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Yoo YJ, Hwang JM, Yang HK. Dilute pilocarpine test for diagnosis of Adie's tonic pupil. Sci Rep 2021; 11:10089. [PMID: 33980910 PMCID: PMC8115311 DOI: 10.1038/s41598-021-89148-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 04/12/2021] [Indexed: 11/08/2022] Open
Abstract
We have compared the diagnostic ability of different concentrations of 0.125% and 0.0625% dilute pilocarpine for detecting denervation supersensitivity in unilateral Adie's tonic pupil. This retrospective, observational, case-control study involved 117 subjects, consisting of 56 patients with unilateral Adie's tonic pupil and 61 controls with other causes of unilateral dilated pupils. Subjects underwent the dilute pilocarpine test with one of the two concentrations, 0.125% or 0.0625%. Pupillary light reflex was recorded with a dynamic pupillometer at baseline and at 30-40 min after instilling one of the two concentrations of dilute pilocarpine. Diagnostic accuracy of two different concentrations of the dilute pilocarpine test, 0.125% group versus 0.0625% group, were compared by area under the receiver operating characteristic curve (AUC). Diagnostic ability of the dilute pilocarpine test for detecting denervation supersensitivity in unilateral Adie's tonic pupil was significantly better in the 0.0625% group than in the 0.125% group (AUC = 0.954 vs. 0.840, respectively, P = 0.047). In the 0.0625% group, the change in maximal pupil diameter of ≥ 0.5 mm after topical pilocarpine instillation showed 100% sensitivity and 82.8% specificity for detecting Adie's tonic pupil. This study confirmed that pupillary constriction with 0.0625% pilocarpine is better than 0.125% pilocarpine for detecting denervation supersensitivity in Adie's tonic pupil. Digital pupillometry is a reliable method for assessing denervation supersensitivity in Adie's tonic pupil.
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Affiliation(s)
- Yung-Ju Yoo
- Department of Ophthalmology, Kangwon National University Graduate School of Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Jeong-Min Hwang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, Korea
| | - Hee Kyung Yang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, Korea.
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Hamzianpour N, Lam R, Tetas R, Beltran E. Clinical signs, imaging findings, and outcome in twelve cats with internal ophthalmoparesis/ophthalmoplegia. Vet Ophthalmol 2017; 21:382-390. [PMID: 29284192 DOI: 10.1111/vop.12523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To retrospectively evaluate the clinical signs, imaging findings, and outcome of feline internal ophthalmoparesis/ophthalmoplegia. PROCEDURE Medical records were reviewed from 2008 to 2015. Inclusion criteria included cats that presented with internal ophthalmoparesis/ophthalmoplegia, underwent diagnostic imaging, and had follow-up information available. RESULTS Twelve cases of feline internal ophthalmoparesis/ophthalmoplegia were identified. Nine cats were unilaterally affected, and three cats were bilaterally affected. Affected cats had a median age of 10.54 years (range 5.75 to 13.17), and both sexes of varying breeds were affected (nine males; three females). Clinical signs including abnormal mental status (n = 9; 75%) and additional neurologic abnormalities (n = 10; 83%) were observed. Magnetic resonance imaging and/or computed tomography (MRI/CT) of the head were performed in ten cats, revealing a mass lesion in all cases with varying locations. Multicentric lymphoma was diagnosed in two cats via abdominal ultrasound and cytology. All twelve cats were euthanized due to deterioration of clinical signs and/or quality-of-life concerns. Median time from diagnosis to euthanasia was 3.5 days (range 0 to 80 days). CONCLUSIONS Feline internal ophthalmoparesis/ophthalmoplegia rarely presents as the sole clinical sign in a referral hospital. Advanced imaging (MRI/CT) may be necessary to reach a definitive diagnosis in these cases. However, abdominal ultrasound would be advocated in cats with systemic clinical signs as a less expensive and less invasive diagnostic test to further investigate the possible etiology of internal ophthalmoparesis/ophthalmoplegia prior to advanced imaging. Feline cases with internal ophthalmoparesis/ophthalmoplegia associated with other intracranial signs and/or systemic clinical signs have a poor prognosis.
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Affiliation(s)
- Negar Hamzianpour
- Department of Clinical Science and Services, Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, AL9 7TA, Hatfield, UK
| | - Richard Lam
- Department of Clinical Science and Services, Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, AL9 7TA, Hatfield, UK
| | - Roser Tetas
- Department of Clinical Science and Services, Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, AL9 7TA, Hatfield, UK
| | - Elsa Beltran
- Department of Clinical Science and Services, Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, AL9 7TA, Hatfield, UK
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Lee HJ, Lee JY, Um TW, Lim HT, Ahn HS. Clinical Features of Adie's Tonic Pupil: A Retrospective and Cross-Sectional Study. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2013. [DOI: 10.3341/jkos.2013.54.5.777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Hye Jin Lee
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Young Lee
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Woong Um
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Taek Lim
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyo Sook Ahn
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Werner M, Bhatti MT, Vaishnav H, Pincus DW, Eskin T, Yachnis AT. Isolated anisocoria from an endodermal cyst of the third cranial nerve mimicking an Adie's tonic pupil. J Pediatr Ophthalmol Strabismus 2005; 42:176-9. [PMID: 15977871 DOI: 10.3928/01913913-20050501-06] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We present only the second reported case in the literature of a neuroenteric cyst involving the third cranial nerve. Our case is highlighted by the initial presentation of an isolated anisocoria, initially believed to represent an Adie's tonic pupil as interpreted by pharmacologic testing. False-positive results may occur with the dilute pilocarpine test.
