Rinsing the tear ducts in adults. Rinsing the lacrimal canal in adults and children

Dacryocystitis – medical term, meaning when inflammatory processes the canaliculus located at the nasal septum is affected and inner corner eyes. Symptoms of inflammation occur due to obstruction of the lacrimal duct. As a result, microorganisms accumulate in it, leading to the occurrence of an inflammatory process. Let's consider what the treatment of the disease should be in children and adults.

Symptoms

Sometimes, contrary to our wishes, tears may come out while watching some heartbreaking scenes in a movie. We cry from happiness, pain, resentment, but we don’t even imagine how important it is for human body tears. Tear fluid performs the most important function moisturizing, but what to do if tears flow from only one eye, or are absent altogether? In this case, it’s time to think about treatment. Because without treatment there is obstruction nasolacrimal duct will lead to inflammation.

Symptoms of inflammation of the tear duct are usually the following:

Typically, treatment and symptoms of tear duct inflammation are observed in only one eye.

There is very strong lacrimation

In the area of ​​the inner corner of the eye, pain is felt, redness and swelling occur.

Discharge – also important signs diseases.

During diagnosis, the doctor examines the tear ducts, assesses the degree of development of the process and examines the patient for additional detection concomitant pathology.

Treatment

Depending on the patient’s age, cause and nature of the disease, individual treatment for inflammation of the lacrimal canal is prescribed. For adults, the ducts are washed with symptoms of inflammation disinfectant. If surgical treatment of inflammation is required, endoscopy is performed. This complex operation completely painless. Sometimes the operation is performed using the usual method.

Pediatric methods

Treatment and symptoms of inflammation of the lacrimal duct in children. In the case of a small child, in order to clean the tear duct, the mother is recommended to massage the area daily. tear ducts, as if squeezing out of them purulent discharge and freeing the ducts. Prescribed along with massage antibacterial drops, applying tetracycline ointment. Several times a day, the child’s eye should be washed with chamomile decoction, tea leaves, or weak solution aloe juice

Surgery carried out with complete ineffectiveness traditional therapy within a certain period. Before the operation itself, the child is prescribed antibacterial treatment in order to prevent complications during the operation, since the infection through the blood can also enter parts of the brain. The operation is performed under complete anesthesia.

If you suspect your child has symptoms of an illness, you should never try to solve the problem yourself. Any purulent processes that may result from washing the eyes at home can be life-threatening for your baby. The specialist will massage the tear duct for several days in order to break the membrane artificially. If during this time the lacrimation cannot be restored, then in order to clean the canal, you will need to carry out a bougienage procedure. During this operation, the doctor, using a very thin metal rod - bougie, will carefully cut the membrane.

If the obstruction causes symptoms of inflammation, then before receiving qualified medical assistance, you can wipe the inflamed area sterile wipe, soaked in chamomile decoction. This compress must be applied every hour.

Causes of the inflammatory process

In the area of ​​the lower eyelid, at the inner corner of the eye, there is a lacrimal punctum - a hole less than a millimeter in diameter. A tear flows down her. This mechanism is very interestingly thought out by nature: the pressure in the lacrimal sac is always negative, due to this, the eye fluid is sucked out. Through the lacrimal opening, the fluid passes into the lacrimal canal, and from there it can flow freely into the nose. Therefore, a person who cries immediately develops a runny nose, this is normal reaction with an excess of tears and proof of the excellent functioning of the tear duct.

As a rule, inflammation of the canal caused by obstruction occurs either in infants or in old age. In newborns, the cause of obstruction is the fusion of the nasolacrimal canal. The fact is that a child, while still in the womb, forms a special membrane in this canal, which must break by the time of birth. Therefore, most often, pathological lacrimal duct occurs in premature babies.

Symptoms of the disease may include:

congenital obstruction of the lacrimal duct,

damage,

infectious ophthalmological diseases and complications after such diseases.

The disease is very common in newborns. Often, inflammation is caused by the initial underdevelopment of the tear ducts or secondary infection. In any case, this problem is solved as the child grows.

Causes of inflammation in adults

In an adult, this disease most often occurs after injury, or after inflammatory disease in the nasal cavity as a complication. But in most cases, the cause of inflammation is not established.

