The use of pupillometry in joint and connective tissue diseases

Ocular Involvement in Systemic Sclerosis: Updated Review and New Insights on Microvascular Impairment

Systemic sclerosis (SSc) is a chronic multisystemic disease characterized by immunological activation, diffuse vasculopathy, and generalized fibrosis exhibiting a variety of symptoms. A recognized precursor of SSc is Raynaud's phenomenon, which is part of the very early disease of systemic sclerosis (VEDOSS) in combination with nailfold videocapillaroscopy (NVC) impairment. The pathophysiology of ocular involvement, alterations in internal organs, and body integumentary system involvement in SSc patients are complicated and poorly understood, with multiple mechanisms presumptively working together. The most prevalent ocular symptoms of SSc are abnormalities of the eyelids and conjunctiva as well as dry eye syndrome, due to fibroblasts' dysfunction and inflammation of the ocular surface. In particular, lagophthalmos, blepharophimosis limitation of eyelid motion, eyelid telangiectasia, and rigidity or tightening of the lids may affect up to two-third of the patients. In addition, reduction in central corneal thickness, iris defects and higher rates of glaucoma were reported. In the first reports based on retinography or fluorescein angiography, about 50% of SSc patients showed signs of vascular disease: peripheral artery occlusion, thinning of retinal pigment epithelium and choroidal capillaries, ischemic areas surrounded by intraretinal extravasation and microaneurysms, and peripheral capillary non-perfusion. Successively, thanks to the advent of optical coherence tomography angiography (OCTA), several studies highlighted significant impairment of either the choriocapillaris and retinal vascular plexuses, also correlating with NVC involvement and skin disease, even in VEDOSS disease. Given the sensitivity of this technique, ocular micro-vasculopathy may act as a tool for early SSc identification and discriminate between disease stages.

Neuromodulation of the Autonomic Nervous System in Chronic Low Back Pain: A Randomized, Controlled, Crossover Clinical Trial

Chronic pain is a societal concern influencing the autonomic nervous system. This system can be captured with automated pupillometry. The direct connection between the epidermal cells and the brain is presented as part of the central nervous system, reflecting the modulation of the autonomic system. This study's aim was to investigate if tape containing magnetic particles (TCMP) has an immediate effect on the autonomic nervous system (ANS) and influences chronic low back pain. Twenty-three subjects completed this study. Subjects were randomized to either receive the control tape (CT) or TCMP first. Each subject underwent a pain provocative pressure test on the spinous process, followed by the skin pinch test and automated pupillometry. Next, the TCMP/control tape was applied. After tape removal, a second provocative spinous process pressure test and skin pinch test were performed. Subjects returned for a second testing day to receive the other tape application. The results demonstrate that TCMP had an immediate significant effect on the autonomic nervous system and resulted in decreased chronic lower back pain. We postulate that this modulation by TCMP s has an immediate effect on the autonomic system and reducing perceived pain, opening a large field of future research.

Do static and dynamic pupillary parameters differ according to childhood, adulthood, and old age? A quantitative study in healthy volunteers

Purpose

We aimed to evaluate the normative pupillometry values and mean pupil dilatation speed in healthy individuals in different age groups in our study.

Methods

The study group included 180 eyes of 90 healthy volunteers in different age groups. Group 1 consisted of 30 participants between the ages of 6 and 18, group 2 consisted of 30 participants aged 19-40, and group 3 consisted of 30 participants aged 41-75. Scotopic, mesopic, photopic, and dynamic measurements were taken with automatic pupillometry of Sirius Topographer (CSO, Firenze, Italy). The mean pupil dilation speed at the 18^th second was calculated according to dynamic measurements.

Results

Group 1 had a significantly larger pupil diameter than groups 2 and 3 in all static and dynamic parameters, and the mean pupil dilation speed was the highest among the groups (P < 0.001 for all static and dynamic parameters). In addition, group 2 had a significantly larger pupil diameter than group 3 (P < 0.001 for all static and dynamic parameters) and the mean pupil dilation speed was faster than group 3 (P = 0.027).

Conclusion

We have presented the static and dynamic parameters and the mean speed of pupil dilatation at the 18^th second with automatic pupillometry in healthy individuals in childhood, adulthood, and old age. More studies with higher participants and younger age children are needed.

