玻璃体病第一节概述.ppt

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1、 玻玻 璃璃 体体 病病第一节第一节 概概 述述n n特性粘液性胶样组织透明凝胶状态精细的n型胶原纤维网支架和透明质酸99%是水n n可溶性蛋白(白蛋白、糖蛋白)葡萄糖游离氨基酸电解质皮质部有少数玻璃体细胞玻璃体的功能大致为玻璃体的功能大致为:n n在胚胎期对眼球发育起重要作用在胚胎期对眼球发育起重要作用保持玻璃体腔高度透明，对光线的散射极少保持玻璃体腔高度透明，对光线的散射极少对晶状体、视网膜等周围组织有支持、减震作用对晶状体、视网膜等周围组织有支持、减震作用n n具有代谢作用，有主动转运过程具有代谢作用，有主动转运过程n n具有屏障作用，细胞和大分子不易侵入玻璃体具有屏障作用，细胞和大分子

2、不易侵入玻璃体正常玻璃体成分具有对新生血管和细胞增生的抑制正常玻璃体成分具有对新生血管和细胞增生的抑制作用作用n n玻璃体液化：玻璃体凝胶状态破坏，变为液体。玻璃体液化：玻璃体凝胶状态破坏，变为液体。n n玻璃体混浊：透明质酸因代谢、光化学作用发玻璃体混浊：透明质酸因代谢、光化学作用发生解聚，胶原纤维支架塌陷浓缩，水分析出。生解聚，胶原纤维支架塌陷浓缩，水分析出。同时，由于固体成分凝聚，或者有血液及其他同时，由于固体成分凝聚，或者有血液及其他有形成分侵入，使玻璃体的透明性改变，出现有形成分侵入，使玻璃体的透明性改变，出现不透明体。不透明体。n n飞蚊症：玻璃体病的常见症状为眼前有飘浮物。飞蚊症

3、：玻璃体病的常见症状为眼前有飘浮物。感觉有小点状或丝状物在眼前飘动感觉有小点状或丝状物在眼前飘动玻璃体病的治疗原则玻璃体病的治疗原则n n保守疗法病因疗法手术疗法第二节第二节 玻璃体液化与后脱离玻璃体液化与后脱离n n多见于老年人n n近视眼可较早发生n n飞蚊症n n玻璃体视网膜牵拉造成视网膜裂孔一、老年玻璃体液化一、老年玻璃体液化(synchysissenilis)(synchysissenilis)n n玻璃体内代谢变化，或因光线与玻璃体内的维生素C、氧和铁离子发生光氧化反应，使透明质酸大分子降解，凝胶变性而成为液体。40岁以后首先发生在玻璃体中央部小的液化腔点状白色混浊或膜状物飘浮二、

4、玻璃体后脱离二、玻璃体后脱离(posteriorvitreousdetachment)(posteriorvitreousdetachment)n n玻璃体皮质与视网膜的分离，通常在老年玻璃体玻璃体皮质与视网膜的分离，通常在老年玻璃体液化的基础上发生。液化的基础上发生。n n原因原因老年因素老年因素玻璃体出血玻璃体出血炎症炎症高度近视高度近视变性疾病变性疾病外伤外伤三、玻璃体视网膜牵引三、玻璃体视网膜牵引n n玻璃体皮质与黄斑部、视网膜周边部的粘连较紧玻璃体皮质与黄斑部、视网膜周边部的粘连较紧随着眼球的转动，后玻璃体膜对视网膜产生前后随着眼球的转动，后玻璃体膜对视网膜产生前后方向或切线方向的牵

5、引力方向或切线方向的牵引力视网膜周边部变性，高度近视眼黄斑部发生变性视网膜周边部变性，高度近视眼黄斑部发生变性造成周边部视网膜裂孔或黄斑裂孔造成周边部视网膜裂孔或黄斑裂孔孔源性视网膜脱离孔源性视网膜脱离玻璃体液化、后脱离所产生的玻璃体视网膜牵引，玻璃体液化、后脱离所产生的玻璃体视网膜牵引，是孔源性视网膜脱离发病的重要机理。是孔源性视网膜脱离发病的重要机理。四四 飞蚊症飞蚊症(muscaevoants(muscaevoants，或，或vitreousfloaters)vitreousfloaters)n n中老年或近视眼病人感觉眼前有飘动的小黑影，尤其看白色或明亮的背景时症状更明显，有时病人还可

6、能有闪光感。n n原因：玻璃体液化和后脱离n n生理性“飞蚊症”，无临床意义五、星状玻璃体变性五、星状玻璃体变性(asteroidhyalosis)(asteroidhyalosis)n n少数老年人80%为单眼发病玻璃体内出现含钙的脂质白色小球无玻璃体液化六、闪辉性玻璃体液化六、闪辉性玻璃体液化(synchysisscintillans)(synchysisscintillans)n n玻璃体内出现胆固醇结晶颗粒及玻璃体液化为特征的一种病变。双眼发病炎症、外伤或出血后发生35岁左右玻璃体内闪光的结晶随眼球飘动第三节第三节 玻璃体出血玻璃体出血n n病因 视网膜血管性疾病 视网膜静脉阻塞、视网

7、膜静脉周围炎、糖尿病性视网膜病变眼球外伤或手术 眼球穿孔伤、球内异物、眼球钝挫伤老年黄斑变性视网膜血管瘤、某些类型的葡萄膜炎玻璃体出血临床表现玻璃体出血临床表现 n n少量出血时，飞蚊症，细小混浊点或飘浮物，视力多不受影响大量出血时，视力急剧减退，无红光或仅见微弱红光反射有引起玻璃体出血的原发伤病的表现玻璃体出血病程与预后玻璃体出血病程与预后n n玻璃体液化和后脱离。大量出血可刺激视网膜表面的细胞增生玻璃体视网膜增殖性病变，造成牵引性视网膜脱离血影细胞性青光眼玻璃体出血治疗玻璃体出血治疗n n药物治疗及物理疗法 n n止血药、透明质酸酶、尿激酶n n超声波、激光n n手术治疗 玻璃体切割术玻璃

