Parasympathetic Nervous System Dysfunction, as Identified by Pupil Light Reflex, and Its Possible Connection to Hearing Impairment

Utility of iPhone-Based Pupillometry in Comparing Pupillary Dynamics Between Sport Concussed Subjects With Photosensitivity and Healthy Controls

BACKGROUND

To compare the pupillary dynamics using an iPhone-based pupillometry technique in subjects with sports concussion with photosensitivity and aged-matched controls.

METHODS

Fifty subjects with sports concussion were compared with 50 aged-matched healthy controls. Athletes with persistent concussive symptoms for 1 year or more after the initial injury were included. All the subjects underwent a Post-Concussion Symptom Scale (PCSS) administration followed by pupillary dynamics measurement using an iPhone-based application (Reflex-Pro PLR analyzer).

RESULTS

The mean age was 27 ± 4 years in the concussed group and 26 ± 5 years in the control group. In subjects with concussion, there was a significant decrease in the mean of the following parameters: average constriction speed (1.10 ± 0.15 vs 1.78 ± 0.12 mm/s; P < 0.001), maximum constriction speed (2.05 ± 0.26 vs 3.84 ± 0.28 mm/s; P < 0.001), average diameter (3.64 ± 0.12 vs 0.36 ± 0.05 mm; P < 0.001), maximum diameter (4.75 ± 0.17 vs 5.23 ± 0.16 mm; P < 0.001), and minimum diameter (2.75 ± 0.17 vs 3.64 ± 0.11 mm; P < 0.001). An increase in the following parameters was noted in concussion vs age-matched controls: dilation release amplitude (0.54 ± 0.96 vs 0.36 ± 0.05 mm; P < 0.001) and latency (0.25 ± 0.05 vs 0.21 ± 0.02 s; P < 0.001). Subjects with concussion with photosensitivity exhibited increased dilation release amplitudes ( P < 0.001).

CONCLUSIONS

Individuals with sport concussion had impairment in pupillary constriction velocities, latency, and diameter in more than 1 year after concussion. The increase in dilation release amplitude among subjects with concussion might serve as a biomarker in diagnosing the underlying symptom of photosensitivity. The iPhone-based pupillometry could serve as a convenient and diagnostic tool in diagnosing these symptoms.

Symptoms Associated With Exercise Intolerance and Resting Heart Rate Following Mild Traumatic Brain Injury

OBJECTIVES

People may experience a myriad of symptoms after mild traumatic brain injury (mTBI), but the relationship between symptoms and objective assessments is poorly characterized. This study sought to investigate the association between symptoms, resting heart rate (HR), and exercise tolerance in individuals following mTBI, with a secondary aim to examine the relationship between symptom-based clinical profiles and recovery.

METHODS

Prospective observational study of adults aged 18 to 65 years who had sustained mTBI within the previous 7 days. Symptoms were assessed using the Post-Concussion Symptom Scale, HR was measured at rest, and exercise tolerance was assessed using the Buffalo Concussion Bike Test. Symptom burden and symptom-based clinical profiles were examined with respect to exercise tolerance and resting HR.

RESULTS

Data from 32 participants were assessed (mean age 36.5 ± 12.6 years, 41% female, 5.7 ± 1.1 days since injury). Symptom burden (number of symptoms and symptom severity) was significantly associated with exercise intolerance ( P = .002 and P = .025, respectively). Physiological and vestibular-ocular clinical profile composite groups were associated with exercise tolerance ( P = .001 and P = .014, respectively), with individuals who were exercise intolerant having a higher mean number of symptoms in each profile than those who were exercise tolerant. Mood-related and autonomic clinical profiles were associated with a higher resting HR (>80 bpm) ( P = .048 and P = .028, respectively), suggesting altered autonomic response for participants with symptoms relating to this profile. After adjusting for age and mechanism of injury (sports- or non-sports-related), having a higher mood-related clinical profile was associated with persisting symptoms at 3 months postinjury (adjusted odds ratio = 2.08; 95% CI, 1.11-3.90; P = .013).

CONCLUSION

Symptom-based clinical profiles, in conjunction with objective measures such as resting HR and exercise tolerance, are important components of clinical care for those having sustained mTBI. These results provide preliminary support for the concept that specific symptoms are indicative of autonomic dysfunction following mTBI.

Characterising cerebrovascular reactivity and the pupillary light response-a comparative study

Introduction

Smooth muscle is integral to multiple autonomic systems, including cerebrovascular dynamics through vascular smooth muscle cells and in ocular muscle dynamics, by regulating pupil size. In the brain, smooth muscle function plays a role in cerebrovascular reactivity (CVR) that describes changes in blood vessel calibre in response to vasoactive stimuli. Similarly, pupil size regulation can be measured using the pupillary light response (PLR), the pupil's reaction to changes in light levels. The primary aim of this study was to explore the interplay between cerebral blood flow and pupil dynamics, evaluated using CVR and PLR, respectively.

Methods

A total of 20 healthy adults took part in a CVR gas stimulus protocol and a light and dark flash PLR protocol. CVR was calculated as the blood flow velocity change in the middle cerebral artery, measured using transcranial Doppler ultrasound in response to a 5% increase in CO2. Multiple PLR metrics were evaluated with a clinical pupillometer.

Results

CVR and PLR metrics were all within the expected physiological ranges for healthy adults. Nine different PLR metrics, assessed through the light and dark flash protocols, were compared against CVR. A significant negative relationship was observed between the latency of the PLR in the dark flash protocol and CVR. No statistically significant relationships were found between CVR and other PLR metrics.

Conclusion

This is the first study to investigate the relationship between cerebral blood flow and pupil dynamics. A significant relationship between dark flash latency and CVR was observed. Future work includes evaluating these relationships using more robust CVR and PLR measurement techniques in a larger, more diverse cohort. Notably, more research is warranted into the PLR using a dark flash protocol and its connection to cerebrovascular function.

A hybrid approach for driver drowsiness detection utilizing practical data to improve performance system and applicability

BACKGROUND

Numerous systems for detecting driver drowsiness have been developed; however, these systems have not yet been widely used in real-time.

OBJECTIVE

The purpose of this study was to investigate at the feasibility of detecting alert and drowsy states in drivers using an integration of features from respiratory signals, vehicle lateral position, and reaction time and out-of-vehicle ways of data collection in order to improve the system's performance and applicability in the real world.

METHODS

Data was collected from 25 healthy volunteers in a driving simulator-based study. Their respiratory activity was recorded using a wearable belt and their reaction time and vehicle lateral position were measured using tests developed on the driving simulator. To induce drowsiness, a monotonous driving environment was used. Different time domain features have been extracted from respiratory signals and combined with the reaction time and lateral position of the vehicle for modeling. The observer of rating drowsiness (ORD) scale was used to label the driver's actual states. The t-tests and Man-Whitney test was used to select only statistically significant features (p < 0.05), that can differentiate between the alert and drowsy states effectively. Significant features then combined to investigate the improvement in performance using the Multilayer Perceptron (MLP), the Support Vector Machines (SVMs), the Decision Trees (DTs), and the Long Short Term Memory (LSTM) classifiers. The models were implemented in Python library 3.6.

RESULTS

The experimental results illustrate that the support vector machine classifier achieved accuracy of 88%, precision of 85%, recall of 83%, and F1 score of 84% using selected features.

CONCLUSION

These results indicate the possibility of very accurate detection of driver drowsiness and a viable solution for a practical driver drowsiness system based on combined measurement using less-intrusive and out-of-vehicle recording methods.

Impact of SNR, peripheral auditory sensitivity, and central cognitive profile on the psychometric relation between pupillary response and speech performance in CI users

Despite substantial technical advances and wider clinical use, cochlear implant (CI) users continue to report high and elevated listening effort especially under challenging noisy conditions. Among all the objective measures to quantify listening effort, pupillometry is one of the most widely used and robust physiological measures. Previous studies with normally hearing (NH) and hearing-impaired (HI) listeners have shown that the relation between speech performance in noise and listening effort (as measured by peak pupil dilation) is not linear and exhibits an inverted-U shape. However, it is unclear whether the same psychometric relation exists in CI users, and whether individual differences in auditory sensitivity and central cognitive capacity affect this relation. Therefore, we recruited 17 post-lingually deaf CI adults to perform speech-in-noise tasks from 0 to 20 dB SNR with a 4 dB step size. Simultaneously, their pupillary responses and self-reported subjective effort were recorded. To characterize top-down and bottom-up individual variabilities, a spectro-temporal modulation task and a set of cognitive abilities were measured. Clinical word recognition in quiet and Quality of Life (QoL) were also collected. Results showed that at a group level, an inverted-U shape psychometric curve between task difficulty (SNR) and peak pupil dilation (PPD) was not observed. Individual shape of the psychometric curve was significantly associated with some individual factors: CI users with higher clinical word and speech-in-noise recognition showed a quadratic decrease of PPD over increasing SNRs; CI users with better non-verbal intelligence and lower QoL showed smaller average PPD. To summarize, individual differences in CI users had a significant impact on the psychometric relation between pupillary response and task difficulty, hence affecting the interpretation of pupillary response as listening effort (or engagement) at different task difficulty levels. Future research and clinical applications should further characterize the possible effects of individual factors (such as motivation or engagement) in modulating CI users' occurrence of 'tipping point' on their psychometric functions, and develop an individualized method for reliably quantifying listening effort using pupillometry.