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Affiliation(s)
- Mark Werner
- Department of Ophthalmology, University of Florida College of Medicine, Box 100284 JHMHSC, Gainesville, FL 32610-0284, USA
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Abstract
PURPOSE This review emphasizes the importance of neuro-ophthalmological signs and symptoms in sarcoidosis. The presence of ophthalmological and neuro-ophthalmological findings may lead to diagnosis of the disease and the initiation of adequate treatment. MATERIAL AND METHODS Patients who had been diagnosed with neurosarcoidosis during the period 1990 - 2001 were identified from the departmental diagnostic index. The history, clinical, laboratory and imaging data of patients were analysed. RESULTS Fifteen patients were identified, four men and 11 women, with a mean age of 44.1 years (range 26-65 years). In six of the 15 (40%), neurological deficits were the initial symptoms. Nine (60%) had known sarcoidosis at the time of presentation. Ten patients (66%) had ophthalmological/neuro-ophthalmological symptoms and signs. CONCLUSION Neuro-ophthalmological symptoms may develop early in neurosarcoidosis. If neuro-ophthalmological symptoms arise in patients with established biopsy-proven sarcoidosis, the diagnosis is usually easy to make. However, a number of patients with neurosarcoidosis may present with neuro-ophthalmic symptoms before systemic involvement becomes obvious. In this situation the diagnosis is challenging, and the major goal is to establish the presence of systemic sarcoidosis.
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Affiliation(s)
- Kjell Heuser
- Department of Neurology, Rikshospitalet, University of Oslo, Oslo, Norway.
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Granholm E, Morris S, Galasko D, Shults C, Rogers E, Vukov B. Tropicamide effects on pupil size and pupillary light reflexes in Alzheimer's and Parkinson's disease. Int J Psychophysiol 2003; 47:95-115. [PMID: 12568941 DOI: 10.1016/s0167-8760(02)00122-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Diagnostic tests for Alzheimer's disease (AD) involving tropicamide blockade of cholinergic oculomotor functions were examined in AD patients (n=15), Parkinson's disease (PD) patients (n=15), and non-clinical control (NC) participants (n=15). Pupillographic methods were used to measure pupil diameter and pupillary light reflexes after double-blind ocular administration of dilute tropicamide (0.01%) in one eye and saline in the other eye. Changes in pupil size were measured in bright background light and near-darkness. Tropicamide increased pupil diameter to a similar extent in all three groups in light and darkness. Tropicamide also reduced the amplitude and latency of the pupillary light reflex to a similar extent for all three groups. Tropicamide pupillary response tests, therefore, were not sensitive or specific diagnostic tests for AD. Peak constriction amplitude of the pupillary light reflex was significantly reduced in both eyes in AD and PD groups relative to non-clinical controls, but AD and PD groups did not differ significantly. The pupillary light reflex test, therefore, was sensitive to AD, but lacked adequate specificity. Finally, peak constriction amplitude correlated significantly with dementia severity and donepezil treatment may have partially normalized pupillary light reflex abnormalities in AD patients. The pupillary light reflex test, therefore, may index central cholinergic dysfunction associated with disease progression and improvement in cholinergic function associated with pharmacologic treatment response in AD.
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Affiliation(s)
- Eric Granholm
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
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Leavitt JA, Wayman LL, Hodge DO, Brubaker RF. Pupillary response to four concentrations of pilocarpine in normal subjects: application to testing for Adie tonic pupil. Am J Ophthalmol 2002; 133:333-6. [PMID: 11860969 DOI: 10.1016/s0002-9394(01)01420-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE To determine the amount of pupillary constriction to four different concentrations of pilocarpine in normal human subjects and to determine if pupillary constriction correlates with bioavailability of the instilled concentrations. The amount of pupillary constriction to dilute pilocarpine is utilized as a diagnostic test for Adie tonic pupil as distinguished from a normal pupil response. DESIGN Twenty healthy volunteers had automated binocular infrared pupillography in the dark after instillation of four different concentrations of dilute pilocarpine. Ocular penetration of eye drops was also assessed using 2% fluorescein sodium as a tracer. METHODS Prospective institutional double-masked study of both eyes of twenty healthy volunteers, ten with brown irides, ten with blue irides, between the ages of 20-40 years. RESULTS A pilocarpine dose-dependent curve showed decreased pupil size within 15 minutes, peaking at 30-60 minutes. No difference was noted between right and left eyes, iris color, or corneal permeability. CONCLUSIONS Normal pupils constrict to dilute concentrations of pilocarpine (0.25% or 0.125%), but constrict insignificantly to concentrations of 0.0313% or 0.0625%. Pupil constriction with 0.0625% pilocarpine should distinguish an Adie pupil from normal. This confirms the utility of this simple office diagnostic procedure.
