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   2014| October-December  | Volume 21 | Issue 4  
    Online since October 4, 2014

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The Status of Childhood Blindness and Functional Low Vision in the Eastern Mediterranean Region in 2012
Rajiv Khandekar, H Kishore, Rabiu M Mansu, Haroon Awan
October-December 2014, 21(4):336-343
DOI:10.4103/0974-9233.142273  PMID:25371641
Childhood blindness and visual impairment (CBVI) are major disabilities that compromise the normal development of children. Health resources and practices to prevent CBVI are suboptimal in most countries in the Eastern Mediterranean Region (EMR). We reviewed the magnitude and the etiologies of childhood visual disabilities based on the estimates using socioeconomic proxy indicators such as gross domestic product (GDP) per capita and <5-year mortality rates. The result of these findings will facilitate novel concepts in addressing and developing services to effectively reduce CBVI in this region. The current study determined the rates of bilateral blindness (defined as  Best corrected visual acuity(BCVA)) less than 3/60 in the better eye or a visual field of 10° surrounding central fixation) and functional low vision (FLV) (visual impairment for which no treatment or refractive correction can improve the vision up to >6/18 in a better eye) in children <15 years old. We used the 2011 population projections, <5-year mortality rates and GDP per capita of 23 countries (collectively grouped as EMR). Based on the GDP, we divided the countries into three groups; high, middle- and low-income nations. By applying the bilateral blindness and FLV rates to high, middle- and low-income countries from the global literature to the population of children <15 years, we estimated that there could be 238,500 children with bilateral blindness (rate 1.2/1,000) in the region. In addition, there could be approximately 417,725 children with FLV (rate of 2.1/1,000) in the region. The causes of visual disability in the three groups are also discussed based on the available data. As our estimates are based on hospital and blind school studies in the past, they could have serious limitations for projecting the present magnitude and causes of visual disabilities in children of EMR. An effective approach to eye health care and screening for children within primary health care and with the available resources are discussed. The objectives, strategies, and operating procedures for child eye-care are presented. Variables impacting proper screening are discussed. To reach the targets, we recommend urgent implementation of new approaches to low vision and rehabilitation of children.
  10,121 430 7
Blepharitis: Always remember demodex
Vipul Bhandari, Jagadeesh K Reddy
October-December 2014, 21(4):317-320
DOI:10.4103/0974-9233.142268  PMID:25371637
Purpose: To determine the incidence and density of Demodex species on the eyelashes of subjects with normal eyelids, anterior blepharitis (AB), meibomian-gland dysfunction (MGD), and mixed blepharitis (MB). Materials and Methods: One hundred and fifty consecutive patients diagnosed with AB, MGD, and MB were recruited. An additional 50 individuals were recruited who were free of lid and margin disease to serve as a control group. All patients underwent a standard eye examination. Data on ocular symptomatology were gathered. Digital photography was performed of the lid margins. Lash sampling was performed by epilating the lashes and the lashes were checked for Demodex based on morphology using light microscopy. The total number of mites were tabulated for each eye. Comparison between the affected eyes and the control eyes was performed. Data were analyzed using the Chi-square test. Results: A total of 200 patients were included. Twenty percenth had AB, 40% had MGD, and 40% had MB. The incidence of Demodex infestation was 90% in cases of AB, 60% in MGD cases, and 90% in MB cases. The incidence of Demodex in control subjects was 18%. Conclusions: The incidence and density of Demodex infestation was highest in patients with AB and MB. Lid irritation and presence of cylindrical dandruff were indicative of a high-density infestation. These signs should alert the clinician to treat concomitant Demodex infestation.
