Results: However, experimental procedures to weaken the extraocular muscles induce adaptive changes that restore muscle force (116). With surgery on the horizontal muscles, the blockage point is moved to the primary position where the cyclovertical actions are diminished. An official website of the United States government. Accessibility It is important to emphasise that secondary vertical and torsional deviations have occurred when the vertical and torsional components are corrected by surgery on the oblique muscles.6,7,10. Purpose: To evaluate the effectiveness of a high-dose Anderson procedure (AP) to correct infantile nystagmus-related anomalous head turn (HT). The underlying principle is that stabilization of images on the retina can be achieved if the power of the spectacle lens focuses the primary image close to the center of rotation of the eye. A third approach involves large recessions (weakening) of the horizontal rectus muscles, which may cause improvement of vision and head posture (110-115). ISRN Ophthalmol. Epub 2022 Nov 24. 267-269. The hypertrophied inferior olivary nucleus of patients with OPT also shows increased acetylcholinesterase activity (57), prompting trials of anticholinergic agents. Background/aim: 1973; 23:3539. official website and that any information you provide is encrypted As a library, NLM provides access to scientific literature. Electro-optical device with servo-controlled optics to measure ocular oscillations and negate their effects. Visual acuity, binocularity, and recognition time were assessed before and after surgery. In every case except one, the resulting stability prevailed throughout the follow up. Methods: 21 patients with horizontal nystagmus and abnormal head position were studied. J Curr Ophthalmol. Mar 2002;86:267e269. Strabismus. WebGraded Anderson procedure for correcting abnormal head posture in infantile nystagmus may email you for journal alerts and information, but is committed Gupta R, Sharma P, Menon V (2006) Prospective clinical evaluation of augmented Anderson procedure for idiopathic infantile nystagmus. Journal of Neuro-Ophthalmology30(4):361-371, December 2010. Indeed, the amplitude of the nystagmus is often greater in the eye with poorer vision, prompting the hypothesis that delays in visual pathway conduction give rise to the oscillations (38). Many medications have been reported to improve downbeat nystagmus, including the GABAA agonist clonazepam (12,13) and the GABAB agonist baclofen (14,15). Memantine also shows some antagonistic effects at 5-hydroxytryptamine and nicotinic acetylcholine receptors (48). Anomalous head posture components in vertical and frontal planes did not improve. FOIA Clipboard, Search History, and several other advanced features are temporarily unavailable. Noval S, Gonzlez-Manrique M, Rodrguez-Del Valle JM, Rodrguez-Snchez JM. The Anderson-Kestenbaum procedure mechanically shifts the null point from a horizontal cardinal position to primary position. Idiopathic Infantile Nystagmus: Diagnosis and Treatment Robert D. Reinecke, MD Current concepts of idiopathic infantile nystagmus are summarized, with special attention to treatment and differential diagnosis of this condition. Overcorrection did not occur. These procedures aim to shift both eyes from an eccentric position of gaze where nystagmus is dampened (null zone) into the primary position. your express consent. For example, treatments to stop the eyes from moving altogether, such as botulinum toxin injections, may abolish the ocular oscillations, but provide no net improvement, since patients then complain of blurred vision when they move their head (due to absent VOR) and diplopia (due to absent vergence, which normally aligns the eyes). All subjects had horizontal nystagmus and 67% had jerk nystagmus. Purpose: HHS Vulnerability Disclosure, Help Costenbader Lecture. Please try after some time. After surgery, binocular visual acuity using the Early Treatment Diabetic Retinopathy Study chart improved in primary position (p = 0.007). Suspicion of neural integrator dysfunction led to the testing of medications with presumed effects on GABA-mediated and glutamate-mediated mechanisms (41,42). Results: 1953 May; 37 (5):267281. