Case Reports in Ophthalmological Medicine最新文献

{"title":"Unilateral Toxic Anterior Segment Syndrome Resulting in Cataract and Urrets-Zavalia Syndrome after Sequential Uneventful Implantation of a Posterior Chamber Phakic Toric Intraocular Lens at Two Different Surgical Facilities: A Series of Unfortunate Events.","authors":"Kepa Balparda,&nbsp;Claudia Marcela Vanegas-Ramirez,&nbsp;Johny Márquez-Tróchez,&nbsp;Tatiana Herrera-Chalarca","doi":"10.1155/2020/1216578","DOIUrl":"https://doi.org/10.1155/2020/1216578","url":null,"abstract":"<p><strong>Background: </strong>Phakic Intraocular Lens (P-IOL) implantation is a safe, easy, predictable intervention designed to manage moderate to high refractive errors. Complications are relatively uncommon and include mainly cataract and intraocular pressure spikes. Toxic Anterior Segment Syndrome (TASS) is a rather unusual sterile anterior segment inflammation after uneventful intraocular surgery, extremely rarely reported after P-IOL implantation. Urrets-Zavalia Syndrome (UZS) is also very rarely described after P-IOL. To date, to the best of the authors' knowledge, no article has ever described the simultaneous occurrence of TASS and UZS in a patient after P-IOL implantation.</p><p><strong>Objective: </strong>In this article, the authors present the case of a female patient with moderate myopic astigmatism, who underwent sequential P-IOL implantation at two different facilities. The postoperative course of the first eye was uneventful, but she developed complications associated to the intervention in the second eye.</p><p><strong>Materials: </strong>The article describes the case of a young patient who underwent a sequential Phakic Intraocular Lens (P-IOL) implantation at two different institutions. The postoperative course of the first eye (left eye) was uneventful; however, the second eye (right eye) initially developed Toxic Anterior Segment Syndrome (TASS). Although timely and correct management was instituted, upon resolution of TASS, the patient developed Urrets-Zavalia Syndrome, anterior subcapsular cataract, and significant endothelial damage in the same eye.</p><p><strong>Results: </strong>The patient was followed closely and managed accordingly; corneal edema and anterior segment inflammation of the right eye eventually resolved. Nevertheless, an anterior subcapsular cataract and a fixed dilated pupil remained; with normal intraocular pressure (IOP). Specular microscopy confirmed an endothelial cell loss in the TASS eye (right eye). Pupil size showed no reaction to repeated doses of Pilocarpine 2%. A month after surgery, refraction on her right eye was +0.25 + 0.75 × 93, which resulted in a 20/50 vision.</p><p><strong>Conclusions: </strong>TASS and UZS are both extremely rare complications after uneventful P-IOL implantation, with only a handful of cases having been reported of each of them. To date, this is the very first case where UZS ensued after and potentially as a consequence of TASS in a patient who had undergone P-IOL implantation. Although a direct causative element could not be pinpointed, the fact that the complication ensued after being operated in one surgical institution and not the other, could suggest some role of different sterilization and handling procedures, but no direct conclusion can be made on this case.</p>","PeriodicalId":9603,"journal":{"name":"Case Reports in Ophthalmological Medicine","volume":"2020 ","pages":"1216578"},"PeriodicalIF":0.9,"publicationDate":"2020-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1155/2020/1216578","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38720787","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Isolated Superior Oblique Muscle Swelling Causing Acute Vertical Strabismus in Graves' Disease.","authors":"Keiichi Aomatsu,&nbsp;Shunji Kusaka","doi":"10.1155/2020/8829655","DOIUrl":"https://doi.org/10.1155/2020/8829655","url":null,"abstract":"<p><strong>Purpose: </strong>To report a case of isolated superior oblique muscle swelling causing acute vertical strabismus in Graves' disease.