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Adamkiewicz D, Magazin M, Thomas D. A Case of Pharmacologic Anisocoria in Systemic Glycopyrrolate Use from Presumed Local Ocular Inoculation. Neuroophthalmology 2024; 48:41-45. [PMID: 38357624 PMCID: PMC10863343 DOI: 10.1080/01658107.2023.2273473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/08/2023] [Indexed: 02/16/2024] Open
Abstract
Anisocoria is a common finding in ophthalmic clinical practice. History taking and examination is critical in appropriately diagnosing and managing anisocoria, as the differential can be extensive ranging from benign to life-threatening entities. This case discusses the presentation of a 22-year-old female with a history of myopia and hyperhidrosis who presented with pharmacologic anisocoria which was presumed to be from inadvertent topical exposure to conventional glycopyrrolate tablets. To our knowledge, pharmacologic mydriasis from exposure to residue from conventional glycopyrrolate tablets has not been reported in the English literature. This case highlights the importance of medication and contact lens handling with anticholinergic agents.
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Affiliation(s)
- Daniel Adamkiewicz
- Department of Ophthalmology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Maja Magazin
- Department of Ophthalmology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Dilip Thomas
- Department of Ophthalmology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
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Sasher T, Bomar P, Feuer D, McDonald L. Anisocoria in patients with hyperhidrosis: A case series for the primary care physician. J Family Med Prim Care 2024; 13:797-799. [PMID: 38605781 PMCID: PMC11006025 DOI: 10.4103/jfmpc.jfmpc_698_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/03/2023] [Accepted: 10/31/2023] [Indexed: 04/13/2024] Open
Abstract
The differential diagnosis for anisocoria is broad and ranges from benign to life-threatening causes. Often, patients with new onset anisocoria present to their primary care physician, an urgent care center, or an emergency room. As such, it is important for non-ophthalmologist physicians to be familiar with its common causes. We present two cases of pharmacologic anisocoria from Qbrexza (glycopyronnium), a wipe used in the treatment of hyperhidrosis. Identifying this medication as a cause of anisocoria in patients with hyperhidrosis can reduce costs and unnecessary testing. Furthermore, physician education about safer usage can be provided.
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Affiliation(s)
- Tianna Sasher
- Lake Erie College of Osteopathic Medicine, Bradenton, FL, United States
| | - Parker Bomar
- Edward Via College of Osteopathic Medicine, Auburn, AL, United States
| | - Daniel Feuer
- University of Florida College of Medicine, Florida, United States
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3
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Jha S. Isolated ophthalmoplegia with alternating aniscoria in anti-GQ1b negative syndrome. Acta Neurol Belg 2024:10.1007/s13760-024-02482-4. [PMID: 38265634 DOI: 10.1007/s13760-024-02482-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 01/18/2024] [Indexed: 01/25/2024]
Affiliation(s)
- Shreyashi Jha
- Department of Neurology, Institute of Neurosciences, Kolkata, 700017, India.
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Parihar A, Mani A, Mishra A. Holmes-Adie syndrome and vitamin B12 - associated peripheral neuropathy: An association or coincidence? Med J Armed Forces India 2023; 79:S315-S320. [PMID: 38144644 PMCID: PMC10746827 DOI: 10.1016/j.mjafi.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/15/2022] [Indexed: 11/18/2022] Open
Abstract
A 30-year-old male patient presented to the eye department with complaints of blurring of vision of right eye at distance and near for a duration of 1.5 months. Ocular examination revealed Anisocoria with enlarged pupil in the right eye. On instillation of 0.1% pilocarpine, there was a pronounced miosis in the dilated pupil seen at 30 min associated with an improvement in distance and near vision. On slit lamp examination, vermiform movements were seen in the affected pupil on shining the slit from temporal aspect. Fundus examination was within normal limits. Systemic examination revealed absent deep tendon reflexes. Based on the clinical features, a diagnosis of Holmes-Adie syndrome was reached and the patient was started on 0.1% pilocarpine eye drops. This case highlights the importance of thorough systemic examination and investigations in all cases of anisocoria.
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Affiliation(s)
- A.S. Parihar
- Classified Specialist & Head (Ophthalmology), INHS Sanjivani, Kochi, India
| | - Anita Mani
- Graded Specialist (Ophthalmology), INHS Jeevanti, Goa, India
| | - A.B. Mishra
- Graded Specialist (Medicine), INHS Kasturi, Lonavla, Maharashtra, India
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Ota K, Kobata H, Hamada Y, Mizutani S, Okuyama T, Ota K, Takeda Y, Takasu A. Anisocoria without extraocular muscle impairment due to moderate traumatic brain injury with midbrain contusion: a case report. BMC Neurol 2023; 23:270. [PMID: 37454064 DOI: 10.1186/s12883-023-03331-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 07/12/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND New-onset anisocoria is an important clinical clue to life-threatening intracranial injury. Anisocoria alone without impairment of extraocular muscles is a rare presentation of moderate traumatic brain injury (TBI). CASE PRESENTATION A 79-year-old woman was transported to hospital soon after falling off a bicycle. Glasgow Coma Scale score on arrival was 11 (E3V3M5). On examination at admission, she was found to be drowsy. Bruising was seen around the right eye and pupil diameters differed (right, 4.5 mm; left, 3.0 mm; both reactive to light). Computed tomography of the head revealed hemorrhagic contusion in the left temporal lobe and left pretectal area of the midbrain, right clavicular fracture, and pulmonary contusion with fractures of the 3rd and 4th ribs. Magnetic resonance imaging confirmed hemorrhagic contusion of the midbrain. The patient achieved full recovery of motor and mental functions with conservative treatment and was discharged on hospital day 17. CONCLUSION We encountered a case of anisocoria without major extraocular muscle impairment due to moderate TBI with midbrain contusion.
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Affiliation(s)
- Koshi Ota
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki City, 596-8686, Osaka, Japan.
| | - Hitoshi Kobata
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki City, 596-8686, Osaka, Japan
| | - Yoshisuke Hamada
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki City, 596-8686, Osaka, Japan
| | - Saki Mizutani
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki City, 596-8686, Osaka, Japan
| | - Terunari Okuyama
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki City, 596-8686, Osaka, Japan
| | - Kanna Ota
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki City, 596-8686, Osaka, Japan
| | - Yuriko Takeda
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki City, 596-8686, Osaka, Japan
| | - Akira Takasu
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki City, 596-8686, Osaka, Japan
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Kaushal A, Andleeb R, Gupta P, Talawar P. Postoperative Anisocoria-need not be Concerned Always. Turk J Anaesthesiol Reanim 2023; 51:278-279. [PMID: 37455544 DOI: 10.4274/tjar.2022.221013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Affiliation(s)
- Ashutosh Kaushal
- Department of Anaesthesiology, All India Institute of Medical Sciences, Bhopal, India
| | - Roshan Andleeb
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, India
| | - Priyanka Gupta
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, India
| | - Praveen Talawar
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, India
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Clausen K, Davis S, Pourmand A. Approach to anisocoria in the emergency department; A case report and literature review. Am J Emerg Med 2023:S0735-6757(23)00245-0. [PMID: 37179218 DOI: 10.1016/j.ajem.2023.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
Anisocoria describes asymmetric pupillary diameter, which can result from traumatic, pharmacologic, inflammatory, or ischemic effects on the eye. In many cases, anisocoria represents a normal physiologic variant. Morbidity associated with anisocoria is directly related to the inciting cause and can vary from benign to life-threatening. A thorough understanding by emergency physicians of normal ocular neuroanatomy, and of common causes of pathologic anisocoria, including medication-induced anisocoria, can facilitate appropriate resource utilization and timely subspecialty consultation, and can help prevent irreversible ocular injury and patient morbidity. We describe a patient who presented to the emergency department with acute onset of blurry vision with anisocoria.
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Affiliation(s)
- Kellan Clausen
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Steven Davis
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Ali Pourmand
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
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Chronopoulos A, Consigli A, Heim J, Schutz JS, Becker M, Krastel H, Hattenbach LO. Isolated Internal Ophthalmoplegia from Posterior Cerebral Artery Neurovascular Conflict. Case Rep Ophthalmol 2023; 14:104-110. [PMID: 36968808 PMCID: PMC10035546 DOI: 10.1159/000529231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/09/2023] [Indexed: 03/29/2023] Open
Abstract
We report a rare case of recurrent isolated internal ophthalmoplegia attributed to oculomotor nerve (CN III) compression by the posterior cerebral artery (PCA). A 30-year-old female patient presented with recurrent right-sided headaches, right periorbital pain, and slight anisocoria. Slit-lamp examination revealed normal anterior and posterior segments except for vermiform movements of the right pupil with a temporal hyporeactive flat area. Tonic pupils were ruled out with pilocarpine 0.1% testing. Suspecting an internal ophthalmoplegia, magnetic resonance imaging was ordered which demonstrated the right CN III indented by the PCA, fulfilling the criteria of a neurovascular conflict. The evaluation of unilateral mydriasis from internal ophthalmoplegia should prompt neuroimaging with exclusion of aneurysmal or compressive lesions. CN III palsy can rarely be caused by vascular anatomical variants because of the proximity of the posterior intracranial circulation and CN III. Newer, more precise imaging techniques will better help characterize neurovascular conflicts presenting as cranial nerve palsies.