In older people, symptoms of the disease are caused by atherosclerosis of blood vessels, in particular those responsible for tears. Insidious cholesterol can be deposited even in the openings of the lacrimal ducts, which are already tiny. In this case, the tear ducts are widened by rinsing various solutions under pressure, for example, furacilin.

The inflammatory process of the lacrimal canal also occurs in middle-aged people. The reason is a congenital abnormality. In this case, the patient usually complains that in the cold season a tear constantly runs from one eye. This is due to the fact that any person in the wind and cold experiences a spasm of the tear duct, and if it is initially narrowed, then the poor fellow simply bursts into tears.

A patient with symptoms of inflammation can protect their eyes from frost regular glasses. The fact is that under the glasses there is an almost greenhouse environment, the temperature of which is much higher than the surrounding one. It has long been noted that among bespectacled people there are practically no people with obstruction of the lacrimal canal.

Video: Treatment and symptoms of inflammation of the lacrimal duct

Obstruction of the lacrimal duct is the name of an ophthalmological disease inflammatory in nature, which is a blockage of the lacrimal canal and blood vessels in adults or children. With this pathology, there is a blockage of the lacrimal sac of the eye, which many confuse with CAS (blockage of the main channel central artery retina) is a disease that in most cases has chronic inflammation. In this case, CSA is accompanied by a sharp, sudden blindness affected eye.

Most often, obstruction of the lacrimal canal or blood vessels appears in women aged 35-60 years; in men, this disease occurs 5-6 times less often. Blockage of the tear duct in women is associated with anatomical features structure of the organs of vision.

With this disease, only one eye is affected; when the canal is blocked, the fluid cannot fully come out. If a plug is formed, the process of secretion outflow is disrupted, and active reproduction of pathogenic microorganisms begins. As a result of this process, purulent secretion begins to be produced.

Every person should have a clear idea of ​​how to cure dacryocystitis and what it is, since with this pathological process the likelihood of developing complications of a purulent-septic nature increases significantly subcutaneous tissue eyelids, as well as other areas of the visual organs.

Chronic dacryocystitis in adults is most often not independent disease, but secondary, that is, it develops against the background of another, underlying pathology. In order to understand what dacryocystitis is, it is necessary to have a clear understanding of the forms in which the ophthalmological disease can manifest itself.

At the first symptoms of the disease, you should consult a doctor so that the disease does not become chronic.

Congenital dacryocystitis of the eye can be of several types:

• The stenosing type of disease develops against the background of tuberculosis, syphilis, trachoma and some other vascular diseases.
• Qatar lacrimal ducts. This is the name of chronic catarrhal simplex dacryocystitis.
• Phlegmon of the lacrimal sac. With this form of pathology, purulent discharge from the eye canals, so you definitely need to apply for medical assistance.
• Empyema - obstruction of the lacrimal canal and blood vessels is accompanied by increased secretion purulent contents.

Canal obstruction chronic type accompanied by increased lacrimation, swelling of the lacrimal sac, and discharge of pus. If the disease occurs in acute stage, there is a danger of acquiring chronic dacryocystitis. The latter is most often accompanied by phlegmon of the lacrimal sac, increased production of purulent secretion from the canal.

There is also a type of disease known as dacryocystocele - congenital disease, which, unlike conjunctivitis, is cystic edema in the area tear ducts or nasal canal.

Causes of the disease

The causes of dacryocystitis in most cases are based on obstruction of the nasal canals, blockage of one or both lacrimal canals.

Chronic dacryocystitis in most cases develops against the background of another, underlying pathology.

Blocked tear ducts can occur for the following reasons:

• Congenital stenosis of the fetal lacrimal duct, an abnormality of the vessels or lacrimal ducts.
• Injury maxillofacial area.
• Syphilis, rhinitis, other pathologies that carry serious danger nasolacrimal duct.
• Pathological process could develop against the background of tuberculosis of the lacrimal sac.
• Purulent inflammation eyelids, which causes the development of dacryocystitis.

In some cases, obstruction is provoked various pathologies, received at the moment intrauterine development fetus

Symptoms of dacryocystitis

The main symptoms of dacryocystitis most often appear in the later stages of the disease, at initial stage It is quite difficult to determine the presence of pathology.

Most often, the patient turns to an ophthalmologist late, when the obstruction of the lacrimal duct progresses to more later stages. In this case, the main signs of dacryocystitis appear more clearly and pronounced.