The immediate effect of a single session of pain neuroscience education on pain and the autonomic nervous system in subjects with persistent pain, a pilot study

BACKGROUND

The autonomic nervous system is a system that operates at the subconscious level and has been associated with neurobehavioral aspects of pain. Overall, persistent pain has a stimulating effect on the sympathetic nervous system. A promising emerging nonpharmacological treatment to manage persistent pain is neuroscience-based pain education. The overarching goal of neuroscience-based pain education is to change cognitions about pain and the pain experience through education. The aim was to determine the immediate and short-term impact of a neuroscience-based pain education video on the autonomic nervous system and pain in a subgroup of individuals with persistent pain.

METHODS

A convenience sample of 26 subjects were recruited for this study. Each subject indicated their pain level at the time of testing using a Visual Analogue Scale. Automated pupillometry was utilized to measure pupil diameter. After two minutes of accommodation to the goggles, the pupil was measured continuously for 60 s. Following this a 5-minute video presentation "Understanding Pain" was watched, followed by a continuous pupil measurement for 60 s. Three minutes after this measure, the final pupil diameter measurement was taken for 60 s. After completing the final pupil measure, the subject was asked to fill out a second Visual Analogue Scale and a Global Rate of Change.

OUTCOMES

Each subject completed a Global Rating of Change Scale and the mean score was 1.14 (SD = 1.61 and a SEM = 0.), supporting the hypothesis of an overall self-perceived benefit from the intervention. There was a statistically significant difference in pain following the video, P < 0.01. A significant correlation was observed between the self-perceived decrease in pain level and the Global Rating of Change score, p = 0.02. There was no statistically significant difference in the mean pupil diameter following the video with p = 0.76 for the right eye and p = 0.250 for the left eye.

DISCUSSION

This pilot study demonstrated that a 5-minute neuroscience-based pain education video reduced perceived pain in a small sample of subjects with persistent pain. Watching the neuroscience-based pain education video did not seem to result in an immediate generalized autonomic nervous system response. However, it resulted in a different reaction on each eye. This unequal response might be the result of the hemispheric lateralization of the ANS. This study supports the fact that the pain experience is determined by the balance between conscious cognitive processes and subconscious processes based on previous psychological experiences.

Ocular manifestations in patients with systemic sclerosis

Systemic sclerosis (SSc) is a rare, chronic autoimmune disease with unknown etiology. Its prominent features are fibrosis, vasculopathy and impaired immune response. Disease can also affect eyes leading to various findings in ophthalmological examination.

The objective of this study was to determine the prevalence and type of ocular involvement in patients with SSc. A systematic literature review was conducted using electronic databases. A combination of following keywords was used: “systemic sclerosis” and ophthalmology-related search terms, including the keywords “eye”, “ocular” and “ophthalmic”.

In conclusion, eyelid and conjunctival abnormalities and dry eye disease are among the most common ocular manifestations of SSc. Their diversity is connected to complexity of the disease.

Time effect for in-situ dry needling on the autonomic nervous system, a pilot study

Study design: Pilot study.Background: Dry needling has been an emerging treatment option for physical therapists over the last decade. Despite the fact that studies have demonstrated the overall benefit of dry needling, there is no clear understanding how long needles should be left in place (situ). This pilot study investigated the effects of needles remaining in situ based on autonomic responses over time.Methods: A convenience sample of 21 subjects were recruited for this study. Automated pupillometry was utilized to obtain a direct measure of autonomic nervous system activity. Directly following a baseline measurement, 8 type J Seirin Acupuncture needles were inserted paravertebral at the C7-T3 segments. A total of 8 post-needling 60 seconds pupil measurements were taken at 3 minutes intervals for 24 minutes post needling.Outcomes: A statistical significant difference in mean pupil diameter was found following the needle intervention (p < .01), which implies an increased sympathetic activity. This subject sample had a statistically significantly larger mean pupil diameter immediately after the needling, which lasted until measure point 7, at 18 minutes (P < .05). At measure point 8 there was no longer a statistical significant difference compared to the premeasurement measure.Discussion: The results of this study provide evidence that dry needling results in a significant increased activity of the sympathetic nervous system for up to 18 minutes. Between 18 and 21 minutes autonomic activity returned to a non-significant difference compared to baseline. The results of this study could assist clinicians in clinical decision making to determine needle placement time.

Pupillary autonomic dysfunction in patients with ANCA-associated vasculitis

OBJECTIVE

To assess autonomic function by infrared dynamic pupillometry in patients with ANCA-vasculitis (AAV) in correlation to autonomic symptoms, disease specific clinical parameters and cardiovascular reflex tests.

