Does anisocoria by clonidine reflect a central sympathetic dysfunction in cluster headache?

Static anisocoria in cats and dogs with naturally occurring tick paralysis (Ixodes holocyclus)

OBJECTIVE

To characterise the novel occurrence and neuro-ophthalmological features of static anisocoria in cats and dogs with tick paralysis (TP) (Ixodes holocyclus) due to a single tick located remote from the head and neck.

DESIGN

Observational case series with retrospective analysis.

METHODS

Medical records were reviewed from 69 cats and 169 dogs treated for TP from a suburban veterinary hospital in Newcastle, New South Whales, between September 2005 and October 2021.

RESULTS

Anisocoria was observed in 2/18 (11.1%) cats and 3/30 (10.0%) dogs with a single tick located remote from the head and neck. These proportions were not different when compared within species to 4 of 28 (14.3%) cats and 16 of 98 (16.3%) dogs with aniscocoria with a single tick located on the head and neck region (P = 1 and 0.56 respectively). Anisocoria arose from pupillary efferent dysfunction and included unilateral oculoparasympathetic dysfunction (internal ophthalmoplegia) in one dog, unilateral oculosympathetic dysfunction (Horner's syndrome) in one cat and one dog, and a combination of bilateral, but asymmetric, oculosympathetic and oculoparasympathetic dysfunction in one cat and one dog.

CONCLUSION

It is proposed that anisocoria in cases of TP with a tick located remote from the head and neck is due to an intrinsic latent asymmetry in the safety factor for pupillary efferent function that is unmasked by a systemically distributed holocyclotoxin inhibiting neural transmission within this system, and this is the prevailing pathomechanism, rather than a direct local effect, underscoring anisocoria with a tick located on the head or neck.

Comparison of the effects of clonidine and yohimbine on pupillary diameter at different illumination levels

AIMS

To evaluate the pupillary effects of single doses of the alpha2-adrenoceptor agonist clonidine and the alpha2-adrenoceptor antagonist yohimbine under several illumination conditions.

METHODS

Sixteen healthy male volunteers received clonidine 0.2 mg, yohimbine 22 mg, clonidine 0.2 mg + yohimbine 22 mg in a double-blind placebo-controlled, cross-over study. 2 h post drug ingestion pupil diameter was recorded in darkness, and at luminance levels of 6 Cd m-2, 91 Cd m-2 and 360 Cd m-2. The effects of the active treatments on pupil diameter were also expressed as the differences from the placebo condition ('placebo-corrected' data; mean [95% CI]).

RESULTS

Clonidine had little effect on pupil diameter in darkness; however, it caused a significant, light-dependent, miosis when the eye was illuminated. On the other hand yohimbine increased pupil size; this increase was significant at 91 and 360 Cd m-2. There were no significant differences between the effects of the combined treatment (clonidine 0.2 mg + yohimbine 22 mg) and the effect of placebo.

CONCLUSIONS

The pupillary effects of clonidine and yohimbine are likely to reflect the interaction of these drugs with inhibitory alpha2-adrenoceptors located on central noradrenergic neurones, which in turn would lead to a decrease and an increase, respectively, in sympathetic outflow to the iris. The light dependence of the pupillary effects of these drugs, however, suggests that the parasympathetic light reflex pathway is also involved, which is known to be under inhibitory control from the central noradrenergic neurones. Modulation of parasympathetic outflow seems to play an important role since both drugs had relatively little effect on pupil diameter in darkness when sympathetic activity predominates.

