Anisocoria. Variation and clinical observation with different conditions of illumination and accommodation

Variations in anisocoria in light and dark conditions are used to help diagnose normal and pathologic conditions; however, there have been few observations of anisocoria in different lighting and accommodative conditions. The authors measured pupil size photographically in a group of normal subjects examined in six conditions that were controlled for illumination and accommodation. Greater variation and average extent of anisocoria were found in conditions that resulted in larger pupil size. A subset of subjects repeated several sessions. For this group, the average value of anisocoria and variability tended to be greater in dark conditions. These results show that the observation of anisocoria varies under different conditions, and they suggest careful consideration of conditions used clinically to assess pupil equality. Our analysis shows that for a given observation threshold, conditions that produce even modest changes in variability can cause dramatic changes in the probability of observing anisocoria.

Changes in refractive error for exotropes treated with overminus lenses

The refractive changes of pediatric patients who were prescribed overminus lenses for exotropia were evaluated. Overminus lenses means additional minus power over the lenses required to correct the refractive error at distance. Forty exotropic patients, ages 1 to 15 years, were prescribed overminus lenses (-0.50 D to -3.75 D) for a period of 9 to 86 months. A small but significant correlation was found between the initial refractive error and the mean annual change toward myopia. Other factors such as age when treatment was given, duration of therapy, amount of overminus, and the amount of the exodeviation had little effect on the rate of myopic change. The mean annual changes in refractive error for hyperopes (-0.13 +/- 0.44 D, N = 15), emmetropes (-0.26 +/- 0.37 D, N = 17), and myopes (-0.75 +/- 0.77 D, N = 18) were similar to values reported in the literature for nonexotropic children.

Monovision correction for diplopia

Acquired, incomitant strabismus frequently results in diplopia. Affected patients complain of chronic annoyance and frustration with the false image. Therapy has usually been aimed at either re-establishing binocularity by using prisms or vision training, or by eliminating one image through occlusion. An alternative approach is to allow each eye its own "domain," one eye corrected for distance vision and the other for near vision. This alternative may eliminate the competitive, unfusible images and yet maintain visual function in each eye.

Sensory fusion disruption syndrome

Unlike the typical manifestation of acquired strabismus, patients with sensory fusion disruption syndrome are unable to fuse targets even when bifoveally aligned under ideal clinical conditions. This condition usually follows trauma and a period of coma. These patients suffer from chronic diplopia which is not relieved by optical or surgical means. Recognition of this entity may result in more effectual management. As a phenomenon, it serves as a potential clue to physiological composition of binocularity.

Analysis of binocular visual function using tests made under binocular conditions

Accommodation and vergence have a complex relation which occasionally breaks down, resulting in a loss of visual efficiency along with symptoms of discomfort associated with use of the eyes. Studies of accommodation/vergence interactions and tonic vergence disorders indicate that, using classical analysis techniques, separate methods are frequently necessary to determine whether existing binocular deficiencies are causing reported symptoms. The problem with current systems of binocular visual function analysis is that the vergence error which exists under binocular conditions is often not the same as that which is measured under monocular conditions. A rationale for, and technique of, analyzing binocular function using results of tests made under binocular conditions is described. This analysis incorporates the concepts of CA/C, proximal vergence (PV), and fixation disparity along with several accommodative measures (facility, lag, sustaining ability, and accuracy). By identifying relevant binocular components and the interrelations, the clinician should be better able to assess the contribution of each and examine which may be modified most easily by vision therapy, lenses, and/or prism intervention.

Interexaminer reliability of the optic cup to disc ratio assessment

Previous controlled reliability studies of cup to disc (C/D) ratio estimations may have been biased by lack of criteria for cup determination, small sample size; and/or large interval grouping of collected data. In our study four examiners independently estimated the C/D ratios of 40 patients by direct ophthalmoscopy using a contour criterion for cup determination. Results indicated that 75% of the estimate pairs differed by 0.10 or less. Fewer than 14% of the estimate pairs differed by 0.2 or greater. The results of the study suggest that when examiners use a specified criterion of contour cupping, interexaminer assessment of the C/D ratio estimation is clinically and statistically reliable.

