Leukocoria Due to Persistent Hyperplastic Primary Vitreous

This case report discusses a diagnosis of persistent hyperplastic primary vitreous presenting as leukocoria in a boy aged 50 days.

Comparison of cycloplegia with atropine 1% versus cyclopentolate 1

PURPOSE

Cycloplegic refraction is mandatory for children to know the eye's refractive status. In this study, we compared cycloplegia induced by cyclopentolate 1% to that induced by atropine 1% by means of retinoscopy.

METHODS

In this parallel-designed interventional study, we included 67 children aged between 4 and 17 years. After the initial retinoscopy under cyclopentolate 1% (used twice in each eye), we repeated it a week later under atropine ointment 1% (used twice a day for 3 days); both were done by the same trained optometrist masked to the drug. Each eye's refraction was converted to spherical equivalents (SEs), and the values averaged between the two eyes of each child under each drug. We compared SE with paired t-test (JASP 16.4). In addition, we performed correlational analysis, and looked for agreement using the Bland-Altman plot. Significance was set at P < 0.05. Wherever possible, 95% confidence intervals (CIs) are quoted.

RESULTS

The mean SE with atropine was +1.93 ± 2.0 D, compared to +1.75 ± 1.95 D under cyclopentolate. On average, atropine induced greater cycloplegia by a mere 0.18 D (95% CI: 0.07 to 0.29 D, P value 0.002). The two cycloplegic refractions correlated significantly (Pearson's r: 0.975, P < 0.001). The Bland-Altman plot revealed the limits of agreement as 1.06 and -0.71 D.

CONCLUSION

Our study suggests that cyclopentolate works for the most part as well as atropine to attain cycloplegia. Atropine may be considered for children less than 15 years of age with greater than 5.0 D of hyperopia. Cycloplentolate, with its advantages of quick action and short duration, should form the first go-to topical cycloplegic in busy outpatient clinics.

Ocular Manifestations in Head and Neck Cancer: A Cross-Sectional Study from a Tertiary Care Centre from South India

Introduction: Head and neck cancers (HNCs) present a significant global health burden, especially in India, where oral cavity cancers, notably affecting the tongue, are prevalent. A substantial portion of global HNCs (57.5%) is concentrated in Asia, India contributing with 30%. Despite advancements, challenges persist due to HNCs' invasive nature and metastatic potential. This study aims to explore the link between HNCs and ocular manifestations. Methods: A cross-sectional study was conducted at Bangalore Medical College and Research Institute involving 47 patients with diagnosed HNCs and ocular complaints. Clinical evaluations encompassed visual acuity, anterior and posterior segment examinations, and specialized investigations when necessary. Results: A diverse range of malignancies were observed, with SCC maxilla and xeroderma pigmentosa, each accounting for 10.63% of cases. Ocular examinations unveiled visual acuity challenges, anterior segment findings like masses, exotropia, pigmented lesions, and varied fundus abnormalities. The anterior segment findings encompassed masses often accompanied by protrusion or relative afferent pupillary defect (RAPD). Additionally, exotropia, pigmented lesions, and other conditions were observed. Fundus examination revealed a spectrum of findings, including media haziness (10.63%), lack of view (17.02%), and pale discs (6.38%). Treatment plans were diverse, including excision biopsies (42.55%), exenteration procedures, Mitomycin-C applications, and referrals for chemotherapy and radiotherapy. Conclusion: The present study underscores the significance of ophthalmological assessment and investigations in patients with diagnosed HNCs, emphasizing the value of early detection and intervention. Abbreviations: HNC = Head and Neck Cancer, OCT = Optical Coherence Tomography, WNL = Within Normal Limits, SCC = Squamous Cell Carcinoma, MRI = Magnetic Resonance Imaging, CT = Computed Tomography, RAPD = Relative Afferent Pupillary Defect, XP = Xeroderma Pigmentosa.

Changes in Anterior Segment Parameters After Laser Peripheral Iridotomy in Caucasian Eyes With Different Primary Angle Closure Mechanisms

PRCIS

Subgrouping of angle closure mechanisms based on the swept-source optical coherence tomography images may help to identify the predominant underlying anatomic mechanism, evaluate personal treatment, and improve the better outcomes.

PURPOSE

The purpose of this study was to evaluate changes in anterior segment parameters in Caucasian eyes with different angle closure mechanisms before and after laser peripheral iridotomy (LPI).

METHODS

Sixty-six subjects underwent swept-source optical coherence tomography (CASIA, Tomey Corporation) angle imaging in the dark before and 7 days after LPI. On the basis of the baseline swept-source optical coherence tomography images, the eyes were categorized into 4 angle closure mechanisms, namely pupillary block (PB), plateau iris configuration (PIC), thick peripheral iris (TPI), and large lens vault (LLV). Sixteen out of 128 cross-sectional images (11.25 degrees apart) per volume scan were selected for analysis. We used a generalized estimating equation to compare quantitative parameters among angle closure mechanisms and between before and after LPI after adjusting the intereye correlation.