  6,454 527 25
Pattern of uveitis at a referral center in Iraq
Faiz I Al-Shakarchi
October-December 2014, 21(4):291-295
DOI:10.4103/0974-9233.142263  PMID:25371632
Purpose: To determine the etiologies of uveitis and the causes of visual loss in uveitis patients at a referral center in Baghdad, Iraq. Patients and Methods: A 4-year prospective study was performed at the uveitis clinic at Ibn Al-Haetham teaching eye hospital in Baghdad, Iraq. Referral cases of active uveitis were included. A complete ophthalmic examination was performed in all cases. If clinical picture did not indicate a specific etiology, patients were sent for a routine set of tests while ancillary tests were conducted when indicated. Results: Out of 318 patients included in this study, 236 patients (74.2%) had bilateral uveitis, and 212 patients (66.7%) had non-granulomatous uveitis. Posterior uveitis was recorded in 123 cases (38.7%) followed by panuveitis in 97 cases (30.5%), anterior uveitis in 78 cases (24.5%), and intermediate uveitis in 20 cases (6.3%). A diagnosis was established in 210 cases (66%) while etiology could not be determined in the remaining 108 cases (34%). Most common infectious causes were toxoplasmosis (13.8%) and presumed ocular tuberculosis (11.4%) while most common non-infectious causes were Vogt-Koyanagi-Harada disease (12.3%), Behηet's disease (8.2%), and pars planitis (5.7%). Out of 49 eyes with irreversible blindness, macular degenerations, or scars (46.9%) and optic nerve atrophy (34.7%) were the most important causes. Conclusion: At this referral center, toxoplasmosis and presumed ocular tuberculosis were the most common infectious causes of uveitis while Vogt-Koyanagi-Harada disease, Behηet's disease, and pars planitis were, in that order, the most common non-infectious causes. Macular degenerations or scars and optic nerve atrophy were the most important causes of irreversible blindness.
  5,223 331 10
Comparative evaluation between ranibizumab combined with laser and bevacizumab combined with laser versus laser alone for macular oedema secondary to branch retinal vein occlusion
Shorya Vardhan Azad, Amjad Salman, Deepankur Mahajan, Siddharth Sain, Rajvardhan Azad
October-December 2014, 21(4):296-301
DOI:10.4103/0974-9233.142264  PMID:25371633
Purpose: To evaluate the anatomical and functional efficacy of combination therapy of intravitreal ranibizumab with laser or intravitreal bevacizumab with laser treatment compared to only laser treatment for macular edema due to branch retinal vein occlusion (BRVO). Materials and Methods: Thirty eyes of 30 patients with BRVO of at least 6 weeks duration were randomized into three groups: Group 1 received a single dose of intravitreal Ranibizumab followed by grid laser treatment, Group 2 received a single dose of intravitreal Bevacizumab followed by grid laser treatment, and Group 3 received grid laser alone. Outcomes at 6 months follow-up were reported. Data were collected on best corrected visual acuity (BCVA), central foveal thickness (CFT), and gain in lines of Snellen acuity. Results: At 6 month follow-up, the difference in the mean BCVA and CFT between the three treatment groups was not statistically significant (P > 0.05, all comparisons). Six eyes (60%) in Group 1, four eyes (40%) in Group 2 and two eyes (20%) in Group 3 had a statistically significant gain of ≥3 lines of Snellen acuity (P < 0.05). Conclusion: Both ranibizumab and bevacizumab combined with laser photocoagulation, resulted in better outcomes than grid laser treatment.
  5,159 273 1
Ocular dirofilariasis: A case series of 8 patients
Chris D Kalogeropoulos, Maria I Stefaniotou, Konstantina E Gorgoli, Chrissanthy V Papadopoulou, Chrysavgi N Pappa, Costas A Paschidis
October-December 2014, 21(4):312-316
DOI:10.4103/0974-9233.142267  PMID:25371636
Purpose: Dirofilaria repens is an endemic parasite in Mediterranean countries that mostly affects animals. Rarely, however, it can infect humans. This case series presents patients with ocular infections due to D. repens. Materials and Methods: A chart review was performed of patients with ocular dirofilariasis after the year 2000, treated at a tertiary referral centre in Greece. Data were collected on the ocular, microbiological, or/and histopathological aspects and treatment. Results: Eight cases of unilateral ocular dirofilariasis were identified, of which 5 were subconjunctival (1 masquerading as nodular scleritis) and were removed through a conjunctival incision, 2 cases were intravitreal and were removed with vitrectomy, and 1 was intraorbital (adjacent to the roof of the orbit). The latter appeared as an encapsulated mass and subsequent histological examination revealed the presence of the parasite. Of the 8 cases recorded after the year 2000, 7 appeared within the last 6 years (4 cases within the last 3 years). The majority of cases involved residents of the Ionian Islands (7 of 8 cases). Conclusions: D. repens can affect various ocular and periocular tissues. A progressive increase in the incidence of dirofilariasis was observed, which is potentially associated with climate changes in warm and moist areas where this parasite is endemic.
