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Graefe's Archive For Clinical and... Dec 2016Giant cell arteritis (GCA) is a systemic granulomatous vasculitis, primarily affecting medium-large arteries. It has a predilection for the aorta and its major branches,... (Review)
Review
BACKGROUND
Giant cell arteritis (GCA) is a systemic granulomatous vasculitis, primarily affecting medium-large arteries. It has a predilection for the aorta and its major branches, including the carotid and vertebral arteries. Ophthalmic artery involvement frequently leads to irreversible visual loss, and therefore GCA is one of the few true ophthalmic emergencies. GCA, although classified as a large vessel vasculitis, is known to affect smaller-sized vessels, resulting in a multiplicity of signs in the eye, some of which are often missed.
PURPOSE
We set out to highlight some of the less frequently observed clinical signs, which may provide clues to clinically diagnosing GCA in patients presenting with non-classical features and inconclusive inflammatory markers.
METHODS
We review the literature and describe the diverse ocular features and some of the systemic findings that can be associated with GCA.
RESULTS
Although the most common ocular manifestation of GCA is anterior ischaemic optic neuropathy, the clinical presentation of GCA can vary dramatically. In the absence of obvious ocular involvement, more subtle ophthalmic signs of anterior segment ischaemia, such as hypotony and anisocoria, may be present at the time of initial clinical examination.
CONCLUSION
There are no specific biomarkers for disease to date; therefore, pertinent history and clinical examination can guide towards diagnosis in the acute setting. The diagnostic process is not always straightforward, yet appropriate and prompt diagnosis is critical to enable timely intervention and prevent significant morbidity.
Topics: Biopsy; Blindness; Giant Cell Arteritis; Humans; Ophthalmic Artery; Optic Neuropathy, Ischemic; Prognosis; Temporal Arteries
PubMed: 27495301
DOI: 10.1007/s00417-016-3434-7 -
Biomedical Optics Express Oct 2016The advances in new techniques for correcting presbyopia, such as a small aperture combined with monovision, require an in-depth study of binocular aspects. In this...
The advances in new techniques for correcting presbyopia, such as a small aperture combined with monovision, require an in-depth study of binocular aspects. In this work, we have studied binocular visual performance of 12 subjects after inducing different degrees of anisocoria combined with two different add powers in the non-dominant eye. We have analysed visual performance in terms of the visual-discrimination capacity (a function to evaluate the strength of bothersome halos) and the contrast-sensitivity. The results show a deterioration of the binocular vision when inducing anisocoria and with any add power, with a higher perception of halos, a lower contrast sensitivity and poorer binocular summation of these visual functions on increasing anisocoria. This deterioration is clinically acceptable in the case of low add power, since positive binocular summation is maintained in contrast sensitivity, and visual discrimination is not altered.
PubMed: 27867729
DOI: 10.1364/BOE.7.004250 -
Neurology India 2019We aimed to estimate the prevalence of physiological anisocoria and also evaluate the accuracy of clinical assessment of anisocoria employed in routine bedside...
AIM
We aimed to estimate the prevalence of physiological anisocoria and also evaluate the accuracy of clinical assessment of anisocoria employed in routine bedside examination.
MATERIALS AND METHODS
A total of 708 voluntary subjects between the ages of 20-69 years who had no history of ophthalmologic or neurological disease other than refractive error were included in the study. In a closed room with uniform ambient lighting, the subjects' pupils were examined clinically and the presence or absence of anisocoria was recorded. This was followed by photography of the subjects' pupils using a digital camera secured on a tripod at a fixed distance from the subject's face. A difference in pupillary size of 0.4 mm or more was considered anisocoria.
RESULTS
Of the 708 subjects, 361 (51%) were males. The average pupillary diameter of the subjects was 4.99 mm. Ninety-seven (13.7%) had measured anisocoria on photography. Ninety-seven subjects (13.7%) also had anisocoria on clinical examination, however, only 45 of them had measured anisocoria. The clinical measurement of anisocoria, therefore, showed a specificity of 0.91 and a sensitivity of 0.46. With a prevalence of anisocoria of 13.7%, the positive predictive value was 0.46, and the negative predictive value was 0.91.