METHODS

Patients with AAV and healthy controls underwent pupillometry at rest and after sympathetic stimulation (cold pressor test). Three parasympathetic parameters (amplitude, relative amplitude, maximum constriction velocity) and one sympathetic parameter (late dilatation velocity) were assessed. Results were correlated with clinical parameters, symptoms of autonomic dysfunction (COMPASS31 questionnaire), heart rate variability during deep breathing test and blood pressure response to pain.

RESULTS

23 patients and 18 age-matched controls were enrolled. Patients had a smaller amplitude (1.44 vs. 1.70 mm; p = 0.009) and a slower constriction velocity (4.15 vs. 4.71 mm/s; p = 0.028) at baseline and after sympathetic stimulation (1.47 vs. 1.81 mm, p = 0.001; 4.38 vs. 5.19 mm/s, p = 0.006, respectively). Relative amplitude was significantly smaller in patients after sympathetic stimulation (28.6 vs. 32.5%; p = 0.043), but not at baseline. There was no difference in sympathetic pupillary response between the groups. In patients, parasympathetic pupil response was correlated negatively with age and positively with parasympathetic cardiac response. After adjusting for age, no significant correlation was observed with clinical parameters. However, there was a trend towards a negative correlation with disease duration, vasculitis damage index and CRP.

CONCLUSION

Patients with AAV exhibit parasympathetic pupillary autonomic dysfunction. Although correlations were weak and not significant, pupillary autonomic dysfunction is rather linked to chronic damage than to active inflammation or symptoms of autonomic dysfunction.

Adie's Tonic Pupil in Systemic Sclerosis: A Rare Association

We report a rare association of Adie's tonic pupil in a patient with systemic sclerosis who was otherwise systemically stable. This paper is an effort to unravel whether the tonic pupil and systemic sclerosis are an association by chance (which may be the case) or systemic sclerosis is the source of the tonic pupil.

Pupillometric findings in children with obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) leads to intermittent hypoxia, activation of the sympathetic nervous system, and eventually cardiovascular morbidity. Alterations in autonomic nervous system (ANS) tone and reflexes are likely to play major roles in OSA-associated morbidities, and have been identified in a subset of children with OSA.

OBJECTIVES

To evaluate whether pupillometry, a noninvasive and rapid bedside test for the assessment of autonomic nervous system dysfunction (ANS), would detect abnormal ANS function in children with OSA.

METHODS

Children ages 2-12 years underwent polysomnography (PSG), and were divided based on PSG findings into two groups; Habitual Snorers (HS; AHI < 1 h/TST, n = 17) and OSA (AHI > 1 h/TST, n = 49), the latter then sub-divided into AHI severity categories (>1 but <5, >5 but <10, and >10 h/TST). Pupillometric measurements were performed during the clinic visit in a dark room using an automated pupillometer device.

RESULTS

A total of 66 subjects with a mean age of 7.3 ± 2.6 years were recruited. There were no statistically significant differences between any of the groups, even when comparing severe OSA (n = 15) and HS in any of the measures related to pupillary reflexes. However, mild, yet significant increases in systolic blood pressure and morning plasma norepinephrine levels were detected in the severe OSA group.

CONCLUSION

Although ANS perturbations are clearly present in a proportion of children with OSA, particularly those with severe disease, pupillary responses do not appear to provide a sensitive method for the detection of ANS dysfunction in OSA children.

Immediate effects of a thoracic spine thrust manipulation on the autonomic nervous system: a randomized clinical trial

Thoracic spine manipulation has been shown to be effective for the management of neck pain. The purpose of this study was to investigate the immediate effect of a T3-T4 spinal thrust manipulation on autonomic nervous system activity in subjects with chronic cervical pain. An additional aim was to determine if the manipulation resulted in an immediate pain relief in patients with chronic neck pain when compared to a placebo intervention. One hundred subjects with chronic neck pain were randomly assigned to receive either a thoracic thrust manipulation or a placebo intervention. The Friedman's test was used to evaluate the change in pupil diameter within both groups. The Wilcoxen signed-ranks test was used to explore pupil changes over time and to make paired comparisons of the pupil change between the groups. The Mann-Whitney U test was used to compare the change in pain perception for the chronic cervical pain group subjects receiving either the thrust manipulation or the placebo intervention. The results demonstrated that manipulation did not result in a change in sympathetic activity. Additionally, there was no significant difference in the subject's pain perception (P = 0.961) when comparing the effects of the thrust manipulation to the placebo intervention within this group of subjects with chronic neck pain. The clinical impression of this study is that manipulation of the thoracic spine may not be effective in immediately reducing pain in patients with chronic neck pain.