Urinary tract involvement in EEC syndrome

A patient with fully expressed, sporadic ectrodactyly, ectodermal dysplasia, and cleft lip and/or palate (EEC) syndrome with renal involvement is presented; descriptions of four similar patients were found in the literature. Based on these patients, we suggest that the renal involvement is a form of dysplasia secondary to fetal urinary tract obstruction. We emphasize the importance of searching for a urinary tract anomaly in patients with this uncommon syndrome.

Pseudomembranous colitis following low dose trimethoprim-sulfamethoxazole

A 94-year-old man had pseudomembranous colitis while taking low dose trimethoprim-sulfamethoxazole for recurrent urinary tract infection. The suppressive effect of low dose trimethoprim-sulfamethoxazole on normal colonic flora appeared to be a factor in the development of pseudomembranous colitis in this patient.

Soft bifocal contact lenses for patients with nearpoint asthenopia

Bifocal contact lenses have generally been considered solely for the presbyopic population. However, pre-presbyopic individuals with accommodative or vergence disorders who respond favorably to plus lenses at near may be good candidates for bifocal contact lenses. A group of ten non-presbyopic patients who manifest accommodative dysfunctions or near point esophoria were fit with the Ciba BI-SOFT contact lenses. Nearpoint accommodative and vergence findings were evaluated through both near point plus spectacle lenses and the bifocal soft lenses. Results indicate that the BI-SOFT bifocal contact lens was effective in changing the near point visual posture. However, poor distance vision acuity due to ghost images reduced the subjective success rate of the BI-SOFT lens on this non-presbyopic population.

Unilateral absence of a pulmonary artery

Congenital absence of a main pulmonary artery is a rare anomaly. Most patients without associated congenital cardiac abnormalities are asymptomatic, and the diagnosis is first suggested by the appearance of the involved lung on a routine chest roentgenogram. The ipsilateral lung will be smaller than normal, and the contralateral lung will be overinflated and may herniate across the midline. We describe eight children with unilateral pulmonary arterial atresia (seven on the right side, four of whom were without associated cardiac anomalies).

Regulation of intracellular chloride activity during perfusion with hypertonic solutions in the Necturus proximal tubule

In a previous study we presented evidence that chloride transport across the basolateral membrane in Necturus proximal tubule cells occurs predominantly via exchange for both Na+ and HCO3-. In this study the regulation of intracellular chloride was further examined in the doubly-perfused kidney preparation using conventional and chloride-sensitive microelectrodes. Application of hypertonic basolateral solutions containing 80 mM raffinose stimulated an efflux of chloride such that chloride activity remained unchanged at control levels. Membrane potential did not change in these experiments. Inhibition of Cl- exit across the basolateral cell membrane by removal of either HCO3- or Na+ from the perfusion solution resulted in a significant increase in intracellular chloride activity, aiCl, when basolateral osmolarity was raised. Hypertonic basolateral solutions also produced a significant rise in aiCl in the presence of SITS. This study provides further evidence that chloride is transported across the basolateral cell membrane in exchange for both Na+ and HCO3-. Since this exchange mechanism is activated in response to hypertonic solutions, these studies suggest a functional role for this exchanger in the regulation of aiCl in the Necturus proximal tubule cell during volume changes.

Chloride transport across the basolateral cell membrane of the Necturus proximal tubule: dependence on bicarbonate and sodium

The transport of chloride across the Necturus proximal tubule cell was studied in the doubly-perfused kidney using conventional, chloride-sensitive and pH-sensitive microelectrodes. Lowering chloride activity in the basolateral solution results in a reduction in intracellular Cl- activity (aiCl). This reduction in aiCl is inhibited by removing either HCO-3 or Na+ from the perfusion solution, indicating that both HCO-3 and Na+ are required for Cl- movement across the basolateral cell membrane. Reducing either HCO-3 or Na+ in the basolateral solution causes an increase in aiCl. Thus changes in either Na+ or HCO-3 chemical gradients across the basolateral cell membrane significantly affect chloride movement. Changing intracellular pH by means of NH4Cl exposure results in an increase in aiCl followed by a sharp decrease when NH4Cl is removed. These changes in intracellular chloride do not occur in the absence of HCO-3. Likewise, the decrease in aiCl following NH4Cl treatment requires the presence of Na+ in the basolateral solution. We conclude that chloride is transported across the basolateral cell membrane in exchange for both Na+ and HCO-3. Our results also support the presence of a Na+/Cl- cotransport mechanism on the apical cell membrane.