RESULTS

The mean age of subjects was 67.7±9.2 years, with the majority being female (82.2%). One hundred twenty-nine eyes (67 primary angle closure suspects, 34 primary angle closure, and 28 primary angle closure glaucoma) were categorized into PB (n=71, 55%), PIC (n=40, 31%), TPI (n=14, 10.9%), and LLV (n=4, 3.1%). Anterior chamber depth was the shallowest in the LLV, followed by TPI, PB, and PIC group at baseline. Widening of the angle and reduction of the iris curvature (IC) due to LPI were observed in all groups (all P <0.01). When compared to the PB group, the LPI-induced angle widening in the TPI group was significantly less even though the iris curvature reduction in the TPI group was greater (all P <0.05).

CONCLUSIONS

In patients with angle closure, anterior segment morphology and LPI-induced angle widening were different among the various angle closure mechanisms.

Ross syndrome with chronic cough and RF positivity: a case report

Ross syndrome is a rare disorder of unknown etiology, characterized by the triad of segmental anhidrosis, tonic pupil, and areflexia/hyporeflexia. Ross syndrome is thought to be a limited and selective ganglioneuropathy. Its etiology has not been fully elucidated. Autonomic findings may also accompany. We wanted to present our 25-year-old patient who was diagnosed with Ross syndrome and presented with complaints of inability to sweat, heat intolerance, headache, diarrhea and chronic cough. Keyword: cough, tonic pupil, anhidrosis, compensatory.

Comparability of the Retinomax K-plus 3 handheld autorefractometer in quick mode versus on-table autorefractometer in standard mode

INTRODUCTION

This study analyzes the comparability of measurements taken by a Retinomax K-plus 3 handheld autorefractometer in Quick mode and a Topcon KR-800 on-table autorefractometer in standard mode on the pediatric population, and establishes their correlation.

METHODS

It is a retrospective comparative study. Spherical diopter power (SPH), cylindrical diopter power (CYL), angle of cylindrical axis (AX), and spherical equivalent (SE) were measured with the Retinomax in Quick mode and with the Topcon in standard mode. Each patient was evaluated in cycloplegic and non-cycloplegic conditions by both autorefractometers. Student's t-test was performed between the two instruments for SPH, CYL, and SE. The Pearson correlation coefficient was calculated and the dispersion was represented using Bland-Altman graphs, also evaluating the subgroup of patients under 4 years of age. A descriptive analysis of the percentages of measures that differed was performed.

RESULTS

It included 98 eyes of 49 subjects (age range: 3-16 years). The data for HPS without cycloplegia are virtually identical, whereas with cycloplegia there is a hyperopic bias of +0.5 diopters measured with Retinomax. CYL results are very similar with and without cycloplegia. There is a high Pearson correlation for both instruments (>0.91) and a low degree of dispersion in the Bland-Altman plots under cycloplegia.

CONCLUSION

The Retinomax data were consistent with those obtained by Topcon. The Retinomax is a useful instrument for detecting refractive errors in children between 3 and 16 years of age.

Clinical and imaging characteristics, outcomes and prognostic factors of intraocular foreign bodies extracted by vitrectomy

To investigate the clinical and computer tomography (CT) features and visual prognostic factors of pars plana vitrectomy (PPV) for management of retained posterior segment intraocular foreign body (IOFB). Medical records of 96 patients with IOFB removed by PPV between July 2017 and June 2021 were retrieved. The medical records, including demographic data, initial and final best corrected visual acuity (BCVA) using standard Snellen chart, characteristics of IOFB, CT findings, and surgical details, were reviewed. Outcome was evaluated according to the final BCVA and prognostic factors were obtained. The mean age was 42.31 ± 12.05 years (range 13-71 years) with 94 males (97.9%) and two females (2.1%). CT was sensitive of IOFB in 93.75% (90 eyes) and the locations were consistent with that found during PPV: 20 foreign bodies were located in vitreous, 6 near ciliary body, and 70 on or in retina. Mean diameter of IOFB removed by PPV is 3.52 mm ± 3.01 mm (range 1-22; median 3), and mean area is 6.29 ± 6.48 mm2 (range 0.5-40; median 3), which was statistically associated with the initial VA < 0.1 and endophthalmitis. Endophthalmitis was found in 24 (25.0%) eyes and large wound together with scleral entry site might be related to the endophthalmitis. Visual outcome < 0.1 was associated with relative afferent pupillary defect, initial VA < 0.1, and presence of endophthalmitis. Initial VA ≥ 0.1 was independent predictive factor for a better final BCVA. Relative afferent pupillary defect, initial BCVA < 0.1, and presence of endophthalmitis are poor visual prognostic factors.

[Angle closure-glaucoma]

Angle-closure glaucoma is a less common form of glaucoma in Europe than open-angle glaucoma. Nevertheless, the clinical picture should also be known here since it can lead to severe visual disturbances and even blindness within a short time. It is divided into primary and secondary forms and can be further categorized depending on the presence of a pupillary block. In all cases, therapy is initially based on resolving the cause of the angle-closure and treating any underlying disease that may be present. In addition, intraocular pressure reduction must be achieved. This can be effectuated conservatively or surgically. Depending on the specific subtype of angle-closure, different treatments are promising.