Pupil light reflex dynamics in Parkinson's disease

Introduction

Visual disturbance is common symptom in Parkinson's disease (PD), and defective pupil light reflex (PLR) is an anticipated contributing factor that may be associated to the presence of autonomic dysfunction, which is a common non-motor feature of PD. Studies investigating the intercorrelation between PLR and dysautonomia in PD are limited.

Methods

The aim of this study was to investigate differences of PLR parameters, measured by eye-tracker, between patients with PD, with and without signs of dysautonomia, and healthy controls (HC). In total, 43 HC and 50 patients with PD were recruited and PLR parameters were measured with Tobii Pro Spectrum, during a long (1,000 ms) and a short (100 ms) light stimulus. Presence of orthostatic hypotension (OH) was used as proxy marker of dysautonomia. Linear mixed-effects model and non-parametric comparative statistics were applied to investigate differences among groups.

Results

Peak constriction velocity was slower in PD compared with HC, after adjustment for age and sex in the mixed model, and the difference was greater in the subgroup of PD with OH (unadjusted). Dilation amplitude and velocity were also gradually slower in HC vs. PD without OH vs. PD with OH (unadjusted for confounders). In the mixed model, age was significant predictor of dilation response.

Discussion

Our results support previous observations on defective PLR in PD, evaluated with eye-tracker, and show a possible association with autonomic dysfunction. Further studies with more patients and rigorous evaluation of autonomic dysfunction are needed to validate these findings.

The impact of Alzheimer's disease risk factors on the pupillary light response

Alzheimer's disease (AD) is the leading cause of dementia, and its prevalence is increasing and is expected to continue to increase over the next few decades. Because of this, there is an urgent requirement to determine a way to diagnose the disease, and to target interventions to delay and ideally stop the onset of symptoms, specifically those impacting cognition and daily livelihood. The pupillary light response (PLR) is controlled by the sympathetic and parasympathetic branches of the autonomic nervous system, and impairments to the pupillary light response (PLR) have been related to AD. However, most of these studies that assess the PLR occur in patients who have already been diagnosed with AD, rather than those who are at a higher risk for the disease but without a diagnosis. Determining whether the PLR is similarly impaired in subjects before an AD diagnosis is made and before cognitive symptoms of the disease begin, is an important step before using the PLR as a diagnostic tool. Specifically, identifying whether the PLR is impaired in specific at-risk groups, considering both genetic and non-genetic risk factors, is imperative. It is possible that the PLR may be impaired in association with some risk factors but not others, potentially indicating different pathways to neurodegeneration that could be distinguished using PLR. In this work, we review the most common genetic and lifestyle-based risk factors for AD and identify established relationships between these risk factors and the PLR. The evidence here shows that many AD risk factors, including traumatic brain injury, ocular and intracranial hypertension, alcohol consumption, depression, and diabetes, are directly related to changes in the PLR. Other risk factors currently lack sufficient literature to make any conclusions relating directly to the PLR but have shown links to impairments in the parasympathetic nervous system; further research should be conducted in these risk factors and their relation to the PLR.

PupillOmetry for preDIction of DeliriUM in ICU (PODIUM): protocol for a prospective multicentre cohort study

INTRODUCTION

Delirium is a severe complication that is associated with short-term adverse events, prolonged hospital stay and neurological sequelae in survivors. Automated pupillometry is an easy-to-use device that allows for accurate objective assessment of the pupillary light responses in comatose patients in the intensive care unit (ICU). Whether automated pupillometry might predict delirium in critically ill patients is not known. We hypothesise that automated pupillometry could predict the occurrence of delirium in critically ill patients without primary brain injury, requiring more than 48 hours of invasive mechanical ventilation in the ICU.

METHODS AND ANALYSIS

The PupillOmetry for preDIction of DeliriUM in ICU (PODIUM) study is a prospective cohort study, which will be conducted in eight French ICUs in the Paris area. We aim to recruit 213 adult patients requiring invasive mechanical ventilation for more than 48 hours. Automated pupillometry (Neurological Pupil Index; NPi-200, Neuroptics) will be assessed two times per day for 7 days. Delirium will be assessed using the Confusion Assessment Method in ICU two times per day over 14 days in non-comatose patients (Richmond Agitation and Sedation Scale ≥-3).The predictive performances of the seven automated pupillometry parameters (ie, pupillary diameter, variation of the pupillary diameter, pupillary constriction speed, pupillary dilatation speed, photomotor reflex latency, NPi and symmetry of pupillary responses) measured to detect the delirium occurrence within 14 days will be the main outcomes. Secondary outcomes will be the predictive performances of the seven automated pupillometry parameters to detect complications related to delirium, ICU length of stay, mortality, functional and cognitive outcomes at 90 days.

ETHICS AND DISSEMINATION

The PODIUM study has been approved by an independent ethics committee, the Comité de Protection des Personnes (CPP) OUEST IV-NANTES (CPP21.02.15.45239 32/21_3) on 06 April 2021). Participant recruitment started on 15 April 2022. Results will be published in international peer-reviewed medical journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT05248035; clinicaltrials.gov.

Sensory sensitivity after acquired brain injury: A systematic review

Patients with acquired brain injury frequently report experiencing sensory stimuli as abnormally under- (sensory hyposensitivity) or overwhelming (sensory hypersensitivity). Although they can negatively impact daily functioning, these symptoms are poorly understood. To provide an overview of the current evidence on atypical sensory sensitivity after acquired brain injury, we conducted a systematic literature review. The primary aim of the review was to investigate the behavioural and neural mechanisms that are associated with self-reported sensory sensitivity. Studies were included when they studied sensory sensitivity in acquired brain injury populations, and excluded when they were not written in English, consisted of non-empirical research, did not study human subjects, studied pain, related sensory sensitivity to peripheral injury or studied patients with a neurodegenerative disorder, meningitis, encephalitis or a brain tumour. The Web of Science, PubMed and Scopus databases were searched for appropriate studies. A qualitative synthesis of the results of the 81 studies that were included suggests that abnormal sensory thresholds and a reduced information processing speed are candidate behavioural mechanisms of atypical subjective sensory sensitivity after acquired brain injury. Furthermore, there was evidence for an association between subjective sensory sensitivity and structural grey or white matter abnormalities, and to functional abnormalities in sensory cortices. However, further research is needed to explore the causation of atypical sensory sensitivity. In addition, there is a need for the development of adequate diagnostic tools. This can significantly advance the quantity and quality of research on the prevalence, aetiology, prognosis and treatment of these symptoms.

Association of nocturnal sleep duration and midday napping with subjective poor hearing among middle-aged and older adults in China

Background

Hearing loss has occurred as a critical concern for aging and health. However, it remains unknown whether nocturnal sleep and midday napping duration are associated with hearing loss in middle-aged and older adults.

Methods

The study comprised 9,573 adults from China Health and Retirement Longitudinal Study, who have completed the survey for sleep characteristics and subjective functional hearing. We collected self-reported nocturnal sleep duration (<5, 5 to <6, 6 to <7, 7 to <9, ≥9 h/night) and midday napping duration (≤5, 5 to ≤30, and >30 min). The sleep information was classified into different sleep patterns. The primary outcome was self-reported hearing loss events. Multivariate Cox regression models and restricted cubic splines were used to investigate the longitudinal association of sleep characteristics with hearing loss. We applied Cox generalized additive models and bivariate exposure-response surface diagrams to visualize the effects of different sleep patterns on hearing loss.

Results

We confirmed 1,073 cases of hearing loss (55.1% female) during the follow-up. After adjusting for demographic characteristics, lifestyle factors and health condition, nocturnal sleep with < 5 h was positively associated with hearing loss [hazard ratio (HR): 1.45, 95% confidence interval [CI]: 1.20, 1.75]. Individuals with napping for 5 to ≤30 min had a 20% (HR: 0.80, 95%CI: 0.63, 1.00) lower risk of hearing loss compared with those with napping ≤ 5 min. Restrictive cubic splines showed the reverse J-shaped association between nocturnal sleep and hearing loss. Moreover, we found significant joint effects of sleeping < 7 h/night and midday napping ≤ 5 min (HR: 1.27, 95% CI: 1.06, 1.52) on hearing loss. Bivariate exposure-response surface diagrams also reflected the finding that short sleep without napping existed the highest risk of hearing loss. Compared with persistently sleeping moderately (7-9 h/night), those who persistently slept < 7 h/night or shifted from < 7 h/night to moderate or > 9 h/night had higher risks of hearing loss.

Conclusion

Inadequate nocturnal sleep was associated with an elevated risk of poor subjective hearing in middle-aged and older adults, while moderate napping decreased the risk of hearing loss. Keeping sleep stable within recommendation duration may be a useful strategy for preventing poor hearing loss.

Luminance effects on pupil dilation in speech-in-noise recognition

There is an increasing interest in the field of audiology and speech communication to measure the effort that it takes to listen in noisy environments, with obvious implications for populations suffering from hearing loss. Pupillometry offers one avenue to make progress in this enterprise but important methodological questions remain to be addressed before such tools can serve practical applications. Typically, cocktail-party situations may occur in less-than-ideal lighting conditions, e.g. a pub or a restaurant, and it is unclear how robust pupil dynamics are to luminance changes. In this study, we first used a well-known paradigm where sentences were presented at different signal-to-noise ratios (SNR), all conducive of good intelligibility. This enabled us to replicate findings, e.g. a larger and later peak pupil dilation (PPD) at adverse SNR, or when the sentences were misunderstood, and to investigate the dependency of the PPD on sentence duration. A second experiment reiterated two of the SNR levels, 0 and +14 dB, but measured at 0, 75, and 220 lux. The results showed that the impact of luminance on the SNR effect was non-monotonic (sub-optimal in darkness or in bright light), and as such, there is no trivial way to derive pupillary metrics that are robust to differences in background light, posing considerable constraints for applications of pupillometry in daily life. Our findings raise an under-examined but crucial issue when designing and understanding listening effort studies using pupillometry, and offer important insights to future clinical application of pupillometry across sites.

