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The Neurohospitalist Oct 2015Neuro-ophthalmological emergencies constitute vision or life-threatening conditions if diagnosis and treatment are not promptly undertaken. Even with immediate therapy,... (Review)
Review
Neuro-ophthalmological emergencies constitute vision or life-threatening conditions if diagnosis and treatment are not promptly undertaken. Even with immediate therapy, these clinical entities carry a high rate of morbidity. They may present with diplopia, visual loss, and/or anisocoria. Arteritic anterior ischemic optic neuropathy is an ominous condition, which can cause permanent and severe vision loss, stroke, or aortic dissection, requiring immediate steroid therapy. Pituitary apoplexy may go unnoticed if only computed axial tomography is performed. Diseases affecting the cavernous sinus and orbital apex region, such as cavernous sinus thrombosis or mucormycosis, can give rise to simultaneous vision loss and diplopia and, if not treated, may extend to the brain parenchyma causing permanent neurological sequela. An isolated third nerve palsy may be the harbinger of a cerebral aneurysm, carrying a significant risk of mortality. Horner syndrome can be the initial presentation of a carotid dissection, an important cause of stroke in the young adult. The neurohospitalist should be familiar with the workup and management of neuro-ophthalmological emergencies.
PubMed: 26425250
DOI: 10.1177/1941874415583117 -
Der Ophthalmologe : Zeitschrift Der... Jun 2021A 53-year-old female patient presented with increased light sensitivity 3 weeks after oral intake of moxifloxacin tablets for an upper respiratory tract infection. The...
A 53-year-old female patient presented with increased light sensitivity 3 weeks after oral intake of moxifloxacin tablets for an upper respiratory tract infection. The symptoms were anisocoria and the pupils did not react to light or accommodation. The examination of the anterior segment of the eye revealed extensive bilateral iris transillumination defects (ITD). We diagnosed a bilateral acute iris transillumination (BAIT) syndrome. The BAIT syndrome is a rare disorder associated with massive depigmentation of the iris and atrophy of the iris musculature. A risk factor for BAIT syndrome seems to be the oral intake of antibiotics, in particular moxifloxacin after an upper respiratory tract infection but cases of spontaneous occurrence have also been described. Middle-aged women are particularly affected. The exact cause of BAIT syndrome is so far unknown but a potential mechanism involves the concentration of the antibiotic in the vitreous body. Differential diagnoses include other causes for ITD, such as albinism, intraocular inflammation, pseudoexfoliation syndrome and pigment dispersion syndrome. To date there is no specific treatment for BAIT syndrome. Possible complications include increased light sensitivity and post-BAIT glaucoma. Knowledge of the rare BAIT syndrome can be useful in the clinical routine for the differential diagnostic classification of an anisocoria and can possibly contribute to avoidance of unnecessary diagnostic steps.
Topics: Anisocoria; Female; Glaucoma, Open-Angle; Humans; Iris; Iris Diseases; Middle Aged; Moxifloxacin
PubMed: 32588124
DOI: 10.1007/s00347-020-01153-y -
Indian Journal of Critical Care... Nov 2019The realities, recognition, and remedial aspects of anisocoria at the bedside were highlighted by Adhikari et al., which is almost similar to an earlier report from...
UNLABELLED
The realities, recognition, and remedial aspects of anisocoria at the bedside were highlighted by Adhikari et al., which is almost similar to an earlier report from India. Since this condition involves patient safety and clinical assessment, we would like to touch upon 3 Ps (physiological, pathological, and pharmacological) of anisocoria. First and foremost is to elicit a thorough clinical history and then to assess the case in detail which not only rules out injuries, infections, instillation, or ingestion of medicines and instigating mechanisms but also helps rule out various other life-threatening conditions.
HOW TO CITE THIS ARTICLE
Senthilkumaran S, Jena NN, Balamurugan N, Florence B, Thirumalaikolundusubramanian P. Anisocoria: Realities, Recognition, and Remedial Aspects. IJCCM 2019;23(11):543.