Qualitative ultrasound biomicroscopy in glaucoma

Background

UBM is a high-resolution ultrasound technique which allows non-invasive, in vivo imaging of the anterior segment and iridocorneal angle.

Purpose

This video is compilation of short video clips and images which gives description on identification of angle closure due to pupillary block, peripheral anterior synechiae, iris bombe, plateau iris, supra ciliary effusion, and malignant glaucoma. It also shows video demonstrating partially and fully patent iridotomy and features of trabeculectomy bleb. Synopsis: This video summarizes importance of UBM application in angle closure glaucoma to understand its pathophysiology by showing the relationship between the peripheral iris, trabecular meshwork and ciliary processes.

Highlights

UBM provides two-dimensional, grayscale images of the angle structures and allows identification of non-pupillary block mechanism in angle closure glaucoma, which can be recorded for qualitative and quantitative analyses.

Video Link

https://youtu.be/prsmGnR8jYc.

Detection of Relative Afferent Pupillary Defects Using Eye Tracking and a VR Headset

Purpose

The purpose of this study was to assess the feasibility of detecting relative afferent pupillary defects (RAPDs) using a commercial virtual reality headset equipped with an eye tracker.

Methods

This is a cross-sectional study in which we compare the new computerized RAPD test with the traditional clinical standard using the swinging flashlight test. Eighty-two participants including 20 healthy volunteers aged 10 to 88 years were enrolled in this study. We present a bright/dark stimulus alternating between the eyes every 3 seconds using a virtual reality headset, and we simultaneously record changes in pupil size. To determine the presence of an RAPD, we developed an algorithm analyzing the pupil size differences. For the assessment of the performance of the automated and the manual measurement a post hoc impression based on all available data is created. The accuracy of the manual clinical evaluation and the computerized method is compared using confusion matrices and the gold standard of the post hoc impression. The latter is based on all available clinical information.

Results

We found that the computerized method detected RAPD with a sensitivity of 90.2% and an accuracy of 84.4%, as compared to the post hoc impression. This was not significantly different from the clinical evaluation with a sensitivity of 89.1% and an accuracy of 88.3%.

Conclusions

The presented method offers an accurate, easy to use, and fast method to measure an RAPD. In contrast to today's clinical practice, the measures are quantitative and objective.

Translational Relevance

Computerized testing of Relative Afferent Pupillary Defects (RAPD) using a VR-headset and eye-tracking reaches non-inferior performance compared with senior neuro-ophthalmologists.

The yield of neuroimaging in patients presenting to the emergency department with isolated neuro-ophthalmological complaints: A retrospective chart review

Neuro-ophthalmological emergencies require prompt assessment and management to avoid vision or life-threatening sequelae. The decision to perform a neuroimaging procedure is based on the clinical judgment of the medical team, without defined indications. This study aims to identify presenting symptoms and physical exam findings associated with relative positive findings on neuroimaging studies. Electronic medical records of patients presenting to the emergency department (ED) with isolated neuro-ophthalmologic complaints between January 1, 2013 and September 30, 2019 were reviewed. We collected data on the clinical presentation, neuroimaging procedures and results, consults, and diagnoses. Two hundred eleven patients' charts were reviewed. Most presented with unilateral eye complaints (53.6%), and the most common symptoms were blurred vision (77.3%) and headaches (42.2%). A total of 126 imaging procedures were performed of which 74.6% were normal, while 25.4% showed relevant abnormal findings. Complaining of blurry vision (P = .038) or visual field changes (P = .014) at presentation as well as having a visual field defect (P = .016), abnormal pupil reactivity (P = .028), afferent pupillary defect (P = .018), or abnormal optic disc exam (P = .009) were associated with positive findings on imaging. Neuroimaging is more likely to yield positive findings in patients presenting to the ED with visual field irregularities, afferent pupillary defects, or abnormal optic discs. These findings - when combined with the proper clinical setting - should lower the threshold to proceed with neuroimaging in the emergency department. Based on our results, larger-scale studies might lead to a well-structured algorithm to be followed by ED physicians in decision making.

Correlation between clinical presentations, radiological findings and high risk histopathological features of primary enucleated eyes with advanced retinoblastoma at Queen Sirikit National Institute of Child Health: 5 years result

Purpose

To evaluate the correlation between clinical presentations, radiological findings and high risk histopathological features of primary enucleated eyes in patients with advanced retinoblastoma at a tertiary child hospital in Thailand.

Materials and methods

We retrospectively reviewed the medical records of patients who were treated with primary enucleation of tumor eyes between 2015–2020. Demographic data, radiological assessment, and histopathological findings were collected. The association between clinical presentations and high-risk histopathological features in the primary enucleated eyes were evaluated. The radiological findings, which showed characteristic of high risk features, were compared with the histopathological findings.

Results

Thirty-three enucleated eyes were enrolled in this study. The mean age at diagnosis was 23.12 months. Most patients had unilateral group E retinoblastoma, with no difference in sex and laterality of the eye. Leukocoria was the most common presentation, followed by proptosis and uveitis. Older age at presentation were statistically associated with post laminar cribrosa optic nerve invasion (P-value 0.0027) and high-risk histopathological features in enucleated eyes (P-value 0.0032). Clinical presentations with proptosis were statistically associated with post laminar cribrosa optic nerve invasion, while leukocoria and uveitis were statistically associated with anterior segment invasion. Unifocal intraocular mass with necrosis was the most common histopathological finding. High-risk features were found in 45% of primary enucleated eye. The sensitivity and specificity of magnetic resonance imaging (MRI) for detected optic nerve invasion in retinoblastoma patients were 75% and 54%, respectively.