Cervical muscle stiffness and parasympathetic nervous system improvements for treatment-resistant depression

BACKGROUND

Although treatment-resistant depression (TRD) is a major public health problem that increases mortality due to suicides, a considerable percentage of patients do not respond adequately to variable treatments. Patients with TRD sometimes have comorbid cervical stiffness. This observational study aims to examine the association of local modulation of cervical muscles with TRD and to learn the involvement of the parasympathetic nervous system in the underlying mechanism.

METHODS

A total of 1103 hospitalized patients with TRD who were resistant to outpatient care were enrolled between May 2006 and October 2021. All patients underwent local modulation of the cervical muscles by physical therapy during hospitalization. The presence or absence of TRD and whole-body disorders, such as headache, dazzling, cervical stiffness, and cardiovascular and gastrointestinal disorders, was determined by the patient's subjectivity using the self-rated medical interview sheet at admission and discharge. Pupil light reflex parameters were also measured at admission and discharge using a binocular infrared pupilometer.

RESULTS

The improvement rate of TRD during hospitalization was 72.1%, and did not differ significantly by sex, age, and hospitalization period. The improvement of TRD showed a strong association with those of cervical stiffness and dazzling, a pupil light reflex disorder (p < 0.001: odds ratios = 12.76 and 6.39, respectively), but not with those of headache or cardiovascular and gastrointestinal disorders (p > 0.05). In the TRD-improved patients, the pupil light reflex parameters representative of the parasympathetic nervous system function ameliorated: pupil diameter decreased, while constriction rate and velocity increased during hospitalization. In contrast, little amelioration of the parameters was seen in the TRD-unimproved patients.

CONCLUSIONS

Cervical muscle stiffness may be associated with TRD, possibly through dysfunction of the parasympathetic nervous system.

TRIAL REGISTRATION

ID: UMIN000040590. First registration date: 30/05/2020.

Eye tracking identifies biomarkers in α-synucleinopathies versus progressive supranuclear palsy

OBJECTIVES

This study (1) describes and compares saccade and pupil abnormalities in patients with manifest alpha-synucleinopathies (αSYN: Parkinson's disease (PD), Multiple System Atrophy (MSA)) and a tauopathy (progressive supranuclear palsy (PSP)); (2) determines whether patients with rapid-eye-movement sleep behaviour disorder (RBD), a prodromal stage of αSYN, already have abnormal responses that may indicate a risk for developing PD or MSA.

METHODS

Ninety (46 RBD, 27 PD, 17 MSA) patients with an αSYN, 10 PSP patients, and 132 healthy age-matched controls (CTRL) were examined with a 10-min video-based eye-tracking task (Free Viewing). Participants were free to look anywhere on the screen while saccade and pupil behaviours were measured.

RESULTS

PD, MSA, and PSP spent more time fixating the centre of the screen than CTRL. All patient groups made fewer macro-saccades (> 2◦ amplitude) with smaller amplitude than CTRL. Saccade frequency was greater in RBD than in other patients. Following clip change, saccades were temporarily suppressed, then rebounded at a slower pace than CTRL in all patient groups. RBD had distinct, although discrete saccade abnormalities that were more marked in PD, MSA, and even more in PSP. The vertical saccade rate was reduced in all patients and decreased most in PSP. Clip changes produced large increases or decreases in screen luminance requiring pupil constriction or dilation, respectively. PSP elicited smaller pupil constriction/dilation responses than CTRL, while MSA elicited the opposite.

CONCLUSION

RBD patients already have discrete but less pronounced saccade abnormalities than PD and MSA patients. Vertical gaze palsy and altered pupil control differentiate PSP from αSYN.

Pupil size and pupillary light reflex in early infancy: heritability and link to genetic liability to schizophrenia

BACKGROUND

Measures based on pupillometry, such as the pupillary light reflex (PLR) and baseline pupil size, reflect physiological responses linked to specific neural circuits that have been implicated as atypical in some psychiatric and neurodevelopmental conditions.

METHODS

We investigated the contribution of genetic and environmental factors to the baseline pupil size and the PLR in 510 infant twins assessed at 5 months of age (281 monozygotic and 229 dizygotic pairs), and its associations with common genetic variants associated with neurodevelopmental (autism spectrum disorder and attention deficit hyperactivity disorder) and mental health (bipolar disorder, major depressive disorder and schizophrenia) conditions using genome-wide polygenic scores (GPSs).

RESULTS

Univariate twin modelling showed high heritability at 5 months for both pupil size (h²  = .64) and constriction in response to light (h²  = .62), and bivariate twin modeling indicated substantial independence between the genetic factors influencing each (r_G  = .38). A statistically significant positive association between infant tonic pupil size and the GPS for schizophrenia was found (β = .15, p = .024), while there was no significant association with the GPS for autism or any other GPSs.

CONCLUSIONS

This study shows that some pupil measures are highly heritable in early infancy, although substantially independent in their genetic etiologies, and associated with common genetic variants linked to schizophrenia. It illustrates how genetically informed studies of infants may help us understand early physiological responses associated with psychiatric disorders which emerge much later in life.

Clinical potential of pupillary light reflex and heart rate variability parameters as objective indicators of tonsillectomy-induced pain

Establishing objective indicators of subjective pain intensity is important in pain assessment. Pupillary light reflex (PLR) and heart rate variability (HRV) indicate autonomic nervous system (ANS) activity and may serve as pain indicators because pain can affect ANS activity. In this prospective longitudinal study, we aimed to investigate the potential of PLR/HRV parameters as objective indicators of subjective pain intensity after tonsillectomy. Sixty-seven patients undergoing tonsillectomy were enrolled. Subjective pain intensity based on a numeric rating scale (NRS) and eight PLR/HRV parameters were assessed at five time points. We investigated the changes in the NRS values over time. We estimated regression coefficients reflecting parameter changes per unit change in the NRS score using linear mixed-effects models. The mean NRS score was 0 at two pre-surgery time points, 5 on postoperative days (PODs) 1 and 2, and 0 at postoperative week 3. Two parameters (initial pupil size [INIT] and constriction latency [LAT]) showed significant changes on POD1 and POD2 in comparison to baseline data measured at the pre-surgery time point. Among these parameters, only LAT showed no significant changes between POD1 and POD2. Significant regression coefficients with the narrowest 95% confidence intervals were observed for INIT and LAT. Increased NRS scores were associated with decreased INIT and shortened LAT. LAT was a robust indicator of subjective pain intensity. Our patients showed decreased INIT with increased NRS scores, indicating the predominance of the parasympathetic, not sympathetic, tone in pupils. Further studies are required to investigate factors causing this predominance.

Ocular Autonomic Nervous System: An Update from Anatomy to Physiological Functions

The autonomic nervous system (ANS) confers neural control of the entire body, mainly through the sympathetic and parasympathetic nerves. Several studies have observed that the physiological functions of the eye (pupil size, lens accommodation, ocular circulation, and intraocular pressure regulation) are precisely regulated by the ANS. Almost all parts of the eye have autonomic innervation for the regulation of local homeostasis through synergy and antagonism. With the advent of new research methods, novel anatomical characteristics and numerous physiological processes have been elucidated. Herein, we summarize the anatomical and physiological functions of the ANS in the eye within the context of its intrinsic connections. This review provides novel insights into ocular studies.

Associations between the pupil light reflex and the broader autism phenotype in children and adults

The pupil light reflex (PLR), a marker of neuronal response to light, is a well-studied index of autonomic functioning. Studies have found that autistic children and adults have slower and weaker PLR responses compared to non-autistic peers, suggesting lower autonomic control. Altered autonomic control has also been associated with increased sensory difficulties in autistic children. With autistic traits varying in the general population, recent studies have begun to examine similar questions in non-autistic individuals. The current study looked at the PLR in relation to individual differences in autistic traits in non-autistic children and adults, asking how differences in the PLR could lead to variation in autistic traits, and how this might change across development. Children and adults completed a PLR task as a measure of sensitivity to light and autonomic response. Results showed that, in adults, increased levels of restricted and repetitive behaviors (RRB) were associated with a weaker and slower PLR. However, in children, PLR responses were not associated with autistic traits. Differences in PLR were also found across age groups, with adults showing smaller baseline pupil diameter and stronger PLR constriction as compared with children. The current study expanded on past work to examine the PLR and autistic traits in non-autistic children and adults, and the relevance of these findings to sensory processing difficulties is discussed. Future studies should continue to examine the neural pathways that might underlie the links between sensory processing and challenging behaviors.