CONCLUSIONS
The prevalence of physiological anisocoria was 13.7%, which is less than what has previously been reported. The sensitivity of clinical examination in detecting early anisocoria is poor. Patients at risk of developing uncal herniation may, therefore, benefit from routine bedside pupillary assessment with a portable device such as a pupillometer.
Topics: Adult; Aged; Anisocoria; Female; Humans; Male; Middle Aged; Neurologic Examination; Prevalence; Prospective Studies; Sensitivity and Specificity; Young Adult
PubMed: 31857545
DOI: 10.4103/0028-3886.273623 -
Clinical Ophthalmology (Auckland, N.Z.) 2018To evaluate the measurement of anisocoria in a group of ocular healthy subjects using a standardized protocol in scotopic, mesopic, and photopic lighting conditions, and...
PURPOSE
To evaluate the measurement of anisocoria in a group of ocular healthy subjects using a standardized protocol in scotopic, mesopic, and photopic lighting conditions, and determine the optimal threshold of difference in pupil diameter in determining physiologic anisocoria.
METHODS
Right and left pupil diameters of 126 ocular healthy subjects with a mean age 30.5±7.8 years (40 males and 86 females) were measured sequentially under photopic conditions using a monocular infrared pupillometer. A sub-group of 51 individuals had right and left pupil measurements performed under three additional lighting conditions, allowing for a 2-minute recovery between measurements. A white light emitting diode (LED) in the eyecup of the pupillometer produced three controlled light settings: scotopic (0 lux), low mesopic (0.3 lux), and high mesopic (3 lux). The criterion for anisocoria was defined as ≥0.4 mm difference in pupil diameter between the eyes.
RESULTS
In the 126 subjects tested, 23.8% (n=30) exhibited anisocoria in photopic conditions. In the sub-group measured under three additional light settings, 43.1% (n=22) exhibited anisocoria in scotopic conditions, 43.1% (n=22) in low mesopic conditions, and 47.1% (n=24) in high mesopic conditions. Approximately 73% of subjects exhibited anisocoria in at least one light setting, while only approximately 8% had anisocoria in every light setting. When the criterion for anisocoria was shifted to ≥0.2 mm or ≥0.6 mm, the prevalence of anisocoria shifted significantly. Using a higher cutoff of ≥0.6 mm effectively reduced the number of healthy individuals who exhibit anisocoria in every light setting to almost zero.
CONCLUSION
Based on our data, anisocoria is more prevalent under varied lighting conditions. To ensure the anisocoria is due to physiologic reasons, one should ensure that it is present under all lighting conditions to avoid excessive false positives.
PubMed: 29379269
DOI: 10.2147/OPTH.S147019 -
Arquivos Brasileiros de Oftalmologia Jun 2018We investigated parasympathetic innervation abnormalities of the iris sphincter and ciliary muscles in chronic Chagas disease by measuring pupillary diameter and... (Clinical Trial)
Clinical Trial
PURPOSE
We investigated parasympathetic innervation abnormalities of the iris sphincter and ciliary muscles in chronic Chagas disease by measuring pupillary diameter and intraocular pressure.
METHODS
A group of 80 patients with Chagas disease was compared with 76 healthy individuals without chagasic infection. The following procedures were performed: pupillometry, hypersensitivity test to pilocarpine 0.125%, intraocular pressure measurement (IOP), basal pupil diameter (BPD), absolute pupillary constriction amplitude (ACA), relative pupillary constriction amplitude (RCA) and the presence of anisocoria.
RESULTS
The prevalence of anisocoria was higher in chagasic patients (p<0.01). These patients had mean basal pupillary diameter, mean photopic pupillary diameter and mean value of absolute pupillary constriction amplitude significantly lower than non-chagasic ones (p<0.01, mean difference -0.50mm), (p=0.02, mean difference -0.20mm), (p<0.01, mean difference -0.29mm), respectively. The relative pupillary constriction amplitude did not differ between the two groups (p=0.39, mean difference -1.15%). There was hypersensitivity to dilute pilocarpine in 8 (10%) of the chagasic patients in the right eye and in 2 (2.5%) in the left eye and in 1 (1.25%) in both eyes. The mean value of intraocular pressure had a marginal statistical significance between the two groups (p=0.06, mean difference -0.91mmHg).