</p><p><strong>Case: </strong>A 26-year-old woman with a 1-month history of misalignment of the right eye and diplopia was referred to us. Her visual acuity and intraocular pressures were normal in both eyes, but eye movement tests showed clear misalignment of her right eye. Antibody tests for myasthenia gravis were negative. However, blood tests revealed abnormal levels of thyroid-related factors, such as decreased thyroid-stimulating hormone, elevated free T3 and T4, and elevated anti-thyroid-stimulating hormone receptor antibody. We performed magnetic resonance imaging (MRI), which showed slight enlargement of the left superior oblique muscle. The patient was eventually diagnosed with Graves' disease with superior oblique muscle involvement and underwent a thyroidectomy. Three months postoperatively, her diplopia and abnormal eye movements had substantially resolved.</p><p><strong>Conclusion: </strong>Isolated superior oblique muscle involvement may be a presenting symptom of Graves' disease. It should be taken into consideration that, in the early stages of thyroid-associated ophthalmopathy (TAO) in adults, only the superior oblique muscle may be enlarged.</p>","PeriodicalId":9603,"journal":{"name":"Case Reports in Ophthalmological Medicine","volume":"2020 ","pages":"8829655"},"PeriodicalIF":0.9,"publicationDate":"2020-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1155/2020/8829655","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38720788","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"<i>Exophiala</i> Keratitis following Descemet Stripping Automated Endothelial Keratoplasty.","authors":"Ana Marta,&nbsp;Paula Costa,&nbsp;Virgínia Lopes,&nbsp;Miguel Mesquita Neves,&nbsp;Miguel Gomes,&nbsp;Luís Oliveira","doi":"10.1155/2020/8872465","DOIUrl":"https://doi.org/10.1155/2020/8872465","url":null,"abstract":"<p><strong>Purpose: </strong>To report a case with <i>Exophiala spp.</i> keratitis in a Portuguese patient.</p><p><strong>Methods: </strong>A case report with deep corneal brown-pigmented infiltrates that developed 2 months after a Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) for pseudophakic bullous keratopathy.</p><p><strong>Results: </strong>Diagnosis was established by positive direct examination and cultures from the surgically obtained corneal button. Slit-lamp images and anterior segment optical coherence tomography (AS-OCT) scans were obtained.</p><p><strong>Conclusion: </strong>This is the first described case of fungal keratitis caused by Exophiala spp. in Portugal and, to our knowledge, the first case following DSAEK in the literature.</p>","PeriodicalId":9603,"journal":{"name":"Case Reports in Ophthalmological Medicine","volume":"2020 ","pages":"8872465"},"PeriodicalIF":0.9,"publicationDate":"2020-10-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1155/2020/8872465","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38687463","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Vitreous Hemorrhage as Presenting Sign of Retinal Arteriovenous Malformation.","authors":"Geraldine P B M Accou,&nbsp;Fanny Nerinckx,&nbsp;Bart P Leroy,&nbsp;Julie De Zaeytijd","doi":"10.1155/2020/8858242","DOIUrl":"https://doi.org/10.1155/2020/8858242","url":null,"abstract":"<p><strong>Objective: </strong>To describe a patient with vitreous hemorrhage and peripheral retinal ischemia, eventually diagnosed with an underlying retinal arteriovenous malformation.</p><p><strong>Methods: </strong>A 15-year-old girl presented with sudden-onset, painless visual loss in the right eye. She underwent a full ophthalmological work-up.</p><p><strong>Results: </strong>BCVA was less than 20/400 in the right eye and 20/20 in the left eye. Intraocular pressure and anterior segment examination were unremarkable. Fundoscopy was impossible due to an opaque vitreous hemorrhage in the right eye. The left eye was completely unremarkable. Examination during a 23-gauge pars plana vitrectomy showed dilated, tortuous arteriovenous vessels extending from the optic disc and silver wiring of the enlarged vessels. A clinical diagnosis of retinal arteriovenous malformation was made. During surgery, a peripheral retinal photocoagulation was executed to avoid rebleeding. Postoperatively, fluorescein angiography demonstrated additional macular microangiopathy and diffuse retinal nonperfusion in the periphery. The MRI brain revealed neither cerebral nor orbital vascular anomaly, confirming a group 2 retinal arteriovenous malformation.