Eye pupil – a window into central autonomic regulation via emotional/cognitive processing

If the eyes are windows into the soul, then the pupils represent at least the gateway to the brain and can provide a unique insight into the human mind from several aspects. The changes in the pupil size primarily mediated by different lighting conditions are controlled by the autonomic nervous system regulated predominantly at the subcortical level. Specifically, parasympathetically-linked pupillary constriction is under the Edinger-Westphal nucleus control and sympathetically-mediated pupillary dilation is regulated from the posterior hypothalamic nuclei. However, the changes in the pupil size can be observed at resting state even under constant lighting, these pupillary changes are mediated by global arousal level as well as by various cognitive factors. In this context, autonomic pathways modulating changes in the pupil size in response to the different light levels can be influenced by multiple central descending inputs driving pupillary changes under steady lighting conditions. Moreover, as the pupillary response is involved in emotional (task-evoked pupillary dilation as an index of emotional arousal) and cognitive (task-evoked pupillary dilation as an index of cognitive workload) stimulation, it can be used to detect the impact of mutual subcortical and cortical structures (i.e. overlapping brain structures included in autonomic, emotional and cognitive regulation) on the pupillary innervation system. Thus, complex understanding of the baseline pupil size´ and pupillary dynamics´ mechanisms may provide an important insight into the central nervous system functioning pointing to the pupillometry as a promising tool in the clinical application.

Eye pupil - a window into central autonomic regulation via emotional/cognitive processing

If the eyes are windows into the soul, then the pupils represent at least the gateway to the brain and can provide a unique insight into the human mind from several aspects. The changes in the pupil size primarily mediated by different lighting conditions are controlled by the autonomic nervous system regulated predominantly at the subcortical level. Specifically, parasympathetically-linked pupillary constriction is under the Edinger-Westphal nucleus control and sympathetically-mediated pupillary dilation is regulated from the posterior hypothalamic nuclei. However, the changes in the pupil size can be observed at resting state even under constant lighting, these pupillary changes are mediated by global arousal level as well as by various cognitive factors. In this context, autonomic pathways modulating changes in the pupil size in response to the different light levels can be influenced by multiple central descending inputs driving pupillary changes under steady lighting conditions. Moreover, as the pupillary response is involved in emotional (task-evoked pupillary dilation as an index of emotional arousal) and cognitive (task-evoked pupillary dilation as an index of cognitive workload) stimulation, it can be used to detect the impact of mutual subcortical and cortical structures (i.e. overlapping brain structures included in autonomic, emotional and cognitive regulation) on the pupillary innervation system. Thus, complex understanding of the baseline pupil size´ and pupillary dynamics´ mechanisms may provide an important insight into the central nervous system functioning pointing to the pupillometry as a promising tool in the clinical application.

Adults with cochlear implants can use prosody to determine the clausal structure of spoken sentences

Speech prosody, including pitch contour, word stress, pauses, and vowel lengthening, can aid the detection of the clausal structure of a multi-clause sentence and this, in turn, can help listeners determine the meaning. However, for cochlear implant (CI) users, the reduced acoustic richness of the signal raises the question of whether CI users may have difficulty using sentence prosody to detect syntactic clause boundaries within sentences or whether this ability is rescued by the redundancy of the prosodic features that normally co-occur at clause boundaries. Twenty-two CI users, ranging in age from 19 to 77 years old, recalled three types of sentences: sentences in which the prosodic pattern was appropriate to the location of a clause boundary within the sentence (congruent prosody), sentences with reduced prosodic information, or sentences in which the location of the clause boundary and the prosodic marking of a clause boundary were placed in conflict. The results showed the presence of congruent prosody to be associated with superior sentence recall and a reduced processing effort as indexed by the pupil dilation. The individual differences in a standard test of word recognition (consonant-nucleus-consonant score) were related to the recall accuracy as well as the processing effort. The outcomes are discussed in terms of the redundancy of the prosodic features, which normally accompany a clause boundary and processing effort.

Clinical potential of pupillary light reflex parameters as objective indicators reflecting chronic rhinosinusitis-specific quality of life: a 12-month prospective longitudinal study

Pupillary light reflex (PLR) and heart rate variability (HRV) parameters can be objective indicators of chronic rhinosinusitis (CRS) status from the viewpoint of autonomic nervous system activity. This study aimed to establish objective indicators for CRS using the 22-item Sino-Nasal Outcome Test (SNOT-22) and PLR/HRV parameters. Sixty-seven patients were prospectively and longitudinally followed up after surgical treatment. We investigated changes in SNOT-22 scores, representing CRS-specific quality of life (QOL). We prepared two models: linear regression model adjusting clinical factors as predictor variables (model 1) and linear mixed-effects model adjusting clinical factors and among-individual variability (model 2). We compared Akaike's information criterion (AIC) values and regression coefficients. The model with lower AIC values was defined as the better-fit model. Model 2 showed lower AIC values in all parameters (better-fit model). Three parameters showed opposite results between the two models. The better-fit models showed significances in the five PLR parameters but not in any HRV parameters. Among these PLR parameters, constriction latency can be the most robust indicator because of the narrowest 95% confidence intervals. Adjusting the among-individual variability while investigating clinical potential of PLR/HRV parameters to reflect CRS-specific QOL can improve the model fit, thereby reaching robust conclusions from obtained data.

Analysis of pupillometer results according to disease stage in patients with Parkinson's disease

We performed pupillometer testing on 132 patients with Parkinson’s disease, stratified into two groups according to the disease stage. Neurological examinations and pupillometry were performed in the ON state. Patients in the Hoehn and Yahr stages 1 and 2 comprised the early group, and patients in stages 3–5 formed the late group. We performed age- and sex-matched (2:1) propensity score matching to compensate for the effect of age on pupil light reflex. Eight pupillometer parameters were measured and compared between the two groups. After the propensity score matching, the early group had 64 patients and the late group had 32 patients. The late group had a longer disease duration and took a higher levodopa equivalent dose than the early group. The constriction velocity (P = 0.006) and maximum constriction velocity (P = 0.005) were significantly faster in the early group than in the late group. Pupil size, minimum diameter, and dilation velocity were similar in both groups. The pupillary contraction velocity decreased with the disease progression, suggesting that the progression of Parkinson’s disease could be identified by the pupil constriction velocity.

Clinical factors affecting pupillary light reflex parameters: a single-centre, cross-sectional study

PURPOSE

To evaluate the effects of stimulus intensity, aging, sex, smoking and eye symmetry on pupillary light reflex (PLR) parameters.

METHODS

We evaluated 2812 eyes from 1406 subjects in a single-centre, cross-sectional study. PLR data were collected using four different stimulus intensities. We prepared two models for each of the eight PLR parameters, and defined the model with the lowest values of Akaike's information criterion (AIC) as being the best-fit. Model A was a linear regression model without adjustment for among-individual variability, while the Model B linear mixed-effects models (LMMs) were adjusted for among-individual variability. The regression coefficients of the two models were compared.

RESULTS

Model B showed the lowest AIC values for all parameters and the best fit. For light stimulus intensity, age and eye symmetry, the two models yielded similar results for all PLR parameters. For sex and smoking index, some PLR parameters showed the opposite results, i.e., Model A showed significant effects while Model B did not.

CONCLUSION

These results indicate that light stimulus intensity, aging, sex, smoking and eye symmetry are factors that affect PLR parameters. These should be adjusted when evaluating the clinical potential of PLR as a diagnostic tool. In addition, adjusting for among-individual variability due to LMMs can improve the model fit and reduce false positives. This can reveal the association between clinical factors and PLR parameters with increased accuracy.

The pupillary dynamics of patients with physiological anisocoria

BACKGROUND

To evaluate static pupillometric measurements and making inter-ocular comparative analysis in healthy subjects for demonstrating the prevalance of physiological anisocoria in various lighting conditions and to compare the variations of the dynamic pupillometric measurements of the patients with physiological anisocoria.

METHODS

Automatic quantitative pupillometry system was used to measure pupillary diameters in low mesopic (0.1 cd/m²), high mesopic (1 cd/m²), low photopic (10 cd/m²) and high photopic (100 cd/m²) conditions. After inter-ocular comparison of these data, the prevalance of physiological anisocoria was detected in four different lighting conditions. The inter-ocular dynamic pupillometric parameters (amplitude, latency, duration and velocity of pupil contraction; latency, duration and velocity of pupil dilation) of these patients were further analysed.

RESULTS

After inter-ocular comparison of pupillary diameters of 195 participants [96 females (49.2%) and 99 males (50.8%)] with a mean age of 38.4 ± 18.9 years (range 7-78 years), six (3.1%) participants under high photopic; 11 (5.6%) participants under low photopic; 25 (12.8%) participants under high mesopic, and 34 (17.4%) participants under low mesopic illumination levels exhibited physiological anisocoria. The mean relative amplitude of anisocoric small pupils' contraction was lower than the mean relative amplitudes of pupil contraction of both isocoric and anisocoric large pupils (p = 0.021, p = 0.035, respectively). The mean velocity of anisocoric small pupils' contraction was lower than the mean velocity of anisocoric large pupils' contraction (p = 0.013).

CONCLUSIONS

The mean contraction amplitude and contraction velocity of smaller pupils was lower when compared to fellow larger pupils of anisocoric patients.

Possible involvement of the autonomic nervous system in cervical muscles of patients with myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS)

BACKGROUND

Patients with myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) sometimes present with stiffness of the cervical muscles. To investigate the pathophysiology of ME/CFS, this observational study compared patients with versus without recovery from ME/CFS through local modulation of the cervical muscles.