CONCLUSIONS
Patients with chagasic infection may exhibit ocular parasympathetic dysfunction, demonstrable by pupillometry and the dilute pilocarpine hypersensitivity test.
Topics: Adolescent; Adult; Aged; Anisocoria; Case-Control Studies; Chagas Disease; Cross-Sectional Studies; Female; Humans; Intraocular Pressure; Male; Middle Aged; Miotics; Pilocarpine; Reflex, Pupillary; Young Adult
PubMed: 29924199
DOI: 10.5935/0004-2749.20180041 -
Clinical Ophthalmology (Auckland, N.Z.) 2022To describe and validate a novel portable smartphone-based infrared pupillographer.
PURPOSE
To describe and validate a novel portable smartphone-based infrared pupillographer.
MATERIALS AND METHODS
A prototype infrared smartphone pupillographer device was custom designed for this project. Infrared video and photo pupillography were attempted on 12 patients with different clinical pupillary examination findings. Captured pupillography media files were assessed by three masked investigators, and the agreement between their qualitative clinical evaluation was tested against the evaluation of the neuro-ophthalmologist who performed the real-time examination and pupillography. Quantitative measurements of the pupillary diameter were performed by three investigators using a custom designed smartphone application on three different smartphones and on a personal computer. Measurements obtained by the three investigators using the smartphone and the desktop computer were compared.
RESULTS
Infrared video pupillography of high quality was successfully captured for light and near pupillary reflexes, and infrared still photographs were obtained in light and dark conditions in 23 eyes of the 12 patients. Examination findings included relative afferent pupillary defect (n = 5), normal pupillary examination (n = 4), anisocoria (n = 2), and relative afferent pupillary reflex by reverse (n = 1). There was 100% agreement in the qualitative pupillary evaluation of the masked investigators compared with real time clinical examination. Quantitative measurements of pupillary size obtained on the smartphone and desktop computer showed excellent agreement among the three investigators with intraclass correlation (ICC) coefficient ranging from 0.982-0.986 (P<0.001) and 0.995 (P<0.001) for the smartphone and the desktop computer groups, respectively. Level of agreement ranged between -0.27 and 0.32. Mean pupil diameter errors were 0.03 ± 0.15 mm between groups (P = 0.248).
CONCLUSION
This pilot study demonstrates the feasibility of smartphone-based infrared pupillography for high quality photo and video documentation of pupillary examination at the bedside and in the clinic with accurate and reproducible measurements of the pupillary size in light and dark conditions.
PubMed: 35173409
DOI: 10.2147/OPTH.S331989 -
The Journal of International Medical... May 2022Strategies for the assessment of abnormal neurological findings during general anesthesia are limited. However, pupil abnormalities may represent serious neurological...
Strategies for the assessment of abnormal neurological findings during general anesthesia are limited. However, pupil abnormalities may represent serious neurological complications. We herein present a case of new-onset anisocoria and mydriasis that developed after scalp nerve block. The patient's signs were possibly related to increased intracranial pressure with resulting brain shift that ultimately affected the oculomotor nerves. A 45-year-old man was scheduled for left cerebellar tumor resection and ventricular drainage surgery; however, anisocoria and left pupillary mydriasis were observed after induction of general anesthesia and performance of scalp nerve block. After reducing the intracranial pressure, the right pupil showed constriction (1 mm) but the left pupil was dilated (5 mm). The pupils were of similar size postoperatively. Although pupillary dilation during general anesthesia has been previously described, this is the first case in which the mydriasis was considered to have been caused by brain shift due to increased intracranial pressure after scalp nerve block. Thus, we propose this phenomenon as a new possible cause of pupillary changes. Actively monitoring this presentation intraoperatively could enable early detection of and intervention for complications, therefore improving the prognosis.
Topics: Anisocoria; Humans; Intracranial Hypertension; Male; Middle Aged; Mydriasis; Nerve Block; Pupil; Scalp
PubMed: 35632980
DOI: 10.1177/03000605221099262 -
Frontiers in Systems Neuroscience 2021Chewing improves cognitive performance, which is impaired in subjects showing an asymmetry in electromyographic (EMG) masseter activity during clenching. In these...