8、体切割术n n3-6个月不吸收的单纯玻璃体出血玻璃体出血合并有视网膜脱离其他玻璃体病变其他玻璃体病变一、玻璃体炎症一、玻璃体炎症n n各种类型的葡萄膜炎或眼内炎都会引起玻璃体炎。玻璃体内出现炎性渗出物和白细胞玻璃体小团状或絮状混浊，严重时为致密灰黄色或灰白色膜状混浊，甚至积脓视力有不同程度影响玻璃体手术二、增殖性玻璃体视网膜病变二、增殖性玻璃体视网膜病变(proliferativevitreoretinopathy(proliferativevitreoretinopathy，PVR)PVR)n n孔源性视网膜脱离或视网膜复位手术后、以及眼球穿通伤后，由于玻璃体内及视网膜表面的细胞增生和收缩，

9、造成牵引性视网膜脱离的病变。细胞增生、形成有收缩能力的膜是这一病变的基本病理过程。参与增生的细胞有视网膜色素上皮细胞、神经胶质细胞、成纤维细胞等。PVRPVR分级分级n nA A为为“轻度轻度”，玻璃体内有色素团和混浊，但此级非，玻璃体内有色素团和混浊，但此级非PVRPVR所特有所特有n nB B级为级为“中度中度”，视网膜表面有皱摺，裂孔卷边，血管，视网膜表面有皱摺，裂孔卷边，血管扭曲抬高，表明有增生膜存在扭曲抬高，表明有增生膜存在n nC C级为级为“明显明显”，表现为全层的视网膜固定皱襄，按范，表现为全层的视网膜固定皱襄，按范围又分为围又分为ClCl、C2C2和和C3C3，分别指病变位于

10、，分别指病变位于1 1、2 2和和3 3个象限个象限n nD D为为“广泛广泛”，指固定皱摺累及，指固定皱摺累及4 4个象限，以视乳头为个象限，以视乳头为中心呈放射状皱摺，视网膜完全脱离呈漏斗状。此级中心呈放射状皱摺，视网膜完全脱离呈漏斗状。此级又分为又分为DlDl、D2D2和和D3D3。玻璃体手术或合并可能的药物治疗。玻璃体手术或合并可能的药物治疗。三、玻璃体猪囊尾锄病三、玻璃体猪囊尾锄病 n n吞食猪肉绦虫的虫卵后，在玻璃体内形成囊尾助吞食猪肉绦虫的虫卵后，在玻璃体内形成囊尾助所致。所致。视力下降视力下降虫体变形或蠕动虫体变形或蠕动眼底可见囊尾蝴呈黄白色半透明圆形眼底可见囊尾蝴呈黄白色半透

11、明圆形大小约大小约1 1 56PD56PD有时可见头部吸盘有时可见头部吸盘多伴有玻璃体混浊与葡萄膜炎多伴有玻璃体混浊与葡萄膜炎玻璃体手术方法取出玻璃体手术方法取出四、先天性玻璃体异常及遗传病四、先天性玻璃体异常及遗传病玻璃体动脉残留玻璃体动脉残留(persistenthyaloidartery)(persistenthyaloidartery)n n在胚胎发育过程中，自视乳头至晶状体有一玻璃体动脉，通常在胚胎7个月时逐渐萎缩。但少数人玻璃体动脉萎缩不全，有灰白色条索状物残留。有时仅存在点状残留物，见于晶状体后囊部位，或在视乳头前有纤维条索。永存原始玻璃体增生症永存原始玻璃体增生症persist

12、enthyperplasiaofprimaryvitreous persistenthyperplasiaofprimaryvitreous n n婴幼儿或儿童婴幼儿或儿童90%90%为单眼发病为单眼发病发育期原始玻璃体的残留物发育期原始玻璃体的残留物小眼球、浅前房、小而扁平的晶状体小眼球、浅前房、小而扁平的晶状体晶状体后原始玻璃体增殖形成纤维膜晶状体后原始玻璃体增殖形成纤维膜瞳孔区晶状体后方为一片致密的白色纤维膜且常伴有瞳孔区晶状体后方为一片致密的白色纤维膜且常伴有新生血管新生血管睫状突受纤维膜的牵引被拉向晶状体，形成放射状条睫状突受纤维膜的牵引被拉向晶状体，形成放射状条索索白内障白内障继发

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21、lThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#TiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A

22、+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#TiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQe

23、MbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y

24、(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnVkShPdMaJ7F4C1z)w&s!pYmUjR

25、gOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkThPeMaJ7G4C1

26、z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2B+x(u$rZoWk

27、ThQeMbJ7C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMbJ7G4C1z-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B

28、+y(u%r#oWlThQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQ

29、fNcK8H5E2A+x*u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0

30、y)v&s#pXmUiRfNcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qZnVk

31、SgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D

32、2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#ohPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWlTh

33、QeMbJ8G4D1A-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#ohPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*

34、t$qZnVkSgPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQf

35、NbK8H5D2A-x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t$qYnVjSgPdLaI7B+y(u%r#oWlTiQeNbJ8G5D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u

36、$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfO

37、cK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t$qYnVjSgPdLaI7B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%

38、s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOd

39、LaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w

40、*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-wpXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMa

41、J7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-wpXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qY

42、nVjSgOdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8

43、G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgP9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZn

44、WkThPeMaJ7G4C1z-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgP9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E

45、2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&sw&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s