METHODS

Over a period of 11 years, a total of 1226 inpatients with ME/CFS who did not respond to outpatient care were enrolled in this study. All patients received daily cervical muscle physical therapy during hospitalization. Self-rated records documenting the presence or absence of ME/CFS, as well as the representative eight symptoms that frequently accompany it at admission and discharge, were compared. Pupil diameter was also measured to examine autonomic nervous system function involvement.

RESULTS

The recovery rate of ME/CFS after local therapy was 55.5%, and did not differ significantly by sex, age strata, and hospitalization period. The recovery rates of the eight symptoms were variable (36.6-86.9%); however, those of ME/CFS in the symptom subpopulations were similar (52.3-55.8%). The recovery rates of all symptoms showed strong associations with that of ME/CFS (p < 0.001). The pupil diameter was more constricted in the ME/CFS-recovered patients than in the ME/CFS-unrecovered patients in the total population and the subpopulations stratified by sex, age, and hospitalization period.

CONCLUSIONS

There was a strong association between the recovery of ME/CFS and other related whole-body symptoms. The recovery of ME/CFS may be partly linked to amelioration of the autonomic nervous system in the cervical muscles.

TRIAL REGISTRATION

UMIN000036634 . Registered 1 May 2019 - Retrospectively registered.

Effect of Speech-to-Noise Ratio and Luminance on a Range of Current and Potential Pupil Response Measures to Assess Listening Effort

In hearing research, pupillometry is an established method of studying listening effort. The focus of this study was to evaluate several pupil measures extracted from the Task-Evoked Pupil Responses (TEPRs) in speech-in-noise test. A range of analysis approaches was applied to extract these pupil measures, namely (a) pupil peak dilation (PPD); (b) mean pupil dilation (MPD); (c) index of pupillary activity; (d) growth curve analysis (GCA); and (e) principal component analysis (PCA). The effect of signal-to-noise ratio (SNR; Data Set A: -20 dB, -10 dB, +5 dB SNR) and luminance (Data Set B: 0.1 cd/m2, 360 cd/m2) on the TEPRs were investigated. Data Sets A and B were recorded during a speech-in-noise test and included TEPRs from 33 and 27 normal-hearing native Dutch speakers, respectively. The main results were as follows: (a) A significant effect of SNR was revealed for all pupil measures extracted in the time domain (PPD, MPD, GCA, PCA); (b) Two time series analysis approaches (GCA, PCA) provided modeled temporal profiles of TEPRs (GCA); and time windows spanning subtasks performed in a speech-in-noise test (PCA); and (c) All pupil measures revealed a significant effect of luminance. In conclusion, multiple pupil measures showed similar effects of SNR, suggesting that effort may be reflected in multiple aspects of TEPR. Moreover, a direct analysis of the pupil time course seems to provide a more holistic view of TEPRs, yet further research is needed to understand and interpret its measures. Further research is also required to find pupil measures less sensitive to changes in luminance.

Ocular Manifestations and Neuropathy in Type 2 Diabetes Patients With Charcot Arthropathy

OBJECTIVE

Diabetes can affect the eye in many ways beyond retinopathy. This study sought to evaluate ocular disease and determine any associations with peripheral neuropathy (PN) or cardiac autonomic neuropathy (CAN) in type 2 diabetes (T2D) and Charcot arthropathy (CA) patients.

DESIGN

A total of 60 participants were included, 16 of whom were individuals with T2D/CA, 21 of whom were individuals with T2D who did not have CA, and 23 of whom were healthy controls. Ocular surface evaluations were performed, and cases of dry eye disease (DED) were determined using the Ocular Surface Disease Index (OSDI) questionnaire, ocular surface staining, Schirmer test, and Oculus Keratograph 5M exams. All variables were used to classify DED and ocular surface disorders such as aqueous deficiency, lipid deficiency, inflammation, and ocular surface damage. Pupillary and retinal nerve fiber measurements were added to the protocol in order to broaden the scope of the neurosensory ocular evaluation. PN and CAN were ascertained by clinical examinations involving the Neuropathy Disability Score (for PN) and Ewing's battery (for CAN).

RESULTS

Most ocular variables evaluated herein differed significantly between T2D patients and controls. When the controls were respectively compared to patients with T2D and to patients with both T2D and CA, they differed substantially in terms of visual acuity (0.92 ± 0.11, 0.73 ± 0.27, and 0.47 ± 0.26, p=0.001), retinal nerve fiber layer thickness (96.83 ± 6.91, 89.25 ± 10.44, and 80.37 ± 11.67 µm, p=0.03), pupillometry results (4.10 ± 0.61, 3.48 ± 0.88, and 2.75 ± 0.81 mm, p=0.0001), and dry eye symptoms (9.19 ± 11.71, 19.83 ± 19.08, and 24.82 ± 24.40, p=0.03). DED and ocular surface damage also differed between individuals with and without CA, and were associated with PN and CAN.

CONCLUSION

CA was found to be significantly associated with the severity of ocular findings. DED in cases of CA was also associated with PN and CAN. These findings suggest that intrinsic and complex neurosensory impairment in the eyes, peripheral sensory nerves, and the autonomic nervous system are somehow connected. Thus, a thorough ocular evaluation may be useful to highlight neurological complications and the impact of diabetes on ocular and systemic functions and structures.

Central autonomic regulation assessed by pupillary light reflex is impaired in children with attention deficit hyperactivity disorder

It is assumed that the Attention Deficit Hyperactivity Disorder is associated with the central autonomic dysregulation, however, the studies are rare. Analysis of pupillary light reflex represents a non-invasive tool to provide information related to the central autonomic regulation; thus, we aimed to evaluate potential disturbances in the central autonomic integrity using pupillary light reflex examination in Attention Deficit Hyperactivity Disorder. We have examined 20 children with Attention Deficit Hyperactivity Disorder (10 boys, 13.0+/-2.3 years) and 20 age/gender-matched healthy subjects. Pupillary light reflex was examined at rest for both eyes using Pupillometer PLR-2000 (NeurOptics, USA). Evaluated parameters were: diameter of the pupil before the application of light stimulus and after illumination at the peak of the constriction, the percentual change of the pupil diameter during constriction, average constriction velocity, maximum constriction velocity and average dilation velocity. We found significantly lower percentual change of the pupil diameter during constriction for both eyes in Attention Deficit Hyperactivity Disorder group compared to controls (right eye: -25.81+/-1.23 % vs. -30.32+/-1.31 %, p<0.05, left eye: -25.44+/-1.65 % vs. -30.35+/-0.98 %, p<0.05). The average constriction velocity and maximum constriction velocity were significantly shortened in left eye in Attention Deficit Hyperactivity Disorder group compared to controls (p<0.05). Our findings revealed altered pupillary light reflex indicating abnormal centrally-mediated autonomic regulation characterized by parasympathetic underactivity associated with relative sympathetic predominance in children suffering from Attention Deficit Hyperactivity Disorder.

Pupillometry Assessment of Speech Recognition and Listening Experience in Adult Cochlear Implant Patients

Objective

The aim of the present study was to investigate the pupillary response to word identification in cochlear implant (CI) patients. Authors hypothesized that when task difficulty (i.e., addition of background noise) increased, pupil dilation markers such as the peak dilation or the latency of the peak dilation would increase in CI users, as already observed in normal-hearing and hearing-impaired subjects.

Methods

Pupillometric measures in 10 CI patients were combined to standard speech recognition scores used to evaluate CI outcomes, namely, speech audiometry in quiet and in noise at +10 dB signal-to-noise ratio (SNR). The main outcome measures of pupillometry were mean pupil dilation, maximal pupil dilation, dilation latency, and mean dilation during return to baseline or retention interval. Subjective hearing quality was evaluated by means of one self-reported fatigue questionnaire, and the Speech, Spatial, and Qualities (SSQ) of Hearing scale.

Results

All pupil dilation data were transformed to percent change in event-related pupil dilation (ERPD, %). Analyses show that the peak amplitudes for both mean pupil dilation and maximal pupil dilation were higher during the speech-in-noise test. Mean peak dilation was measured at 3.47 ± 2.29% noise vs. 2.19 ± 2.46 in quiet and maximal peak value was detected at 9.17 ± 3.25% in noise vs. 8.72 ± 2.93% in quiet. Concerning the questionnaires, the mean pupil dilation during the retention interval was significantly correlated with the spatial subscale score of the SSQ Hearing scale [r(8) = −0.84, p = 0.0023], and with the global score [r(8) = −0.78, p = 0.0018].

Conclusion

The analysis of pupillometric traces, obtained during speech audiometry in quiet and in noise in CI users, provided interesting information about the different processes engaged in this task. Pupillometric measures could be indicative of listening difficulty, phoneme intelligibility, and were correlated with general hearing experience as evaluated by the SSQ of Hearing scale. These preliminary results show that pupillometry constitutes a promising tool to improve objective quantification of CI performance in clinical settings.