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Affiliation(s)
- Argyrios Chronopoulos
- Department of Ophthalmology, Ludwigshafen Hospital, Ludwigshafen, Germany
- Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland
| | - Andrea Consigli
- Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland
| | - Julia Heim
- Department of Ophthalmology, Ludwigshafen Hospital, Ludwigshafen, Germany
| | - James S. Schutz
- Department of Ophthalmology, Ludwigshafen Hospital, Ludwigshafen, Germany
| | - Minerva Becker
- Division of Radiology, Department of Diagnostics, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland
| | - Hermann Krastel
- Department of Ophthalmology, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
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Xiao C, Chen F, Tan Y, Bao X, Jing S. Anisocoria and mydriasis after scalp nerve block: a case report. J Int Med Res 2022; 50:3000605221099262. [PMID: 35632980 PMCID: PMC9150241 DOI: 10.1177/03000605221099262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/19/2022] [Indexed: 11/21/2022] Open
Abstract
Strategies for the assessment of abnormal neurological findings during general anesthesia are limited. However, pupil abnormalities may represent serious neurological complications. We herein present a case of new-onset anisocoria and mydriasis that developed after scalp nerve block. The patient's signs were possibly related to increased intracranial pressure with resulting brain shift that ultimately affected the oculomotor nerves. A 45-year-old man was scheduled for left cerebellar tumor resection and ventricular drainage surgery; however, anisocoria and left pupillary mydriasis were observed after induction of general anesthesia and performance of scalp nerve block. After reducing the intracranial pressure, the right pupil showed constriction (1 mm) but the left pupil was dilated (5 mm). The pupils were of similar size postoperatively. Although pupillary dilation during general anesthesia has been previously described, this is the first case in which the mydriasis was considered to have been caused by brain shift due to increased intracranial pressure after scalp nerve block. Thus, we propose this phenomenon as a new possible cause of pupillary changes. Actively monitoring this presentation intraoperatively could enable early detection of and intervention for complications, therefore improving the prognosis.
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Affiliation(s)
- Cheng Xiao
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, PLA, No. 83 Xinqiao Road, Shapingba, Chongqing, China
| | - Fang Chen
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, PLA, No. 83 Xinqiao Road, Shapingba, Chongqing, China
| | - Yuting Tan
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, PLA, No. 83 Xinqiao Road, Shapingba, Chongqing, China
| | - Xiaohang Bao
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, PLA, No. 83 Xinqiao Road, Shapingba, Chongqing, China
| | - Sheng Jing
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, PLA, No. 83 Xinqiao Road, Shapingba, Chongqing, China
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Bellégo C, Borruat FX, Kawasaki A. Long-term prognosis of patients with idiopathic Horner syndrome. J Neurol 2021; 269:2781-2783. [PMID: 34839389 DOI: 10.1007/s00415-021-10916-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Claire Bellégo
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - François-Xavier Borruat
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Neuro-Ophthalmology, Hôpital Ophtalmique Jules Gonin, Fondation Asile des Aveugles, University of Lausanne, Avenue de France 15, 1004, Lausanne, Switzerland
| | - Aki Kawasaki
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland. .,Department of Neuro-Ophthalmology, Hôpital Ophtalmique Jules Gonin, Fondation Asile des Aveugles, University of Lausanne, Avenue de France 15, 1004, Lausanne, Switzerland.
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Reena Durai CV, Rajendran S, Webster MA, Vempati S, Bharadwaj SR. The magnitude of monocular light attenuation required to elicit the Pulfrich illusion. Vision Res 2021; 187:85-93. [PMID: 34225133 PMCID: PMC8363548 DOI: 10.1016/j.visres.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 06/17/2021] [Accepted: 06/19/2021] [Indexed: 11/17/2022]
Abstract
In the Pulfrich illusion, the depth of a moving object is misperceived due to induced retinal disparity and/or interocular velocity differences arising from differences in luminance, contrast, or spatial frequency between the two eyes. These effects have been shown to occur both for visual deficits and for optical corrections that introduce significant binocular differences between the retinal images. However, it remains unknown to what extent the illusion might arise given normal variation between the eyes, such as natural interocular variation in pupil diameter (anisocoria). To assess this, we examined the threshold interocular retinal illuminance difference required to experience illusory depth in two random-dot fields moving in opposite directions in 24 normally-sighted observers with dilated pupils. Interocular difference in retinal illuminance was induced by placing neutral density filters of different intensities before the left eye. A minority of subjects (n = 8) did not provide meaningful data on changes in the experience of illusory depth with interocular difference in retinal illuminance and four subjects showed biases >±10% from the 50% point of subjective equality in the psychometric function. For the remaining 12 participants, the retinal illuminance had to differ by approximately 40% for the depth between the planes to become visible at threshold levels. This difference was approximately constant over a range of absolute luminance levels from 10 to 80 cd/m2. Our results suggest that while motion-in-depth illusions due to interocular differences in retinal illuminance may be pronounced in certain ophthalmic diseases or following certain optical interventions, it is unlikely to be manifest as a result of normal interocular variations in retinal illuminance. Further, our results also point towards the existence of substantial individual differences in the experience of what is otherwise thought of as a readily appreciable motion-in-depth illusion.
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Affiliation(s)
- C Vijay Reena Durai
- Brien Holden Institute of Optometry and Vision Sciences, LV Prasad Eye Institute, Road no. 2, Banjara Hills, Hyderabad 500034, Telangana, India; Prof. Brien Holden Eye Research Centre, Hyderabad Eye Research Foundation, LV Prasad Eye Institute, Road no. 2, Banjara Hills, Hyderabad 500034, Telangana, India
| | | | | | - Sandeep Vempati
- Center for Innovation, LV Prasad Eye Institute, Hyderabad 500034, Telangana, India
| | - Shrikant R Bharadwaj
- Brien Holden Institute of Optometry and Vision Sciences, LV Prasad Eye Institute, Road no. 2, Banjara Hills, Hyderabad 500034, Telangana, India; Prof. Brien Holden Eye Research Centre, Hyderabad Eye Research Foundation, LV Prasad Eye Institute, Road no. 2, Banjara Hills, Hyderabad 500034, Telangana, India.
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Aslankurt M, Aslan L. Horner's syndrome secondary to heart surgery in a pediatric patient. Saudi J Ophthalmol 2021; 34:303-305. [PMID: 34527878 PMCID: PMC8409344 DOI: 10.4103/1319-4534.322597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 12/10/2019] [Accepted: 01/06/2020] [Indexed: 11/04/2022] Open
Abstract
Horner's Syndrome (HS) is a disease characterized by miosis, ptosis, and ipsilateral lack of sweating. It can occur with any injury at the level of the ocular sympathetic system neurons from the hypothalamus to the cervical postganglionic fibers. We present here a case of HS that developed after heart surgery in a 9-year-old boy. Ventricular septal defect, aortic and mitral valves repair, and pacemaker implant procedures were noted in his medical records. Preganglionic HS was diagnosed with bilateral unresponsiveness to a 0.1% adrenaline and positive result in the right eye to 0.5% apraclonidine tests. HS is often related to injuries of the brain stem, upper spinal cord, lung apex tumors and lesions, aortic coarctation, cervical lesions, and carotid lesions have been reported. However, it is rare secondary to heart surgery among the pediatric age group.
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Affiliation(s)
- Murat Aslankurt
- Department of Ophthalmology, Sütcü Imam University, Faculty of Medicine KSU Faculty of Medical, Kahramanmaraş, Turkey
| | - Lokman Aslan
- Department of Ophthalmology, Sütcü Imam University, Faculty of Medicine KSU Faculty of Medical, Kahramanmaraş, Turkey
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Garcia Castro J, Díaz de Terán J. Reversible Mydriasis of Sudden Onset: Think Before You Act. J Emerg Med 2021; 61:e77-e79. [PMID: 34215471 DOI: 10.1016/j.jemermed.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/05/2021] [Accepted: 05/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The presence of abrupt anisocoria in clinical examination usually leads to the performance of urgent neuroimaging studies to exclude intracranial hemorrhage, although unilateral mydriasis might be the result of other benign etiologies. CASE REPORT In this work, we report an illustrative case of a patient presenting with sudden-onset anisocoria while receiving ipratropium bromide nebulization in the emergency department to treat acute asthma. No other abnormalities were found on neurological examination and the computed tomography scan was normal. As a muscarinic antagonist, ipratropium bromide can produce mydriasis if accidentally instilled on one eye, thus leading to the suspicion of pharmacologic mydriasis. The pupils became isocoric after the discontinuation of the drug. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A careful neurological examination and the history of treatment with mydriatic drugs might avoid unnecessary tests and radiation exposure.
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Affiliation(s)
| | - Javier Díaz de Terán
- Department of Neurology, La Paz University Hospital, Madrid, Spain; La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.
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Abstract
Eine 53-jährige Patientin beklagte erhöhte Blendempfindlichkeit 3 Wochen nach Einnahme von Moxifloxacin-Tabletten bei Infekt der oberen Atemwege. Es bestand eine Anisokorie, die Pupillenreaktion, sowohl auf Licht als auch auf Naheinstellung, war aufgehoben. In der Untersuchung des vorderen Augenabschnittes fielen beidseits ausgeprägte Iristransilluminationsdefekte (ITD) auf. Wir diagnostizierten ein BAIT-Syndrom (bilaterales akutes Iristransilluminationssyndrom). Dies ist ein seltenes Syndrom, welches mit einer massiven Depigmentierung der Iris sowie einer Atrophie der Irismuskulatur einhergeht. Risikofaktor für die Entstehung eines BAIT-Syndroms scheint die orale Einnahme von Antibiotika, insbesondere Moxifloxacin, im Rahmen eines Infektes der oberen Atemwege zu sein, aber auch spontan auftretende Fälle sind beschrieben. Betroffen sind v. a. Frauen mittleren Alters. Die genaue Ursache des BAIT-Syndroms ist bisher unklar. Diskutiert wird ein möglicher Einfluss der Konzentration des Antibiotikums im Glaskörper. Differenzialdiagnostisch muss bei Iristransilluminationsdefekten insbesondere auch an Albinismus, intraokuläre Entzündungen, Pseudoexfoliationssyndrom und Pigmentdispersionssyndrom gedacht werden. Eine spezifische Therapie des BAIT-Syndroms besteht bisher nicht. Erhöhte Lichtempfindlichkeit und ein Post-BAIT-Glaukom können mögliche Komplikationen sein. Die Kenntnis des seltenen BAIT-Syndroms kann im klinischen Alltag hilfreich bei der differenzialdiagnostischen Einordnung einer Anisokorie sein und ggf. zur Vermeidung unnötiger diagnostischer Schritte beitragen.