  5,051 290 20
Postoperative necrotizing scleritis: A report of four cases
Sudipta Das, Kumar Saurabh, Jyotrimay Biswas
October-December 2014, 21(4):350-353
DOI:10.4103/0974-9233.142277  PMID:25371644
Postoperative necrotizing scleritis should be considered in cases of persistent localized postoperative inflammation following all forms of surgical trauma. We present the history, clinical findings, and follow-up data of four patients with postoperative necrotizing scleritis. The clinical records of four patients who developed scleritis following ocular surgery were retrospectively reviewed. The first step in managing necrotizing scleritis is to rule out infectious etiology. Surgically induced necrotizing scleritis is an immune-mediated condition that can coexist with concomitant infectious condition, i.e. endophthalmitis, but response to immunosuppression leads to resolution of the disease and verifi es the diagnosis.
  5,009 242 5
Effect of anterior chamber depth on the choice of intraocular lens calculation formula in patients with normal axial length
Mohammad Miraftab, Hassan Hashemi, Akbar Fotouhi, Mehdi Khabazkhoob, Farhad Rezvan, Soheila Asgari
October-December 2014, 21(4):307-311
DOI:10.4103/0974-9233.142266  PMID:25371635
Purpose: To compare the accuracy of  Sanders-Retzlaff-Kraff II (SRK II) and 3 rd and 4 th generation intraocular lens (IOL) formulas and to compare the effect of different anterior chamber depths among the IOL formulas in cataract patients with normal axial length (AL; 22.0-24.5 millimeters, mm). Materials and Methods: A retrospective chart review was performed of patients with normal AL who underwent cataract surgery. The SRK II and 3 rd generation IOL formulas (Hoffer Q, SRK T, Holladay 1) were compared to the 4 th generation Haigis formula. For analysis, preoperative anterior chamber depth (ACD) was divided into three subgroups: ≤3, 3-3.5, and ≥ 3.5 mm. The mean error (ME) and mean absolute error (MAE) of each formula was compared for each subgroup against the total. The difference between the ME and MAE of the formulas were compared for each ACD subgroup. P < 0.05 was considered statistically significant. Results: The study sample was comprised of 309 eyes. The MAE were 0.56 D, 0.52 D, 0.51 D, 0.50 D, and 0.50 D with Haigis, Hoffer Q, SRK T, Holladay 1, and SRK II formulas, respectively. The Haigis formula was a significantly weaker predictor than the SRK T (P < 0.001) and Holladay 1 (P = 0.035) formulas. The ME with Haigis formula was -0.23 D which changed to -0.06 D with ACD ≥ 3.5 mm (P = 0.002). The ME was -0.24 D with SRK II and changed to -0.09D with ACD ≤ 3 mm (P = 0.004). There was no statistically significant difference between Hoffer Q, SRK T, and Holladay formulas 1 in ACD subgroups (P > 0.05, all comparisons). Conclusion: The SRK II formula can predict refraction in patients with normal AL and ACD less than 3 mm with less error and is preferred over other formulas. The Haigis formula is the preferred choice in patients with a normal AL and ACD longer than 3.5 mm. The prediction accuracy of Hoffer Q, SRK T, and Holladay 1 is comparable in normal AL.
  4,796 380 10
Retinoblastoma referral pattern in kenya
Joseph M Nyamori, Kahaki Kimani, Margaret W Njuguna, Helen Dimaras
October-December 2014, 21(4):321-327
DOI:10.4103/0974-9233.142270  PMID:25371638
Purpose: Kenya is a large country with a widely dispersed population. As retinoblastoma requires specialized treatment, we determined the referral pattern for patients with retinoblastoma in Kenya to facilitate the formulation of a national policy. Materials and Methods: A retrospective study was performed for retinoblastoma patients who presented from January 1, 2006 to December 31, 2007. Data were collected on the referral process from presenting health facility to the hospital where patient was treated. Data were also collected on the time interval when the first symptoms were noticed to the time of presentation at a health facility (lag time). For cases that could be traced to a referral hospital, the time delay due to referral (referral lag time) was recorded. Results: There were 206 patients diagnosed with retinoblastoma in 51 Kenyan and 2 foreign healthcare facilities, and they received final treatment at a Kenyan hospital. Mean lag time was 6.8 months (۰.45). Of all patients, 18% (38/206) were treated at the hospital where they first presented and 82% (168/206) were referred elsewhere. Of those referred, 35% (58/168) were lost to follow-up. The mean referral lag time was 1.7 months (۬.5). Conclusions: A significant proportion of cases presented late, and either delayed seeking further treatment or were lost after initial referral. We recommend the implementation of a national strategy that emphasizes early detection, documentation and follow up of retinoblastoma patients.