Pupillometry as an Objective Measure of Sustained Attention in Young and Older Listeners

The ability to sustain attention on a task-relevant sound source while avoiding distraction from concurrent sounds is fundamental to listening in crowded environments. We aimed to (a) devise an experimental paradigm with which this aspect of listening can be isolated and (b) evaluate the applicability of pupillometry as an objective measure of sustained attention in young and older populations. We designed a paradigm that continuously measured behavioral responses and pupillometry during 25-s trials. Stimuli contained a number of concurrent, spectrally distinct tone streams. On each trial, participants detected gaps in one of the streams while resisting distraction from the others. Behavior demonstrated increasing difficulty with time-on-task and with number/proximity of distractor streams. In young listeners (N = 20; aged 18 to 35 years), pupil diameter (on the group and individual level) was dynamically modulated by instantaneous task difficulty: Periods where behavioral performance revealed a strain on sustained attention were accompanied by increased pupil diameter. Only trials on which participants performed successfully were included in the pupillometry analysis so that the observed effects reflect task demands as opposed to failure to attend. In line with existing reports, we observed global changes to pupil dynamics in the older group (N = 19; aged 63 to 79 years) including decreased pupil diameter, limited dilation range, and reduced temporal variability. However, despite these changes, older listeners showed similar effects of attentive tracking to those observed in the young listeners. Overall, our results demonstrate that pupillometry can be a reliable and time-sensitive measure of attentive tracking over long durations in both young and (with caveats) older listeners.

Comparisons of the Sensitivity and Reliability of Multiple Measures of Listening Effort

OBJECTIVES

The objective of this study was to evaluate the sensitivity and reliability of one subjective (rating scale) and three objective (dual-task paradigm, pupillometry, and skin conductance response amplitude) measures of listening effort across multiple signal to noise ratios (SNRs).

DESIGN

Twenty adults with normal hearing attended two sessions and listened to sentences presented in quiet and in stationary noise at three different SNRs: 0, -3, and -5 dB. Listening effort was assessed by examining change in reaction time (dual-task paradigm), change in peak to peak pupil diameter (pupillometry), and change in mean skin conductance response amplitude; self-reported listening effort on a scale from 0 to 100 was also evaluated. Responses were averaged within each SNR and based on three word recognition ability categories (≤50%, 51% to 71%, and >71%) across all SNRs. Measures were considered reliable if there were no significant changes between sessions, and intraclass correlation coefficients were a minimum of 0.40. Effect sizes were calculated to compare the sensitivity of the measures.

RESULTS

Intraclass correlation coefficient values indicated fair-to-moderate reliability for all measures while individual measurement sensitivity was variable. Self-reports were sensitive to listening effort but were less reliable, given that subjective effort was greater during the dual task than either of the physiologic measures. The dual task was sensitive to a narrow range of word recognition abilities but was less reliable as it exhibited a global decrease in reaction time across sessions. Pupillometry was consistently sensitive and reliable to changes in listening effort. Skin conductance response amplitude was not sensitive or reliable while the participants listened to the sentences. Skin conductance response amplitude during the verbal response was sensitive to poor (≤50%) speech recognition abilities; however, it was less reliable as there was a significant change in amplitude across sessions.

CONCLUSIONS

In this study, pupillometry was the most sensitive and reliable objective measure of listening effort. Intersession variability significantly influenced the other objective measures of listening effort, which suggests challenges for cross-study comparability. Therefore, intraclass correlation coefficients combined with other statistical tests more fully describe the reliability of measures of listening effort across multiple difficulties. Minimizing intersession variability will increase measurement sensitivity. Further work toward standardized methods and analysis will strengthen our understanding of the reliability and sensitivity of measures of listening effort and better facilitate cross-modal and cross-study comparisons.

Clinical potential of pupillary light reflex and heart rate variability parameters as biomarkers for assessing pain relief effects on autonomic function: a prospective longitudinal study

OBJECTIVE

To investigate the association between subjective pain intensity and objective parameters obtained from two autonomic function tests in a longitudinal study targeting acute pain model in otolaryngology-head and neck region: pupillary light reflex (PLR) and heart rate variability (HRV).

APPROACH

We enrolled 35 patients with acute otolaryngology-head and neck region inflammatory disorders at pre-treatment stage. The acute inflammatory disorders were defined as acute tonsillitis, peritonsillar abscess, acute epiglottitis, acute sinusitis, and deep neck space abscess. Patients underwent a numeric rating scale (NRS) to monitor subjective pain intensity, PLR, and HRV as objective tests at 4 time-points during the follow-up term. As main outcome variables, we used 15 analyzable PLR/HRV parameters. To improve robustness of conclusions about the association between NRS and PLR/HRV parameters, we prepared four linear mixed-effects models (LMMs) including predictor variables such as NRS, sociodemographic factors, and individual variability. And then, we selected the better-fit model based on the lowest Akaike's information criterion.

MAIN RESULTS

NRS significantly decreased due to treatments. In 14 out of 15 parameters, better-fit models were models including not only sociodemographic factors but also individual variability. We observed significant parameter alterations to one unit change of NRS in five PLR and four HRV parameters.

SIGNIFICANCE

The current study revealed that PLR/HRV parameters can be used as biomarkers reflecting pain relief effects. In addition, the findings suggest the importance of adjusting predictor variables, especially individual variability defined as random effects in LMMs, for obtaining more accurate parameter estimation in the longitudinal study.

Estimation and interrater reliability of pupillography by digital mobile app: Digital movil pupillography app validity

OBJECTIVE

The examination of pupillary light reflexes is widely employed to evaluate the autonomic system's balance, ocular, and neurological conditions, typically evaluated by qualitative observation. To describe and evaluate the inter-rater reliability and agreement of pupillometric values obtained with a novel semi-automatic mobile pupillography app.

METHODS

Two examiners and two graders perform the measurements with an android app which corrects the device-face distance, measure the maximum contraction of the pupil, and calculates its slope, in a hospital room setting with three levels of environmental light intensity: <100, 101 to 200, and 201 to 300 lux, at 200, 400, 600, 900, 1200, and 1500 milliseconds.

RESULTS

Sixty healthy individuals, aged 18 to 45, were included; 85% had brown eyes. The reliability of the pupil/iris ratio had Ri = 70% to 88%, and bland Altman graphics show a uniform agreement. The pupillography curves show a similar slope at different light intensities, during the contraction phase.

CONCLUSION

There were very good repeatability and inter-rater reproducibility of the measurements at average levels of illumination in examination rooms, even in dark-eyed people. This app provides a highly promising approach to pupillary measurements in clinical practice.

Evaluation of pupil responses and anterior chamber parameters in overactive bladder syndrome before and after antimuscarinic treatment

PURPOSE

To evaluate the static and dynamic pupillometric responses and anterior chamber parameters in overactive bladder (OAB) patients before and after solifenacin succinate treatment and to compare these results with those of healthy control subjects.

MATERIALS AND METHODS

Forty OAB patients who were planned to be treated with solifenacin succinate and 40 control subjects without any systemic or ocular diseases were included in the study. Following detailed ophthalmological examination, Pentacam imaging in order to detect anterior chamber angle, depth and volume; and static and dynamic pupillometry measurement in order to detect high-photopic (100 cd/m²), low-photopic (10 cd/m²), mesopic (1 cd/m²) and scotopic (0.1 cd/m²) pupil diameters, amplitude of pupil contraction, latency of pupil contraction, duration of pupil contraction, velocity of pupil contraction, latency of pupil dilation, duration of pupil dilation and velocity of pupil dilation were performed at baseline and at the first month of treatment. Data from the right eyes of the participants were used for statistical analysis.

RESULTS

Baseline low- and high-photopic pupil diameters, duration of pupil contraction, latency of pupil dilatation and velocity of pupil dilatation values were significantly higher; and velocity of pupil contraction and duration of pupil dilation values were lower in the OAB group compared to the control group (P < 0.05 for all). One-month treatment with oral solifenacin succinate revealed higher scotopic and mesopic pupil diameters (P = 0.042, P = 0.031, respectively). Also, latency of pupil contraction was found to be increased and velocity of pupil dilatation was found to be decreased compared to pretreatment (P = 0.003, P < 0.001, respectively). We did not find any significant change in anterior chamber angle, depth and volume measured with Pentacam HR compared to pretreatment.

CONCLUSIONS

Patients with OAB also have pupil abnormalities which probably reflect an underlying autonomic disorder that affects the bladder and pupils. One-month treatment of solifenacin succinate may lead to enlargement of pupil diameters under low illumination conditions and may lead to changes in dynamic pupillometric responses compatible with antimuscarinic treatment. Systemic antimuscarinic therapy has no effect on anterior chamber depth and intraocular pressure.

Pupillometry measurement and its relationship to retinal structural changes in children with attention deficit hyperactivity disorder

PURPOSE

This study aims to assess the pupillometry measurements of the attention deficit hyperactivity disorder (ADHD) patients and to investigate their correlations with macular and RNFL thickness parameters by comparing the values with a healthy control group.

METHODS

Newly diagnosed ADHD patients in a child and adolescent clinic of a tertiary hospital were consulted in an ophthalmology clinic. All participants had undergone a standard ophthalmological examination including refractometry, best corrected visual acuity, color vision, anterior segment biomicroscopy, fundoscopy, pupillometry, and OCT. All results were compared with a healthy control group at the same age.

RESULTS

The study group consisted of 32 patients and there were 43 children in the control group. Mean pupillary velocities of ADHD patients and control group were 0.60 ± 0.11 mm/s and 0.63 ± 0.11 mm/s, and 0.49 ± 0.12 mm/s and 0.50 ± 0.10 mm/s, for right and left eyes, respectively. The difference was statistically significant for both eyes (p < 0.05). Mean RNFL thickness measurements of the study group were 90.69 ± 8.58 μm and 89.63 ± 8.14 μm for right and left eyes, respectively and those were 87.35 ± 7.67 μm and 88.77 ± 7.44 μm, respectively in the healthy group. Correlation between right pupillary velocity and RNFL thickness was statistically significant (r = 0.339, p = 0.003).