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Affiliation(s)
- Jan Klonner
- Universitäts-Augenklinik, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - Daniel Salchow
- Universitäts-Augenklinik, Leitung der Sektion Kinderaugenheilkunde, Strabologie/Orthoptik, Neuroophthalmologie, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
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15
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Alemu HW, Kumar P. Monocular Diplopia: An Optical Correction Modality. Case Rep Ophthalmol 2021; 12:501-506. [PMID: 34248582 PMCID: PMC8255654 DOI: 10.1159/000513215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/19/2020] [Indexed: 11/19/2022] Open
Abstract
Post-surgical or traumatic corectopia is among the rare causes of monocular diplopia. A 26-years-old student presented to the Institute with a complaint of monocular double vision in the left eye. He had a penetrating ocular injury in the left eye and subsequently, undergone for multiple ocular surgeries. Following the final intraocular lens implantation, he experienced a monocular double vision in his left eye. Upon contact lens clinic presentation, visual acuities were 20/20 in the right and 20/320 in the left eye (improved to 20/25 with pinhole). Slit-lamp examination on the left eye revealed scarring in the superior nasal quadrant of the cornea, irregular mid-dilated pupil with exposed aphakic and pseudophakic portions. A range of different optical management options were implemented to eliminate monocular diplopia and to correct refractive error. Finally, a combination of prosthetic soft contact lens and spectacle correction was able to remove diplopia and provide binocular single vision.
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Affiliation(s)
- Haile W. Alemu
- Department of Optometry, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Preetam Kumar
- L.V.Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India
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Derinoz-Guleryuz O, Fidanci İ, Men-Atmaca Y. Nebulized Ipratropium Bromide-induced Anisocoria: Why Is Anisocoria Observed? Iran J Allergy Asthma Immunol 2021; 20:125-128. [PMID: 33639629 DOI: 10.18502/ijaai.v20i1.5420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 12/22/2020] [Indexed: 11/24/2022]
Abstract
Pharmacological anisocoria is a rare but benign condition. This paper presents an eleven-year-old patient with asthma who developed ipratropium bromide-associated anisocoria during nebulizer treatment. Hypotheses regarding the possible causes of anisocoria are discussed and precautions to be taken during treatment are presented. To prevent the development of anisocoria, it was found that it is important to use the appropriate mask during nebulizer treatment, to place the mask on the face properly, and, if possible, to administer drugs by closing the eyes. Further, it is recommended that patients undergo an ophthalmological examination before discharge and that they and their families be informed that the condition is temporary.
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Affiliation(s)
- Oksan Derinoz-Guleryuz
- Department of Pediatrics, Division of Pediatric Emergency, Faculty of Medicine, Gazi University, Ankara, Turkey.
| | - İlknur Fidanci
- Department of Pediatrics, Division of Pediatric Emergency, Faculty of Medicine, Gazi University, Ankara, Turkey.
| | - Yasemin Men-Atmaca
- Department of Pediatrics, Division of Pediatric Emergency, Faculty of Medicine, Gazi University, Ankara, Turkey.
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17
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Abstract
Neuroblastoma is the most common neoplasm associated with pediatric Horner syndrome. The laboratory and imaging evaluation of isolated pediatric Horner syndrome is controversial. We review the literature published in the last several decades and present the rationale for the imaging work-up in this patient cohort.
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Affiliation(s)
- Hedieh Khalatbari
- Department of Radiology, University of Washington School of Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
| | - Gisele E Ishak
- Department of Radiology, University of Washington School of Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
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18
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Nguyen MTB, Farahvash A, Zhang A, Micieli JA. Apraclonidine for the pharmacologic confirmation of acute Horner syndrome. J Neurol Sci 2020; 419:117190. [PMID: 33075593 DOI: 10.1016/j.jns.2020.117190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/22/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
Apraclonidine is the most widely used pharmacologic agent to confirm Horner syndrome. It is a strong α-2 and a weak α-1 adrenergic agonist and reversal of anisocoria is considered a positive test. The utility of apraclonidine in acute Horner syndrome remains controversial as the exact timing for denervation sensitivity to develop remains unknown. The goal of this study was to describe the use of apraclonidine in the diagnosis of acute Horner syndrome in patients with an unequivocal onset within 7 days. We identified 3 patients who were referred to ophthalmology/neuro-ophthalmology service and had reversal of anisocoria within 7 days. Two cases of second-order Horner syndrome after cardiac surgery and a case of a third-order Horner syndrome from a carotid cavernous sinus fistula resulted in reversal of anisocoria 72 h, 48 h, and 5 days after onset. Photographic documentation was provided for all cases. Our results suggest that apraclonidine has utility in the acute period and positive results can be seen as early as 48 h after onset. Apraclonidine should therefore still be considered to confirm the presence of acute Horner syndrome before extensive neuroimaging is performed.
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Affiliation(s)
- Michael T B Nguyen
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Armin Farahvash
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Angela Zhang
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan A Micieli
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; Kensington Vision and Research Centre, Toronto, Ontario, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Ophthalmology, St. Michael's Hospital, Toronto, Ontario, Canada.
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19
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Cisarik PM, Brise L, Ramos G. Anisocoria assessment in subjects with dark irides - Custom-built infrared screening device vs. millimeter ruler. J Optom 2020; 13:235-241. [PMID: 32331923 PMCID: PMC7520532 DOI: 10.1016/j.optom.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 02/25/2020] [Accepted: 03/01/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE Detection of anisocoria in those with dark irides is difficult, and failure to detect anisocoria can have dire consequences. Whether infrared pupillometry and gross measurement would yield different prevalence rates for anisocoria in those with dark irides is unknown. We compared the frequency of anisocoria in healthy adults with dark irides assessed with mm ruler versus infrared pupillometry. METHODS Pupil diameters in light (L) and dark (D) conditions were obtained to identify anisocoria in 59 human subjects with dark irides using two techniques. To avoid bias, gross measurements (S) with ruler were taken first. Pupils were imaged under infrared illumination mounted in a spectacle frame with mm tape attached. Adobe Photoshop was used to measure pupil sizes on the digital images (O). RESULTS Proportions of anisocoria by group were SL .034, OL .130, SD 0.00, OD .135. Fisher's exact test showed that anisocoria in dim light was more frequent with the infrared photo technique. Exact binomial probability testing showed that the anisocoria in SL and SD conditions was not different from an expected proportion of 5%; whereas anisocoria in OL condition was not different from an expected proportion of 20%, and anisocoria in OD condition was not different from expected proportions of 10, 15, and 20%. CONCLUSIONS In people with dark irides, ruler measurements of pupil size underestimate the frequency of anisoria in dim lighting conditions compared to the use of infrared pupillometry. Whether detection rates of pathologic anisocoria differ with measurement technique remain to be explored.
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Affiliation(s)
- Patricia M Cisarik
- Southern College of Optometry, 1245 Madison Avenue, Memphis, TN 38117, United States.
| | - Lindsey Brise
- Southern College of Optometry, 1245 Madison Avenue, Memphis, TN 38117, United States
| | - Greyson Ramos
- Southern College of Optometry, 1245 Madison Avenue, Memphis, TN 38117, United States
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20
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Olcucu MT, Teke K, Yildirim K, Toğac M, Işık B, Yilmaz YC. Comparision effects of solifenacin, darifenacin, propiverine on ocular parameters in eyes: A prospective study. Int Braz J Urol 2020; 46:185-193. [PMID: 32022506 PMCID: PMC7025839 DOI: 10.1590/s1677-5538.ibju.2019.0094] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 10/13/2019] [Indexed: 11/22/2022] Open
Abstract
Objective To evaluate the effects of solifenacin, darifenacin, and propiverine on nasal-, subfoveal-, temporal choroidal thicknesses (NCT, SFCT, TCT), intraocular pressure (IOP) and pupil diameter (PD). Materials and Methods Patients with overactive bladder (OAB) diagnosed according to The International Continence Society were administered with solifenacin, darifenacin or propiverine on a daily basis between November 2017 and May 2018. NCT, SFCT, TCT, IOP, and PD of these patients were measured and compared as initial, fourth and twelfth weeks. Results A total of 165 patients (330 eyes) with OAB were evaluated. Solifenacin (n=140) significantly reduced IOP from 17.30±2.72 mmHg to 16.67±2.56 mmHg (p=0.006) and 16.57±2.41 mmHg (p=0.002), at the fourth and twelfth weeks, respectively. Darifenacin (n=110) significantly reduced NCT from 258.70±23.96 μm to 257.51±22.66 μm (p=0.002) and 255.36±19.69 μm (p=0.038), at the fourth and twelfth weeks, respectively. Propiverine (n=80) significantly increased PD from 4.04±0.48 mm to 4.08±0.44 mm (p=0.009) and 4.09±0.45 mm (p=0.001), at the fourth and twelfth weeks, respectively. Conclusion These findings can help to decide appropriate anticholinergic drug choice in OAB patients. We finally suggest further well-designed randomized prospective studies with a larger population to evaluate the anticholinergic-related complications in eyes.