Conclusion

Patients with unilateral retinoblastoma who presented with older age related to high-risk features after enucleation. Ophthalmic examination with slitlamp is the best way for detection of anterior segment invasion. Choroidal invasion was unable to predict with clinical presentation. MRI was the better imaging for detection of post laminar cribrosa optic nerve invasion.

Compatibility of Pupil Size Measured with Nidek ARK-1a Table Top Autorefractometer and Plusoptix A12C Photoscreener

Aim: To evaluate the differences in pupil size measured with and without cycloplegia by a table top autorefractometer, ARK-1a Auto Ref/Keratometer, Nidek, Japan, 2014 release, compared to handheld photoscreener, Plusoptix A12C, software 6.1.12, under monocular and binocular conditions.Materials and Methods: In the study, 100 eyes of 100 patients ages 18-55 years were included. The patients' pupil sizes were measured with a table top autorefractometer, Nidek ARK 1a without cycloplegia, and then the pupils were remeasured under monocular and binocular conditions with a photoscreener, Plusoptix A12C, respectively. After that the measurements with cycloplegia were repeated in the same order. The values obtained with both devices were compared.Results: In the measurement results without cycloplegia, the pupil size measured by Nidek ARK 1a was found to be significantly different than that measured by Plusoptix A12C under both monocular and binocular conditions. Pupil size measured with Plusoptix A12C under monocular conditions was also different than pupil diameter measured under binocular conditions. In the measurements with cycloplegia, it was observed that the pupil size measured with Plusoptix A12C under monocular and binocular conditions was not different from the diameter measured with Nidek ARK 1a.Conclusion: Pupil sizes measured with Nidek ARK 1a and Plusoptix A12C in monocular and binocular conditions without cycloplegia are different, but measurements with cycloplegia are similar. We believe that pupil size measurement with Plusoptix A12C under binocular conditions without cycloplegia will be more appropriate when necessary as a screening device in clinical settings.

Strabismus as a Presenting Sign in Retinoblastoma

PURPOSE

To report the presenting signs of retinoblastoma in a large cohort of patients who underwent orthoptic assessment at presentation.

METHODS

A retrospective medical chart review was conducted on 131 patients with retinoblastoma who presented consecutively to a single institution during a 6-year period. The main outcome measure was the presenting sign(s) of the disease.

RESULTS

Of 131 patients with retinoblastoma, 88 presented with unilateral disease and 43 presented with bilateral disease (mean ages: 22.7 and 14.8 months, respectively). Leukocoria was the presenting sign in 56% of patients, leukocoria and strabismus in 18%, strabismus in 13%, inflammation in 8%, and "other" signs in 5%. The fovea was affected by the retinoblastoma tumor or its sequelae in 75% of patients. Patients who presented with strabismus were significantly more likely to have foveal involvement than patients who presented with leukocoria alone (P = .001). Thirty-one percent of patients had strabismus as a component of their presentation; 63% had exotropia, 23% had esotropia, and 14% had variable strabismus. The percentage of patients with strabismus increased to 66% when small angle and variable strabismus were also considered. Patients with inflammation had worse ocular survival (P < .05).

CONCLUSIONS

This study assessed the combination of leukocoria and strabismus as presenting features of retinoblastoma. Foveal involvement is common in patients who have strabismus and may influence decision-making regarding globe salvage. The authors confirmed that exotropia is more common than esotropia in retinoblastoma in the largest cohort to have undergone an orthoptic assessment. [J Pediatr Ophthalmol Strabismus. 2021;58(5):324-330.].

Occlusion of AquaPORT Flow in a Case of Toxic Anterior Segment Syndrome Following Implantable Collamer Lens Surgery Causing Severe Pupillary Block

PURPOSE

To present a case where following Implantable Collamer Lens (ICL) implantation the patient developed toxic anterior segment syndrome (TASS) with a subsequent pupillary block as a consequence of the occlusion of the AquaPORT (STAAR Surgical) flow hole.

METHODS

Case report and literature review.

RESULTS

A V4c toric ICL (STAAR Surgical) was implanted in the left eye of a 32-year-old woman. After 1 week, the lens was 15° off axis and uneventful lens alignment correction was performed. At postoperative day 1, an intraocular pressure (IOP) of 11 mm Hg and mild corneal edema were observed. At postoperative day 7, there was an uncorrected distance visual acuity of 20/800, an IOP of 44 mm Hg, diffuse corneal edema, and fibrin strands in the anterior chamber. TASS was diagnosed and topical steroids, cycloplegia, antiglaucoma drops, and oral acetazolamide were prescribed. At postoperative day 9, dispersed endothelial pigment with a fixed mid-dilated pupil were identified. Anterior segment optical coherence tomography showed strands of fibrin blocking the central ICL hole and angle closure. Pupillary block related to the fibrin occluding the AquaPORT hole consecutive to TASS was diagnosed. The patient underwent ICL removal, but had a persistent atonic, hyporeflexive pupil as a complication.