  4,826 237 11
An unusual ocular emergency in severe dengue
Kalpana Badami Nagaraj, Chaitra Jayadev, Soumya Yajmaan, Savitha Prakash
October-December 2014, 21(4):347-349
DOI:10.4103/0974-9233.142276  PMID:25371643
Dengue, one of the most common mosquito-borne flavivirus diseases affecting humans, is spread by the Aedes aegypti mosquito. Most people infected with dengue virus are asymptomatic or only have mild symptoms such as an uncomplicated fever; few have more severe features, while in a small proportion it is life-threatening. Severe dengue is defined as that associated with severe bleeding, severe organ dysfunction, or severe plasma leakage. Ophthalmic manifestations can involve both the anterior and posterior segment. We report an ocular emergency of proptosis and globe rupture in a patient with severe dengue.
  4,702 220 2
Prevalence of chronic ocular complications in Stevens-Johnson syndrome and toxic epidermal necrolysis
Lourens Van Zyl, Henry Carrara, Karin Lecuona
October-December 2014, 21(4):332-335
DOI:10.4103/0974-9233.142272  PMID:25371640
Purpose: The aim of this study is to identify and grade the severity of chronic ocular complications in patients who suffered from Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) treated in Cape Town, South Africa. Methods: A total of 54 patients with SJS or TEN for 6 months or longer were examined. The ocular complications were classified into corneal, eyelid and conjunctival complications. The complications were graded from 0 to 3 depending on the severity. Results: A total of 108 eyes were included in the study. Medications caused SJS or TEN in all cases, and the most common associated drugs were anti-retroviral medications. 59.3% of patients were HIV-positive, with CD4 counts ranging from 6 to 521. Although only 11% of patients with SJS or TEN had acute ocular complications during the initial illness, 89% developed chronic ocular complications. Loss of the palisades of Vogt was the most common corneal complication. Among the six components of conjunctival and eyelid complications, irregularity of the mucocutaneous junction abnormalities was the most common, followed by mild conjunctival hyperemia. There was no statistically significant difference in the severity of chronic ocular complications between HIV-positive and HIV-negative patients (P = 0.4). In addition, the severity of chronic ocular complications was not statistically significantly associated with visual acuity loss (P = 0.3). Conclusion: We conclude that almost 90% of patients who are diagnosed with SJS or TEN will develop chronic ocular complications. Unless eyelids are severely affected, most chronic complications are mild to moderate ocular surface abnormalities and not necessarily vision-threatening complications.
  4,103 228 6
Colloid Cyst of the Third Ventricle Presenting with Features of Terson's Syndrome
Mary K Jacob, SK Anand, Prasad George
October-December 2014, 21(4):344-346
DOI:10.4103/0974-9233.142275  PMID:25371642
This report describes a middle-aged man presenting to the ophthalmologist with history of seeing floaters before both eyes since 2-weeks duration. A history of intermittent headache and dizziness of recent onset was elicited on questioning. Ocular examination showed bilateral early papilloedema and mild vitreous hemorrhage. Brain computed tomography (CT) disclosed features suggestive of colloid cyst of the third ventricle in the region of foramen of Monro with moderate hydrocephalus. Emergency craniotomy and excision of the cyst was done, and the patient is doing well for the last 18 months after the surgical intervention. The mechanism of this presentation, importance of early investigations, and timely intervention are highlighted in order to avoid serious neurological sequelae. The literature was extensively reviewed for atypical presentations of intraventricular colloid cyst.