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Affiliation(s)
| | - Kerem Teke
- Department of Urology, Agri State Hospital, Agri, Turkey
| | - Kadir Yildirim
- Department of Urology, Elaziğ Education and Research Hospital, Elazig, Turkey
| | - Mesut Toğac
- Department of Ophthalmology, Agri State Hospital, Agri, Turkey
| | - Burcu Işık
- Department of Ophthalmology, Agri State Hospital, Agri, Turkey
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21
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Cerveró A, López-de-Eguileta A, Cano-Abascal Á, Sedano-Tous MJ, Drake-Pérez M, Casado A. Anisocoria as initial manifestation of multiple sclerosis. Use of 3 tesla magnetic resonance imaging. Arch Soc Esp Oftalmol (Engl Ed) 2020; 95:192-195. [PMID: 32147131 DOI: 10.1016/j.oftal.2020.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/29/2019] [Accepted: 01/03/2020] [Indexed: 06/10/2023]
Abstract
A 21-year-old woman seen in this clinic with non-reactive mydriasis in the right eye that contracted with 1% pilocarpine. Cranial angio-CT and 1.5 T magnetic resonance imaging (MRI) did not detect any disease. Given a subsequent limitation of adduction, supraduction, and infarction of the right eye, a 3 T MRI was requested. This showed a lesion of the midbrain at the exit of the 3rd cranial nerve. After improvement, no new episodes were observed until 18 months later, when the patient presented with probable optic neuritis and systemic symptoms. At this time the 1.5 T MRI detected infratentorial and supratentorial demyelinating plaques. A subsequent lumbar puncture and clinic outcome confirmed the diagnosis of relapsing-remitting multiple sclerosis.
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Affiliation(s)
- A Cerveró
- Departamento de Oftalmología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, España.
| | - A López-de-Eguileta
- Departamento de Oftalmología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, España
| | - Á Cano-Abascal
- Departamento de Neurología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, España
| | - M J Sedano-Tous
- Departamento de Neurología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, España
| | - M Drake-Pérez
- Departamento de Radiología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, España
| | - A Casado
- Departamento de Oftalmología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, España
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22
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Catarino D, Ribeiro C, Gomes L, Paiva I. Corticotroph adenoma and pituitary fungal infection: a rare association. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200010. [PMID: 32213650 PMCID: PMC7159253 DOI: 10.1530/edm-20-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 03/04/2020] [Indexed: 01/16/2023] Open
Abstract
SUMMARY Pituitary infections, particularly with fungus, are rare disorders that usually occur in immunocompromised patients. Cushing's syndrome predisposes patients to infectious diseases due to their immunosuppression status. We report the case of a 55-year-old woman, working as a poultry farmer, who developed intense headache, palpebral ptosis, anisocoria, prostration and psychomotor agitation 9 months after initial diabetes mellitus diagnosis. Cranioencephalic CT scan showed a pituitary lesion with bleeding, suggesting pituitary apoplexy. Patient underwent transsphenoidal surgery and the neuropathologic study indicated a corticotroph adenoma with apoplexy and fungal infection. Patient had no preoperative Cushing's syndrome diagnosis. She was evaluated by a multidisciplinary team who decided not to administer anti-fungal treatment. The reported case shows a rare association between a corticotroph adenoma and a pituitary fungal infection. The possible contributing factors were hypercortisolism, uncontrolled diabetes and professional activity. Transsphenoidal surgery is advocated in these infections; however, anti-fungal therapy is still controversial. LEARNING POINTS Pituitary infections are rare disorders caused by bacterial, viral, fungal and parasitic infections. Pituitary fungal infections usually occur in immunocompromised patients. Cushing's syndrome, as immunosuppression factor, predisposes patients to infectious diseases, including fungal infections. Diagnosis of pituitary fungal infection is often achieved during histopathological investigation. Treatment with systemic anti-fungal drugs is controversial. Endocrine evaluation is recommended at the time of initial presentation of pituitary manifestations.
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Affiliation(s)
- Diana Catarino
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Cristina Ribeiro
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Leonor Gomes
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Isabel Paiva
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
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23
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George AS, Abraham AP, Nair S, Joseph M. The Prevalence of Physiological Anisocoria and its Clinical Significance - A Neurosurgical Perspective. Neurol India 2019; 67:1500-1503. [PMID: 31857545 DOI: 10.4103/0028-3886.273623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Aim We aimed to estimate the prevalence of physiological anisocoria and also evaluate the accuracy of clinical assessment of anisocoria employed in routine bedside examination. Materials and Methods A total of 708 voluntary subjects between the ages of 20-69 years who had no history of ophthalmologic or neurological disease other than refractive error were included in the study. In a closed room with uniform ambient lighting, the subjects' pupils were examined clinically and the presence or absence of anisocoria was recorded. This was followed by photography of the subjects' pupils using a digital camera secured on a tripod at a fixed distance from the subject's face. A difference in pupillary size of 0.4 mm or more was considered anisocoria. Results Of the 708 subjects, 361 (51%) were males. The average pupillary diameter of the subjects was 4.99 mm. Ninety-seven (13.7%) had measured anisocoria on photography. Ninety-seven subjects (13.7%) also had anisocoria on clinical examination, however, only 45 of them had measured anisocoria. The clinical measurement of anisocoria, therefore, showed a specificity of 0.91 and a sensitivity of 0.46. With a prevalence of anisocoria of 13.7%, the positive predictive value was 0.46, and the negative predictive value was 0.91. Conclusions The prevalence of physiological anisocoria was 13.7%, which is less than what has previously been reported. The sensitivity of clinical examination in detecting early anisocoria is poor. Patients at risk of developing uncal herniation may, therefore, benefit from routine bedside pupillary assessment with a portable device such as a pupillometer.
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Affiliation(s)
- Anjali Sarah George
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ananth P Abraham
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shalini Nair
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
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24
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Rai BB, Sabeti F, Carle CF, Rohan EMF, Saraç Ö, van Kleef J, Maddess T. Recovery dynamics of multifocal pupillographic objective perimetry from tropicamide dilation. Graefes Arch Clin Exp Ophthalmol 2019; 258:191-200. [PMID: 31720837 DOI: 10.1007/s00417-019-04523-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/14/2019] [Accepted: 10/23/2019] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To study the pupillary system by combining mydriasis and multifocal pupillographic objective perimetry (mfPOP). In particular, we explored how the dynamics of recovery differ for concurrently measured direct and consensual sensitivity, response delay, and signal-to-noise ratios (SNRs) for binocular mydriasis. METHODS We recruited 26 normal participants, all with brown irides. The dichoptic mfPOP stimuli concurrently assessed 44-region/eye and both pupils. Two pre-dilation tests were followed by pairs of repeated tests at 1, 2, 4, 6, 8, 12, 24, and 48 h following dilation of both pupils with 1% tropicamide. Three subjects were retested with only the right pupil dilated. Linear models determined the independent effects of mydriasis upon the per-region and pupil measures over time. RESULTS Post-dilation, the per-region delays initially decreased by 16.3 ± 6.02 ms (mean ± SE) (p < 0.0001, cf. baseline of 471.1 ± 4.36 ms), then increased to slower than baseline by 17.42 ± 5.57 ms after 4 h (p < 0.002), recovering to baseline at 8 h. By comparison, per-region sensitivities (constriction amplitudes) were still reduced by - 6.20 ± 0.70 μm at 8 h (p < 0.0001, cf. baseline of 21.1 ± 0.55 μm), recovered at 24 h, but rebounded at 48 h (p = 0.005). The SNRs for sensitivities and delays both recovered by 8-12 h. Across all the data, sensitivities reduced by 2.67 ± 0.25 μm/decade of age, and delay increased by 15.4 ± 1.98 ms/decade (both p < 0.00001). Data from 3 of the 26 subjects who repeated the testing for monocular dilation found that consensual response sensitivities were larger than direct for 8 h (p < 0.018). CONCLUSIONS The per-region sensitivities were affected for longer than SNRs or delays. Strong early SNRs indicated proportionately lower pupil noise for larger pupil diameters. Following mydriasis with tropicamide 1%, the constriction amplitude measurements with mfPOP should be considered only after 48 h, but time-to-peak can be measured after 8-12 h.
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Affiliation(s)
- Bhim Bahadur Rai
- Division of Neuroscience, John Curtin School of Medical Research, Australian National University, Building 131 Garran Road, Canberra, ACT, 2601, Australia.
| | - Faran Sabeti
- Division of Neuroscience, John Curtin School of Medical Research, Australian National University, Building 131 Garran Road, Canberra, ACT, 2601, Australia.,School of Optometry, University of Canberra, Bruce, ACT, Australia
| | - Corinne F Carle
- Division of Neuroscience, John Curtin School of Medical Research, Australian National University, Building 131 Garran Road, Canberra, ACT, 2601, Australia.,ANU Medical School, ANU, Canberra, ACT, Australia
| | - Emilie M F Rohan
- Division of Neuroscience, John Curtin School of Medical Research, Australian National University, Building 131 Garran Road, Canberra, ACT, 2601, Australia
| | - Özge Saraç
- Division of Neuroscience, John Curtin School of Medical Research, Australian National University, Building 131 Garran Road, Canberra, ACT, 2601, Australia.,Department of Ophthalmology, Ankara Atatürk Training and Research Hospital, Yildirim Beyazit University, Ankara, Turkey
| | - Joshua van Kleef
- Division of Neuroscience, John Curtin School of Medical Research, Australian National University, Building 131 Garran Road, Canberra, ACT, 2601, Australia
| | - Ted Maddess
- Division of Neuroscience, John Curtin School of Medical Research, Australian National University, Building 131 Garran Road, Canberra, ACT, 2601, Australia
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25
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Gupta P, Adabala VB, Barik AK. [Unilateral mydriasis: a complication of spine surgery in prone position]. Rev Bras Anestesiol 2019; 69:319-321. [PMID: 30914141 DOI: 10.1016/j.bjan.2018.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 11/16/2018] [Accepted: 12/03/2018] [Indexed: 11/15/2022] Open
Abstract
Prone position is commonly used for better access to surgical site, but may be associated with a variety of complications. Perioperative Visual Disturbances or loss is rare but a devastating complication that is primarily associated with spine surgeries in prone position. In this case we report a 42 year old ASA-II patient who developed anisocoria with left pupillary dilatation following lumbar microdiscectomy in prone position. Following further evaluation of the patient, segmental pupillary palsy of the left pupillary muscles was found to be the possible because of anisocoria. Anisocoria partially improved but persisted till follow up.