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Abstract
Significant contributions on the neuroophthalmologic manifestations of systemic disease have been published in the past year. The first part of this paper is devoted to practical guidelines that may help in the diagnosis and the management of oculomotor disorders, especially in connection with systemic diseases; the second part is focused on specific entities. Including idiopathic intracranial hypertension and ophthalmoplegic migraine in this review might be debatable; however, although the cause of these conditions is still unclear, relevant findings suggest that they may be the consequence of other adjacent processes rather than the cause itself. We believe that the diagnosis of idiopathic intracranial hypertension as well as that of ophthalmoplegic migraine remains a challenging issue for the ophthalmologist and may easily be overlooked.
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Affiliation(s)
- M Spiritus
- Department of Ophthalmology, Université Catholique de Louvain, Brussels, Belgium.
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Sternberg TL, Cuddy BG, Walker A. Pilocarpine Should Not Be Used to Diagnose Postoperative Anisocoria. Anesth Analg 1997. [DOI: 10.1213/00000539-199704000-00050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sternberg TL, Cuddy BG, Walker A. Pilocarpine should not be used to diagnose postoperative anisocoria. Anesth Analg 1997; 84:939. [PMID: 9085992 DOI: 10.1097/00000539-199704000-00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Saito H, Onodera J. Parasympathetic and sympathetic pupillary involvement in inflammatory parasellar lesions. Neuroophthalmology 1997. [DOI: 10.3109/01658109709044659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sitzman BT, Bogdonoff DL, Bleck TP, Spiekermann BF, Chang CW. Postoperative anisocoria: neurogenic or phenylephrine induced? A rapid diagnostic test. Anesth Analg 1996; 83:633-5. [PMID: 8780295 DOI: 10.1097/00000539-199609000-00035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- B T Sitzman
- Department of Anesthesiology, University of Virginia Health Sciences Center, Charlottesville, USA
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Abstract
PURPOSE To describe the clinical features of the syndrome of neurologically isolated episodic unilateral mydriasis. METHODS Information was obtained by reviewing the case records of 24 patients evaluated by the author and collected by polling other neuro-ophthalmologists. RESULTS Nineteen patients were women. The median age was 31 years. Fourteen patients had migraines. The median interval between onset of events and evaluation was 6 months. The median duration and frequency of events were 12 hours and two to three per month, respectively. Most patients did not identify any factor that could precipitate an occurrence. The most common associated symptoms during an episode included visual blur in 15 patients, headache in 9, and orbital pain in 5. Eleven patients were examined during an attack. Three patients who were examined had impaired near vision, four had impaired accommodative function, and six had an anisocoria that increased with added ambient light. None of these patients had a tonic pupil or cholinergic agonist-induced pharmacologic mydriasis. Five other patients examined during an attack had normal vision and unimpaired direct light reactivity of their large pupil. No neurologic disorder was identified after neurodiagnostic testing, clinical evaluation, and natural history observation. CONCLUSIONS The syndrome of idiopathic episodic unilateral mydriasis probably comprises a heterogeneous group of conditions that result in parasympathetic insufficiency of the iris sphincter in some patients, and sympathetic hyperactivity of the iris dilator in others. Patients with episodes similar in characteristics to the ones described in this survey appear to have a benign neurologic prognosis, and do not require further neurodiagnostic studies.
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Affiliation(s)
- D M Jacobson
- Department of Neurology, Marshfield Clinic, Wisconsin 54449, USA
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Jacobson DM. A prospective evaluation of cholinergic supersensitivity of the iris sphincter in patients with oculomotor nerve palsies. Am J Ophthalmol 1994; 118:377-83. [PMID: 8085595 DOI: 10.1016/s0002-9394(14)72963-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
To evaluate the frequency and clinical correlates of preganglionic cholinergic supersensitivity of the iris sphincter, I prospectively tested 31 consecutive outpatients with oculomotor nerve palsies by comparing their pupil diameters in darkness before and 30 minutes after topical application of pilocarpine 0.1%. Supersensitive pupil responses were observed in the involved eye in five of 11 patients with compressive palsies, four of five patients with traumatic palsies, in the two patients with congenital palsies, and in none of the patients with ischemic palsies. Supersensitivity was statistically significantly associated with pupil involvement but not with aberrant regeneration of the extraocular muscles or pupil. The degree of supersensitivity was directly correlated with the amount of baseline anisocoria. These results establish that cholinergic supersensitivity of the pupil occurs frequently with nonischemic oculomotor nerve palsies and may be related to the degree of preganglionic injury to the pupillomotor fibers.
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Affiliation(s)
- D M Jacobson
- Department of Neurology, Marshfield Clinic, Wisconsin 54449
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