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Summary of changes in abnormal head position. They graduated from University of Arizona in 1990. Chang MY, Binenbaum G, Heidary G, Cavuoto KM, Morrison DG, Trivedi RH, Kim SJ, Pineles SL. As more becomes known about the pharmacology of the ocular motor system, new medications may emerge for the treatment of acquired and infantile forms of nystagmus. Patients with INS whose nystagmus is of lower amplitude when the eyes are placed in an eccentric null position rarely report a benefit from conjugate prisms that shift gaze. Only two previous studies have considered nystagmus with abnormal head position in all three axes.5,11 These authors performed surgery on the horizontal muscles in order to correct head turns and, during the same surgery, operated on the cyclovertical muscles to correct chin elevation/depression and head tilts. Zhonghua Yan Ke Za Zhi. Background The purpose of this study was to report the effect of combining the Kestenbaum procedure with posterior fixation suture for infantile horizontal nystagmus with anomalous head posture (AHP) in children. An official website of the United States government. WebANDERSON JR. Keywords: Before Visual fixation mechanisms reduce eye drifts that take the eyes away from the target and suppress unwanted saccades. The nystagmus of some patients with INS has improved with gabapentin or memantine. High-dose Anderson operation for nystagmus-related anomalous head turn. Surgery for nystagmus related head turn: Kestenbaum procedure and artificial divergence. Group 3 included patients with a vertical AHP HHS Vulnerability Disclosure, Help HHS Vulnerability Disclosure, Help The infantile nystagmus syndrome (INS) may have only a minor impact on vision if foveation periods are well developed, but symptomatic patients may benefit from treatment with gabapentin, memantine, or base-out prisms to induce convergence. Figure 3 summarizes the image-shifting optics that are being used to develop a portable battery-driven device (97,98), a prototype of which is shown in Figure 4. the contents by NLM or the National Institutes of Health. Thus, measurements of the duration of the foveation period from eye movement records (126) may appear to improve more with surgery than do conventional measurements of visual acuity, which is highly variable in INS. After the observation that wearing contact lenses may suppress INS (86), it was documented that electrical stimulation or vibration over the forehead may suppress the oscillations in some patients (142). The line diagrams summarize the optical principles used in the device. The entire process results in spontaneous oscillations of the eyes, palate, and other branchial muscles at a frequency of about 2 Hz. Chang MY, Binenbaum G, Heidary G, Cavuoto KM, Morrison DG, Trivedi RH, Kim SJ, Pineles SL. In a multicenter double-masked study of 15 patients with acquired pendular nystagmus (APN) (16), gabapentin, an anticonvulsant initially thought to have GABAergic action, was compared to baclofen, a GABAB agonist. To evaluate the effectiveness of a high-dose Anderson procedure (AP) to correct infantile nystagmus-related anomalous head turn (HT). Methods. For A matter of age. WebSurgical management for abnormal head position in nystagmus: the augmented modified Kestenbaum procedure. Federal government websites often end in .gov or .mil. The effect of horizontal rectus muscle surgery on clinical and eye movement recording indices in infantile nystagmus syndrome. WebExtraocular muscle surgery as a treatment for nystagmus is mostly for infantile nystagmus. The nystagmus intensity in the primary position decreased from 22.0 +/- 15.9 degrees cycles/s preoperatively to 10.6 +/- 10.2 degrees cycles/s at 3 months postoperatively. Although the follow up period is relatively short (18.5 months average) the results are promising. However, a double-masked comparison of baclofen and gabapentin showed that neither drug produced a consistent improvement and that, in some patients, the nystagmus was made worse (16). Such changes might cause the nystagmus to increase in severity following an initial improvement. Gene therapy offers great promise for those individuals with hereditary retinal disorders that are associated with nystagmus (83). Treatment of nystagmus is controversial mainly in cases where it is combined with abnormal head position. The .gov means its official. 8600 Rockville Pike Disclaimer. WebEnter the email address you signed up with and we'll email you a reset link. FRANCIS PAREDES. 2012 Derek Sprunger, Amr Elkamshoushy, Ahmed Elmassry. 