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Affiliation(s)
- Priyanka Gupta
- All India Institute of Medical Sciences (AIIMS), Department of Anesthesia, Rishikesh, Índia.
| | - Vijay B Adabala
- All India Institute of Medical Sciences (AIIMS), Department of Anesthesia, Rishikesh, Índia
| | - Amiya K Barik
- All India Institute of Medical Sciences (AIIMS), Department of Anesthesia, Rishikesh, Índia
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26
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Ebner R. Fourth Nerve Paresis and Ipsilateral Horner's Syndrome: An Unusual Association. Neuroophthalmology 2019; 43:289-290. [PMID: 31741671 DOI: 10.1080/01658107.2018.1562475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/13/2018] [Accepted: 12/19/2018] [Indexed: 10/27/2022] Open
Abstract
Presence of a fourth nerve palsy and ipsilateral Horner's Syndrome (HS) is an exceptional association. A case of a 54 year-old patient with diplopia due to a fourth nerve palsy and acquired HS on the same is presented along with magnetic resonance images (MRI) revealing a mass in the right cavernous sinus. This new combination of ipsilateral signs is analyzed.
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Affiliation(s)
- Roberto Ebner
- Chairman of Ophthalmology, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
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27
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Chang VA, Meyer DM, Meyer BC. Isolated Anisocoria as a Presenting Stroke Code Symptom is Unlikely to Result in Alteplase Administration. J Stroke Cerebrovasc Dis 2019; 28:163-166. [PMID: 30322757 PMCID: PMC6512309 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/07/2018] [Accepted: 09/15/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Acute stroke codes may be activated for anisocoria, but how often these codes lead to a final stroke diagnosis or alteplase treatment is unknown. The purpose of this study was to assess the frequency of anisocoria in stroke codes that ultimately resulted in alteplase administration. METHODS We retrospectively assessed consecutive alteplase-treated patients from a prospectively-collected stroke registry between February 2015 and July 2018. Based on the stroke code exam, patients were categorized as having isolated anisocoria [A+(only)], anisocoria with other findings [A+(other)], or no anisocoria [A-]. Baseline demographics, stroke severity, alteplase time metrics, and outcomes were also collected. RESULTS Ninety-six patients received alteplase during the study period. Of the 94 who met inclusion criteria, there were 0 cases of A+(only). There were 9 cases of A+(other) (9.6%). A+(other) exhibited higher baseline National Institutes of Health (NIH) Stroke Scale scores compared to A- (17 versus 7; P = .0003), and no additional differences in demographics or alteplase time metrics. Final stroke diagnosis and other outcome measures were no different between A+(other) and A-. Of the A+ patients without pre-existing anisocoria, 5 of 6 (83%) had posterior circulation events or diffuse subarachnoid hemorrhage. CONCLUSIONS In this exploratory analysis, zero patients with isolated anisocoria received alteplase treatment. Anisocoria as a part of the neurologic presentation occurred in 10% of alteplase patients, and was strongly associated with a posterior circulation event. Therefore, we conclude that anisocoria has a higher likelihood of leading to alteplase treatment when identified in the presence of other neurologic deficits.
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Affiliation(s)
- Victoria A Chang
- University of California, San Diego, School of Medicine, La Jolla, California.
| | - Dawn M Meyer
- Department of Neurosciences, University of California, San Diego, La Jolla, California.
| | - Brett C Meyer
- Department of Neurosciences, University of California, San Diego, La Jolla, California.
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28
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Papaioannou I, Xristopoulos K, Baikousis A, Korovessis P, Kokkinis K. Anisocoria after Posterior Spine Surgery: A Rare but Disastrous Complication - A Case Report and Literature Review. J Orthop Case Rep 2019; 9:92-95. [PMID: 32405498 PMCID: PMC7210915 DOI: 10.13107/jocr.2019.v09.i04.1496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Ocular complications after spine surgery in prone position are very rare and are described centrally in elective surgeries with long duration. The most well-known ocular complications are vision loss and acute angle-closure glaucoma. To the best of our knowledge, anisocoria after prone spinal surgery has never been reported previously in literature. Case Report: We present a very rare case of a transient harmless anisocoria in a 23-year-old otherwise healthy female patient, who underwent in the traditionally prone position lumbosacral spinal fractures stabilization and calcaneal fracture reduction and external fixation. We describe step by step the diagnosis algorithm and we discuss detaily the differential diagnosis of the unilaterally fixed and dilated pupil. Careful stepwise medical history and examination are mandatory to establish correct diagnosis and avoid unnecessary, expensive, and potentially hazardous or invasive diagnostic testing. Conclusion: The wrong position during prone spine surgery can cause iris sphincter muscle tears and transient or permanent dilation of the affected pupil. Fixed dilated pupil is a permanent abnormality of the iris, causing irregular cosmetic appearance, especially in young females, and requires further conservative or surgical intervention. Positioning of the patient and duration of surgery should be taken into consideration both by spine surgeons and anesthesiologists.
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Affiliation(s)
- Ioannis Papaioannou
- Department of Orthopedic, General Hospital of Patras Spine and Trauma Unit, Patras, Greece
| | | | - Andreas Baikousis
- Department of Orthopedic, General Hospital of Patras Spine and Trauma Unit, Patras, Greece
| | - Panagiotis Korovessis
- Department of Orthopedic, General Hospital of Patras Spine and Trauma Unit, Patras, Greece
| | - Kyriakos Kokkinis
- Department of Anesthesiology, General Hospital of Patras, Patras, Greece
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Overdorf P, Farkas GJ, Romanoski N. Transient anisocoria after a traumatic cervical spinal cord injury: A case report. J Spinal Cord Med 2018; 43:398-401. [PMID: 30124383 PMCID: PMC7241474 DOI: 10.1080/10790268.2018.1509532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Context: Autonomic dysreflexia and dysautonomia can be a common complication following spinal cord injury, especially at levels of T6 and above and can lead to complications associated with the pupil. In this case report, we review autonomic dysreflexia, the anatomy and physiology of the sympathetic nervous system of the eye, as well as review the clinical relevance in understanding autonomic and pupillary changes in response to autonomic dysfunction.Findings: We present a patient with an incomplete C4 level injury who was found to have isolated anisocoria on two separate occasions during his acute inpatient rehabilitation stay.Conclusion/Clinical Relevance: Anisocoria associated with abnormal sympathetic activation may be a clinical sign of dysautonomia.
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Affiliation(s)
- Paul Overdorf
- Department of Physical Medicine and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA,Correspondence to: Paul Overdorf Jr., Department of Physical Medicine and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, P.O. Box 850, Mail Code HP28, Hershey, PA 17033-0850, USA; Ph: 717-531-7010.
| | - Gary J. Farkas
- Department of Physical Medicine and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Natasha Romanoski
- Department of Physical Medicine and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Abstract
The cavernous sinus (CS) is a paired venous sinus that runs along either side of the pituitary gland on the floor of the calvarium. Cavernous sinus syndrome (CSS) refers to deficits in more than one of the cranial nerves III, IV, V, and VI, as they are in close association in this region. The purpose of this study was to identify the presenting complaints, neurologic findings, diagnosis, and outcomes in dogs and cats with confirmed cavernous sinus syndrome (CSS). Medical records between 2002 and 2015 were reviewed. Inclusion criteria were neurologic signs consistent with CSS and advanced imaging and/or post-mortem examination. Thirteen dogs and 2 cats were included. Twelve dogs received advanced imaging. Post-mortem examination was performed on 2 cats and 3 dogs. Dogs were 6 -13 years (mean= 10.8 years) of age and comprised of several different breeds. Both cats were male neutered domestic shorthair, ages 3 and 14 years. Presenting complaints included mydriasis (N=4), behavior changes (N=3), hyporexia (N=3), ptosis (N=2), ataxia (N=2), pain (N=2), weakness (N=2), lethargy (N=2), and one each of epiphora, ocular swelling, polydipsia, seizures, facial muscle atrophy, dysphagia, and head tilt. Neurologic signs included ophthalmoparesis/plegia (N=13), reduced/absent pupillary light response (N= 11), mydriasis (N= 10), reduced/absent corneal sensation (N= 7), ptosis (N= 6), reduced facial sensation (N= 2), and enophthalmos (N=1). Thirteen patients had a mass lesion within the cavernous sinus, 6 of which were confirmed neoplastic via histopathology. Median survival time for the 4 patients treated with radiation therapy was 1035 days (range 150-2280). Median survival for the 4 patients that received medical treatment was 360 days (range 7-1260 days), and for the 5 non-treated patients 14 days (range 0-90 days). In conclusion mydriasis and ophthalmoplegia are common signs of CSS. A mass lesion within the CS is the most common cause. Survival time may be improved with radiation therapy.