New insights into the diagnosis and treatment of neurotrophic keratopathy

Abnormalities of the ocular surface can be acquired or inherited disorders of the central nervous system. Loss of neural stimulation from the sensory division of the trigeminal nerve or from the autonomic nervous system can have devastating consequences on corneal epithelial wound healing and the precorneal tear film, leading to decreased vision. The pathogenesis of neurotrophic keratopathy is reviewed, and treatment modalities are recommended.

Clinical implications of quantitative infrared pupillometry in neurosurgical patients

Pupillometry has been widely employed in the evaluation of a large number of pathological conditions, including intracranial pathology. The recent introduction of a portable, user-friendly, infrared pupillometer (ForSite, NeurOptics Inc., Irvine, CA) has enabled the accurate and reproducible measurement of several pupillary parameters, such as maximum and minimum apertures, constriction and dilation velocities, and latency period. It should be noted that various clinical conditions, especially neurological and ocular diseases, as well as numerous medications, may interfere with the measurements. Furthermore, a number of physiological parameters, such as the intensity of retinal illumination, the level of patient's alertness, the intensity of ambient light, as well as the time of day that the examination is performed may alter the obtained values. The potential implications of pupillometry in the clinical assessment of neurosurgical patients, including its complex relationship to intracranial pressure changes, mandate the undertaking of prospective clinical studies validating the clinical significance of this noninvasive, diagnostic modality.

Sjögren's syndrome: the diagnostic potential of early oral manifestations preceding hyposalivation/xerostomia

Sjögren's syndrome (SS) is a systemic autoimmune exocrinopathy that affects mainly the salivary and lacrimal glands, leading to progressive reduction in saliva and tear flow. Although the underlying immuno-mediated glandular destruction is thought to develop slowly over several years, a long delay from the start of the symptoms to final diagnosis has been frequently reported. A limited knowledge concerning SS natural history is among the major causes of the actual diagnostic delay. Although very few studies have been focused on the analysis of SS early clinical onset, a series of oral features preceding xerostomia/hyposalivation development in patients eventually diagnosed as having SS have been reported. Sialochemistry alterations, salivary gland swelling, early dental loss and sialorrhea have been observed before the onset of typical signs and symptoms (namely xerostomia and/or hyposalivation), which usually lead to SS clinical presentation and diagnosis. Here we suggest, after evaluating available data, that the traditional 'untouchable' association between SS and xerostomia/hyposalivation might probably be reconsidered, and that astute clinicians should not underestimate the possible presence or development of SS in patients without xerostomia/hyposalivation and presenting these atypical early oral features.

Damage of cutaneous peripheral nervous system evolves differently according to the disease phase and subset of systemic sclerosis

OBJECTIVE

Evidence shows that peripheral nervous system (PNS) is involved in systemic sclerosis (SSc), but few morphological studies have assessed the ultrastructural pathological modifications. The aim was to study ultrastructural modifications of skin PNS fibres in SSc according to subsets [limited SSc (lSSc) and diffuse SSc (dSSc)] and phases (early and advanced) of the disease.

METHODS

Skin biopsies were taken from the forearms of 23 SSc patients (11 lSSc and 12 dSSc) and 10 controls. Each biopsy was processed for transmission electron microscopy (TEM).

RESULTS

At TEM, observation in skin from early lSSc, signs of inflammation were evident, while PNS fibres were not damaged. The microvascular wall showed hypertrophic endothelial cells bulging into the lumen. In advanced lSSc, fibrosis prevailed on inflammation and slight ultrastructural alterations of PNS fibres were evident in the papillary derma. In early dSSc, ultrastructural alterations of PNS fibres, similar to those observed in the advanced phase of lSSc, were found together with signs of inflammation and fibrosis. In advanced dSSc, in the papillary and reticular dermis PNS fibres were reduced and showed relevant ultrastructural alterations.

CONCLUSIONS

In SSc, PNS ultrastructure damage is linked to the progression and severity of skin involvement. The alterations evolve from the early to the advanced phase mainly in the diffuse subset. In particular, the severe PNS lesions found in advanced lSSc are already present and widely diffuse in early dSSc and the microvascular involvement in early lSSc seems to precede the modification of the PNS in the skin. Thus, an early therapeutic approach can be useful to reduce the progression of PNS and skin damage in SSc patients.