CONCLUSIONS

This case demonstrates that an AquaPORT hole may not be enough to prevent pupillary block in cases with postoperative intraocular inflammation, causing severe postoperative complications such as Urrets-Zavalia syndrome. Clinicians should consider this diagnosis in cases with corneal edema in the early postoperative period following AquaPORT ICL insertion. [J Refract Surg. 2020;36(12):856-859.].

Phentolamine Eye Drops Reverse Pharmacologically Induced Mydriasis in a Randomized Phase 2b Trial

SIGNIFICANCE

After a dilated eye examination, many patients experience symptoms of prolonged light sensitivity, blurred vision, and cycloplegia associated with pharmacological mydriasis. Phentolamine mesylate ophthalmic solution (PMOS) may expedite the reversal of mydriasis in patients, potentially facilitating return to functional vision and reducing barriers to obtaining dilated eye examinations.

PURPOSE

The protracted reversal time after pharmacologically induced pupil dilation impairs vision. We tested the hypothesis that PMOS rapidly reduces pupil diameter in this acute indication.

METHODS

In this double-masked placebo-controlled, randomized, two-arm crossover phase 2b trial, we evaluated the effects of one drop of 1% PMOS applied bilaterally in subjects who had their pupils dilated by one of two common mydriatic agents: 2.5% phenylephrine or 1% tropicamide. End points included change in pupil diameter, percent of subjects returning to baseline pupil diameter, and accommodative function at multiple time points.

RESULTS

Thirty-one subjects completed the study (15 dilated with phenylephrine and 16 with tropicamide). Change in pupil diameter from baseline at 2 hours after maximal dilation with 1% PMOS was -1.69 mm and was significantly greater in magnitude compared with placebo for every time point beyond 30 minutes (P < .05). At 2 hours, a greater percentage of study eyes given 1% PMOS returned to baseline pupil diameter compared with placebo (29 vs. 13%, P = .03), which was this also seen at 4 hours (P < .001). More subjects treated with PMOS in the tropicamide subgroup had at least one eye returning to baseline accommodative amplitude at 2 hours (63 vs. 38%, P = .01). There were no severe adverse events, with only mild to moderate conjunctival hyperemia that resolved in most patients by 6 hours.

CONCLUSIONS

Phentolamine mesylate ophthalmic solution at 1% reversed medically induced pupil dilation more rapidly than placebo treatment regardless of which mydriatic was used (adrenergic agonists and cholinergic blockers) with a tolerable safety profile.

Pierson Syndrome Associated with Hypothyroidism and Septic Shock

Pierson syndrome is caused by mutations in the laminin β2 gene causing absent β2 laminin, which is a normal component of the basement membranes of the mature glomerulus, structures in the anterior eye and neuromuscular junctions. The mutations manifest as congenital nephrotic syndrome and microcoria which are characteristic ocular features of this disease. These mutations may also result in neurological abnormalities such as hypotonia and psychomotor retardation. We report a two-month old boy who presented to the Pediatrics Department of Dr. Ruth K. M. Pfau Civil Hospital, Karachi, Pakistan, in 2015, with the typical features of microcoria and congenital nephrotic syndrome. The hypocalcaemia, hypoproteinaemia and probable immunocompromised state consequent to nephrotic syndrome resulted in seizures, hypothyroidism and urosepsis. Despite being treated aggressively with high dose antibiotics, ionotropic support, angiotensin-converting enzyme inhibitors, thyroxine replacement and nutritional support, the infant died due to significant multiorgan disease including renal failure and septic shock.

Clinical profile and visual outcomes after treatment in patients with dysthyroid optic neuropathy

PURPOSE

To report the clinical data and visual outcomes after treatment of patients with dysthyroid optic neuropathy (DON).

METHODS

We retrospectively reviewed the medical records and orbital images of 40 patients (65 eyes) with DON and analyzed the visual outcomes after treatment with intravenous steroids pulse therapy, radiotherapy and orbital decompression.

RESULTS

The study included 21 men and 19 women, with 10 (25%) being diabetic patients. Visual field test results revealed defects in 88.7% of DON eyes; afferent pupillary defects in 63.2%; reduced color vision in 78.5%; and abnormal visual evoked potentials in 84%. Orbital imaging showed moderate to severe apical crowding in 95% of the orbits and intracranial fat prolapse in 24.2%. Median best corrected visual acuity improved from 0.4 to 1.0 after one year of treatment (p < 0.001). We noted more improvement in vision with the use of decompressive surgery than with non-surgical methods (p < 0.05). Recurrences occurred in 7 patients who had not received orbital radiotherapy.

CONCLUSIONS

Visual field defects and apical crowding seen on orbital imaging were the most sensitive indicators for the detection of DON. Treatment with intravenous steroids pulse therapy, radiotherapy and orbital decompression effectively improved visual outcomes in cases of DON.