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Affiliation(s)
- Aslynn M Jones
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, WI 53706, USA.,Current Address: Colorado State University, Fort Collins, CO 80523, USA
| | - Ellison Bentley
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, WI 53706, USA
| | - Helena Rylander
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, WI 53706, USA
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Prasad S. A Window to the Brain: Neuro-Ophthalmology for the Primary Care Practitioner. Am J Med 2018; 131:120-128. [PMID: 29079403 DOI: 10.1016/j.amjmed.2017.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/03/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022]
Abstract
Visual symptoms, including acute monocular visual loss, papilledema, visual field deficits, anisocoria, limitations of eye movements, and nystagmus, can be the presenting feature of a wide range of important neurologic diseases. It is important for primary care clinicians to be to be able to direct appropriate initial diagnostic assessment, treatment, and referral for further evaluation of these conditions.
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Affiliation(s)
- Sashank Prasad
- Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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Bremner FD, Nordström JG. A Case of Synchronised Pupillary and Nasal Cycling: Evidence for a Central Autonomic Pendulum? Neuroophthalmology 2018; 41:241-246. [PMID: 29339957 DOI: 10.1080/01658107.2017.1315144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 03/29/2017] [Accepted: 03/30/2017] [Indexed: 10/19/2022] Open
Abstract
We previously reported that some healthy individuals show alternating anisocoria. We now describe one such individual who also exhibits a classic nasal cycle (alternating periods of nasal congestion and decongestion). We made measurements of his pupil asymmetry and nasal asymmetry at 21 different time points and found that these variables were always synchronised such that greater nasal airflow was invariably found on the same side as the larger pupil. We hypothesise that a common central oscillator may be responsible for co-modulating the sympathetic outflow to both nasal vessels and iris dilator muscles in some healthy individuals.
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Affiliation(s)
- Fion D Bremner
- National Hospital for Neurology & Neurosurgery, London, UK
| | - Jonas Gälldin Nordström
- Husie Health Centre, Department of General Practice, Skane University Hospital, Malmö, Sweden
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Chen L, Yeung JC, Anderson DR. Anisocoria Secondary to Anticholinergic Mydriasis from Homeopathic Pink Eye Relief Drops. Clin Med Res 2017; 15:93-95. [PMID: 29042447 PMCID: PMC5849440 DOI: 10.3121/cmr.2017.1356] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 09/26/2017] [Accepted: 10/09/2017] [Indexed: 11/18/2022]
Abstract
A woman, aged 70 years, developed anisocoria after applying homeopathic eye drops (Similasan Pink Eye Relief) to her left eye. Her pupil was dilated for two weeks and did not respond to light or near stimuli for one week. Both 0.1% and 1% pilocarpine failed to constrict her left pupil, and magnetic resonance imaging of her brain did not reveal any abnormality. The eye drops she had used contain belladonna extracts which have a natural atropine component. This case demonstrates the importance, when evaluating a patient presenting with anisocoria, of knowing the chemical ingredients of the homeopathic eye drops, which often are not listed.
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Affiliation(s)
- Lin Chen
- Department of Ophthalmology, Marshfield Clinic - Minocqua Center, Minocqua, Wisconsin, USA
| | - Joseph C Yeung
- Department of Ophthalmology, Marshfield Clinic - Minocqua Center, Minocqua, Wisconsin, USA
| | - Dennis R Anderson
- Department of Ophthalmology, Marshfield Clinic - Marshfield Center, Marshfield, Wisconsin, USA
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Martin GC, Aymard PA, Denier C, Seghir C, Abitbol M, Boddaert N, Bremond-Gignac D, Robert MP. Usefulness of cocaine drops in investigating infant anisocoria. Eur J Paediatr Neurol 2017; 21:852-7. [PMID: 28807373 DOI: 10.1016/j.ejpn.2017.07.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 07/27/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Whereas apraclonidine has eclipsed cocaine test in the exploration of unilateral miosis in adults, its use in infants is avoided because of the risk of central nervous system depression. This chart review evaluates the usefulness of cocaine drops in infants. METHODS Infants under the age of one referred for unilateral miosis between November 1, 2009 and November 1, 2015, were reviewed. Patients underwent the following protocol: (1) in case of isolated miosis, cocaine test was performed. If the miotic pupil did not dilate, imaging was performed. Dilation in both eyes led to simple clinical follow-up. (2) In case of miosis associated with ptosis or iris heterochromia, imaging of the brain, neck and chest was directly performed. RESULTS Twenty-six children were included. Twenty-two presented an isolated miosis; three had ipsilateral ptosis, and one had no pupillary light reflex in the miotic eye. Cocaine tests performed in the 22 patients led to imaging in four, which was always normal. No side effect of the test was noticed. Imaging found one neuroblastoma and one intraorbital hemolymphangioma in two patients presenting miosis plus another sign. Imaging was avoided for 18 patients thanks to negative cocaine test. DISCUSSION Urgent imaging is mandatory in infants presenting with miosis associated with other localizing sign on the sympathetic nerve pathway (Horner syndrome). Since the uselessness of complementary investigations in isolated infantile miosis cannot be proven so far, cocaine test remains the gold standard, as it is safe, cheaper and less stressful than systematic imaging.
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Lee JI, Kang SJ, Jeon SP, Sun H. Transient Anisocoria during Medial Blowout Fracture Surgery. Arch Craniofac Surg 2017; 17:154-157. [PMID: 28913273 PMCID: PMC5556804 DOI: 10.7181/acfs.2016.17.3.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 07/18/2016] [Accepted: 07/20/2016] [Indexed: 11/23/2022] Open
Abstract
Transient anisocoria is rare during blowout fracture reconstruction. We report a case of transient anisocoria occurring during medial blowout fracture reconstruction and review the relevant literature. A 54-year-old woman was struck in the face and was admitted for a medial blowout fracture of the left eye. During the operation, persistent bleeding occurred. To control this bleeding, a 1% lidocaine solution with 1:200,000 epinephrine was applied to the orbital wall with cotton pledgets. In total, 40 mL of local anesthetic was used for the duration of the operation. After approximately three hours of the surgery, the ipsilateral pupil was observed to be dilated, with sluggish response to light. By 3 hours after the operation, the mydriasis had resolved with normal light reflex. In conclusion, neurological and ophthalmologic evaluation must be performed prior to blowout fracture surgery. Preoperative ophthalmic evaluation is simple and essential in ruling out any preexisting neurologic condition. Moreover, surgeons must be aware of the fact that excessive injection of lidocaine with epinephrine for hemostasis during orbital wall surgery can result in intraoperative anisocoria. Anisocoria-related situations must be addressed in a proficient manner through sufficient understanding of the mechanism controlling the pupillary response to various stimuli.
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Affiliation(s)
- Jae Il Lee
- Department of Plastic and Reconstructive Surgery, Busan Baik Hospital, Inje University School of Medicine, Busan, Korea
| | - Seok Joo Kang
- Department of Plastic and Reconstructive Surgery, Busan Baik Hospital, Inje University School of Medicine, Busan, Korea
| | - Seong Pin Jeon
- Department of Plastic and Reconstructive Surgery, Busan Baik Hospital, Inje University School of Medicine, Busan, Korea
| | - Hook Sun
- Department of Plastic and Reconstructive Surgery, Busan Baik Hospital, Inje University School of Medicine, Busan, Korea
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Pejic R, Klaric B. Transient anisocoria in a patient treated with nebulized ipratropium bromide. Am J Ophthalmol Case Rep 2017; 7:11-13. [PMID: 29260071 PMCID: PMC5722162 DOI: 10.1016/j.ajoc.2017.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 04/10/2017] [Indexed: 11/19/2022] Open
Abstract
Purpose We present a case report of a 44-year old female patient with complicated pneumonia who developed anisocoria after treatment with inhaled ipratropium bromide. Discontinuation of ipratropium bromide treatment led to complete resolution of anisocoria. Observation A 44-year old female patient was admitted to the Department of Pulmonology due to high body temperature (40.0 °C), coughing and general weakness. After a general examination and tests the patient was diagnosed with right-sided pneumonia. Since spirometry test showed signs of bronchial obstruction, pulmonologist indicated inhalation therapy with ipratropium bromide. Soon after ipratropium bromide therapy was initiated, the patient noticed enlarged left pupil and stated that some aerosol reached her left eye during the inhalation therapy. After consulting neurology and monitoring neurological signs, ipratropium bromide treatment was discontinued. Twenty-four hours after discontinuing the ipratropium bromide treatment anisocoria was completely resolved. Conclusions and importance Presence of anisocoria may be a concerning neurological sign. If there are no other neurological or ophthalmological signs and symptoms and a recent ipratropium bromide inhalation treatment exists in the patient's history, we should consider iatrogenic side-effect of drugs as a possible reason of anisocoria and possibly spare the patient extensive and invasive diagnostic procedures that can also raise costs of treatment significantly. Observing neurological status and testing with 1% pilocarpine solution may be necessary to determine the etiology of this condition.
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Affiliation(s)
- Renato Pejic
- Department of Ophthalmology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina
- Corresponding author. Splitska 66, 88 000 Mostar, Bosnia and Herzegovina.Splitska 66Mostar88 000Bosnia and Herzegovina
| | - Branka Klaric
- Department of Pulmonology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina
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37
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Abstract
Understanding the anatomy and physiology of the eye, the orbit, and the central connections is key to understanding neuro-ophthalmologic emergencies. Anisocoria is an important sign that requires a systematic approach to avoid misdiagnosis of serious conditions, including carotid dissection (miosis) and aneurysmal third nerve palsy (mydriasis). Ptosis may be a sign of either Horner syndrome or third nerve palsy. An explanation should be pursued for diplopia since the differential diagnosis ranges from the trivial to life-threatening causes.