Serum unconjugated estriol concentrations before and after the oxytocin challenge test: an index of fetal well-being

Serum unconjugated estriol concentrations before and after the oxytocin challenge test (stress test) were measured in 54 high-risk, obstetric patients. Six of the stress test results were positive, and eight were equivocal. Eleven patients demonstrated decrements in estriol of greater than or equal to 25% after stress tests, and the infants of six of these patients demonstrated perinatal morbidity. Three patients exhibited positive stress test results but had estriol concentrations which were unaltered by the stress test; all were delivered vaginally of healthy infants shortly after the stress test. The coefficient of correlation between the stress test and perinatal outcome was 0.58 (P less than 0.001). When the estriol and stress test results were combined to predict outcome, a multiple correlation coefficient of 0.71 was obtained (P less than 0.001). This increment represents a significant (P less than 0.001) and substantial (18%) improvement in the prediction of perinatal outcome. These findings indicate that the measurement of changes in estriol with the stress test significantly improves one's ability to define the fetus at risk.

Role of cholecystokinin in the gastrocolonic response to a fat meal

The fat component of the meal is the major stimulant of the gastrocolonic response. The aim of this study was to characterize the mechanism of the gastrocolonic response after eating fat in healthy human volunteers. A bipolar clip electrode recorded spike activity (SP) from the distal colon. An immediate increase in colonic spike activity occurred after eating a fat meal (18.0 +/- 3.0 SP/30 min) (p less than 0.02). Spike activity remained elevated for 90 min after eating the fat meal (18.6 +/- 2.7 SP/30 min) (p less than 0.01). The intravenous infusion of naloxone or atropine inhibited the fat-induced increase in colonic motility. Cholecystokinin is a candidate mediator of the fat-stimulated gastrocolonic response. The intravenous infusion of the octapeptide of cholecystokinin (20 ng/kg . h) stimulated an increase in distal colonic spike activity (16.0 +/- 3.7 SP/30 min) (p less than 0.025). Intravenous atropine did not affect stimulation of colonic motility by the octapeptide of cholecystokinin. Continuous infusion of naloxone, however, did inhibit stimulation of colonic spike activity by the octapeptide of cholecystokinin. There was no cross-reactivity between opiate or muscarinic receptors. These data suggest (a) fat stimulation of the gastro-colonic response required a muscarinic and opiate receptor, and (b) octapeptide of cholecystokinin can stimulate colonic motility, but it is not the major mediator of the gastrocolonic response.

Episiotomy pain: efficacy and safety of fluproquazone compared to aspirin and placebo

The analgesic efficacy of fluproquazone at 100 mg and 200 mg doses, was measured in 160 patients with episiotomy pain and was compared to that of aspirin (650 mg) and placebo. The 100-mg dose of fluproquazone was more effective in relieving episiotomy pain than the 200-mg dose of fluproquazone, aspirin or placebo in terms of mean pain intensity scores after 1 h. All active compounds were more effective than placebo by all criteria.

Relationship between fixation disparity curves and symptoms in monofixators

Patients with small angle strabismus usually are asymptomatic. Occasionally, however, binocular asthenopic symptoms are reported. Two monofixators, one symptomatic and the other asymptomatic, with similar profiles on strabismic evaluation had forced vergence Fixation Disparity Curves (FDC) measured. Slope of the FDC may help to discriminate between the symptomatic and asymptomatic patient.

Congenital esotropia--a documented case report

Criteria for defining congenital esotropia and its cure are related to a documented case history. A congenitally esotropic child had strabismus surgery at age 13 months. At 11 years of age the had 20 delta of left exotropia. One year of vision training enabled her to achieve some stereopsis but she retained a small angle asotropia whenever the controlled her exophoric tendency.

Optokinetic nystagmus: a review of pathways, techniques and selected diagnostic applications

There are a myriad of conditions producing abnormal OKN responses. In most of these conditions the diagnosis can be made without recourse to OKN. However, in the five conditions described in this paper (suspected poor visual acuity in infants and young children, parietal lesions, subclinical internuclear ophthalmoplegia, Parinaud's syndrome, and aberrant regeneration of the third nerve) OKN can greatly facilitate the diagnosis. A review of the neural pathways of the OKN response and an explanation of the various equipment and techniques used to assess OKN are included.