Transient global brainstem dysfunction after microvascular decompression of the trigeminal nerve

Microvascular decompression of the trigeminal nerve root entry zone has become a standard treatment for trigeminal neuralgia. It has been widely reported with a low morbidity. This case report details an unusual and previously unreported complication of this procedure.

Patterns of neuropathy and autonomic failure in patients with amyloidosis

OBJECTIVE

To define the clinical patterns of peripheral neuropathy and autonomic testing abnormalities in patients with amyloidosis.

PATIENTS AND METHODS

A retrospective chart review was conducted of 65 patients who had biopsy-proven amyloidosis and autonomic function testing between January 1, 1985, and December 31, 1997, at Mayo Clinic's site in Rochester, MN. Patients were required to have neurologic evaluation, autonomic reflex screening, and tissue confirmation of amyloidosis.

RESULTS

We identified 5 clinical patterns of peripheral neuropathy: (1) generalized autonomic failure and polyneuropathy with pain (40 patients [62%]), (2) generalized autonomic failure and polyneuropathy without pain (11 [17%]), (3) isolated generalized autonomic failure (7 [11%]), (4) polyneuropathy without generalized autonomic failure (4 [6%]), and (5) generalized autonomic failure and small-fiber (ie, autonomic and somatic C-fiber) neuropathy (3 [5%]). Moderately severe generalized autonomic failure, involving adrenergic, cardiovagal, or sudomotor domains, was found in all patients, including those without clinically manifested autonomic failure. The diagnosis of amyloidosis was delayed in patients who did not have initial symptoms of pain or generalized autonomic failure (48 months to diagnosis in patients with polyneuropathy without autonomic failure vs 12 months to diagnosis in patients with autonomic failure and small-fiber neuropathy; P=.57).

CONCLUSION

Physicians should test for symptoms of generalized autonomic failure in patients who have peripheral neuropathy of unknown origin. Autonomic testing may give abnormal results in patients without overt symptoms of autonomic failure. Early recognition of autonomic failure may lead to earlier diagnosis of the underlying pathogenesis of amyloidosis, as well as earlier treatment for patients with this condition.

Prognostic predictors of thalamic hemorrhage

BACKGROUND AND OBJECTIVE

There is no study evaluating the role of clinical, evoked potential and radiological parameters in the prognosis of thalamic hemorrhage employing multivariate logistic regression analysis, thus we aimed to evaluate the role of these parameters in predicting the 3 month outcome following thalamic hemorrhage.

SETTING

Tertiary care referral teaching hospital.

METHODS

Fifty-three patients with CT proven thalamic hematoma were evaluated. Conscious level was assessed using the Glasgow Coma Score (GCS), severity of stroke by the Canadian Neurological Scale (CNS), while muscle tone, tendon reflexes and power were also recorded. Hematoma size and type, and evidence of ventricular extension were obtained from the CT scan. Hematomas were classified as (A) thalamic with postero-lateral extension or (B) thalamic without postero-lateral extension. Central motor conduction to upper limb and median somatosensory evoked potentials (SEP) were recorded. Outcome was defined at 3 months on the basis of the Barthel Index (BI) with good being a BI of 12 or greater and poor a BI of less than 12. Best predictors of outcome were evaluated by single variable logistic regression analysis followed by multivariate logistic regression.

RESULTS

Age ranged between 35 and 85 years; 18 were women. Mean GCS was 10.4 and CNS was 3.9. Thirty-one patients had type A hematomas and 22 type B. The hematoma was small in 5, medium in 35 and large in 13 patients. Ventricular extension was present in 34 patients. Motor evoked potentials were unrecordable in 36 and central motor conduction time was prolonged in 8 patients. Median SEP was unrecordable in 37 and N9-N20 conduction time was prolonged in 2 patients. At 3 months, 8 patients had died, 24 had good and 21 had poor outcome. On univariate logistic regression analysis diabetes mellitus, GCS, pupillary asymmetry, CNS score, type and size of hematoma and motor and somatosensory evoked potentials were significant in relation to outcome. On multivariate logistic regression analysis, the best predictors of outcome at 3 months were the type of hematoma and CNS score.

CONCLUSION

CNS score and CT appearance of hematoma are the best predictors of 3 month outcome following thalamic hemorrhage. The proposed model for outcome assessment is simple and easy to apply and could have wide clinical application.

[Acute enterovirus uveitis in infants]

Enterovirus uveitis (EU) is a new infant eye disease that was first detected and identified in Russia in 1980-1981. Three subtypes of human echoviruses (EV19K, EV11A, and EV11/B) caused 5 nosocomial outbreaks of EU in different Siberian cities and towns in 1980-1989, by affecting more than 750 children mainly below one year of age. Sporadic and focal EU cases (more than 200) were also retrospectively diagnosed in other regions of Russia and in different countries of the former Soviet Union. There were following clinical manifestations: common symptoms of the infection; acute uveitis (rapid focal iridic destruction, pupillary deformities, formation of membranes in the anterior chamber of the eye); and in 15-30% of cases severe complications, cataract, glaucoma, vision impairments. Uveitis strains EV19 and EV11 caused significant uveitis in primates after inoculation into the anterior chamber of the eye, as well as sepsis-like fatal disease with liver necrosis after venous infection. The uveitis strains are phylogenetically and pathogenetically close for primates to strains EV19 and EV11 isolated from young children with sepsis-like disease. The contents of this review have been published in the Reviews in Medical Virology, 2004, vol. 14, p. 241-254.

