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Phenotypes and genotypes underlying paradoxical pupillary reaction in children. J AAPOS 2022; 26:205-207. [PMID: 35659618 DOI: 10.1016/j.jaapos.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/03/2022] [Accepted: 04/06/2022] [Indexed: 11/20/2022]
Abstract
Paradoxical pupillary reaction (initial pupillary constriction to darkness) has been most associated with the inherited retinal disorders congenital stationary night blindness and achromatopsia. However, underlying genotypes and associations with other pediatric retinal phenotypes are not well documented. A retrospective review for paradoxical pupillary reaction was performed at the Ocular Genetics Clinic of Cleveland Clinic Abu Dhabi (2016-2020). Four children from 4 different families were identified, all of whom had had genetic confirmation of the clinical diagnosis. Associated pathogenic variants were in TRPM1 (biallelic; two boys; congenital stationary night blindness), CABP4 (biallelic; one boy, congenital cone-rod synaptic disorder) and PAX2 (monoallelic; one girl, papillorenal syndrome). Genetically confirmed affected relatives of the 2 probands with TRPM1-related congenital stationary night blindness did not show the phenomenon. This study documents novel genotypes and phenotypes that can be associated with paradoxical pupillary reaction in children and confirms potential intrafamilial variable expressivity for the phenomenon.
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Papageorgiou E, Gottlob I. The challenges faced by clinicians diagnosing and treating infantile nystagmus Part I: diagnosis. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2021.1860754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Eleni Papageorgiou
- Ulverscroft Eye Unit, Neuroscience, Psychology and Behaviour, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, University of Leicester, Leicester, UK
- Department of Ophthalmology, University Hospital of Larissa, Larissa, Greece
| | - Irene Gottlob
- Ulverscroft Eye Unit, Neuroscience, Psychology and Behaviour, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, University of Leicester, Leicester, UK
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Abstract
In recent years, we have made enormous strides in elucidating the phenomenology of congenital nystagmus. The purpose of this review is to briefly summarize our current understanding of congenital nystagmus in terms of its clinical symptomatology, pathophysiology, differential diagnosis, and ancillary testing, and clinical management. Finally, this discussion provides the reader with an armamentarium of clinical pearls to facilitate diagnosis of the numerous sensory visual disorders that can underlie congenital nystagmus.
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Affiliation(s)
- Michael C Brodsky
- Departments of Ophthalmology and Neurology, Mayo Clinic , Rochester, Minnesota
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Vincent SJ. The use of contact lenses in low vision rehabilitation: optical and therapeutic applications. Clin Exp Optom 2017; 100:513-521. [PMID: 28664572 DOI: 10.1111/cxo.12562] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/25/2017] [Accepted: 03/24/2017] [Indexed: 12/28/2022] Open
Abstract
Ocular pathology that manifests at an early age has the potential to alter the vision-dependent emmetropisation mechanism, which co-ordinates ocular growth throughout childhood. The disruption of this feedback mechanism in children with congenital or early-onset visual impairment often results in the development of significant ametropia, including high levels of spherical refractive error, astigmatism and anisometropia. This review examines the use of contact lenses as a refractive correction, low vision aid and therapeutic intervention in the rehabilitation of patients with bilateral, irreversible visual loss due to congenital ocular disease. The advantages and disadvantages of the use of contact lenses for increased magnification (telescopes and microscopes) or field expansion (reverse telescopes) are discussed, along with the benefits and practical considerations for the correction of pathological high myopia. The historical and present use of therapeutic tinted contact lenses to reduce photosensitivity and nystagmus in achromatopsia, albinism and aniridia are also presented, including clinical considerations for the contact lens practitioner. In addition to the known optical benefits in comparison to spectacles for high levels of ametropia (an improved field of view for myopes and fewer inherent oblique aberrations), contact lenses may be of significant psycho-social benefit for patients with low vision, due to enhanced cosmesis and reduced conspicuity and potential related effects of improved self-esteem and peer acceptance. The contact lens correction of patients with congenital vision impairment can be challenging for both practitioner and patient but should be considered as a potential optical or therapeutic solution in modern low vision rehabilitation.