Obstruction of the lacrimal duct may be accompanied by such a distinguishing symptom as swelling that appears under the lacrimal sacs. The first thing you need to pay attention to is the presence of pain in the area of ​​the tear ducts.

Swelling of the lacrimal sac indicates the development of dacryocystitis.

You can take a simple test: you need to lightly press the swelling under the eye; the appearance of purulent fluid indicates the development of pathology. A doctor will help you make sure that your tear duct is inflamed by palpating the area under your eyes and noting the thickening of the skin and an increase in its elasticity.

The symptoms of the disease are quite varied, and only an ophthalmologist can answer with confidence what it is, dacryocystitis or another disease.

Many patients confuse different ophthalmological diseases, wondering whether conjunctivitis or dacryocystitis is affecting their organs of vision. How to distinguish inflammation of the lacrimal sac from conjunctivitis? It must be remembered that with dacryocystitis, there is redness of the eyelids, their swelling, pain, and the appearance of purulent discharge when pressing on the canal area.

Diagnosis of dacryocystitis

Dacryocystitis of the eye requires careful diagnosis. IN mandatory A collarhead test is performed, which makes it possible to determine where the source of inflammation is located and at what level the patency of the lacrimal canal is maintained, as well as to differentiate dacryocystitis from conjunctivitis.

For dacryocystitis, it is mandatory to take the following tests, allowing us to identify the form of the disease and select the optimal treatment:

• Biomicroscopy of the eyes.
• Probing.
• X-ray of the organs of vision.
• Sowing of the secreted secretion.
• Nasolacrimal duct test.

Diagnosis is the key to a speedy recovery.

Comprehensive diagnostics will help you choose the most effective treatment.

Treatment options for tear duct obstruction

Treatment of dacryocystitis in adults is most often carried out using two methods - medicinal and surgical. Drug treatment consists of instilling special antibacterial and anti-inflammatory drops into the eyes.

Dacryocystitis in adults can be treated at home, based on the recommendations given by your doctor. the main objective treatment - normalization of the lacrimal canal. Besides eye drops lotions with Ofloxacin, Levofloxacin, Tetracycline will help cure obstruction of the lacrimal canal, which allows you to defeat dacryocystitis faster.

Doctors say that those patients whose purulent fluid continues to come out for 2-3 weeks require surgery.

For a disease such as dacryocystitis, treatment is carried out by forming a completely new lacrimal canal, bougienage, probing or rinsing with certain medications.

On active stage diseases it is prohibited to vaccinate. It is especially important to pay attention to the timing of vaccinations in children. younger age and newborns. Any vaccine is an intervention in the body that can cause the most unexpected reaction. In case of inflammatory processes, in particular, with obstruction of the lacrimal canal, vaccination should be abandoned for a while.

From funds traditional medicine effective aids can be dill, chamomile, tea, mint compress, which must be combined with drug treatment.

We must not forget about massage, which helps to quickly defeat the disease. It is better to find out how to do it correctly from an ophthalmologist. However, we will still describe the principle of its implementation. 10 times needed index fingers, pressing firmly or with vibrating movements, go down the line from the beginning of the eyebrows to the wings of the nose. You need to move your fingers in the opposite direction 11 times. If pus comes out during the massage, then you did everything correctly, and purulent discharge should be removed with cotton pads soaked in a decoction of herbs or furatsilin. If you left clear liquid, it should also be removed. It is necessary to perform the massage until the eye has completely healed, that is, until full recovery.

Jul 13, 2017 Anastasia Tabalina

Dacryocystitis is an inflammation of the nasolacrimal duct. Obstruction of the lacrimal duct in newborns is immediate cause dacryocystitis. The disease is curable and responds quite well to conservative therapy. Severe blockage of the nasolacrimal ducts in infants is a reason for surgical treatment.

Causes of dacryocystitis

Dacryocystitis in newborns is always congenital. The cause of this pathology is considered to be blockage of the nasolacrimal duct by a thin membrane. Normally, the membrane is maintained throughout the fetal development and breaks through with the baby’s first breath. In 5% of children, the membrane persists after birth, which leads to the formation of obstruction of the lacrimal canal.
Risk factors for developing dacryocystitis:

• congenital narrowness of the nasal passages;
• abnormalities in the development of the nasal passages and turbinates;
• incorrect placement of the teeth of the upper jaw;
• facial trauma during childbirth.