  4,124 175 -
Optical coherence tomography of fovea before and after laser treatment in retinopathy of prematurity
Subina Narang, Amrita Singh, Suksham Jain, Sunandan Sood, Deepak Chawla
October-December 2014, 21(4):302-306
DOI:10.4103/0974-9233.142265  PMID:25371634
Purpose: To study the fovea in preterm babies with Type I retinopathy of prematurity (ROP) before and after laser treatment using optical coherence tomography (OCT). Materials and Methods: This was a prospective observational case-control study including preterm neonates undergoing screening for ROP from May 2009 to July 2011. Group 1 included 30 eyes of 15 neonates with Type I ROP. A 532-nm laser was used for treatment in all cases for Group 1. Group 2 included 14 eyes of 7 preterm neonates without ROP that served as controls. OCT was performed under sedation in the lateral position before and after laser treatment. P <0.05 was considered statistically significant. Results: The mean initial central macular thickness (CMT) was comparable in both groups (P = 0.832) and statistically significantly correlated with gestational age (P = 0.015). No adverse effects on the anterior segment or posterior segment were observed. There was no significant difference in CMT before and after laser treatment in Group 1 (P = 0.007). There was one case of cystoid macular edema after laser treatment. Conclusion: The macula in preterm babies with Type 1 ROP was comparable to those without ROP. Gestational age was the only predictor of CMT.
  4,020 219 -
Multimodal imaging for the diagnosis of an atypical case of central serous chorioretinopathy
Rim Kahloun, Amel Chebbi, Sofiene Ben Amor, Imen Ksiaa, Leila Nacef, Moncef Khairallah
October-December 2014, 21(4):354-357
DOI:10.4103/0974-9233.142279  PMID:25371645
We report a case of a 52-year-old woman presented with atypical central serous chorioretinopathy (CSCR) that had been misdiagnosed as posterior uveitis and treated with systemic corticosteroids and immunosuppressive therapy, with subsequent severe chorioretinal damage. Diagnosis was straightened through multimodal imaging. Anatomical improvement was achieved after discontinuation of corticosteroids and intravitreal injection of bevacizumab. However, visual acuity remained severely impaired in one eye. Failure to differentiate atypical CSCR from inflammatory chorioretinal diseases may lead to severe and irreversible visual impairment. Multimodal imaging helps recognition of the atypical presentations of CSCR, avoiding misdiagnosis and inappropriate management.
  3,823 202 1
Glass wool tripod foreign bodies in the eye: First ever reported case series
Rahul B Baile, Sahasrabuddhe-Chitnis Meghana, Madhuri S Pattiwar
October-December 2014, 21(4):363-365
DOI:10.4103/0974-9233.142283  PMID:25371648
We present three cases of unusual corneal/conjunctival foreign bodies that were not visible on standard slit lamp examination. All patients presented with complaints of foreign body sensation in the affected eyes. One patient had visited an ophthalmologist prior to presentation to our center and was diagnosed and treated for conjunctivitis. On slit lamp examination minimal congestion was seen hence, all the patients were diagnosed with conjunctivitis with corneal epithelial defects by the residents. However, because the patients complained of foreign body sensation, fluorescein staining of the affected eye was performed. On examination, the corneas had epithelial defects and linear scratch marks. We suspected a foreign body in upper palpebral conjunctiva (UPC). Examination after eyelid eversion indicated tripod-shaped glassy foreign bodies embedded deep within the UPC. We present cases of an unusual type of glassy tripod-shaped foreign body which may go undetected even on slit lamp examination. Fluorescein staining may aid in the detection of these foreign bodies.