PubMed: 31911751
DOI: 10.5005/jp-journals-10071-23279 -
Critical Care Medicine Feb 2022To describe the prevalence and associated risk factors of new onset anisocoria (new pupil size difference of at least 1 mm) and its subtypes: new onset anisocoria...
OBJECTIVES
To describe the prevalence and associated risk factors of new onset anisocoria (new pupil size difference of at least 1 mm) and its subtypes: new onset anisocoria accompanied by abnormal and normal pupil reactivities in patients with acute neurologic injuries.
DESIGN
We tested the association of patients who experienced new onset anisocoria subtypes with degree of midline shift using linear regression. We further explored differences between quantitative pupil characteristics associated with first-time new onset anisocoria and nonnew onset anisocoria at preceding observations using mixed effects logistic regression, adjusting for possible confounders.
SETTING
All quantitative pupil observations were collected at two neuro-ICUs by nursing staff as standard of care.
PATIENTS
We conducted a retrospective two-center study of adult patients with intracranial pathology in the ICU with at least a 24-hour stay and three or more quantitative pupil measurements between 2016 and 2018.
MEASUREMENTS AND MAIN RESULTS
We studied 221 patients (mean age 58, 41% women). Sixty-three percent experienced new onset anisocoria. New onset anisocoria accompanied by objective evidence of abnormal pupil reactivity occurring at any point during hospitalization was significantly associated with maximum midline shift (β = 2.27 per mm; p = 0.01). The occurrence of new onset anisocoria accompanied by objective evidence of normal pupil reactivity was inversely associated with death (odds ratio, 0.34; 95% CI, 0.16-0.71; p = 0.01) in adjusted analyses. Subclinical continuous pupil size difference distinguished first-time new onset anisocoria from nonnew onset anisocoria in up to four preceding pupil observations (or up to 8 hr prior). Minimum pupil reactivity between eyes also distinguished new onset anisocoria accompanied by objective evidence of abnormal pupil reactivity from new onset anisocoria accompanied by objective evidence of normal pupil reactivity prior to first-time new onset anisocoria occurrence.
CONCLUSIONS
New onset anisocoria occurs in over 60% of patients with neurologic emergencies. Pupil reactivity may be an important distinguishing characteristic of clinically relevant new onset anisocoria phenotypes. New onset anisocoria accompanied by objective evidence of abnormal pupil reactivity was associated with midline shift, and new onset anisocoria accompanied by objective evidence of normal pupil reactivity had an inverse relationship with death. Distinct quantitative pupil characteristics precede new onset anisocoria occurrence and may allow for earlier prediction of neurologic decline. Further work is needed to determine whether quantitative pupillometry sensitively/specifically predicts clinically relevant anisocoria, enabling possible earlier treatments.
Topics: Adult; Anisocoria; Brain; Cohort Studies; Female; Humans; Intensive Care Units; Male; Middle Aged; Reflex, Pupillary; Retrospective Studies
PubMed: 34637415
DOI: 10.1097/CCM.0000000000005272 -
Neurocritical Care Aug 2017Basilar artery occlusion can cause locked-in syndrome, which is characterized by quadriplegia, anarthria, and limited communication via eye movements. Here, we describe...
BACKGROUND
Basilar artery occlusion can cause locked-in syndrome, which is characterized by quadriplegia, anarthria, and limited communication via eye movements. Here, we describe an uncommon stroke syndrome associated with endovascular recanalization of the top of the basilar artery: "reverse locked-in syndrome."
METHODS
We report the case of a patient with atypical neurological deficits caused by acute ischemic stroke of the midbrain tegmentum. We perform neuroanatomic localization of the patient's infarcts by mapping the magnetic resonance imaging (MRI) data onto a brainstem atlas.