Use of admission Glasgow Coma Score, pupil size, and pupil reactivity to determine outcome for trauma patients

BACKGROUND

Determination of nonsurvival in trauma patients is difficult because valid prognostic indicators are lacking. It was hypothesized that patients presenting with a Glasgow Coma Score (GCS) of 3 as well as fixed and dilated (FD) pupils do not have a reasonable chance of survival.

METHODS

From 1999 through 2001, adult trauma patients (age, >14 years) admitted with a GCS of 3 were reviewed. Patients receiving paralytic agents before initial assessment were excluded from analysis. Fixed and dilated pupils were defined as being 4 mm or more in diameter bilaterally and nonreactive to light. In this study, the FD patients were evaluated for survival, resuscitative measures, surgical procedures, length of hospital stay, and organ donation. The non-FD patients were evaluated for survival and length of hospital stay.

RESULTS

Of the 137 patients evaluated with a GCS of 3, 104 had FD pupils and 33 did not. In the FD group, there were no survivors. On arrival, 28 (37.3%) of the patients were declared dead, and no further interventions were undertaken. Of the 76 patients (62.7%) who underwent further resuscitation, which included 53 surgical procedures, 30 died in the resuscitation bay, 39 within 24 hours, 4 within 48 hours, 2 within 72 hours, and 1 on day 6. There were 18 (23.7%) organ donors. Of the 33 patients without FD pupils, 11 (33%) survived to discharge (mean hospital stay, 21.4 days). Of the 22 nonsurvivors (67%), 10 died in the resuscitation bay, 8 within 24 hours, 1 within 48 hours, 1 on day 4, and 2 on day 6.

CONCLUSIONS

Patients presenting with a GCS of 3 and FD pupils have no reasonable chance for survival. A significant percentage of these patients can be salvaged for organ donation. This information should be used in deciding to pursue aggressive resuscitation efforts and in discussing prognosis with family. Patients with a GCS of 3 who are not FD should be aggressively resuscitated because many of these patients survive to discharge.

Coexistence of impaired indices of autonomic neuropathy and diabetic nephropathy in a cohort of children with type 1 diabetes mellitus

One hundred and twenty-nine (87%) out of a county population of 150 eligible children with type 1 diabetes mellitus (DM) and 144 age- and sex-matched control children participated in a longitudinal, epidemiological study of the evolution of diabetic microvascular disease. The mean (SD) age of the children with DM was 12.4 (+/- 3.4) years with a mean DM duration of 4.5 (+/- 3.2) years and a mean HbA1c of 11.1 (+/- 2.2)%. Two sets of measurements were made over a period of 18 months. Pupillary adaptation in darkness (PD), as an index of sympathetic dysfunction, was assessed using a portable Polaroid pupillometer. Urinary albumin excretion, as an index of incipient nephropathy, was assessed in children with DM from a fraction of all voidings during two separate 48-h periods and was expressed as urinary albumin/creatinine ratio (A/C). Heart rate variation (HRV), as an index of cardiovascular autonomic dysfunction, was assessed using a heart rate monitor and computer. Blood pressure (BP) was measured using a random zero sphygmomanometer. Reduced PD was found in 14/129 (13.8%) children with DM and in 5.8% of the controls. The diabetic children with reduced PD had longer DM duration, higher HbA1c, raised diastolic BP and higher urinary A/C than those with normal PD. Fifty percent of these children also had increased A/C and impaired HRV, in addition to impaired PD. Another group of 25/129 (19.4%) children with DM presented intermittently raised mean urinary A/C, while five children presented persistently raised A/C in both 48-h urine collections. The characteristics which differentiated the microalbuminuric group from the normoalbuminuric one were older age, longer DM duration, poorer glycemic control, reduced PD, impaired HRV and raised diastolic BP. It seems that diabetic nephropathy (DN) and autonomic neuropathy (DAN) exist in concert in childhood DM. Diabetic children with impaired indices of DN and DAN are older, pubertal and have longer DM duration and higher HbA1c values than the rest of the diabetic population.

Autonomic instability, as measured by pupillary unrest, is not associated with multiple sclerosis fatigue severity

Multiple sclerosis (MS) fatigue is one of the most common symptoms in MS, but its pathophysiology is still not understood Sympathovagal imbalance was suggested as a reason for fatigue in chronic fatigue syndrome. We examined the role of an imbalance in the central autonomic nervous system (ANS) as a cause of MS fatigue in 51 MS patients and a control group of 22 healthy volunteers. Fatigue was assessed with the revised MS Fatigue Severity Scale (FSS) and the Modified Fatigue Impact Scale (MFIS). Depression was evaluated with the Beck Depression Inventory (BDI). Disintegration of the central ANS expressed by pupillary fatigue waves was measured with pupillography and documented in the pupillary unrest index (PUI). All subjects had less than five points on the seven-point Stanford Sleepiness Scale and were therefore not sleepy. MS patients had significant higher mean FSS scores (p=0.001) and mean MFIS scores (p=0.003) than our control group. Mean BDI scores were significant higher (p=0.001) in the MS group, but were in the lowest score range (0-10 points) in both groups. Surprisingly, we found a statistically significant inverse correlation between PUI values and either FSS scores (p=0.001; r=-0.521) or MFIS scores (p=0.002; r=-0.423) in the MS group, but not in healthy participants. We therefore conclude that autonomic instability, as measured by pupillary unrest is not associated with MS fatigue severity.