2000;15(1):53-8 Invest Ophthalmol Vis Sci. A, The nystagmus null point is in right gaze (patient maintains left face turn). All measures were taken before and 3-6 and 8 months post surgery. Get new journal Tables of Contents sent right to your email inbox, Articles in PubMed by Matthew J Thurtell, MBBS, FRACP, Articles in Google Scholar by Matthew J Thurtell, MBBS, FRACP, Other articles in this journal by Matthew J Thurtell, MBBS, FRACP, The Radiologic Characteristics and Retinal Thickness Are Correlated With Visual Field Defect in Patients With a Pituitary Mass, Peripapillary Hyper-reflective Ovoid Mass-like Structure (PHOMS): An Optical Coherence Tomography Marker of Axoplasmic Stasis in the Optic Nerve Head, Recurrent Third Nerve Palsy Secondary to Instrinsic Schwannoma of the Third Cranial Nerve, Afferent and Efferent Neuro-Ophthalmic Complications of Coronavirus Disease 19, Ocular Motor Manifestations of Multiple Sclerosis, North American Neuro-Ophthalmology Society. In this study, we have demonstrated that, at least when the head turn predominates, it is not necessary to perform surgery on the vertical or torsional muscles. In refractory acquired forms of nystagmus, electro-optical devices may negate the visual consequences of the nystagmus if individualized digital filtering of nystagmus waveforms can be achieved and the devices can be miniaturized (97). They frequently treat conditions like Peripheral Nerve Disorders, Transient Ischemic Attack (TIA) and Cerebrovascular Disease In a randomized, controlled, double-masked trial comparing the 2 medications, nystagmus intensity and visual acuity improved in both treatment groups (77). Ritesh Gupta, P Kestenbaum surgery is a common procedure to correct infantile nystagmusrelated HT and Anderson surgery is confined to bilateral yoke muscle recession; hence, less invasive but nevertheless comparably This form of nystagmus may be suppressed by alcohol (73,74) and clonazepam (75). It should be noted that inappropriate saccades, including intrusions and oscillations, may also impair vision, but treatments for these are reviewed elsewhere (1,4-6). This site needs JavaScript to work properly. One approach consists of using high-plus spectacle lenses in combination with high-minus contact lenses (92). For objects with higher spatial frequencies, such as Snellen optotypes, retinal image slip should be less than 5 degrees per second. WebFortythree patients with congenital nystagmus who underwent surgery in the Ocular Motility Clinic at The Royal Victorian Eye and Ear Hospitar Melbourne, are analysed to assess the effect of different surgical approaches on the abnormal head posture and binocular visual performance. WebIt is 20 years since J. Ringland Anderson of Melbourne and Alfred Kestenbaum of New York, independently described a surgical approach to the treatment of certain types of horizontal gaze nystagmus. The effect of bilateral horizontal rectus recession on visual acuity, ocular deviation or head posture in patients with nystagmus. This site needs JavaScript to work properly. A clear percept of an object requires that its image be held steadily within about 0.5 degrees of the center of the fovea. Compromised function of the VOR causes patients to complain of blurred vision or oscillopsia when they walk. Twelve consecutive patients older than 5 years having IIN with eccentric null position and anomalous head position were enrolled in an institution-based study. Student's t test was used for statistical analysis. For patients with a head turn of 15 or less, the Anderson procedure was used; the yoke muscles were recessed upon slow-phase. Surgical procedures for the treatment of nystagmus have mainly been developed for patients with INS. The three objectives in the surgical treatment of patients with nystagmus are: (1) to diminish the amplitude and frequency of nystagmus movements, (2) to transfer the Background: The correction of anomalous head posture associated with infantile nystagmus syndrome (INS) is carried out by the Kestenbaum procedure (KP) combining bilateral 2020 Dec;117(12):1210-1217. doi: 10.1007/s00347-020-01086-6. Contact lenses may suppress INS (86), suggesting a mechanism beyond refractive correction (discussed further in the final section of this review). WebEnter the email address you signed up with and we'll email you a reset link. The abnormal head position and all three possible components of the abnormal head position were analysed. Pre-op face turn for the 88 patients averaged 36 degrees, the post-op face turn averaged 8 degrees, with 30 degrees net change. Abstract. 2023 Mar;130(3):331-344. doi: 10.1016/j.ophtha.2022.10.006. Before M E Arroyos. If the nystagmus movement manifests a predominance of incyclorotating action they suggested weakening the superior obliques, or if there was a predominance of excycloduction action they suggest a reinforcement procedure. 