RESULTS
A 61-year-old man presented with acute coma and quadriplegia due to top of the basilar artery occlusion. He underwent emergent endovascular thrombectomy, with successful recanalization of the basilar artery at 4 h and 43 min post-ictus. The patient regained consciousness and purposeful movement in all four extremities, but the post-procedure neurological examination demonstrated bilateral ptosis with complete pupillary and oculomotor paralysis. MRI revealed infarction of the bilateral oculomotor nuclei in the midbrain tegmentum. At 9-month follow-up, he had anisocoria and dysconjugate gaze, but was living at home and required minimal assistance in performing all activities of daily living.
CONCLUSIONS
Since the patient's deficits were the exact opposite of those described in locked-in syndrome, we propose the term "reverse locked-in syndrome" to describe this neurological entity characterized by bilateral ptosis, non-reactive pupils, and ophthalmoplegia with preservation of consciousness and extremity motor function.
Topics: Basilar Artery; Blepharoptosis; Cerebral Infarction; Humans; Male; Middle Aged; Ophthalmoplegia; Tegmentum Mesencephali; Thrombectomy
PubMed: 28324264
DOI: 10.1007/s12028-017-0391-x -
Ceska a Slovenska Oftalmologie :... 2020The aim of the work is to approach the examination of the pupil with a focus on anisocoria, its characteristics and approach to the diagnosis of pupillotonia and...
The aim of the work is to approach the examination of the pupil with a focus on anisocoria, its characteristics and approach to the diagnosis of pupillotonia and Adie's syndrome and its clinical evaluation. Pupil function is important not only in neurophthalmological examination but also in general ophthalmological examination. First of all, we need to know how the reflex arc works in order to be able to exclude or confirm whether the parasympathetic or sympathetic is affected. It is also necessary to know the exact characteristics of the pupil, such as size, shape, placement, function and reaction to light and at close range. Only on this basis can we distinguish pathological features. We do not often encounter this diagnosis, but it is necessary to keep it in mind, especially in the field of neurophthalmology but also in general ophthalmology. We also present three cases of pupilotonia and Adie's syndrome, which we diagnosed at the Department of Ophthalmology, Faculty of Medicine, Comenius University, after the patient himself came by emergency admission or was sent directly to ophthalmology clinic. In the discussion, we present various other diagnoses, where the reflex arc may not be affected, but the pathological pupil is caused by intraocular tumors, general systemic diseases and, last but not least, local therapy or alkaloids.
Topics: Adie Syndrome; Anisocoria; Humans; Pupil; Tonic Pupil
PubMed: 33499645
DOI: 10.31348/2020/33 -
Eye and Brain 2015Horner syndrome consists of unilateral ptosis, an ipsilateral miotic but normally reactive pupil, and in some cases, ipsilateral facial anhidrosis, all resulting from... (Review)
Review
Horner syndrome consists of unilateral ptosis, an ipsilateral miotic but normally reactive pupil, and in some cases, ipsilateral facial anhidrosis, all resulting from damage to the ipsilateral oculosympathetic pathway. Herein, we review the clinical signs and symptoms that can aid in the diagnosis and localization of a Horner syndrome as well as the causes of the condition. We emphasize that pharmacologic testing can confirm its presence and direct further testing and management.
PubMed: 28539793
DOI: 10.2147/EB.S63633 -
Neurologic Clinics Feb 1996This article reviews the diagnostic testing used in the evaluation of several common neuro-ophthalmologic entities including optic nerve disease, pseudotumor cerebri,... (Review)
Review
This article reviews the diagnostic testing used in the evaluation of several common neuro-ophthalmologic entities including optic nerve disease, pseudotumor cerebri, anisocoria, ptosis, and ocular motor palsies. Emphasis is placed on these bedside tests that help to establish the diagnosis of these common clinical problems. The utility of the cocaine and Tensilon (edrophonium chloride) tests as well as the role of neuroimaging in these conditions are reviewed.
Topics: Brain Diseases; Diagnosis, Differential; Diagnostic Imaging; Humans; Neurologic Examination; Ocular Motility Disorders; Optic Nerve Diseases; Patient Care Team; Vision Tests
PubMed: 8676844
DOI: 10.1016/s0733-8619(05)70250-4