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Affiliation(s)
- Stephen J Vincent
- Contact Lens and Visual Optics Laboratory, School of Optometry and Vision Science, Queensland University of Technology, Kelvin Grove, Queensland, Australia
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Yeh CY, Koehl KL, Harman CD, Iwabe S, Guzman JM, Petersen-Jones SM, Kardon RH, Komáromy AM. Assessment of Rod, Cone, and Intrinsically Photosensitive Retinal Ganglion Cell Contributions to the Canine Chromatic Pupillary Response. Invest Ophthalmol Vis Sci 2017; 58:65-78. [PMID: 28061512 PMCID: PMC5231906 DOI: 10.1167/iovs.16-19865] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Purpose The purpose of this study was to evaluate a chromatic pupillometry protocol for specific functional assessment of rods, cones, and intrinsically photosensitive retinal ganglion cells (ipRGCs) in dogs. Methods Chromatic pupillometry was tested and compared in 37 dogs in different stages of primary loss of rod, cone, and combined rod/cone and optic nerve function, and in 5 wild-type (WT) dogs. Eyes were stimulated with 1-s flashes of dim (1 cd/m2) and bright (400 cd/m2) blue light (for scotopic conditions) or bright red (400 cd/m2) light with 25-cd/m2 blue background (for photopic conditions). Canine retinal melanopsin/Opn4 was cloned, and its expression was evaluated using real-time quantitative reverse transcription-PCR and immunohistochemistry. Results Mean ± SD percentage of pupil constriction amplitudes induced by scotopic dim blue (scDB), scotopic bright blue (scBB), and photopic bright red (phBR) lights in WT dogs were 21.3% ± 10.6%, 50.0% ± 17.5%, and 19.4% ± 7.4%, respectively. Melanopsin-mediated responses to scBB persisted for several minutes (7.7 ± 4.6 min) after stimulus offset. In dogs with inherited retinal degeneration, loss of rod function resulted in absent scDB responses, followed by decreased phBR responses with disease progression and loss of cone function. Primary loss of cone function abolished phBR responses but preserved those responses to blue light (scDB and scBB). Although melanopsin/Opn4 expression was diminished with retinal degeneration, melanopsin-expressing ipRGCs were identified for the first time in both WT and degenerated canine retinas. Conclusions Pupil responses elicited by light stimuli of different colors and intensities allowed differential functional assessment of canine rods, cones, and ipRGCs. Chromatic pupillometry offers an effective tool for diagnosing retinal and optic nerve diseases.
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Affiliation(s)
- Connie Y Yeh
- College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, United States 2School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Kristin L Koehl
- College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, United States
| | - Christine D Harman
- College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, United States
| | - Simone Iwabe
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - José M Guzman
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Simon M Petersen-Jones
- College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, United States
| | - Randy H Kardon
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa, United States 4Veterans Affairs Health Care System, Iowa City, Iowa, United States
| | - András M Komáromy
- College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, United States 2School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Brodsky MC. Marshall M. Parks Memorial Lecture: Ocular Motor Misbehavior in Children: Where Neuro-Ophthalmology Meets Strabismus. Ophthalmology 2017; 124:835-842. [PMID: 28385301 DOI: 10.1016/j.ophtha.2017.01.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/24/2017] [Accepted: 01/26/2017] [Indexed: 01/19/2023] Open
Abstract
Clinical diagnosis has been supplemented by neuroimaging advances, genetic discoveries, and molecular research to generate new neurobiological discoveries pertaining to early maldevelopment of ocular motor control systems. In this focused review, I examine recent paradigm shifts that have transformed our understanding of pediatric ocular motor disease at the prenuclear and infranuclear levels. The pathogenesis of complex ocular motor disorders, such as paradoxical pupillary constriction to darkness, benign tonic upgaze of infancy, congenital fibrosis syndrome, and the constellation of unique eye movements that accompany Joubert syndrome, are elucidated.
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Affiliation(s)
- Michael C Brodsky
- Departments of Ophthalmology and Neurology, Mayo Clinic, Rochester, Minnesota.
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Abstract
Pupil size is determined by the interaction of the parasympathetic and the sympathetic nervous system. The parasympathetic system conducts the light reaction with its major center in the dorsal midbrain. The sympathetic nervous system acts either directly on the dilator muscle (peripherally) or centrally by inhibiting the Edinger-Westphal nucleus. Psychosensory reactions are transmitted via the sympathetic system. The afferent input of the light reflex system in humans is characteristically wired, allowing a detailed analysis of a lesion of the afferent input. Even in humans a subgroup of ganglion cells containing melansopsin plays an important role as a light sensor for the pupillary system. To diagnose normal pupillary function, pupils need to be isocoric and react bilaterally equally to light. Anisocoria indicates a problem of the efferent pupillary pathway. Pupillary disorders may involve the afferent pathways (relative afferent pupillary defect) or the efferent pathways. Physiological anisocoria is a harmless condition that has to be distinguished from Horner's syndrome. In this case pharmacological testing with cocaine eye-drops is helpful. Disorders of the parasympathetic system will impair the light response. They include dorsal midbrain syndrome, third-nerve palsy, and tonic pupil. Tonic pupils are mainly idiopathic and do not need imaging. Disorders of the iris, including application of cholinergic agents, need also to be considered in impaired pupillary light reaction.