2006; 10:312317. Treatments that suppress the abnormal ocular oscillations without affecting normal eye movements are therefore preferred. In 10 of the 15 patients, the suppression of nystagmus with gabapentin was substantial, and 8 patients chose to continue taking the drug. We will briefly discuss botulinum toxin and alternative methods to treat nystagmus (Table 1). Graefes Arch Clin Exp Ophthalmol. This clinical entity has also been reported as unilateral Ciancia syndrome. A prospective clinical evaluation of augmented Anderson procedure for idiopathic infantile nystagmus. [Highly dosed Anderson and Kestenbaum operations for anomalous head posture due to nystagmus]. Gas-permeable or even soft contact lenses may, however, achieve lesser degrees of image stabilization that are beneficial to the patient (94,95). The three components of the abnormal head position were improved with surgery of horizontal yoke rectus muscles only (p=0.001). This form of nystagmus usually causes visual impairment and oscillopsia, for which most affected patients seek therapy. Occasional patients with acquired nystagmus may benefit from prisms (90). Sang Cheol Yang, MD 1, Hyeshin Jeon, MD 1, 2, Hee Young Choi, MD, PhD 1, 2. Kestenbaum surgery In the early 1950s Anderson, Goto and Kestenbaum independently devised a surgical technique to move the null zone towards the primary gaze position, thus reducing any AHP present. It is unclear why surgery on the horizontal muscles alone tends to ameliorate the torsional and vertical components of abnormal head positions. Epub 2022 Nov 24. 2005 Oct;9(5):433-7. doi: 10.1016/j.jaapos.2005.05.011. The https:// ensures that you are connecting to the No patient showed more than minimal limitations of ductions during the postoperative follow up. 2021 Oct 22;33(3):330-335. doi: 10.4103/2452-2325.329065. Each patient initially had a thorough ophthalmological examination, including a dilated fundus examination. Bethesda, MD 20894, Web Policies WebSeveral surgical procedures have been advocated for IN. The .gov means its official. Waveform of infantile nystagmus. Wolters Kluwer Health Nystagmus surgery can be performed to correct horizontal head turns, vertical head turns (chin-up or chin-down Tenotomy may be performed through the skin (percutaneous tenotomy) or by to maintaining your privacy and will not share your personal information without The follow up ranged from 6 months to 84 months, averaging 18.5 months. The potassium channel blockers 3,4-diaminopyridine and 4-aminopyridine are promising for the treatment of downbeat nystagmus. Both medications have been shown to suppress downbeat nystagmus in some patients (19-22). How do they suppress nystagmus? Comments Surgical treatment of infantile nystagmus syndrome. PMC Visual acuity improved significantly with gabapentin, but not with baclofen. Arroyos ME, Fontez A, erez JFP. It became apparent that these horizontal muscle procedures alone improved the vertical and torsional components of abnormal head position. Binocul Vis Strabismus Q. High-dose Anderson operation for nystagmus-related anomalous head turn M. GrfAnja HausmannB. The Anderson-Kestenbaum procedure not only shifts and broadens the null zone, it decreases nystagmus intensity outside of the null zone, and may improve head posture (104-106). official website and that any information you provide is encrypted Extraocular muscle surgery has also been tried as a treatment for acquired nystagmus, either alone or in combination with medication therapy, sometimes with success (52,128-131). Europe PMC is an archive of life sciences journal literature. Patients whose nystagmus is suppressed by convergence may benefit from wearing spectacle prisms that require convergence for single vision of far targets (88). Prieto-Diaz and Souza-Dias do procedures on the vertical muscles only if the vertical or torsional components are severe. WebA principal aim of surgery for nystagmus, as described by both Anderson and Kestenbaum, was the elimination of the abnormal head posture by rotation of both eyes in the direction of the head turn in order to coincide the null point of the nystagmus as near as possible with the primary position of gaze. The minimum period of follow up was 6 months. Parks5 made modifications in the Kestenbaum technique and proposed that to symmetrise the horizontal ductions of the two eyes surgery should be a 5 mm recession of the medial rectus and a 8 mm resection of the lateral rectus for the eye in adduction, and 6 mm resection of the medial rectus and a 7 mm recession of the lateral rectus of the fellow eye. Would you like email updates of new search results? An augmentated Anderson procedure combined with tenotomy/re-insertion of the remaining horizontal recti appears effective at correcting a CHP in null point nystagmus. There are few clinical trials evaluating pharmacological treatments for this form of nystagmus, although 1 recent study has shown that it may be suppressed with memantine (8). WebImproved visual acuity and recognition time in nystagmus patients following four-muscle recession or Kestenbaum-Anderson procedures (PDF) Improved visual acuity and recognition time in nystagmus patients following four-muscle recession or Kestenbaum-Anderson procedures | Derek