The effects of clonidine on the fear-inhibited light reflex

We have shown previously that pupil diameter increases and the amplitude of the pupillary light reflex is reduced when subjects are under threat of an aversive event (electric shock), and that light reflex amplitude correlates negatively with subjective anxiety. Furthermore, we have shown that the threat-induced reduction in light reflex amplitude is sensitive to the effect of the anxiolytic drug diazepam. We have suggested that the 'fear-inhibited light reflex' paradigm could be used as a laboratory model of human anxiety. In the present study, we examined whether a single oral dose (200 microg) of the sedative-sympatholytic drug clonidine would antagonize the effects of threat on the pupillary light reflex. Twelve healthy male volunteers participated in two sessions separated by seven days in which they ingested clonidine 200 mg or placebo in a double-blind, balanced, cross-over design. Light stimuli (0.43 mW/cm2, 200 msec) were generated by a green (peak wavelength 565 nm) light-emitting diode, and pupil diameter was monitored by computerized binocular infrared television pupillometry in the dark. The light reflex response was recorded during either the anticipation of a shock ('threat' blocks) or periods in which no shocks were anticipated ('safe' blocks). The shock was a single square wave current pulse (1.5 mA, 50 msec) applied to the median nerve at the end of the experiment. Following each 'threat' or 'safe' block, subjects rated their anxiety using visual analogue scales. Two-factor ANOVA (treatment x condition) showed that clonidine treatment antagonized both the threat-induced increase in pupil diameter and the threat-induced reduction in light reflex amplitude. These effects, however, were not threat-specific since clonidine also reduced pupil diameter and enhanced light reflex amplitude in the 'safe' condition. Clonidine also reduced subjective alertness but not subjective anxiety in the 'threat' condition. These findings suggest that the mutual antagonism between clonidine and threat is likely to reflect the opposite effects of the two variables on the central noradrenergic control of pupillary functions, rather than a specific anxiolytic effect.

Serotonin metabolism in cluster headache

Despite some evidence of the involvement of the serotonergic system in cluster headache (CH) pathophysiology, the serotonin (5HT) metabolism has so far been poorly studied. The aim of this study was to investigate plasma and platelet levels of 5HT and 5-hydroxyindoleacetic acid (5HIAA) in CH patients in the active period of the disease. Nineteen CH sufferers and 17 sex- and age-matched healthy controls were studied. CH patients showed significantly higher plasma levels of 5HT and 5HIAA compared to controls (5HT: 5.7+/-6.1 ng/ml vs 0.2+/-0.2 ng/ml; p=0.02; 5HIAA: 34.7+/-46.1 ng/ml vs 0.6+/-0.7 ng/ml; p=0.004). In platelet 5HT levels were slightly reduced in CH patients in comparison with those of control subjects (662.4+/-522.3 ng/10(-8) platelets vs 832.4+/-587.9 ng/10(-8) platelets; n.s.) and 5HIAA levels resulted significantly lower in CH sufferers than in control subjects (3.2+/-2.6 ng/10(-8) platelets vs 6.7+/-4.8 ng/10(-8) platelets; p=0.04). Our data suggest that CH is characterized by an increase of plasma serotonergic metabolism that could reflect an involvement of the central serotonergic system in the pathogenesis of CH.

Affinity of the miotic drug, dapiprazole, at alpha 1-adrenoceptor subtypes A, B and D

The functional affinities of the alpha 1-adrenoceptor antagonist, dapiprazole, currently being used to reverse diagnostic pupillary dilation, were determined at subtype A in rat vas deferens, at subtype B in guinea-pig spleen and at subtype D in rat aorta and compared with various alpha 1-adrenoceptor subtype-discriminating antagonists. Dapiprazole had relatively high affinity both at rat vas deferens alpha 1A-adrenoceptors (pA2 = 7.93) and at rat aortic alpha 1D-adrenoceptors (pA2 = 8.26), whereas its affinity at guinea-pig splenic alpha 1B-adrenoceptors (pA2 = 7.13) was lower. The reference antagonists, 5-methylurapidil and the 5-methylurapidil/flesinoxan hybrid, B8805-033 ((+/-)- 1,3,5-trimethyl-6[[3[4(2(2,3-dihydro-2-hydroxymethyl)-1,4-benzodioxin -5-yl)-1-piperazinyl]propyl]-amino]2,4(1H,3H)-pyrimidinedione), were 40- and 1500-fold selective for the A subtype, whereas spiperone and BMY 7378 (8-[2-[4-(2-methoxyphenyl)-1- piperazinyl]ethyl]-8-azaspiro[4,5]decane-7,9-dione diHCI) were confirmed as selective for the B and D subtypes of alpha 1-adrenoceptors, respectively. Thus, in functional experiments dapiprazole seems to be moderately selective (approximately 10-fold) for the A and D over the B subtype of alpha 1-adrenoceptors; the possible therapeutic consequence of this is discussed.