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Affiliation(s)
- J Stephen Huff
- Department of Emergency Medicine, University of Virginia, PO Box 800699, Charlottesville, VA 22902, USA.
| | - Everett W Austin
- Department of Emergency Medicine, University of Virginia, PO Box 800699, Charlottesville, VA 22902, USA
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38
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Lee N, Nam SO, Kim YM, Lee YJ. A neonate with Joubert syndrome presenting with symptoms of Horner syndrome. Korean J Pediatr 2016; 59:S32-S36. [PMID: 28018441 PMCID: PMC5177707 DOI: 10.3345/kjp.2016.59.11.s32] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 04/08/2015] [Accepted: 05/21/2015] [Indexed: 11/27/2022]
Abstract
Joubert syndrome (JS) is characterized by the “molar tooth sign” (MTS) with cerebellar vermis agenesis, episodic hyperpnea, abnormal eye movements, and hypotonia. Ocular and oculomotor abnormalities have been observed; however, Horner syndrome (HS) has not been documented in children with JS. We present the case of a 2-month-old boy having ocular abnormalities with bilateral nystagmus, left-dominant bilateral ptosis, and unilateral miosis and enophthalmos of the left eye, which were compatible with HS. Brain magnetic resonance imaging (MRI) revealed the presence of the MTS. Neck MRI showed no definite lesion or mass around the cervical sympathetic chain. His global development was delayed. He underwent ophthalmologic surgery, and showed some improvement in his ptosis. To the best of our knowledge, the association of HS with JS has not yet been described. We suggest that early neuroimaging should be considered for neonates or young infants with diverse eye abnormalities to evaluate the underlying etiology.
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Affiliation(s)
- Narae Lee
- Department of Pediatrics, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Sang-Ook Nam
- Department of Pediatrics, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Young Mi Kim
- Department of Pediatrics, Pusan National University Hospital, Busan, Korea
| | - Yun-Jin Lee
- Department of Pediatrics, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
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Ergül DF, Ekemen S, Özdemir Ö, Uzan Ç, Yelken B. Delayed Post-Traumatic Anisocoria. Turk J Anaesthesiol Reanim 2016; 43:209-11. [PMID: 27366498 DOI: 10.5152/tjar.2015.79847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/27/2014] [Indexed: 11/22/2022] Open
Abstract
Post-traumatic carotid artery dissection is one of the major causes of ischemic stroke in young patients; its diagnosis remains a challenge for clinicians because of its variable clinical presentation. An otherwise healthy 37-year-old man was referred to the intensive care unit of our faculty for the management of multiple trauma because of a car accident. At 11 days from admission, his doctor noticed the advent of anisocoria. A prompt treatment was instituted with anti-platelet and-coagulant agents. The patient had a complete resolution of symptoms. The prognosis was good, and the patient achieved a complete clinical recovery. He was discharged without any sequelae.
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Affiliation(s)
- Dursun Fırat Ergül
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Serdar Ekemen
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Özcan Özdemir
- Department of Neurology, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Çağdaş Uzan
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Birgül Yelken
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
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Abstract
Unilateral fixed mydriasis can be an ominous sign; however in many cases, it is benign and represents pharmacologic mediated action on the iris dilator or sphincter. Differentiation between pharmacologic mediated anisocoria and physiologic anisocoria can be challenging but may save on costly imaging. An 83 year-old woman was admitted with critical limb ischemia and subsequently developed respiratory failure treated with positive pressure ventilation and ipratropium nebulizers. She was noted to have left unilateral mydriasis without other neurologic deficits. Brain magnetic resonance imaging with MR angiography showed no evidence for a mass lesion or posterior communicating artery aneurysm. Her anisocoria self-resolved within 36 hours after nebulizer treatments were stopped. Ipratropium bromide is one of the most common medications used in the hospital setting and should be consider as a possible etiology when examining patients with unilateral mydriasis in the absence of other neurologic findings.
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Ulusoy MO, Kıvanç SA, Atakan M, Mayalı H. Post-thyroidectomy iatrogenic Horner's syndrome with heterochromia. J Curr Ophthalmol 2016; 28:46-7. [PMID: 27239603 PMCID: PMC4881223 DOI: 10.1016/j.joco.2016.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 02/20/2016] [Accepted: 02/20/2016] [Indexed: 11/07/2022] Open
Abstract
Purpose To present a case of iatrogenic Horner's syndrome seen together with the heterochromia in the post-thyroidectomy period. Methods A 23-year-old female patient was admitted to our clinic with complaints of low vision in the eye and difference in eye color that developed over the past two years. In the left eye, myosis and minimal ptosis (∼1 mm) was detected, and the color of the iris was lighter than the right eye. Results The pre-diagnosis of left iatrogenic Horner's syndrome was finalized after 0.5% topical apraclonidine test. Conclusion Heterochromia can be observed in iatrogenic Horner's syndrome.
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Affiliation(s)
| | - Sertaç Argun Kıvanç
- Department of Ophthalmology, Uludağ University Faculty of Medicine, Bursa, Turkey
| | - Mehmet Atakan
- Department of Ophthalmology, Aksaray State Hospital, Aksaray, Turkey
| | - Hüseyin Mayalı
- Department of Ophthalmology, Celal Bayar University Faculty of Medicine, Manisa, Turkey
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Couret D, Boumaza D, Grisotto C, Triglia T, Pellegrini L, Ocquidant P, Bruder NJ, Velly LJ. Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study. Crit Care 2016; 20:99. [PMID: 27072310 PMCID: PMC4828754 DOI: 10.1186/s13054-016-1239-z] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/17/2016] [Indexed: 11/10/2022]
Abstract
Background In critical care units, pupil examination is an important clinical parameter for patient monitoring. Current practice is to use a penlight to observe the pupillary light reflex. The result seems to be a subjective measurement, with low precision and reproducibility. Several quantitative pupillometer devices are now available, although their use is primarily restricted to the research setting. To assess whether adoption of these technologies would benefit the clinic, we compared automated quantitative pupillometry with the standard clinical pupillary examination currently used for brain-injured patients. Methods In order to determine inter-observer agreement of the device, we performed repetitive measurements in 200 healthy volunteers ranging in age from 21 to 58 years, providing a total of 400 paired (alternative right eye, left eye) measurements under a wide variety of ambient light condition with NeuroLight Algiscan pupillometer. During another period, we conducted a prospective, observational, double-blinded study in two neurocritical care units. Patients admitted to these units after an acute brain injury were included. Initially, nursing staff measured pupil size, anisocoria and pupillary light reflex. A blinded physician subsequently performed measurement using an automated pupillometer. Results In 200 healthy volunteers, intra-class correlation coefficient for maximum resting pupil size was 0.95 (IC: 0.93-0.97) and for minimum pupil size after light stimulation 0.87 (0.83–0.89). We found only 3-pupil asymmetry (≥1 mm) in these volunteers (1.5 % of the population) with a clear pupil asymmetry during clinical inspection. The mean pupil light reactivity was 40 ± 7 %. In 59 patients, 406 pupillary measurements were prospectively performed. Concordance between measurements for pupil size collected using the pupillometer, versus subjective assessment, was poor (Spearmen's rho = 0.75, IC: 0.70-0.79; P < 0.001). Nursing staff failed to diagnose half of the cases (15/30) of anisocoria detected using the pupillometer device. A global rate of discordance of 18 % (72/406) was found between the two techniques when assessing the pupillary light reflex. For measurements with small pupils (diameters <2 mm) the error rate was 39 % (24/61). Conclusion Standard practice in pupillary monitoring yields inaccurate data. Automated quantitative pupillometry is a more reliable method with which to collect pupillary measurements at the bedside. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1239-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Couret
- Neurocritical Care Unit, University Hospital Saint Pierre, Réunion University, BP 350, Saint Pierre, 97448, la Réunion, France.,Inserm, UMR 1188 Diabète athérothrombose Thérapies Réunion Océan Indien (DéTROI), plateforme CYROI, 2 rue Maxime Rivière, Sainte Clotilde, 97490, la Réunion, France
| | - Delphine Boumaza
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Coline Grisotto
- Neurocritical Care Unit, University Hospital Saint Pierre, Réunion University, BP 350, Saint Pierre, 97448, la Réunion, France
| | - Thibaut Triglia
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Lionel Pellegrini
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Philippe Ocquidant
- Neurocritical Care Unit, University Hospital Saint Pierre, Réunion University, BP 350, Saint Pierre, 97448, la Réunion, France
| | - Nicolas J Bruder
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Lionel J Velly
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France.
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Abstract
CASE DESCRIPTION This case reviews the acute care and rehabilitation course of a 44-year-old right-handed woman after an assault with a pocketknife. She suffered multiple stab wounds including penetrating injury to the left side of her neck. Physical examination revealed left hemiplegia (motor score = 57), impaired pinprick sensation on the right caudal to the C5 dermatome, impaired joint position sense on the left, and left ptosis and miosis. Initially she was unable to stand without maximum assistance. MR imaging revealed transection of the left hemicord at the C5 level without cord hemorrhage. CTA of the neck was negative for vascular injury. She completed 18 days of acute inpatient rehabilitation. She used forearm crutches for ambulation at time of discharge. Prior to discharge the patient provided written permission for a case report. DISCUSSION Stab wounds are the most common cause of traumatic Brown-Séquard syndrome. Horner's syndrome is common in spinal cord lesions occurring in the cervical or thoracic region, however the combination of Horner's and Brown-Séquard syndromes is less commonly reported. In this case report, we review recommendations regarding initial imaging following cervical stab wounds, discuss anatomy and associated neurological findings in Brown-Séquard and Horner's syndromes, and review the expected temporal course of motor recovery. CONCLUSIONS Facilitating motor recovery and optimizing function after Brown-Séquard spinal cord injury are important roles for the rehabilitation team. Imaging is necessary to rule out cord hemorrhage or vascular injury and to clinically correlate cord damage with physical examination findings and expected functional impairments. Documenting associated anisocoria and explaining this finding to the patient is an important element of spinal cord injury education. Commonly, patients with Brown-Séquard injuries demonstrate remarkable motor recovery and regain voluntary motor strength and functional ambulation.