CONCLUSION

Higher pupillary velocity values were observed in both eyes of children with ADHD and that was positively correlated with RNFL measurements of their right eyes.

Neuromonitoring of delirium with quantitative pupillometry in sedated mechanically ventilated critically ill patients

BACKGROUND

Intensive care unit (ICU) delirium is a frequent secondary neurological complication in critically ill patients undergoing prolonged mechanical ventilation. Quantitative pupillometry is an emerging modality for the neuromonitoring of primary acute brain injury, but its potential utility in patients at risk of ICU delirium is unknown.

METHODS

This was an observational cohort study of medical-surgical ICU patients, without acute or known primary brain injury, who underwent sedation and mechanical ventilation for at least 48 h. Starting at day 3, automated infrared pupillometry-blinded to ICU caregivers-was used for repeated measurement of the pupillary function, including quantitative pupillary light reflex (q-PLR, expressed as % pupil constriction to a standardized light stimulus) and constriction velocity (CV, mm/s). The relationship between delirium, using the CAM-ICU score, and quantitative pupillary variables was examined.

RESULTS

A total of 59/100 patients had ICU delirium, diagnosed at a median 8 (5-13) days from admission. Compared to non-delirious patients, subjects with ICU delirium had lower values of q-PLR (25 [19-31] vs. 20 [15-28] %) and CV (2.5 [1.7-2.8] vs. 1.7 [1.4-2.4] mm/s) at day 3, and at all additional time-points tested (p < 0.05). After adjusting for the SOFA score and the cumulative dose of analgesia and sedation, lower q-PLR was associated with an increased risk of ICU delirium (OR 1.057 [1.007-1.113] at day 3; p = 0.03).

CONCLUSIONS

Sustained abnormalities of quantitative pupillary variables at the early ICU phase correlate with delirium and precede clinical diagnosis by a median 5 days. These findings suggest a potential utility of quantitative pupillometry in sedated mechanically ventilated ICU patients at high risk of delirium.

Effective combination of pupil light reflex and heart rate variability to assess foot bath effects on autonomic function in healthy adults

OBJECTIVES

To evaluate the effects of a foot bath on autonomic nervous system (ANS) activities as measured by pupil light reflex (PLR) and heart rate variability (HRV) in healthy adults.

METHODS

PLR and HRV were assessed before and during a foot bath in healthy subjects (n = 110). The subjects dipped their feet in 40 °C water at a level below their knees for 15 min The light reflex in PLR was elicited at four ascending stimulus intensities. Linear-mixed effect models were fit with PLR parameters, and a Wilcoxon signed-rank test with HRV parameters. In PLR analysis, an interaction term between the foot bath intervention and the stimulus intensity was included as a fixed effect.

RESULTS

The PLR analysis showed significant interactions in five out of seven parameters. The altered patterns indicated enhanced activity of the parasympathetic nervous system (PNS) due to the intervention. In contrast, the HRV analysis showed few alterations of PNS activities due to the intervention.

CONCLUSIONS

The study results demonstrated differences in altered PNS activity during a foot bath, when assessed by PLR and HRV. In PLR, the stimulus intensity was a crucial factor for the evaluation of foot bath effects. Taken together, the combination of PLR and HRV effectively evaluates ANS activities during a foot bath.

Cervical muscle diseases are associated with indefinite and various symptoms in the whole body

PURPOSE

Patients with various and indefinite symptoms in the whole body occasionally have coincident with stiffness or tenderness of the cervical muscles. This prospective case series examined the effect of local modulation of the cervical muscles in patients with cervical disorders reporting indefinite whole-body symptoms.

METHODS

A total of 1863 hospitalized patients with cervical disorders accompanying three or more indefinite whole-body symptoms, who were resistant to outpatient care, were enrolled in this study for 12 years. All patients underwent daily physical therapies to the cervical muscles during hospitalization. Self-rated records on the medical interview sheets documenting 30 representative symptoms including cervical/shoulder pain or stiffness and 28 representative indefinite whole-body symptoms at admission and discharge were compared across the population.

RESULTS

The number of symptoms decreased significantly with the local modulation of the cervical muscles during hospitalization. All of the 28 indefinite whole-body symptoms at admission showed recovery rates greater than 50% at discharge. The mean number of symptoms decreased significantly from 17.8 at admission to 7.4 at discharge (p < 0.0001). The percentages of patients reporting 10 or more symptoms were 91.1% and 29.3% at admission and discharge, respectively. Moreover, 8.2% of patients reported no residual symptoms at discharge.

CONCLUSION

Cervical muscle lesions may contribute to indefinite whole-body symptoms, possibly through dysfunction of the parasympathetic nervous system in the muscles. Local modulation of cervical muscles could lead to a breakthrough in the management of patients with indefinite whole-body symptoms.

TRIAL REGISTRATION ID

UMIN000035445. These slides can be retrieved under Electronic Supplementary Material.

Anticipatory Baseline Pupil Diameter Is Sensitive to Differences in Hearing Thresholds

Task-evoked changes in pupil dilation have long been used as a physiological index of cognitive effort. Unlike this response, that is measured during or after an experimental trial, the baseline pupil dilation (BPD) is a measure taken prior to an experimental trial. As such, it is considered to reflect an individual’s arousal level in anticipation of an experimental trial. We report data for 68 participants, ages 18 to 89, whose hearing acuity ranged from normal hearing to a moderate hearing loss, tested over a series 160 trials on an auditory sentence comprehension task. Results showed that BPDs progressively declined over the course of the experimental trials, with participants with poorer pure tone detection thresholds showing a steeper rate of decline than those with better thresholds. Data showed this slope difference to be due to participants with poorer hearing having larger BPDs than those with better hearing at the start of the experiment, but with their BPDs approaching that of the better hearing participants by the end of the 160 trials. A finding of increasing response accuracy over trials was seen as inconsistent with a fatigue or reduced task engagement account of the diminishing BPDs. Rather, the present results imply BPD as reflecting a heightened arousal level in poorer-hearing participants in anticipation of a task that demands accurate speech perception, a concern that dissipates over trials with task success. These data taken with others suggest that the baseline pupillary response may not reflect a single construct.

Association of pupil responses with severity of erectile dysfunction in diabetes mellitus

Purpose:

To investigate the relation between erectile dysfunction (ED) severity and pupillary functions in patients with diabetes mellitus (DM).

Methods:

This prospective and observational study included 90 patients with type 2 DM and ED. Patients divided into three subgroups according to severity of ED: (i) Mild ED, (ii) Moderate ED and (iii) Severe ED groups. Thirty age-matched healthy subjects formed the control group. Main outcome measures were pupil diameter and average speed of pupil dilation. Static and dynamic pupillometry analysis was performed using the Sirius Topographer (CSO, Firenze, Italy).

Results:

Mean pupil diameter during static and dynamic pupillometry analysis were significantly greater in the control group than in the all study groups (P < 0.05). Mean pupil diameter in static pupillometry analysis was significantly different in each study group and pupil was more miotic in the Severe ED group than in the both Moderate and Mild ED groups (P < 0.05 for each). Dynamic pupillometry analysis revealed that mean pupil diameter and mean average dilation speed were significantly different in each study group throughout measurement period and the highest speed was observed in the Mild ED group and the lowest speed was observed in the severe ED group (P < 0.005 for each).

Conclusion:

Our study results suggest that abnormal pupil functions due to diabetic autonomic neuropathy may indicate the associated ED in patients with DM.

Pupillometric investigation into the speed-accuracy trade-off in a visuo-motor aiming task

Convergent lines of evidence suggest that fluctuations in the size of the pupil may be associated with the trade‐off between the speed (adrenergic, sympathetic) and accuracy (cholinergic, parasympathetic) of behavior across a variety of task contexts. Here, we explored whether pupil size was related to this trade‐off during a visuospatial motor aiming task. Participants were shown visual targets at random locations on a screen and were instructed and incentivized to move a computer mouse‐controlled cursor to the center of the targets, either as fast as possible, as accurately as possible, or to strike a balance between the two. Behavioral results showed that these instructions led to typical speed‐accuracy trade‐off effects on movement reaction times and hit distances to target centers. Pupillometric analyses revealed that movements were faster and less accurate when participants had relatively large baseline pupil sizes, as measured before target onset. Furthermore, trial‐evoked pupil dilation was related specifically to a bias toward speed in the trade‐off and the speed of the ballistic and error‐correction phases of the motor responses such that larger pupils predicted shorter latencies and higher movement speeds. Pupil responses were also associated with performance in a manner that may reflect the combined influence of a number of factors, including the generation of dynamic urgency and an arousal response to negative feedback. Our results generally support a role for pupil‐linked arousal in regulating the trade‐off between speed and accuracy, while also highlighting how the trial‐related pupil response can exhibit multifaceted, temporally discrete associations with behavior.

The eye’s pupil has been considered a “window into the soul” as its dynamics are related to a wide variety of cognitive processes. Here, we present convergent evidence that both slow, prestimulus fluctuations and fast, event‐related changes in pupil diameter are sensitive to a fundamental trade‐off between the speed and accuracy of visuo‐motor actions—an association that holds for both instructed and endogenous variation in this trade‐off. This finding complements a growing literature linking pupil size to adaptive, contextually appropriate changes in behavior.