Changes in angle lambda during growth: theory and clinical applications

The eye undergoes rapid growth during the first years of life. Using a mathematical model, we analyzed angle lambda from birth through adult life to determine what change in its magnitude occurs with growth of the eye. The effect of changes in angle lambda on measurement and correction of astigmatic errors and on the analysis of fixation patterns are discussed.

An evaluation of the monocular estimate method of dynamic retinoscopy

Monocular Estimate Method (MEM) dynamic retinoscopy is an objective clinical method for determining the accommodative response to a fixed accommodative stimulus. Although MEM has been used in many clinical investigations, it has never been compared with the measurement of accommodative response by the haploscope. This report compares the accommodative responses obtained by MEM and by a haploscopic instrument, the phoroaccommodometer. Linear regression analysis indicates that MEM consistently provides a close approximation to the phoroaccommodometer finding (r = 0.975, p less than 0.001). A conversion table has been generated so MEM findings may be adjusted to correspond with the phoroaccommodometer at higher stimulus values.

Serum hormones and lipoproteins in benign breast disease

Seventeen young women with clinically confirmed mammary dysplasia and six age-matched controls were treated with alpha-tocopherol. Serum samples collected during the luteal phase of each woman at monthly intervals for the 4-month duration of the study were analyzed for serum luteinizing hormone, follicle-stimulating hormone, and prolactin concentrations by radioimmunoassay and for lipoprotein levels by a combination of precipitation, ultracentrifugation, and enzymatic techniques. Fifteen patients showed objective and subjective remission from disease. While prolactin levels did not change significantly, elevated levels of luteinizing and follicle-stimulating hormones were decreased to normal levels. Ratios of serum cholesterol to high-density lipoprotein cholesterol decreased; high-density lipoprotein and free cholesterol associated with low-density lipoproteins increased as a result of therapy. The results suggest that alpha-tocopherol may serve as an effective agent not only to treat patients with benign breast disease but also to normalize abnormal hormone and lipid levels in subjects at high risk for breast cancer.

Problem orientation in vision therapy

Quantification and retrieval of data in vision therapy is a difficult task for both the private practitioner and optometric educator. The problem-oriented record provides an organizational approach that readily identifies patient's problems, therapeutic objectives, and the results of administered therapy. A minimum data base and the resultant problem list for vision therapy has been designed by us. By combining these two through a system of coding, a ready computer data retrieval system was devised. This system provides a method to clearly define terms, objectives, and results. Utilization of this record system by optometric schools and practitioners should reduce much of the confusion existing in the specialty field of vision therapy.

alpha-Tocopherol and serum lipoproteins

Twenty-six patients with clinically confirmed mammary dysplasia and five age-matched controls were treated with alpha-tocopherol, 600 mg/day. Serum samples collected on the 21st day of the menstrual cycle were analyzed for cholesterol in lipoprotein fractions, isolated by a combination of precipitation and ultracentrifugation techniques. Eighty-five percent of patients showed objective and subjective remission from disease following therapy. In mammary dysplasia patients, the ratio of serum cholesterol/high density lipoprotein cholesterol was higher than those in age-matched controls, an abnormality which was corrected by alpha-tocopherol therapy. Furthermore, as a result of therapy, high density lipoproteins increased and ester cholesterol associated with low density lipoproteins decreased. The results suggest that alpha-tocopherol may serve as an effective agent in treating patients with benign disease, as well as correct the inherent abnormality in serum cholesterol distribution in mammary dysplasia patients.

The Hirschberg test: analysis from birth to age 5

The theoretical conversion factor for the Hirschberg test was calculated from birth to age 5. This result, 1 mm = 19.5, delta remains essentially constant from birth.