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Affiliation(s)
- Stephen Johnson
- Correspondence to: Stephen Johnson, Orthopaedic and Spine Specialists, York, PA, USA.
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Chaudhry P, Friedman DI, Yu W. Unilateral pupillary mydriasis from nebulized ipratropium bromide: A false sign of brain herniation in the intensive care unit. Indian J Crit Care Med 2014; 18:176-7. [PMID: 24701070 PMCID: PMC3963203 DOI: 10.4103/0972-5229.128710] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Although there are many causes of anisocoria in the intensive care setting, the development of unilateral mydriasis in patients with intracranial hemorrhage or tumor is a neurological emergency, as it may herald the onset of uncal herniation. We describe two patients with a hemiparesis from neurosurgical disorder who subsequently developed a fixed and dilated pupil. The pupillary abnormality was caused by nebulized ipratropium bromide in both cases, and resolved when the medication was discontinued. Nebulized ipratropium may leak from the mask into ipsilateral eye and cause mydriasis in patients with facial weakness. This benign cause of anisocoria in the intensive care setting is distinguished from uncal herniation by the laterality of neurologic findings, and lack of mental status change, ptosis, and extraocular movement impairment.
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Affiliation(s)
- Priyanka Chaudhry
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Deborah I Friedman
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A ; Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Wengui Yu
- Department of Neurology and Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
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Martín-Santana I, González-Hernández A, Tandón-Cárdenes L, López-Méndez P. Benign episodic mydriasis. Experience in a specialist neuro-ophthalmology clinic of a tertiary hospital. Neurologia 2014; 30:290-4. [PMID: 24582871 DOI: 10.1016/j.nrl.2014.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 12/27/2013] [Accepted: 01/10/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Anisocorias are a relatively frequent reason for consultation in neuro-ophthalmology units. They remain a diagnostic challenge for specialists as they may be due to several etiological factors. In the absence of other accompanying symptoms, anisocorias are usually due to benign processes. Benign episodic mydriasis (BEM) is an isolated cause of intermittent pupil asymmetry, in which the pathophysiology is still not fully understood, and is predominant in young women with migraine. SUBJECTS, MATERIAL AND METHODS We describe the epidemiological and clinical characteristics of patients with BEM, assessed in a neuro-ophthalmology unit in a tertiary hospital. RESULTS A total of 7 patients were diagnosed with BEM, all of them females, with a mean age of 33 ± 10 yrs. The patients presented with pupil asymmetry (n = 5) and blurred vision (n = 2), and 6 of the 7 patients had unilateral involvement. The duration of impairment varied from a few minutes to 48 hrs. Four patients (57%) had a clinical history of migraine without aura. The episodes in these 4 patients were recurrent (75%), often lasted for a few minutes (75%), and had associated blurred vision (50%). The neuroimaging studies were normal. DISCUSSION BEM appears predominantly in young women. It is frequently related to a previous history of migraine, and the specialist must consider if it is a concomitant symptom of common migraine, migraine with aura, or ophthalmoplegic migraine. Although BEM has unilateral predominance, there may be alternation of the affected eye or even bilateral impairment during the same episode, which makes us question the adequacy of the term to describe the process. Imaging tests are not recommended in the absence of other accompanying symptoms, or in short-term episodes.
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Affiliation(s)
- I Martín-Santana
- Servicio de Neurología, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, España.
| | - A González-Hernández
- Servicio de Neurología, Unidad de Neuro-Oftalmología, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, Canarias, España
| | - L Tandón-Cárdenes
- Servicio de Oftalmología, Unidad de Neuro-Oftalmología, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, España
| | - P López-Méndez
- Servicio de Neurología, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, España
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Abstract
The hyoscine patch is effective and is frequently used in motion sickness treatment. Not uncommonly, it is used to control excessive respiratory secretions in palliative patients. Patients, healthcare workers, and caregivers who administer these may experience a benign, although worrying, mydriasis should they inadvertently rub their eye after handling the patch. A 46-year-old staff nurse working in a stroke ward presented with sudden-onset unilateral enlarged pupil. To rule out any intracranial pathology, the stroke team requested an urgent head computed tomography (CT) scan, which showed no abnormality. Upon ophthalmology review, nonreactive dilated left pupil was noted. Examination was otherwise unremarkable with no focal neurology findings. Following further history, she recalled applying a hyoscine patch to a patient in the morning. Two days later, her left pupil returned to normal size. This unique presentation of pharmacological mydriasis reinforces the importance of a detailed targeted history to avoid unnecessary investigations and anxiety, as well as the importance of informing patients, healthcare workers, and caregivers of this peculiar side-effect.
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Affiliation(s)
- Jia Ng
- a University Hospital Ayr , Ayr , South Ayrshire , United Kingdom
| | - James Li Yim
- a University Hospital Ayr , Ayr , South Ayrshire , United Kingdom
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Ghatak T, Singh RK, Baronia AK, Sahu S. Postoperative acute anisocoria and old traumatic brain injury. Indian J Anaesth 2013; 55:611-3. [PMID: 22223908 PMCID: PMC3249871 DOI: 10.4103/0019-5049.90620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Anisocoria is an uncommon entity in general postoperative intensive care. We present a case of a 45-year-old man suffering from severe acute pancreatitis with a past history of traumatic brain injury (TBI), who developed hypertension, bradycardia and anisocoria soon after re-exploration surgery under general anaesthesia. Computed tomography showed no new lesion. Measures directed towards reducing intracranial pressure resulted in amelioration in about 12h. The possible role of old TBI in the causation of anisocoria during general anaesthesia and resuscitation has been explored in this report.
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Affiliation(s)
- Tanmoy Ghatak
- Department of Critical Care Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
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Vicente P, Canelles E, Díaz A, Fons A. [Irreversible Horner's syndrome after bilateral thoracoscopic sympathectomy]. ACTA ACUST UNITED AC 2012; 89:79-81. [PMID: 24269401 DOI: 10.1016/j.oftal.2012.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 05/28/2011] [Accepted: 07/09/2012] [Indexed: 10/27/2022]
Abstract
CASE REPORT A 19 year-old boy who developed a right Horner's syndrome after a bilateral sympathectomy as a treatment for palmoplantar hyperhidrosis. DISCUSSION Horner's syndrome is defined by the occurrence of miosis, ptosis and enophthalmos as a result of involvement of sympathetic innervation. This is quite rare, but identification is very important because it may also be an ominous sign secondary to a neoplasm, neurological diseases, or surgery of the sympathetic chain, as in our case.
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Affiliation(s)
- P Vicente
- Servicio de Oftalmología, Sección de Neurooftalmología, Servicio de Cirugía Torácica, Hospital Clínico Universitario de Valencia, Valencia, España.
| | - E Canelles
- Servicio de Oftalmología, Sección de Neurooftalmología, Servicio de Cirugía Torácica, Hospital Clínico Universitario de Valencia, Valencia, España
| | - A Díaz
- Servicio de Oftalmología, Sección de Neurooftalmología, Servicio de Cirugía Torácica, Hospital Clínico Universitario de Valencia, Valencia, España
| | - A Fons
- Servicio de Oftalmología, Sección de Neurooftalmología, Servicio de Cirugía Torácica, Hospital Clínico Universitario de Valencia, Valencia, España
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Abstract
Abstract We describe the case of a male patient who presented with anisocoria, and was initially diagnosed with an acute Adie's tonic pupil. On subsequent laboratory testing, he was found to have neurosyphilis. Magnetic resonance imaging demonstrated enhancement of the right oculomotor nerve. This case underscores the importance of considering this diagnosis in patients with acute onset internal ophthalmoplegia and hypersensitivity to dilute pilocarpine, even in the absence of other oculomotor nerve findings.
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Inchingolo F, Tatullo M, Abenavoli FM, Marrelli M, Inchingolo AD, Villabruna B, Inchingolo AM, Dipalma G. Severe anisocoria after oral surgery under general anesthesia. Int J Med Sci 2010; 7:314-8. [PMID: 20922052 PMCID: PMC2948214 DOI: 10.7150/ijms.7.314] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 09/07/2010] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Anisocoria indicates a difference in pupil diameter. Etiologies of this clinical manifestation usually include systemic causes as neurological or vascular disorders, and local causes as congenital iris disorders and pharmacological effects. CASE REPORT We present a case of a 47-year-old man, suffering from spastic tetraparesis. After the oral surgery under general anesthesia, the patient developed severe anisocoria: in particular, a ~4 mm diameter increase of the left pupil compared to the right pupil. We performed Computed Tomography (CT) in the emergency setting, Nuclear magnetic resonance (NMR) of the brain and Magnetic Resonance Angiography of intracranial vessels. These instrumental examinations did not show vascular or neurological diseases. The pupils returned to their physiological condition (isocoria) after about 180 minutes. DISCUSSION AND CONCLUSIONS Literature shows that the cases of anisocoria reported during or after oral surgery are rare occurrences, especially in cases of simple tooth extraction. Anisocoria can manifest in more or less evident forms: therefore, it is clear that knowing this clinical condition is of crucial importance for a correct and timely resolution.
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