village life. The village rehabi
litation of the incurably blind consisted of
providing mobility training,
instruction in
communication skills, vocational counselling
and other needed personal adjustment services.
It also planned to establish a mobile unit to
indentify and
treat
persons with visual
impairment, to undertake rehabilitation of the
corneal blind by grafting and to establish low
vision and contact lense centre and to develop
an undergraduate and graduate training pro
gramme in the problems of blindness.
The pro
gramme of rehabilitating persons disabled by
eye disordere has made satisfactory progress.
Sampling Design:
The sampling was done on the basis of the
1971 Census figures and whenever 1971 figures
were not available, 1961 Census figures were
used.
In each centre a total of 6 million
population was covered and 1 per cent sample
of this population was included in the study.
The urban/rural ratio was 1:2.
Urban Areas:
The urban population was divided into 2
strata, one with cities with a population of
one lakh and above and the other with towns
having less than one lakh population.
It was
2
AND
DOCUMENTATION
planned to cover 10,000 persons from each
stratum.
To accomplish this,
one city and 4
towns were selected in each urban area. From
each area 200 blocks from the city and 50
blocks from each of the 4 towns were included
in the study, using random sampling procedure.
Finally 10 households were taken from each of
the. urban blocks using systematic sampling.
All members of the selected households were
examined by trained screeners and observations
recorded on the proformae. Every person cate
gorised as blind on the screening was examined
by an ophthalmologist.
Rural Areas:
In the rural areas 11 tehsils were selec
ted at random and 27 villages were included in
each of the selected tehsils.
Twenty-five
households were taken from each of the selec
ted villages by using systematic sampling.
.that the total prevalence of blindness
in
India was 14 per 1000 population^ On the basis
of this information taking the population as
600 million, it may be computed that there are
approximately 8.4 million persons with vision
6/60 or less in the country.
The' survey
showed that the prevalence of blindness in
urban population was around 11 per 1000, while
in the rural population it was 15 per 1000
i.e. a ratio of 2:3.
It is interesting to note that the higher
prevalence of blindness in rural areas as compared to urban was seen in all centres, except
in those from Indore and Varanasi.
A high
prevalence for blindness was reported from
Cuttak and Madurai.
It is perhaps more diffi
cult to explain the relatively high prevalence
found in Delhi area.
Table 1 gives the preva
lence of blindness in the different centres.
Prevalence of Blindness in Areas Studied:
From the analysed data, it was
estimated
TABLE
I
Blindness in different geographical areas per 1000 population
Centre
Population covered
Urban
Rural
One eye
Urban
Rural
Both eyes
Urban
Rural
Ahmedabad
21568
37120
6.12
7.70
5.06
6.17
Cuttak
20993
33349
5.81
5.99
16.10
3.52
Delhi
21561
44800
7.35
12.46
13.50
20.75
Indore
23586
38368
12.59
3.52
12.63
5.99
Madurai
22023
31898
14.48
9.31
19.30
28.52
Srinagar
20387
24313
2.50
2.92
2.85
5.64
Varanasi
18170
37625
11.01
6.46
7.32
5.64
Sex:
Prevalence of blindness appeared to be
higher in females than in males.
This may be
associated with the fact that the majority of
Indian women are housewives and do not receive
medical treatment till the visual deteriora
tion becomes a handicap in their day to day
life, for which visual requirement is of a
lower order.
Age:
The
survey
showed
that
prevalence
of
blindness increased with advancement of age.
It is suggested that this may, to some extent,
be a cumulative effect of blindness carried
over from the younger to the older age groups
and may also
indicate that blindness in
childhood was often untreated or incurable.
Religion:
The prevalence of blindness is markedly
higher among the Hindus as compared to the
Muslims: the ratio being 2:1.
This was found
both in urban and rural areas and is contrary
3
to the usual concept.
Muslims do have a
higher prevalence of trachoma, but with the
use of chemotherapeutic and antibiotic agents
and the improvement in socio-economic condi
tions, this condition has ceased to be a major
cause of corneal blindness.