</p><p><strong>Conclusion: </strong>Retinal arteriovenous malformations are generally considered stable over time. However, complications due to retinal ischemia can occur. Hence, regular observation is warranted. In so doing, timely treatment can be offered to avoid complications.</p>","PeriodicalId":9603,"journal":{"name":"Case Reports in Ophthalmological Medicine","volume":"2020 ","pages":"8858242"},"PeriodicalIF":0.9,"publicationDate":"2020-10-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1155/2020/8858242","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38657978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Posner-Schlossman Syndrome in Common Variable Immunodeficiency.","authors":"Madiha Huq, Neha Sanan, Phuong Daniels, Robert Hostoffer","doi":"10.1155/2020/8843586","DOIUrl":"10.1155/2020/8843586","url":null,"abstract":"<p><strong>Introduction: </strong>Posner-Schlossman syndrome (PSS) is a rare glaucomatocyclitic crisis with clinical features including recurrent episodes of unilateral elevated intraocular pressure. Autoimmune and infectious causes have been proposed as potential etiologies of PSS. We report the first case of PSS in the setting of common variable immunodeficiency (CVID). <i>Case Report</i>. A sixty-two-year-old Caucasian female with a medical history of CVID and ulcerative colitis presented to the emergency room with complaints of acute right-sided vision changes. She reported image distortion, blurriness, and loss of central vision. Physical exam was significant for mildly injected right conjunctiva, visual acuity of 20/70 in right eye, and 20/25 in left eye. The right intraocular pressure was measured at 34 mmHg and left at 12 mmHg. The gonioscopy and dilated fundus examination were unremarkable. Cup to disc ratio was within normal limits, and no afferent pupillary defects were recorded. The patient was acutely treated with three rounds of dorzolamide/timolol and 0.2% brimonidine which decreased the right eye intraocular pressure to 24 mmHg. On follow-up exam with an ophthalmologist, anterior uveitis including an elevated pressure of 41 mmHg on the right and 18 mmHg on the left eye was noted and a PSS diagnosis was confirmed.</p><p><strong>Conclusion: </strong>PSS remains a rare condition with uncertain etiology and no associated systemic conditions. PSS has been postulated to be linked to autoimmune conditions. CVID is associated with many autoimmune disorders including Sjogren's, rheumatoid arthritis, and colitis. There have been a few reported CVID-associated ocular diseases including granulomatous uveitis and conjunctivitis, chronic anterior uveitis, and birdshot retinopathy. We describe the first case of PSS in a patient with CVID.</p>","PeriodicalId":9603,"journal":{"name":"Case Reports in Ophthalmological Medicine","volume":"2020 ","pages":"8843586"},"PeriodicalIF":0.9,"publicationDate":"2020-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1155/2020/8843586","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38551510","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Orbital Infection by Saksenaea vasiformis in an Immunocompetent Host.","authors":"Mingkwan Lumyongsatien,&nbsp;Pimkwan Jaru-Ampornpan,&nbsp;Mongkol Uiprasertkul,&nbsp;Dinesh Selva","doi":"10.1155/2020/8827074","DOIUrl":"https://doi.org/10.1155/2020/8827074","url":null,"abstract":"<p><p>Orbital mucormycosis caused by <i>Saksenaea vasiformis</i> is extremely rare. Herein, we report an immunocompetent 22-year-old Thai female who presented with two months of progressive right upper eyelid mass, associated with swelling, redness, and ptosis. She failed to improve despite multiple courses of antibiotic and steroid treatment. Computed tomography (CT) scan showed infiltration involving the upper eyelid and lacrimal gland. Fungal hyphae were revealed by histopathological study. Polymerase chain reaction (PCR) was positive for <i>Saksenaea vasiformis</i> (GenBank: accession number FR687327.1). The patient was successfully treated with surgical debridement, amphotericin B, and oral posaconazole.