School environment associates with lung function and autonomic nervous system activity in children: a cross-sectional study

Children are in contact with local environments, which may affect respiratory symptoms and allergic sensitization. We aimed to assess the effect of the environment and the walkability surrounding schools on lung function, airway inflammation and autonomic nervous system activity. Data on 701 children from 20 primary schools were analysed. Lung function, airway inflammation and pH from exhaled breath condensate were measured. Pupillometry was performed to evaluate autonomic activity. Land use composition and walkability index were quantified within a 500 m buffer zone around schools. The proportion of effects explained by the school environment was measured by mixed-effect models. We found that green school areas tended to be associated with higher lung volumes (FVC, FEV1 and FEF25-75%) compared with built areas. FVC was significantly lower in-built than in green areas. After adjustment, the school environment explained 23%, 34% and 99.9% of the school effect on FVC, FEV1, and FEF25-75%, respectively. The walkability of school neighbourhoods was negatively associated with both pupil constriction amplitude and redilatation time, explaining -16% to 18% of parasympathetic and 8% to 29% of sympathetic activity. Our findings suggest that the environment surrounding schools has an effect on the lung function of its students. This effect may be partially mediated by the autonomic nervous system.

Listening effort: Are we measuring cognition or affect, or both?

Listening effort is increasingly recognized as a factor in communication, particularly for and with nonnative speakers, for the elderly, for individuals with hearing impairment and/or for those working in noise. However, as highlighted by McGarrigle et al., International Journal of Audiology, 2014, 53, 433-445, the term "listening effort" encompasses a wide variety of concepts, including the engagement and control of multiple possibly distinct neural systems for information processing, and the affective response to the expenditure of those resources in a given context. Thus, experimental or clinical methods intended to objectively quantify listening effort may ultimately reflect a complex interaction between the operations of one or more of those information processing systems, and/or the affective and motivational response to the demand on those systems. Here we examine theoretical, behavioral, and psychophysiological factors related to resolving the question of what we are measuring, and why, when we measure "listening effort." This article is categorized under: Linguistics > Language in Mind and Brain Psychology > Theory and Methods Psychology > Attention Psychology > Emotion and Motivation.

Exposure to indoor endocrine-disrupting chemicals and childhood asthma and obesity

BACKGROUND

Indoor air contaminants may act as endocrine-disrupting chemicals (EDCs). However, to what extent these contaminants affect health is poorly known. We aimed to assess the association between EDCs exposure and asthma, respiratory symptoms and obesity in schoolchildren.

METHODS

Data from a cross-sectional analysis of 815 participants from 20 schools in Porto, Portugal, were analysed. Symptoms were assessed, asthma was defined on lung function, and airway reversibility and body mass index (BMI) were calculated. The concentrations of 13 volatile organic compounds and 2 aldehydes identified as EDCs were measured in 71 classrooms throughout 1 week. Principal component analysis (PCA) was used to assess the effect of co-exposure. Associations were estimated by regression coefficients using linear and logistic regression models.

RESULTS

Increased individual and combined EDCs levels were found in classrooms having more children with asthma and obesity. Higher levels of hexane, styrene, cyclohexanone, butylated hydroxytoluene and 2-butoxyethanol were associated with obesity, and higher levels of cyclohexanone were associated with increased child BMI. Toluene, o-xylene, m/p-xylene and ethylbenzene were significantly associated with nasal obstruction. A positive association was found between PC1 and the risk of obese asthma (OR = 1.43, 95% CI 1.01, 1.98) and between PC2 and overweight (OR = 1.51, 95% CI 1.28, 1.79). PC1 and PC2 were also associated with nasal obstruction, and PC2 was associated with breathing difficulties and lean body mass, although EDCs concentrations were low.

CONCLUSIONS

Our findings further support the role of EDCs in asthma and obesity development. Moreover, even low levels of indoor exposure may influence the risk of asthma, respiratory symptoms and obesity.

The Pupil Dilation Response to Auditory Stimuli: Current State of Knowledge

The measurement of cognitive resource allocation during listening, or listening effort, provides valuable insight in the factors influencing auditory processing. In recent years, many studies inside and outside the field of hearing science have measured the pupil response evoked by auditory stimuli. The aim of the current review was to provide an exhaustive overview of these studies. The 146 studies included in this review originated from multiple domains, including hearing science and linguistics, but the review also covers research into motivation, memory, and emotion. The present review provides a unique overview of these studies and is organized according to the components of the Framework for Understanding Effortful Listening. A summary table presents the sample characteristics, an outline of the study design, stimuli, the pupil parameters analyzed, and the main findings of each study. The results indicate that the pupil response is sensitive to various task manipulations as well as interindividual differences. Many of the findings have been replicated. Frequent interactions between the independent factors affecting the pupil response have been reported, which indicates complex processes underlying cognitive resource allocation. This complexity should be taken into account in future studies that should focus more on interindividual differences, also including older participants. This review facilitates the careful design of new studies by indicating the factors that should be controlled for. In conclusion, measuring the pupil dilation response to auditory stimuli has been demonstrated to be sensitive method applicable to numerous research questions. The sensitivity of the measure calls for carefully designed stimuli.

A Tipping Point in Listening Effort: Effects of Linguistic Complexity and Age-Related Hearing Loss on Sentence Comprehension

In recent years, there has been a growing interest in the relationship between effort and performance. Early formulations implied that, as the challenge of a task increases, individuals will exert more effort, with resultant maintenance of stable performance. We report an experiment in which normal-hearing young adults, normal-hearing older adults, and older adults with age-related mild-to-moderate hearing loss were tested for comprehension of recorded sentences that varied the comprehension challenge in two ways. First, sentences were constructed that expressed their meaning either with a simpler subject-relative syntactic structure or a more computationally demanding object-relative structure. Second, for each sentence type, an adjectival phrase was inserted that created either a short or long gap in the sentence between the agent performing an action and the action being performed. The measurement of pupil dilation as an index of processing effort showed effort to increase with task difficulty until a difficulty tipping point was reached. Beyond this point, the measurement of pupil size revealed a commitment of effort by the two groups of older adults who failed to keep pace with task demands as evidenced by reduced comprehension accuracy. We take these pupillometry data as revealing a complex relationship between task difficulty, effort, and performance that might not otherwise appear from task performance alone.

The Pupil Dilation Response During Speech Perception in Dark and Light: The Involvement of the Parasympathetic Nervous System in Listening Effort

Recently, the measurement of the pupil dilation response has been applied in many studies to assess listening effort. Meanwhile, the mechanisms underlying this response are still largely unknown. We present the results of a method that separates the influence of the parasympathetic and sympathetic branches of the autonomic nervous system on the pupil response during speech perception. This is achieved by changing the background illumination level. In darkness, the influence of the parasympathetic nervous system on the pupil response is minimal, whereas in light, there is an additional component from the parasympathetic nervous system. Nineteen hearing-impaired and 27 age-matched normal-hearing listeners performed speech reception threshold tests targeting a 50% correct performance level while pupil responses were recorded. The target speech was masked with a competing talker. The test was conducted twice, once in dark and once in a light condition. Need for Recovery and Checklist Individual Strength questionnaires were acquired as indices of daily-life fatigue. In dark, the peak pupil dilation (PPD) did not differ between the two groups, but in light, the normal-hearing group showed a larger PPD than the hearing-impaired group. Listeners with better hearing acuity showed larger differences in dilation between dark and light. These results indicate a larger effect of parasympathetic inhibition on the pupil dilation response of listeners with better hearing acuity, and a relatively high parasympathetic activity in those with worse hearing. Previously observed differences in PPD between normal and impaired listeners are probably not solely because of differences in listening effort.

Nutritional Status Measures Are Correlated with Pupillary Responsiveness in Zambian Children

Background

Impairments in visual function have been well characterized in vitamin A deficiency. However, eye function may also be sensitive to other nutrient deficiencies.

Objective

We examined associations between visual function-characterized by pupillary threshold or pupillary responsiveness-and nutritional status in Zambian children.

Methods

We used digital pupillometry to measure visual responses to calibrated light stimuli (-2.9 to 0.1 log cd/m2) among dark-adapted children aged 4-8 y (n = 542). We defined pupillary threshold as the first light stimulus at which pupil diameter decreased by ≥10% and considered a pupillary threshold ≥-0.9 log cd/m2 as impaired. Pupillary responsiveness was defined by absolute percentage of change in pupil diameter from pre- to poststimulus. We tested associations between these measures and serum concentrations of retinol, β-carotene, ferritin, soluble transferrin receptor, and hemoglobin (Hb <11.0 or 11.5 g/dL were used to define anemia, depending on age), as well as anthropometric indexes, with the use multilevel mixed-effects models.

Results

Pupillary threshold was correlated only with serum retinol (r = 0.12, P < 0.05). The strongest correlates of pupillary responsiveness were Hb (r = -0.16, P < 0.01), height-for-age z score (r = 0.14, P < 0.05), weight-for-age z score (r = 0.14, P < 0.05), and soluble transferrin receptor (r = 0.12, P < 0.05). In multivariate models, anemia was positively associated with pupillary responsiveness (β = 2.99; 95% CI: 1.26, 4.72).

Conclusions

In this marginally nourished population, we found positive correlations between vitamin A status, iron status, or anthropometric indexes and visual function. Hb was negatively associated with visual function, with greater pupillary responsiveness among anemic children. We posit that this may signal altered parasympathetic activity, possibly driven by infection. Future studies should consider a broader range of indicators to better characterize the relation between nutrition and visual function. This trial was registered at clinicaltrials.gov as NCT01695148.