Whatever the reason for the development of dacryocystitis, the result is the same. The nasolacrimal duct becomes obstructed, and tears begin to accumulate in the inner corner of the eye. Stagnation of tears creates optimal conditions for the development of bacteria. Inflammation occurs, leading to the appearance of all the main symptoms of the disease.

With obstruction of the nasolacrimal duct and formed dacryocystitis, the following symptoms occur:

• standing tears in the inner corner of the eye;
• lacrimation;
• redness of the mucous membrane of the eye;
• swelling of the eyelids;
• discharge of pus when pressing on the lacrimal sac in the corner of the eye.

Eye damage can be unilateral or bilateral. IN the latter case obstruction of the lacrimal canal is often confused with ordinary conjunctivitis. A doctor will be able to distinguish one disease from another during a personal meeting with the patient.

Contact an ophthalmologist when the first symptoms of dacryocystitis appear!

For uncomplicated dacryocystitis general state the child is not impaired. Stagnation of tears does not prevent the baby from contacting the outside world and does not cause much concern. The child sleeps well, eats and develops in accordance with his age.

Complications

Over a long period of time, obstruction of the nasolacrimal duct can lead to the development of complications:

• phlegmon of the lacrimal sac;
• purulent corneal ulcer;
• infectious brain lesion.

Phlegmon of the lacrimal sac appears pronounced edema in the area of ​​the inner corner of the eye. The lower eyelid turns red and swells, the baby becomes restless, often cries, and refuses to eat. Possible increase in body temperature.

The phlegmon inevitably breaks open sooner or later, and the pus comes out. This condition is quite favorable, because in this case the entire contents of the phlegmon will be outside the eye. It is much worse if the phlegmon opens inward, and pus gets into the orbit and cranial cavity. This complication is life-threatening for the child and requires immediate assistance from a specialist.

Treatment tactics

If you have dacryocystitis in an infant, you should consult a doctor as soon as possible. If the baby's nasolacrimal duct is clogged, the child needs the help of an ophthalmologist. The sooner the diagnosis is made and treatment begins, the greater the baby’s chances of avoiding the development of complications.

Conservative therapy

Massage of the lacrimal canal in newborns - the basis conservative treatment with dacryocystitis. The massage is carried out every 2-3 hours with cleanly washed hands.

When carrying out the procedure, you must adhere to some rules.

1. Place the baby on his back or side and support his head.
2. Press your little finger on the lacrimal sac.
3. Make several massaging movements at the inner corner of the eye. Imagine that you are drawing a comma and move from the corner of the eye towards the nose. Press the tear sac firmly but gently so as not to damage the baby's thin skin.
4. Repeat the procedure at least 5 times.

The massage is considered effective if after the procedure a few drops of pus are released from the baby’s eyes. Any discharge that appears should be carefully collected with a cotton pad soaked in a solution of furatsilin or boiled water.

Simultaneously with the massage, they are prescribed antibacterial drugs in the form of drops. The medicine is instilled into the eye immediately after massage of the lacrimal sac. The duration of treatment is at least 2 weeks.

What should not be done with dacryocystitis?

• Put breast milk in your eyes.
• Wash your baby's eyes with tea.
• Use antibiotics without a doctor's prescription.

Any of these actions can lead to additional infection and worsen the child's condition.

How can you help your baby? Rinse the eyes with furatsilin solution, remove crusts after sleep and make sure that the child’s eyelashes do not stick together from pus. Careful care behind the area around the eyes will help avoid secondary infection and the development of complications.

Surgery

Probing of the lacrimal canal in newborns is carried out if conservative therapy turned out to be ineffective. For 2 weeks, parents are encouraged to massage their child regularly. If during this time the baby’s condition has not improved, the nasolacrimal duct is washed.

Probing is performed under local anesthesia. During the procedure, the doctor inserts a thin probe into the nasolacrimal duct and breaks the membrane. Next, a antiseptic solution. After the procedure, antibacterial drops and massage of the lacrimal sac, already known to parents, are prescribed.

Lacrimal canal lavage is performed at the age of 2-6 months. In some cases, more than one procedure may be required before the problem is completely eliminated. In the interval between probing, massage and instillation of antibacterial solutions continue.