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Affiliation(s)
- Helmut Wilhelm
- Centre for Ophthalmology, University Eye Hospital, University of Tübingen, Tübingen, Germany.
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Thompson S, Whiting REH, Kardon RH, Stone EM, Narfström K. Effects of hereditary retinal degeneration due to a CEP290 mutation on the feline pupillary light reflex. Vet Ophthalmol 2010; 13:151-7. [DOI: 10.1111/j.1463-5224.2010.00772.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hamed LM. Visual Impairment in Infants: Localizing the Lesion on a Clinical Basis. Semin Ophthalmol 2009. [DOI: 10.3109/08820539709045845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ben Simon GJ, Abraham FA, Melamed S. Pingelapese achromatopsia: correlation between paradoxical pupillary response and clinical features. Br J Ophthalmol 2004; 88:223-5. [PMID: 14736779 PMCID: PMC1771990 DOI: 10.1136/bjo.2003.027284] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To evaluate the paradoxical pupillary constriction in darkness in patients with Pingelapese achromatopsia (PA), and to describe a connection between this phenomenon and the clinical features. METHODS 27 patients with PA were examined. All underwent a full ophthalmic examination which included Snellen visual acuity and ophthalmoscopy. Colour vision examination was performed with Ishihara pseudoisochromatic plates and also with a colour plate consisting of five basic colours (red, green, purple, yellow, and orange). Paradoxical pupillary response was examined and documented with a special infrared video camera. Pupils' images were analysed using the Scion Image program and the ratio of pupil size in darkness to its size in light was calculated and recorded. RESULTS Mean visual acuity was 20/400 (range 20/80-20/800). Colour vision examination showed a mean of 3.2 (SD 1.5) (range 1-5) of Ishihara colour plates, and 0.5 (0.75) (0-3) of basic colour plates. 23 patients (85%) had paradoxical pupillary constriction in darkness. Mean dark/light ratio of pupillary area was 0.86 (range 0.5-1.6). In patients with marked paradoxical pupillary constriction there was a significant correlation of visual acuity and Ishihara score. CONCLUSIONS Clinical manifestations of achromatopsia include total colour blindness, low visual acuity (mean of 20/400), horizontal pendular or rotatory nystagmus, and photophobia. Most patients have paradoxical pupillary constriction in darkness. When this response is brisk it seems to correlate with lower visual acuity and lower Ishihara score.
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Affiliation(s)
- G J Ben Simon
- The Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel 52621.
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Lambert SR, Taylor D, Kriss A. The infant with nystagmus, normal appearing fundi, but an abnormal ERG. Surv Ophthalmol 1989; 34:173-86. [PMID: 2694415 DOI: 10.1016/0039-6257(89)90101-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Many retinal disorders present during infancy with nystagmus, decreased vision, and normal-appearing fundi, but an abnormal ERG. The most common of these disorders are Leber's congenital amaurosis, achromatopsia, and congenital stationary night-blindness. Other disorders with similar ocular manifestations may be associated with a variety of life-threatening systemic abnormalities. This review describes the clinical, electrophysiological, and laboratory findings that can be used to distinguish among these conditions.
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Affiliation(s)
- S R Lambert
- Department of Ophthalmology, Hospital for Sick Children, London, England
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Affiliation(s)
- T A Cox
- Department of Ophthalmology, University of British Columbia, Vancouver, Canada
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Abstract
Patients with congenital achromatopsia and congenital stationary night blindness have been known to show a transient pupillary constriction to darkness. We examined 50 normal subjects and 108 patients with retinal and optic nerve dysfunction to see if any had an initial pupillary constriction to darkness. We used a new infrared television apparatus. Four patients with congenital stationary night blindness, four with achromatopsia, two with bilateral optic neuritis, and one with dominant optic atrophy showed the phenomenon. In the patients who showed this unusual pupillary response to darkness it was the first observable event every time the lights were turned off. The constriction could usually be seen with a handlight, and it was similar in latency to the normal pupillary dilatation to darkness. Pupillary constriction to darkness is a clinically valuable sign that can be used in the detection of congenital retinal disease in children with poor vision.
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