Sikhs featured in
fair numbers in the Delhi and Srinagar figures
and the prevalence of blindness was of the
same level as among the Hindus.
Jains formed a significant part of the
Ahmedabad urban and rural and Indore urban
surveys.
It was noted that the prevalence of
blindness in this community was relatively
high.
Occupation:
For the purpose of the survey,
different
types of activities were grouped into 5 major
categories: professional workers,
clerical
workers, farmers, craftsmen and a non-earning
group consisting .of students, retired persons
and housewives.
The prevalence of blindness
in relation to occupation was estimated in
both urban and rural areas.
Considering only
males, the prevalence rate among farmers, a
major group in rural areas, was between 4-40
per 1000 blind in both eyes and 4-7 per 1000
in one eye.
The rate among professional wor
kers
(urban areas)
ranged between 3-11 per
1000 in both eyes and 8-30 per 1000 in one
eye. The non-earning group (urban
areas)
showed a prevalence rate of 3-15 per 1000
blind in both eyes and 1-7 per 1000 blind in
one eye.
Major causes of blindness in India:
The survey indicated that diseases of the
anterior segment of the eye are the most
common causes of blindness in India.
The pre
valence of cataract and corneal pathology was
higher in 卬ral areas while diseases of the
uvea,
retina and optj.c nerve were slightly
more common among urban population.
Blindness
as a result of cataract was twice as frequent
in rural areas in comparison to urban areas.
This possibly could be due to relative paucity
of treatment facilities in the rural areas.
The highest figures for blindness following
cataract were obtained from the rural areas of
Cuttak and Madurai Centres:
the prevalence
being 38 per 1000 in Cuttak and 25 per 1000 in
Madurai.
Need for Ophthalmic Services:
Cataract, glaucoma and corneal diseases,
the commonest causes of blindness in India,
are conditions which require early diagnosis
and treatment facilities.
The great need for
intensive and continued ophthalmic services in
the country requires no emphasis.
The economic liability to the nation and
to the family caused by blindness is enormous.
A way to prevent this dreadful deformity would
be to ensure early and accurate diagnosis by
providing better training in the subj ect of
ophthalmology to the medical graduates
and
short term refresher courses to the medical
practitioners.
ABSTRACTS
Some Research Projects completed in 1974
OPHTHALMOLOGY
GABA ，九 visual system
with Light，九 its absence
stimulation
Experiments were conducted on healthy
adult albino rabbits without any ocular patho
logy of either sex.
The study revealed that
GABA the proposed neuroinhibitory substance is
present in all the tissues of visual pathways
having neural cells and synapses.
There is no
significant change in the levels of GABA
following adaptation to any condition of en
vironmental illumination that was employed
(viz. continuous illumination of 2000 lux> red
and blue light of 602 nm and 532 nm respec
tively, and total darkness) or under any of the
4
three experimental pathological conditions of
the retina and optic pathways (viz.
oral
alcohol poisoning,
complete sectioning of
optic nerves and blockage of all the four
vortex veins).
However, it was
notable
that various
types of environmental illuminations
employed
seem to, by and large,
diminish most of the
predominant free amino acids of the pool in
the different tissues of the visual pathways.
A similar,
though less,
marked generalised
decrease of the free amino acids was also
found in the retina
following some of the
experimental pathological degenerative condi
tions . Furthermore, it was noted that alongfree
with the diminished levels of various
amino acids,
there was also a decrease of
total proteins, which was without any conomitant or specific changes in the ribonucleic
acids estimated.
The electrophysiological alterations, as
demonstrated by various workers, in visual
pathways following exposure to various types
of environemntal illumination and in the three
types of experimental pathological degenera
tive conditions of retina did not seem to have
any quantitative or quantitative
specific
correlation with the biochemical
parameters
investigated.
S. Goswamy
Dr. R.P. Centre for Ophthalmic Sciences
All India Institute of Medical Sciences
New Delhi.