Autonomic neuropathy: diagnosis and impact on health in adolescents with diabetes

Symptomatic autonomic neuropathy and abnormal cardiovascular autonomic tests are associated with increased mortality due to vascular disease and increased risk of sudden deaths. Intensive therapy in the DCCT caused a significant risk reduction of developing autonomic nerve abnormalities at five years only in the Primary Prevention Group (4 vs. 9%). At the Royal Alexandra Hospital for Children, the prevalence of cardiovascular reflex abnormalities is 28%. Over 5 years, we have found no increase in the rate of single cardiovascular abnormalities and a low rate of persistence. Two or more abnormalities developed in 5%. Repeated measures of pupillary function showed a significant increase in abnormalities and a higher level of persistently abnormal tests. Spectral analysis and 24-hour BP monitoring may detect autonomic dysfunction at earlier stages but longitudinal studies are not yet available.

Changes in the pupillary light reflex of pigmented royal college of surgeons rats with Age

We studied the latency and amplitude of the pupillary light reflex response of the Royal College of Surgeons rat from 10 to 52 weeks of age. The responses of these dystrophic rats were diminished compared to those of normal, non-dystrophic rats at all ages examined. This was most marked at the dimmest light intensity studied here and for the latency of dystrophic animals' responses. The latency deteriorated over the course of 52 weeks, although there was some evidence of improvement beyond 36 weeks of age. The amplitude of the dystrophic animals' responses also suggested some deterioration occurring up to 36 weeks of age, but with a substantial improvement beyond this time. In addition to these parameters, we also observed a break in the constriction phase of the pupillary light reflex that was unique to the dystrophic animals' responses. The frequency with which the anomaly occurred decreased in a light-dependent manner with age. The improvement of the pupillary light reflex at older ages, even when very few photoreceptors remain, may reflect compensatory events occurring in the inner retinal layers and/or in the central connections of the pupillary light reflex pathway. We suggest that the break in the constriction phase is a reflection of dual inputs driving the response, one of which is affected more by the degenerative events. This study provides baseline data on the effect of degeneration on function over time which can be used to evaluate the efficacy of repair strategies such as transplantation.

Idiopathic hypothalamic dysfunction with dilated unresponsive pupils: report of two cases

Idiopathic hypothalamic dysfunction is a rare but well-defined entity in childhood characterized by adipsia-hypernatremia, obesity, poor thermoregulation, and disturbance of pituitary function. Two cases of idiopathic hypothalamic dysfunction are described. There are 10 previously reported cases in the literature, and the clinical features are compared. The present cases are unique in that the patients also had bilaterally dilated unresponsive pupils. In the first case, there was no demonstrable pathology at autopsy; in the second case, lymphocytic infiltration of the hypothalamus and midbrain associated with neuronal loss was present at autopsy. Possible etiologies are discussed.

Autosomal dominant congenital miosis with megalocornea

A family with AD congenital miosis is presented. The ocular symptoms were: megalocornea, iris translucency, microcoria with poor pupillary dilatation and goniodysgenesis with anterior insertion of the iris. This observation confirms that in congenital miosis abnormal development of the whole anterior eye segment may occur. The patients have an increased risk to develop glaucoma. If retinoscopy is impossible due to pin-point pupils, ultrasonic biometry to determine the axial length is recommended. An optical iridectomy could improve visual performance at low illumination; the complaints of photophobia, which are related to the iris translucency, persist.

[Clinical study on the prognostic factors of thalamic hemorrhage]

To investigate the prognostic factors, 30 cases of hypertensive primary thalamic hemorrhages with a poor or fatal outcome were studied. The age of the patients ranged from 42 to 84 years (mean: 64.4). Their level of consciousness, ocular deviations and pupillary abnormalities were analyzed in relation to the estimated volume and the extension of the hematomas. The level of consciousness was classified according to neurological grading (NG) of Kanaya et al. Twelve cases (40.0%) were above NG 4a. In high-aged patients, NG 1 or 2 often indicated a poor prognosis. A downward deviation or gasing nose (also known as 'thalamic eyes') was found in 13 cases (43.3%). Pupillary abnormalities were seen in 26 cases, and bilateral miosis (14 cases) indicated a poor prognosis. The extension of the hematoma consisted of 'downward' (type D), 'lateral' (type L) and 'upward' (type U), and combinations there of. Types U and D were thought to portend a poor prognosis. The following factors were thought to indicate a poor prognosis: (1) uncontrollable high blood pressure, (2) upward extension of the hematoma associated with large ventricular cast, (3) downward ocular deviation, bilateral miosis and downward extension of the hematoma (the first two were considered as indication of the hypothalamus and the midbrain being affected), (4) advanced age.