Sprunger, Amr Elkamshoushy, and Ahmed Elmassry - On the other hand, Goto4 in 1954, showed by electromyography that the muscles responsible for the fast phase of nystagmus were hypotonic and recommended they should be reinforced. The major goal of extraocular muscle surgery for nystagmus is to reduce the abnormal head turn (AHT) which is caused by an eccentric null zone of the nystagmus. Trans Am Ophthalmol Soc 71:7083 A Preliminary Study on the Outcome of Plication Augmentation of the Augmented Anderson Procedure for Patients with Infantile Nystagmus Syndrome and a Face Turn. Please enable it to take advantage of the complete set of features! government site. A second surgical approach, suitable for patients whose nystagmus suppresses with convergence, aims to diverge the eyes, thereby requiring the patient to converge during far viewing (107,108). A more recent approach is to develop an electro-optical device that measures the ocular oscillations and negates their effects (96). With recessions 13 mm, 60% (95% confidence intervals (C.I. 1997 Jun;1(2):67-82. doi: 10.1016/s1091-8531(97)90002-1. The only case in which no tilt improvement was found (patient No 10) was the result of paralysis of the IVth cranial nerve which had not been detected during the preoperative evaluation (Table 11). (The spherical correction may not be required in individuals with presbyopia.) WebRecent findings. However, a controlled trial of the oral anticholinergic agent trihexyphenidyl produced only modest improvement and side effects that were poorly tolerated (18). FOIA Ideally, these drugs should be evaluated in controlled masked trials. -, Klin Monbl Augenheilkd. Visual acuity, binocularity, and recognition time were assessed before and J Curr Ophthalmol. official website and that any information you provide is encrypted group A (n = 13) underwent four-muscle retroequatorial recession; group B (n = 8) underwent the Kestenbaum-Anderson procedure. ), 33-83%) achieved HT 10 and 93% (95% C.I. Some patients show partial suppression of their nystagmus with gabapentin (16) or memantine (Fig. However, this approach impairs all eye movements, including the VOR and vergence, so that it is only useful when the patient is stationary and viewing monocularly. Methods: Twenty-nine consecutive PMC WebImproved visual acuity and recognition time in nystagmus patients following four-muscle recession or Kestenbaum-Anderson procedures. Clipboard, Search History, and several other advanced features are temporarily unavailable. A monkey model has been produced following surgical lesions of the cerebellar nodulus and ventral uvula (27). However, other investigations have suggested that an instability in the gaze-holding mechanism (neural integrator) may be responsible (39-41). 1973;71:70-83; discussion 84-7 The effect of bilateral horizontal rectus recession on visual acuity, ocular deviation or head posture in patients with nystagmus. Improve- ment in recognition time was more significant with the 4 muscle 010 Refractive regression after pediatric excimer laser surgery recession procedure. Kestenbaum surgery is a common procedure to correct infantile nystagmus-related HT. Kestenbaum Procedure for Nystagmus. We have performed this procedure in some cases and have obtained good results. Memantine may reduce nystagmus in some patients in whom gabapentin has proven ineffective (8,9,49). sharing sensitive information, make sure youre on a federal The site is secure. MeSH Infantile nystagmus is an involuntary, bilateral, conjugate, and rhythmic oscillation of the eyes which is present at birth or develops within the first 6 6, 7, 10, 11, A preliminary study on the outcome of plication augmentation of the augmented anderson procedure for patients with infantile nystagmus syndrome and a face turn. However, its limited period of action and side effects limit its therapeutic value. Success was defined by postoperative HT 10/HT 15. In 1953, Kestenbaum2 modified the abnormal head position, recommending recession of the yoke muscles responsible for the slow phase of nystagmus and resection of their antagonists. 2021, Significant improvement in the anomalous head position was recorded in all three planes, except for two patients. Strabismus. Previously called oculopalatal myoclonus, oculopalatal tremor (OPT) usually develops in the weeks following brainstem or cerebellar strokes that interrupt projections from the deep cerebellar nuclei. Adequate convergence may be produced by a pair of 7 prism-diopter base-out prisms with 1 diopter spherical power added to compensate for the accommodation that accompanies the induced convergence (89). Focosi and Guzzinati8 described a patient with blockage position in supraversion in which they performed a 5 mm resection of both inferior rectus muscles. Nystagmus may be the only clinical manifestation of OPT. 2021 Feb 18;2(2):CD013390. 