Aetiopathogenesis of Contracted Socket
Experiments were
conducted
oh adult
rhesus monkeys of 2-3 years of age with one of
the two eyes enucleated. 'An experimental
model for study of contracted socket was set
up. This simulated the
clinical condition
seen in human beings and permitted a critical
evaluation of the various parameters which
were supposed to be responsible for production
of clinical condition of contracted socket.
Again in the same model it was possible to
study the various preventive measures too.
In
the study it was observed that the presence of
infection adversely affected the process of
contracture. The vertical suturing of con
junctiva seemed to help in reducing the inci
dence of shallowing of fornices.
Early inser
tion of prosthesis was seen to reduce the
degree of contractures.
Histologically it was found that presence
of prosthesis increased the degree of lymphoid
hyperplasia,
squamous cell
metaplasia and
hyperplasia and hypertrophy of the goblet
cells.
Cartilagenous metaplasia was observed
for the first time in the orbital tissues.
The insertion of the bone
implant could
favourably modify the process of contracture.
Y. Dayal
Dr. R.P. Centre for Ophthalmic Sciences
All India Institute of Medical Sciences
New Delhi.
Immunological studies £九 keratoconjunctivitis
A preliminary study has been carried out
in cases of Keratoconjunctivitis which were
divided into three groups: Group A - Kerato
conjunctivitis
sicca
only
(11 cases);
Group B - Keratoconjunctivitis
sicca
and
rheumatoid arthritis
(17 cases);
Group C Keratoconjunctivitis and Xerostomia (2 cases).
Abnormal immunological reactions were seen in
all the groups but were mininum in Group A and
maximum in Group B.
Out of group B maximum
changes were observed in 4 female cases having
keratoconjunctivitis sicca,
xerostomia and
rheumatoid arthritis. These were labelled as
sjogren
syndrome and
cases
of definite
patients having keratoconjunctivitis sicca and
rheumatoid arthritis only, were labelled as
having possible sjogren syndrome.
Because of minimum immunological changes
in pure keratoconjunctivitis sicca cases,
it
was difficult to postulate auto-iiamunity as.
the basis for its aetiopathogenesis. Trachoma
also does not appear to play any role in its
aetiology. No clear relationship between pure
keratoconjunctivitis sicca *and sjogren syn
drome could be established.
But it was felt
that pure keratoconjunctivitis sicca could be
the earliest manifestation of the sjogren syn
drome.
With the passage of time,
either
components of sjogren syndrome may appear and
more and more of immunological reactions may
become positive. But there is no evidence to
support this hypothesis in the present study.
In the present study,
positive antinuclear
factor and positive thyroid antibodies were
much less and no case showed LE cell pheno
menon and antibodies against lacrimal gland,
so it was felt that there is a different spec
trum of this disease in this geographical
area.
S.D. Gupta
Postgraduate Institute of Medical
Education and Research
Chandigarh.
Fluorescein Fundus Photography
various types of retinopathies
in
normal
and
The study of various retinopathies was
carried out and Fluorescein Fundus Photography
was standardised, for which an old retinophot
camera was
suitably modified.
During the
course of this enquiry 900 angiographs were
carried out which included diabetic retino
pathy (70),
liypertensive retinopathy (67),
retinopathy of iron deficiency anaemias (72),
central nervous retinopathy (78),
phlebitic
retinopathy and presumed sickle retinopathy
(110)9 methyl alcohol retinopathy (7),
circi
5
nate retinopathy
lesions.
and a wide
range of
fundus
Fluorescein angiography revealed that the
frequency of disc oedema in Anaemic Reginopathy was much higher (found in 50 per cent of
eyes),
than hitherto
recognised.
Micro
aneurysm ,soft exudate and a peculiar promi
nence of the capillary system on the fluore
scence photographs were some of the interest
ing findings.
In cases of methyl alcohol
poisoning .there was an initial disc oedema
with
a
clinical
picture
of papillitis
follox^ed
by
optic
atrophy
with
deep excavation of the cup.
There was a
distinct peripapillary vascular atrophy simi
lar to glaucomatic discs. The most interest
ing finding was a damage to the pigment epi
thelium.