After the baby reaches six months, the membrane film becomes overgrown and probing becomes ineffective. In such a situation, a full-fledged operation under general anesthesia. For abnormal development of the nasolacrimal duct surgical intervention carried out at the age of 5-6 years.

Dacryocystitis refers to infectious disease accompanied by inflammatory processes. At the same time they are amazed tear ducts and bags. The risk group includes people aged 30 to 60 years. Surprisingly, it is the female half of humanity that is most susceptible to the development of pathology. This is due to the fact that the nasolacrimal ducts of the fair sex are slightly narrower than those of men. Dacryocystitis in adults is most often observed in only one eye and much less often in two at the same time. The main cause of the pathology is blockage of the tear duct, as a result of which tear fluid cannot come out. When the outflow is disrupted, they actively reproduce pathogens, resulting in the formation of purulent fluid.

A person needs tears for protection. visual organ from infection and penetration of foreign bodies. Without tears, the eyes dry out and begin to become inflamed. Dacryocystitis occurs not only in adulthood, but also in newborns. In this case, it develops due to obstruction or significant narrowing of the channels responsible for the secretion of tears. The obstruction occurs due to the presence of gelatin plugs or membranes that should have dissolved before birth. While inside the mother's womb, the fetus forms a kind of film that does not allow intrauterine fluid to penetrate the respiratory tract. When a child is born, he immediately does deep breath, causing the film to rupture. If this does not happen, dacryocystitis occurs, that is, congestion. And they can lead to infection eyeball.

Symptoms of dacryocystitis

The main symptom of the disease is uncontrolled lacrimation and discharge of purulent fluid. And if you press on the lacrimal sac, the pus is instantly released. It should also be noted the swelling of the lacrimal sac, swelling and pain syndrome. If treatment is not promptly treated, the infection spreads to the cornea and other elements. eye organ, and this is fraught with the development of ulcers. Upon palpation, a compaction under the skin is subsequently noted, which has some specific elasticity.

How to correctly diagnose pathology

First of all, you need to contact an ophthalmologist and tell him about the date of initial manifestations. That is, when exactly lacrimation appeared and pus began to be released. Next, the doctor visually examines the affected eye and takes a sample of purulent fluid to determine the etiology of the occurrence. Moreover, the doctor takes a sample from both the lacrimal canal and the nasal canal. To clarify the diagnosis, contrast radiography and other instrumental research methods are performed.

Treatment of dacryocystitis

Treatment of dacryocystitis in adults is carried out using a similar method, but with the difference that other drugs are used. That is, more strong antibiotics(for example, Ciprofloxacin, Levomycetin, etc.) and anti-inflammatory drugs (Dexamethasone). When drug therapy does not provide positive result, the ophthalmologist prescribes surgery. Today there are several methods for opening the tear duct:

1. The method of bougienage and rinsing of the lacrimal canal restores the natural outflow of tears through the canals.
2. Dacryocystorhinostomy allows you to form new way or restore the old one between the lacrimal sac and the nasal cavity. The operation is safe. Quite often used for severe suppuration and abscesses. In this case, the ulcer is opened and drained, after which it is washed with special solutions.

How to do a massage correctly

IMPORTANT! To learn the rules of massaging the lacrimal sac, you must first undergo training with your doctor. Massage for dacryocystitis is carried out with light movements and always washed and disinfected hands. You can use special liquid products for this. antiseptic in nature. Remember that a new infection can enter through the canal!

Before massaging, be sure to cleanse your eyes of purulent substance using Furacilin solution. To prepare it, you need to take water and tablets of the same name in a 1:1 ratio, that is, for 1 glass of water you will need 1 tablet. Remember that the eyes are always washed from outer corners visual organ to internal ones. For washing and cleaning, you can use chamomile decoction or not strong tea. Now you can proceed directly to the massage. To do this, use your index fingers to find the bump in the inner corner of the eye. It is always located at the base of the nose. Place your finger so that the pad is on the bridge of the nose, and the side of the finger is on the tubercle. Now begin to lightly press on this tubercle, since this is where the film is located that closes the lumen of the canal. Then you need to press on the bridge of your nose, going down. At the very bottom, loosen your fingers, but do not lift them from skin. Next, lift your finger up in the same way as you lowered it. Return to the tubercle. About 10 such movements are needed. This may cause purulent fluid to be squeezed out. If this happens, be sure to wipe it with Furacilin.