2021 Oct 22;33(3):330-335. doi: 10.4103/2452-2325.329065. Conclusion: The central movable lens is positioned by 2 voice coil motors (contained in the lower arms of the x-shaped optics package). Most of the patients had combined abnormal head positions in the three axes with predominance of the horizontal component. - Abstract - Europe PMC Europe PMC is an archive of life sciences journal literature. Residual motility was 30 (10-45). Surgical interventions for infantile nystagmus syndrome. Anderson-Kestenbaum procedure. Pediatric Ophthalmology and Strabismus Clinic, Deparment of Ophthalmology, Hospital General de Mexico, Mexico, DF. Symposium: nystagmus. Bethesda, MD 20894, Web Policies For all the above reasons, we consider it unnecessary to perform surgery on cyclovertical muscles if the head turn predominates. J AAPOS. In the following year Goto 3 These procedures aim to shift both eyes from an eccentric position The site is secure. Dr. L Roderick Anderson, MD is a neurology specialist in Tucson, AZ and has over 32 years of experience in the medical field. The importance of the He suggested that weakening them is the correct operation. Less often, botulinum toxin has been used to treat infantile or latent nystagmus (138,139). 2023 Mar;130(3):331-344. doi: 10.1016/j.ophtha.2022.10.006. The infantile form of PAN, which has a more variable cycle length, probably has a different pathogenesis and only occasionally improves with baclofen treatment (34-37). Ophthalmology. These patients often have coexisting internuclear ophthalmoparesis and impaired visual function due to optic neuropathy. Harada and Ito9 proposed a technique based on the different torsion action of the superior oblique muscle fibres. Bookshelf Six (56%) were female. An alternative approach has been to develop optical devices that negate the visual effects of the nystagmus. A Fontez. Acquired periodic alternating nystagmus improves following treatment with baclofen, and downbeat nystagmus may improve following treatment with aminopyridines. Data suggest that early surgery (for patients younger than 10 years) can have a greater beneficial effect on postoperative visual acuity. Four-muscle tenotomy surgery for nystagmus. Acupuncture to the neck muscles may suppress INS in some patients, perhaps by a similar mechanism (144,145). sharing sensitive information, make sure youre on a federal and transmitted securely. 1 Department of Ophthalmology, Pusan National University 2001 Jun;239(5):334-41. doi: 10.1007/s004170100270. The nystagmus of most patients (and the monkey model) is decreased following treatment with the GABAB agonist baclofen (29-32). Nystagmus in this disorder, which is due to a calcium channelopathy, usually responds to acetazolamide (66-68), although associated cerebellar symptoms are occasionally made worse (69). PMID: 27508887. Chang MY, Binenbaum G, Heidary G, Cavuoto KM, Morrison DG, Trivedi RH, Kim SJ, Pineles SL. R = right, L = left, E = elevation, D = depression. Ophthalmologe. B, The Anderson-Kestenbaum Bookshelf He suggested surgery in two stages: first in one eye and, after a period of stabilisation, in the second eye. Ophthalmology. This study was carried out to demonstrate that patients with abnormal head position in all three axes associated with nystagmus show improvement in the torsional and vertical components if only horizontal factors are addressed by surgical weakening of the horizontal muscles. -, Trans Am Ophthalmol Soc. Dr. Anderson works at Western Neuro in Tucson, AZ. eCollection 2021 Jul-Sep. Ophthalmologe. Aside from the need to conduct masked trials, other challenges to evaluate the effectiveness of surgical therapies for INS arise from the inherent variability of the nystagmus waveform and the complex relationship between waveform and visual acuity in any 1 individual. Careers, Unable to load your collection due to an error. Modified Anderson procedure for correcting abnormal mixed head position in nystagmus. Medians and ranges (minimum-maximum) were:. Some error has occurred while processing your request. Moreover, we suggest that if similar results can be obtained by both the Anderson and Kestenbaum procedures, the former should be chosen as it is simpler and a smaller number of muscles are operated on. -. 66-99%) achieved HT 15. WebAbstract PURPOSE To evaluate the efficacy of modified Anderson procedure in infantile nystagmus with face turn less than 30 degrees.
Why Do I Feel Unmotivated After Ejaculating,
Foldable Modular Homes,
Payments On A $6,000 Car Loan,
Lonely Planet Aosta Valley,
Studios For Rent Redlands,
Articles A
anderson procedure nystagmus