Circinate retinopathy could develop
in a variety of conditions where there was a
leakage of fluorescein to the
subretinal
space.
It was established by both horizontal
and vertical studies that whatever may be the
etiology a phlebitis of sufficient severity
can lead to a clinical picture of Eales's
disease.
(Phlebitic retinopathy).
S.R.K. Malik
Deptt.'of Ophthalmology
Maulana Azad Medical College
New Delhi.
Comparative evaluation of immunosuppressive
agents 乞九 corneal graft reaction
The results obtained will be useful to
clinicians.
It was inferred from the study
that the corticosteroids are the best immuno
suppressive agents as they suppress graft
reaction in as high as 90 per cent of cases
and are free
from serious systemic side
effects. They can also reverse an established
graft reaction. Mitomycin-C has good immuno
suppressive effects but is not free from
serious side effects, and requires more elabo
rate clinical studies before its clinical
application.
Irradiation and Chloromycetin,
though
produce
profound immunosuppressive
effects have serious systemic side effects and
prove fatal in high percentage of cases.
Antilymphocytic serum is a potent immuno
suppressive agent
but it has serious side
effects in the form of anaphylactic reaction
and marked haemopoetic depression.
S.R.K. Malik
Deptt. of Ophthalmology
Maulana Azad Medical College
New Delhi.
Relationship of Cup-Disc ratio to tonometryy
tonography, central field changes after ravszng the intraocular pressure artificially ，九
normal eyes
Normal
cases
with clear
media an
corrected vision better than 6/12 were picked
up and studied at random from the eye out
patients departments. It was found that the
susceptibility to field defect on artificially
raised intraocular
pressure had a direct
correlation with the Cup-Disc (area) ratio of
high statistical significance
(P<0.001) .
In
other words, persons with high Cup-Disc ratio
are more susceptible to field defects if
affected with glaucoma.
The Cup-Disc ratio
has no significant relationship with age, sex,
intraocular- pressure and out flow facility.
The Cup-Disc ratio on the basis of their
areas was found to be most accurate and fairly
practical. It can be obtained in 5 minutes by
use of Polar Planimeter,
a slit lamp with
f undos copy arrangements and an ocular micro
meter.
B. Patnaik
Department of Ophthalmology
Maulana Azad Medical College
New Delhi.
ICMR NEWS
Dr. Usha K. Luthra,
Deputy Director-General,
Indian Council of Medical Research,
parti
cipated in Second Asian Cancer Conference held
at Singapore from September 22 to 25, 1975.
She presented a paper entitled "Prevalence and
distribution of cancer of the uterine cervix
in an urban population of Delhi".
Dr. Vijai Dhanda,
Research Centre,
6
Assistant
Poona has
Director, Virus
been deputed to
Fiji and Tonga islands for carrying out in
vestigations of the outbreak of Dengue-like
fever and to advise methods of Vector Control
for a period of three months w.e.f.
September
15, 1975.
Dr. A.J. Baxi, Senior Research Officer, Blood
Bombay has proceeded
Group Reference Centre,
to Australia to avail himself of the WHO
Research Training Grant for study in the field
of nBiochemical genetics-iso-enzyme polymor
ph ismn at the Australian National University,
Canberra, Australia for a period of six months
from September 20 , 1975.
Dr. (Mrs.) Shanta S. Rao,
Deputy
Director,
Institute for Research in Reproduction, Bombay
attended Third International Symposium
of
Reproduction held at Varna, Bulgaria from September 21 to 25, 1975.
Dr.(Mrs.) R.A. Vaidya, Senior Research Officer
Institute for Research in Reproduction, Bombay
attended the meeting of
WHO Task Force on
methods to regulate sperm migration and sur
vival in Human Female (Section on intravaginal
medication) at Geneva from September 25 to 27,
1975.
Shri D.A. Gadkari, Assistant Research Officer,
Virus Research Centre, Poona has proceeded to
U.K. to avail himself of the Conmionwealth
Research Training Grant for Study in the field
of Virology at the University of Glasgow to be
held from October 1, 1975 to July 10, 1977.
