[Survival with no sequelae after near-drowning with very poor signs for prognosis including persistent bilateral non-reactive mydriasis]

INTRODUCTION

The outcome of cases of near-drowning and initially poor prognostic signs are usually discouraging because of the severity of the consequent encephalopathy in most survivors. However, good recovery has been described, in spite of bad prognostic factors initially. It is difficult to establish the predictors of poor outcome which would enable one to decide when to establish and maintain advanced cardio-pulmonary resuscitation measures (CPR), since each case of near-drowning is different.

CLINICAL CASE

A four year old boy survived near-drowning in cold water without sequelas but with initial signs of very poor prognosis, including prolonged immersion time, coma, severe metabolic acidosis, hyperglycemia and persistent bilateral arreactive mydriasis.

DISCUSSION

The beneficial effect of hypothermia is well known, and explains (at least partially) survival in cases of apparently irreversible near-drowning. Potential benefits are reduced metabolic demand which prevents the adverse effects of hypoxia and the 'diving reflex' which short-circuits the blood supply to vital organs such as the brain and heart. We consider that the persistently arreactive pupils were not due to hypoxia, but rather to bilateral uncal compression of the third cranial nerves due to cerebral edema secondary to initial hypoxia and water intoxication.

CONCLUSION

This observation is yet another argument for the establishment and maintenance of aggressive manoeuvers of CPR and treatment in all children who have nearly-drowned, independently of the apparent seriousness or irreversibility.

[Axial displacement of IOL and visual impairment]

BACKGROUND

After a cataract surgery procedure with vitreous loss a vitreous strand remained in the wound. An unusual visual impairment was observed.

PATIENT

A shift in refraction depending on the pupillary diameter was observed. In miosis the refraction was estimated to +1.0 sph, in mydriasis -1.0 sph/ -0.5 cyl, respectively.

METHOD

We presumed that the vitreous strand between the iris and the intraocular lens caused an axial displacement of the IOL during the change from miosis to mydriasis and v.v. Therefore the vitreous strand was surgically eliminated. After surgery the refractive changes by pupillary actions were overcome. In a computer simulation (ray tracing), the amount of axial displacement of the IOL was estimated to 1.5 mm.

CONCLUSION

This paper reminds of considering other reasons for loss of VA than CME, e.g. axial displacement of IOL. An adequate method of examination is the measurement of refraction in miosis and mydriasis.

[A case of an incomplete Urrets-Zavalia syndrome as a result of operated keratoconus]

The article presents a case of incomplete Urrets-Zavalia syndrome after perforant corneal transplant for advanced keratoconus, as well as some considerations about the technique of perforant keratoplasty and the pre/postoperative cares.

Histopathological and ultrasound biomicroscopy findings in a case of irreversible mydriasis after keratoplasty in keratoconus

This report describes the histopathological and ultrasound biomicroscopy findings of a 35-year-old woman with keratoconus who developed an irreversible mydriasis after keratoplasty.

[Bilateral congenital mydriasis with accommodation failure]

In the literature congenital mydriasis is described as a very rare condition and explained as a result of isolated aplasia of the iris sphincter muscle. Aplasia of the ciliary muscle was assumed to cause congenital accommodation insufficiency. A case of congenital mydriasis with lack of accommodation is presented. The first ophthalmological check-up was 2 weeks after surgery for a persistent ductus arteriosus Botalli. The girl was 15 weeks old. Her parents had watched her dilated pupils since birth. The diameter of both pupils was 6.5 mm. They did not react to light, lid closure, or conjunctival administration of pilocarpine solutions up to 1%. A refractive error of OD +3.0 D and OS +2.5 D was measured by retinoscopy. The hypermetropia was also uninfluenced by topical locarpine 1%. Two drops of pheylephrine 2.5% caused additional pupillary dilatation of 0.5 mm. Besides the lack of accommodation and pupillary constriction, all ocular findings were regular. No chromosomal abnormalities were found. No further cases of pupillary disorders are known in the family. These findings can only result from the lack of cholinergic sensitivity or aplasia of the pupillary sphincter and ciliary muscle. The infant was supplied with bifocals and sunglasses. The near correction was spontaneous. At the age of 15 months there was a grating acuity of 20/80, which is in the normal range, as measured by preferential looking.

[Monosymptomatic pupillary dilatation caused by scopolamine patch]

A case of monosymptomatic unilateral mydriasis caused by scopolamine patches is presented. The same symptom caused by pressure from an aneurysm on the oculomotor nerve is exceptionally rare.

Internal ophthalmoplegia associated with migraine attacks

The case of a young woman presenting with repeated headache episodes associated with right eye midriasis is described. CT scan, MR of the brain and selective cerebral angiography were unremarkable. Tyramine eyedrop response suggested parasympathetic hypofunction on the affected side. The diagnosis of ophthalmoplegic migraine is proposed.

Amaurotic mydriasis

Amaurotic mydriasis is characterized by larger than normal pupils in patients with visual loss. In sought to establish whether amaurotic mydriasis can reliably identify different kinds of visual loss and whether this static measurement might prove useful in discerning "balanced" bilateral optic neuropathies where no relative afferent pupillary defect (RAPD) is detected. Patients with binocular pregeniculate visual loss, patients with balanced binocular pregeniculate loss without RAPD, and patients with monocular pregeniculate visual loss had significantly larger pupils than age-matched controls. Although pupils of patients with binocular pregeniculate visual loss (20/50 or better in one or both eyes) were significantly smaller than pupils of age-matched patients with binocular pregeniculate deficits of worse than 20/50 in one or both eyes, no such correlation between Snellen visual acuity and amaurotic mydriasis was found in patients with monocular pregeniculate visual loss. Amaurotic mydriasis is a clinically useful phenomenon that may identify pregeniculate disease in the absence of a RAPD or distinguish pregeniculate from postgeniculate visual loss.

[Reversible mydriasis and cycloplegia after isocyanate exposure]

We saw three patients working in the production of polyurethanes, who showed mydriasis and cycloplegia of unknown origin. In one patient there was also a transient opacification of corneal stroma. After discontinuation of working both mydriasis and cycloplegia resolved completely within 3-5 days. Because of the history and the analysis of chemical reactions involved in the production of polyurethanes there is strong evidence that both mydriasis and cycloplegia have been caused by topical and (/or) systemic intoxication with the aryl diet of the isocyanate molecule.