  3,866 151 -
Effects of fasting on intraocular pressure in a black population
Mustapha B Hassan, Michaeline A Isawumi
October-December 2014, 21(4):328-331
DOI:10.4103/0974-9233.142271  PMID:25371639
Introduction: There is a dearth of literature available on the effects of fasting on Intraocular pressure (IOP) among all races and worldwide. Objectives : To determine the effects of fasting on IOP in a black African population. Materials and Methods: A population-based survey utilizing multistage random sampling techniques was carried out among healthy adult Muslims who were examined before and during Ramadan fast in Osogbo, Nigeria. Demographics were obtained, visual acuities, clinical examination of both eyes, and IOPs were done. Weights and waist circumference were measured. Data were analyzed using Statistical Package for Social Sciences ( SPSS) Version 16. Analysis generated frequencies and cross tabulations, whereas statistical significant values were derived using paired sample t-test and P < 0.05. Results: A total of 60 subjects with 120 eyes were examined. Mean age was 42.3 years standard deviation (SD) 16.7, and the male to female ratio was 3:2. Majority were professionals (33.3%). Only 18.3% had less than secondary school education. Over 90% had normal vision (6/5-6/18). Before and during fasting, the mean weights were 65.92 kg SD 12.98 and 65.29 kg SD 12.41 with a reduction of 0.63 kg SD 3.82 (P = 0.214, 95% confidence interval (CI): 0.372-1.626); and the mean waist circumference was 87.20 cm SD 12.39 and 81.78 cm SD 11.65 (P = 0.000, 95% CI 4.128-6.720), respectively. Mean IOPs were 15.98 mmHg SD 3.11 and 14.08 mmHg SD 2.71 before and during fasting, respectively (P = 0.000, 95% CI 0.98558-2.82798). Conclusions: The study shows that fasting significantly reduced IOP in an ocularly healthy black African population.
  3,780 192 5
Last issue of 2014: Interesting assortment of ocular pathology
Majid Moshirfar
October-December 2014, 21(4):289-290
DOI:10.4103/0974-9233.142262  PMID:25371631
  3,483 194 -
Failure of globe conservation in a case of adult onset retinoblastoma
Vikas Khetan, Appukuttan Bindu, Pradnya Kamat, S Krishna Kumar
October-December 2014, 21(4):358-360
DOI:10.4103/0974-9233.142280  PMID:25371646
Adult onset retinoblastoma is a rare intraocular malignancy. The majority of the cases are treated with enucleation, due to late presentation and advanced-stage tumors. Here we report a case of a 30-year-old female who presented with an intraocular mass with exudative retinal detachment in her right eye. B-scan ultrasound and magnetic resonance imaging (MRI) confirmed the diagnosis of retinoblastoma. In an attempt to salvage the globe, she was treated with chemotherapy, which resulted in excellent regression of the tumor mass by the end of 8 months follow-up. The patient was followed-up regularly with focal treatment whenever necessary. Two years later, she developed a massive recurrence necessitating enucleation. Histopathologic examination revealed a moderately differentiated retinoblastoma with choroidal invasion. Attempt to salvage the globe in adult onset retinoblastoma with chemoreduction and focal therapy may be possible; however, regular long-term follow-up is necessary for recurrence which warrants timely intervention.
  3,475 150 2
Intracorneal rhinosporidiosis managed with deep anterior lamellar keratoplasty
Somnath Mukhopadhyay, Himadri Datta, Debanjan Sen
October-December 2014, 21(4):361-362
DOI:10.4103/0974-9233.142282  PMID:25371647
A healthy 22-year-old male presented to Institutional Cornea Clinic with an intracorneal mass overlying the pupil with lobulated edges having many tiny greyish white dots. The patient had a history of trauma while swimming in a pond with subsequent removal of intracorneal foreign body in the left eye approximately a year prior to presentation. Anterior segment optical coherence tomography (OCT) confirmed that an intracorneal mass sparing deep stroma and Descemet's membrane. A deep anterior lamellar keratoplasty (DALK) was performed in left eye and the mass was sent for histology examination. Histology evaluation was suggestive of rhinosporidiosis. The patient achieved 20/60 BCVA with -1.25 Χ× 120° 1 year postoperatively without any evidence of recurrence at the graft-host interface. This unique presentation (as an 'intracorneal mass') of ocular rhinosporidiosis emphasizes that clinicians from our region of the world must consider rhinosporidiosis in the differential diagnosis especially with a history of penetrating injury while swimming in pond or river water.
  3,383 163 1
Primary and secondary implantation of scleral fixated intraocular lens in adult patients
Kanupriya Agarwal, Deepa Sharma, Manisha Agarwal, Rahul Mayor, Ramesh Venkatesh
October-December 2014, 21(4):366-366
DOI:10.4103/0974-9233.142284  PMID:25371649
  3,086 154 -
Author's Reply
Zuleyha Yalniz-Akkaya, Ayse Burcu, Umit Eksioglu, Mehmet Akif Acar, Firdevs Ornek
October-December 2014, 21(4):366-367
  2,579 108 -