</p>","PeriodicalId":9603,"journal":{"name":"Case Reports in Ophthalmological Medicine","volume":"2020 ","pages":"8827074"},"PeriodicalIF":0.9,"publicationDate":"2020-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1155/2020/8827074","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38493840","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Ipsilateral Lymphatic and Venous Malformations Affecting the Midface Area.","authors":"Şükran Bekdemir,&nbsp;Ahmet Kaan Gündüz,&nbsp;Ömür Ataoğlu","doi":"10.1155/2020/2845035","DOIUrl":"https://doi.org/10.1155/2020/2845035","url":null,"abstract":"<p><p>A 22-year-old woman presented with progressive swelling of the nasal conjunctiva in the left eye. Anterior segment examination revealed a diffuse cystic appearance to the inferonasal bulbar conjunctiva and plica semilunaris. Anterior segment swept-source optical coherence tomography (OCT) revealed clear hyporeflective spaces demarcated by hyperreflective septae in the affected conjunctiva, consistent with the diagnosis of lymphatic malformation (LM). Magnetic resonance imaging revealed a well circumscribed intraconal mass located inferonasally in the left orbit. Systemic examination revealed a lesion similar to LM on the left hard palate. The left conjunctival mass was excised subtotally. Subsequently, a transconjunctival anterior orbitotomy was performed and the left orbital mass was completely removed intact. Histopathologically, the conjunctival mass was diagnosed as LM and the orbital mass as venous malformation (VM). This case represents a rare coexistence of histopathologically proven conjunctival LM and orbital VM as well as a presumed LM of the hard palate, all 3 lesions occurring in the ipsilateral midface area.</p>","PeriodicalId":9603,"journal":{"name":"Case Reports in Ophthalmological Medicine","volume":"2020 ","pages":"2845035"},"PeriodicalIF":0.9,"publicationDate":"2020-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1155/2020/2845035","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38455541","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Case Series of Perforated Keratomycosis after Laser-Assisted In Situ Keratomileusis.","authors":"Taher Eleiwa,&nbsp;Eyup Ozcan,&nbsp;Samar Abdelrahman,&nbsp;Omar Solyman,&nbsp;Abdelrahman M Elhusseiny,&nbsp;Gehad Youssef,&nbsp;Ahmed Bayoumy","doi":"10.1155/2020/7237903","DOIUrl":"https://doi.org/10.1155/2020/7237903","url":null,"abstract":"<p><strong>Background: </strong>Fungal keratitis is an extremely rare complication of laser vision correction resulting in poor visual outcomes. Amniotic membrane transplantation should be kept in mind in eyes with corneal perforation prior to penetrating keratoplasty.</p><p><strong>Aim: </strong>To assess the outcomes of multilayered fresh amniotic membrane transplantation (MLF-AMT) in patients with severe keratomycosis after laser-assisted in situ keratomileusis (LASIK). <i>Study design</i>. Hospital-based prospective interventional case series.</p><p><strong>Methods: </strong>Five eyes of 5 patients were included in the study. All cases underwent microbiological scrapings from residual bed and intrastromal injections of amphotericin (50 mcg/mL), with flap amputation if needed, followed by topical 5% natamycin and 0.15% amphotericin. MLF-AMT was performed after corneal perforation. Later, penetrating keratoplasty (PK) was performed when corneal opacity compromised visual acuity. The outcome measures were complete resolution of infection, corneal graft survival, and best-corrected visual acuity (BCVA).