LIST OF TOPICS AND DATES OF WEEKLY SYMPOSIA/LECTURES TO BE
HELD ON SATURDAYS AT 3. 30 P. M. IN ICMR OFFICE, NEW DELHI
DURING OCTOBER - NOVEMBER, 1975
Speaker(s)
Topic
Date
4.10.1975
Guineaworm and Hydatid diseases in
Andhra Pradesh
Dr. C.R.R.M. Reddy,
Visakhapatnam.
18.10.1975
Mental functions and role of pyridoxine
in Pellagra
Dr. Kamala Krishnaswamy,
Hyderabad.*
25.10.1975
Management of Burns
Dr. J.L. Gupta, New Delhi.
1.11.1975
The role of hormones in the evolution of
Kwashiorkor and marasmus
(Dr. V.N. Patwardhan Oration)
Dr. Kamala S. Jaya Ra。,
Hyderabad
15.11.1975
Hypnosis and its medical applications
Dr. H. Jana, Ahmedabad.•
22.11.1975
Thyroid Physiology and Rad io immunoas s ay
Dr. G.K. Rastogi, Chandigarh..
29.11.1975
Biologically active components of Cobra
venom in relation to-cancer research
(Sandoz Oration)
Dr. B.M. Braganca, Bdmbay
INDIAN COUNCIL OF MEDICAL RESEARCH
TECHNICAL REPORT SERIES
1.
Research in Medical Education 1970
5.
Exfoliative Cytology 1971
2,
Research in Health Practices 1970
6.
Symposium on Nutrition
1971
3.
Acute Encephalopathy Syndrome in
1970.
7.
Developments in
India 1971
8.
Study Group in Urolithiasis 1971
4.
Technical Review
India 1970
on
and
Heart Disease
Children
Pneumoc oniosis
Industrial Psychology
in
in
7
9.
Proceedings
^Seminar on immunity and
Immunoprophylaxis in Cholera 1971
10. Assessment of the National Filaria Control
Programme (India 1961-70)
1971
11. Diagnosis and Treatment of Pesticide Pois
oning 1971
『
e
12. Symposium on
Drugs 1972
Evaluation
Clinical
13. Techniques in Blood
Group
14. Laboratory Methods in
Thyroid Diseases 1972
of new
Serology 1972
Investigation
of
15. Symposium on 1Health in Relation to Work &
Heat Stress in Place of Work1 1972
16. Young Scientific Workers1 Conference
in March 1973 (in press)
Supply
20. Genetics and our Health 1972
21. All India Conference on Research in Repro
duction and Fertility 1973
22. A study of Morbidity Patterns and Standard
of Medical
Care
in the Rural Health
Centres of West Bengal 1973
23. Proceedings of the First All-India
shop Conference on Stroke, 1971
Work
24. Proceedings of Seminar on Infectious Hepa
titis and Study Group on Australia Anti
gen, 1971
25. Atlas of
Histopathology
of
Hepatitis and Cirrhosis, 1974
Liver:
held
26. Studies on Pre-school Children 1974.
17. Proceedings of the First Annual Meetings
of the Indian Academy of Cytologists 1972
18. Growth and Physical Development of
Infants and Children 1972
19. Review of Work Done in Rural Water
in India 1972
27. Studies on Weaning and Supplementary Foods
1974.
Indian
(Price Rs.4/- each except No.25 = Rs.10/-)
(Available from Division of Publication & In
formation, Indian Council of Medical Researchi
Ansari Nagar, New Delhi-110016)
EDITORIAL BOARD
Members
Prof. Usha K. Luthra
Chairman
Dr. C. Gopalan
Director-General
Dr. Sabita Tej.uja
Editor
Dr. N.D. Datta Banik
Dr. A.D. Taskar
Dr. S.V. Apte
Printed and Published by Shri Prem Chand for the Indian Council of Medical
Research, New Delhi at the ICMR Offset Press, New Delhi.
R.N. 21813/71
Position: 2040 (14 views)