Fetal acceleration determinations and perinatal outcome

The importance of a laboratory test, especially when used as a screening procedure, is its ability to accurately provide information which can be used in the clinical management of patients. The fetal acceleration determination (FAD) has been utilized by many clinical obstetric services to assess the fetus at risk and to avoid the cumbersome and expensive oxytocin challenge test (OCT). In an effort to determine the usefulness of this modality in assessing the high-risk obstetric patient, a retrospective study of FADs was performed on 264 patients. All the tests were performed within one week of delivery. Fetal outcome was measured by Apgar scores, fetal morbidity and mortality and length of nursery stay. Chi square row by column contingency analysis was performed, and Bayes theorem was applied to our data to predict FAD specificity. The probability of false-positive and false-negative tests was high, and no correlation with outcome was observed. Analysis of these data indicates that the FAD is of limited value in identifying the fetus at risk.

Reliability of stress thallium-201 scanning in the clinical evaluation of coronary artery disease

Stress thallium-201 scanning proved to be a highly sensitive and specific screening procedure for myocardial ischemia in 52 consecutive cases with coronary arteriograms. Stress thallium-201 scanning was considerably more accurate and more specific than the exercise electrocardiogram (ECG) as evidenced by a sensitivity of 83% compared to 55%, and a specificity of 94% compared to 82%. When submaximal stress tests were excluded, improved sensitivity of thallium scan to exercise ECG was 95% to 64% with no change in specificity. Factors producing negative thallium scans in the presence of coronary artery disease were: delay in obtaining the first post-exercise scan, positioning and observing variability, severe three-vessel disease uniformly affecting all myocardial segments, and failure to achieve maximal stress testing due to attenuation of the heart-rate response by propranolol or somatic complaints.

A prospective evaluation of placental lactogen as a test for neonatal risk

This study evaluates the usefulness of maternal serum concentrations of human placental lactogen in the management of high-risk pregnancies. The study was performed in a community hospital over a year's time and involved 250 gestations. The test detected only 11.4% of the pregnancies defined as high-risk by clinical criteria and none of the pregnancies in which the newborn was compromised. Serum human placental lactogen is an insensitive test in predicting the outcome of pregnancies in an obstetric population unless historical information regarding maternal disease is unavailable.

Educational intervention for preschool children in a pediatric clinic

A parent education program aimed at promoting cognitive development in 2- and 3-year-olds was instituted in both a pediatric clinic of a general hospital and a child health station in the community. Parent participants were asked to work at home daily with their children using age-graded play materials supplied by the program. They were tutored individually, in the clinic playroom, by bilingual playroom assistants using role-playing techniques. One hundred fifty children completed the program out of a total of 468. Subjects were tested before and after training on the Cattell: Stanford-Binet and showed a positive gain in performance. Parents reported that their program experiences made them aware of their ability to teach their children. This was reflected in their changing view of the children's activities which were previously seen as aimless and "bad" and were now viewed as constructive and amenable to modification by the parents.

Mid-trimester abortion with intra-amniotic prostaglandin F2 alpha and intravenous oxytocin infusion

Induction of abortion in mid-trimester pregnancies were performed on 26 patients. The first 12 patients were treated by intra-amniotic instillation of Prostaglandin F2 alpha, with a mean dosage of 40.2 mg. and mean abortion time of 24 hours and 41 minutes (ten patients). Fourteen additional mid-trimester abortions were performed using identical protocol plus the addition of oxytocin by intravenous infusion two hours after injection of the prostaglandin. All patients aborted, with mean dosage of PGF2 alpha of 28.2 mg. and mean abortion time of 15 hours and 37 minutes.

Role of parasympathetic inhibition in the hyperkinetic type of borderline hypertension

Eleven patients with borderline hypertension and high cardiac output were compared to 16 paid healthy volunteers. Cardiac output, heart rate, and intraarterial blood pressure were determined at rest, after administration of 0.2 mg/kg of propranolol i.v., and after administration of an additional 0.04 mg/kg of atropine. In four additional patients, response to infusion of isoproterenol before and after administration of 0.2 mg/kg of propranolol i.v. was evaluated. Resting heart rate and cardiac output in patients with borderline hypertension were elevated. After propranolol infusion, the values decreased more in the patients with borderline hypertension, but remained significantly elevated. After atropine administration, the difference in cardiac output and heart rate between the two groups disappeared. Consequently, patients with borderline hypertension and hyperkinetic circulation simultaneously exhibit an increase of sympathetic and a decrease of parasympathetic tone.