Chewing improves cognitive performance, which is impaired in subjects showing an asymmetry in electromyographic (EMG) masseter activity during clenching. In these subjects, the simultaneous presence of an asymmetry in pupil size (anisocoria) at rest indicates an imbalance in Ascending Reticular Activating System (ARAS) influencing arousal and pupil size. The aim of the present study was to verify whether a trigeminal EMG asymmetry may bias the stimulating effect of chewing on cognition. Cognitive performance and pupil size at rest were recorded before and after 1 min of unilateral chewing in 20 subjects with anisocoria, showing an EMG asymmetry during clenching. Unilateral chewing stimulated performance mainly when it occurred on the side of lower EMG activity (and smaller pupil size). Following chewing on the hypotonic side, changes in cognitive performance were negatively and positively correlated with those in anisocoria and pupil size, respectively. We propose that, following chewing on the hypotonic side, the arousing effects of trigeminal stimulation on performance are enhanced by a rebalancing of ARAS structures. At variance, following chewing on the hypertonic side, the arousing effect of trigeminal stimulation could be partially or completely prevented by the simultaneous increase in ARAS imbalance.
PubMed: 35002642
DOI: 10.3389/fnsys.2021.749444 -
Neuro-ophthalmology (Aeolus Press) Feb 2017The aim of this study was to evaluate the pupil size of normal subjects at different illumination levels with a novel pupillometer. The pupil size of healthy study...
The aim of this study was to evaluate the pupil size of normal subjects at different illumination levels with a novel pupillometer. The pupil size of healthy study participants was measured with an infrared-video PupilX pupillometer (MEye Tech GmbH, Alsdorf, Germany) at five different illumination levels (0, 0.5, 4, 32, and 250 lux). Measurements were performed by the same investigator. Ninety images were executed during a measurement period of 3 seconds. The absolute linear camera resolution was approximately 20 pixels per mm. This cross-sectional study analysed 490 eyes of 245 subjects (mean age: 51.9 ± 18.3 years, range: 6-87 years). On average, pupil diameter decreased with increasing light intensities for both eyes, with a mean pupil diameter of 5.39 ± 1.04 mm at 0 lux, 5.20 ± 1.00 mm at 0.5 lux, 4.70 ± 0.97 mm at 4 lux, 3.74 ± 0.78 mm at 32 lux, and 2.84 ± 0.50 mm at 250 lux illumination. Furthermore, it was found that anisocoria increased by 0.03 mm per life decade for all illumination levels ( = 0.43). Anisocoria was higher under scotopic and mesopic conditions. This study provides additional information to the current knowledge concerning age- and light-related pupil size and anisocoria as a baseline for future patient studies.
PubMed: 28228832
DOI: 10.1080/01658107.2016.1226345 -
The Israel Medical Association Journal... Jan 2017The identification and prompt diagnosis of Horner syndrome (HS) is essential for preventing permanent damage. HS may arise when a lesion presents anywhere along the... (Review)
Review
The identification and prompt diagnosis of Horner syndrome (HS) is essential for preventing permanent damage. HS may arise when a lesion presents anywhere along the three-neuron oculosympathetic pathway that begins at the posterior-lateral nuclei of the hypothalamus all the way through to the orbit. We present four cases and review the literature to familiarize the reader with the identification, diagnosis and treatment of Horner syndrome. The four patients, three adults and one child, were followed for at least 6 months following the initial diagnosis (range 6-18 months). There was partial resolution in three of the four cases, while the fourth resolved completely. There are numerous causes of HS, some of them iatrogenic. While iatrogenic cases of HR are rare in both adults and children, HS is seen more often following surgical procedures. Prompt recognition of the syndrome and correction of the offending agent may prevent permanent damage to the neuronal pathway. It is therefore recommended that practitioners be aware of the risks for development of iatrogenic HS and the signs for early detection.
Topics: Adult; Aged; Anisocoria; Blepharoptosis; Female; Horner Syndrome; Humans; Iatrogenic Disease; Infant; Male; Young Adult
PubMed: 28457112
DOI: No ID Found