In contact with

If a person is blocked tear ducts, then the normal outflow of tear fluid is disrupted, the eyes constantly water, and an infection develops.

About 20% of newborn babies have this condition, but the tear ducts usually clear by the end of the first year of life.

In adults, a blocked tear duct can occur as a result of infection, inflammation, injury, or tumor. This disease is almost always curable, but treatment depends on the age of the patient and the specific cause of the disease.

Causes of the disease

Causes of tear duct obstruction include:

Congenital obstruction. Some children drainage system may be underdeveloped. Often the tear duct becomes blocked with a thin mucus plug. This defect may disappear on its own in the first months of life, but may require a special procedure - bougienage (probing).

Abnormal development of the skull and face. The presence of abnormalities such as those found in Down syndrome increases the risk of tear duct obstruction.

Age-related changes. Older people may experience age-related changes associated with narrowing of the openings of the lacrimal canals.

Infections and inflammation of the eyes. Chronic inflammation eyes, nose and tear ducts leads to obstruction.

Facial injuries. When a facial injury occurs, the bones near the tear ducts can be damaged, which disrupts normal drainage.

Tumors of the nose, lacrimal sac, bones, when significantly enlarged, sometimes block the lacrimal canals.

Cysts and stones. Sometimes cysts and stones form within this complex drainage system, causing drainage problems.

External medications. IN in rare cases Using eye drops (for example, to treat glaucoma) may cause blockage of the tear ducts.

Internal medicines. Obstruction is one of the possible side effects the drug docetaxel (Taxoret), used to treat breast or lung cancer.

Risk factors

Age and gender. Older women are more likely to suffer from this disease as a result of age-related changes.

Chronic inflammation of the eyes. If your eyes are constantly irritated and inflamed (conjunctivitis), there is an increased risk.

Surgeries are a thing of the past. Surgeries on the eye, eyelid, or nasal sinuses can cause scarring in the drainage system of the eye.

Glaucoma. Glaucoma medications sometimes cause tear duct obstruction.

Cancer treatment in the past. If a person has had facial exposure or taken certain antitumor drugs, the risk increases.

Symptoms of tear duct obstruction

Signs of this disease may be due to direct blockage of the canals or an infection that develops as a result of the blockage:

Excess tear fluid (wet eyes).
. Frequent inflammations eyes (conjunctivitis).
. Inflammation of the lacrimal sac (dacryocystitis).
. Painful swelling in the inner corner of the eye.
. Mucous or purulent discharge from the eye.
. Blood in tear fluid.
. Blurred vision.

Diagnosis of the disease

Fluorescent dye test. The test is done to check how well the eye's drainage system is working. A drop of a special solution with a dye is dropped into the patient’s eyes. If after a few minutes with normal blinking a large number of dye remains on the eye, then there is a problem in the outflow system.

Probing the lacrimal canal. The doctor may use a special thin instrument to probe the canal to check its patency. During the procedure, the canal expands, and if the problem existed before the procedure, it may simply be resolved.

Dacryocystography or dacryoscintigraphy. This test is designed to obtain images of the ocular outflow system. Before the examination, it is instilled into the eye contrast agent, after which an x-ray, computed tomography or magnetic resonance imaging is performed. The dye highlights the tear ducts in the pictures.

Treatment of tear duct obstruction

If an infection is suspected, your doctor will likely prescribe antibiotics.

If the tumor has caused the obstruction, treatment will focus on controlling the tumor. To do this, the tumor is usually removed surgically.

Conservative treatment

Minimally invasive treatment

Surgery

Surgeries are necessary to reconstruct damaged or underdeveloped tear ducts. One of the operations - dacryocystorhinostomy - consists of creating a new passage between the nasal cavity and lacrimal sac. Such operations are quite complex and are performed under general anesthesia.

After surgery, patients will need to take medications for some time. The doctor may prescribe a nasal spray to relieve swelling of the mucous membrane, as well as eye drops to prevent infection and reduce post-operative inflammation.

Complications of the disease

In infants, the main sign of obstruction of the tear ducts is suppuration (“sourness”) of one or both eyes. The doctor immediately prescribes antibiotic drops, the condition improves, but after stopping treatment, the infection reappears.

Disease prevention

Konstantin Mokanov