</p><p><strong>Results: </strong>The mean age of patients was 22 ± 1.2 years with 4/5 (80%) were females. The mean interval between LASIK and symptom onset was 8.8 ± 1 day, and the mean interval between symptom onset and referral was 14 ± 1.4 days. Potassium hydroxide (KOH) smears showed filamentous fungi, and Sabouraud's medium grew Aspergillus in all cases. Melted flaps were amputated in 4 (80%) cases. MLF-AMT was performed in all cases due to corneal perforation after a mean time of 12.4 ± 1.2 days of antifungals. In all cases, complete resolution of infection was seen 26 ± 1.8 days after MLF-AMT, and optical PK was done at a mean of 2.4 months later. No postoperative complications after MLF-AMT or PK were observed, with a 0% incidence of corneal graft rejection, and a final BCVA ranged from 20/20 to 20/80 after a mean follow-up of 14 ± 1.1 months.</p><p><strong>Conclusion: </strong>MLF-AMT is a safe and valid option to manage corneal perforation during keratmycosis treatment to avoid emergency therapeutic keratoplasty.</p>","PeriodicalId":9603,"journal":{"name":"Case Reports in Ophthalmological Medicine","volume":"2020 ","pages":"7237903"},"PeriodicalIF":0.9,"publicationDate":"2020-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1155/2020/7237903","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38455542","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Image-Guided Intensity-Modulated Radiation Therapy for IgG4-Related Ophthalmic Disease.","authors":"Rachel A Sabol,&nbsp;Virginia Bubenzer,&nbsp;Krzysztof Moroz,&nbsp;Shams Halat,&nbsp;Audrey Dang,&nbsp;Keith Ferdinand,&nbsp;Angela Traylor,&nbsp;Carol Boyd,&nbsp;Kendra Harris","doi":"10.1155/2020/8873078","DOIUrl":"https://doi.org/10.1155/2020/8873078","url":null,"abstract":"<p><strong>Background: </strong>IgG4-related ophthalmic disease is a rare, newly recognized entity with high failure rates on first-line therapy of systemic corticosteroids and no other proven management options. <i>Case Presentation.</i> Here, we present the clinical course of a patient with IgG4 ophthalmic disease who achieved a favorable response from radiotherapy. Our patient initially presented with a history of recurrent painful flares of orbital inflammation, a pathologic diagnosis follicular lymphoid hyperplasia from a right lacrimal gland biopsy, and MRI imaging noting expansion of the lateral rectus muscle of the right eye. Initial treatment with dacryoadenectomy and multiple courses of corticosteroids failed to keep his symptoms at bay. Further evaluation revealed florid IgG4 staining. In this context, he was evaluated for image-guided intensity-modulated radiotherapy (IG-IMRT) to the orbit to 20 Gy in 10 fractions. His ophthalmic symptoms resolved.</p><p><strong>Conclusions: </strong>This treatment experience suggests radiotherapy may be a favorable option for symptom relief in patients with IgG4-related ophthalmic disease not controlled by corticosteroids.</p>","PeriodicalId":9603,"journal":{"name":"Case Reports in Ophthalmological Medicine","volume":"2020 ","pages":"8873078"},"PeriodicalIF":0.9,"publicationDate":"2020-09-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1155/2020/8873078","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38408221","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Rare Coexistence of Isolated Unilateral Conjunctival Telangiectasia and Retinal Vascular Tortuosity.","authors":"Hilal Kilinç Hekimsoy,&nbsp;Mehmet Ali Şekeroğlu","doi":"10.1155/2020/8814961","DOIUrl":"https://doi.org/10.1155/2020/8814961","url":null,"abstract":"<p><p>A 55-year-old woman with no known systemic disorder and without any history of ocular disease, trauma, and surgery presented with a nonremitting conjunctival redness on her left eye that was existing since her childhood. On ophthalmological examination, an extremely rare coexistence of isolated unilateral bulbar conjunctival telangiectasia and ipsilateral retinal vascular tortuosity without any systemic and neuroradiological association was detected. We aimed to demonstrate this rare vascular coexistence and discuss differential diagnosis of the underlying causes.</p>","PeriodicalId":9603,"journal":{"name":"Case Reports in Ophthalmological Medicine","volume":"2020 ","pages":"8814961"},"PeriodicalIF":0.9,"publicationDate":"2020-08-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1155/2020/8814961","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38459315","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}