Sutureless intrascleral intraocular lens fixation and modified iris cerclage pupilloplasty for aphakia and traumatic mydriasis

PURPOSE

To evaluate the safety and efficacy of sutureless intrascleral intraocular lens (IOL) fixation combined with modified iris cerclage pupilloplasty for treating aphakia and traumatic mydriasis.

METHODS

Five patients with aphakia and traumatic mydriasis were operated on by the same surgeon. All patients underwent sutureless intrascleral IOL fixation combined with modified iris cerclage pupilloplasty and were followed up for ≥6 months. Best-corrected visual acuity (BCVA) was measured using the logarithm of the minimum angle of resolution (logMAR). BCVA, intraocular pressure (IOP), pupil diameter, and corneal endothelial cell count (CECC) preoperatively and postoperatively were statistically analyzed. The pupil shape, photophobia, IOL position, and surgical complications were evaluated.

RESULTS

The mean BCVA was significantly improved 6 months postoperatively (0.26 ± 0.17 logMAR, P = 0.042) than preoperatively (0.50 ± 0.30 logMAR). No significant difference was observed between the preoperative and postoperative IOP (P = 0.138). The mean pupil diameter significantly reduced postoperatively than preoperatively (3.44 ± 0.35 mm vs. 7.28 ± 0.35 mm, P = 0.043). There was no significant decrease in CECC postoperatively (P = 0.225). The pupil shape was round-like, and photophobia disappeared in all patients. No intraoperative or postoperative complications occurred.

CONCLUSION

Sutureless intrascleral IOL fixation combined with modified iris cerclage pupilloplasty is a safe and efficient procedure for treating aphakia traumatic mydriasis patients without sufficient capsular support.

Persistent Mydriasis Following Gonioscopy-Assisted Transluminal Trabeculotomy

Herein we describe 2 cases of persistent mydriasis after gonioscopy-assisted transluminal trabeculotomy for open angle glaucoma. Both surgeries were uneventful, but the patients experienced postoperative hyphema and intraocular pressure elevation. They then developed persistent fixed and dilated pupils resistant to pilocarpine that led to intolerable photosensitivity and glare. An iris cerclage pupilloplasty was performed with adequate relief of symptoms in one case.

Sudden-Onset Bilateral Mydriasis in a Young Girl

A 3-year-old girl presented to the emergency department with 1 day of abnormal gait and bilateral mydriasis. Repeat magnetic resonance imaging demonstrated diffuse enhancement of the lower thoracic and cauda equina nerve roots and enhancement of the left oculomotor nerve.

Pharmacologic Mydriasis Secondary to Topical Glycopyrronium Tosylate Cloths: Clinical Characterization From a Multicenter Analysis

BACKGROUND

Topical glycopyrronium tosylate (GT) is an anticholinergic medication for treatment of axillary hyperhidrosis. Pharmacologic mydriasis and anisocoria from topical GT has been reported and may be underrecognized. This study aims to clinically characterize patients presenting with pharmacologic mydriasis from exposure to this medication.

METHODS

This study is a retrospective observational case series. A multicenter chart review of 16 patients diagnosed with pharmacologic mydriasis secondary to topical GT was performed.

RESULTS

Eight patients (50.0%) were age 18 years and younger, and 14 patients (87.5%) were female. Unilateral mydriasis (anisocoria) occurred in 14 patients (87.5%). Fourteen patients (87.5%) did not initially volunteer topical GT as a "medication," and the history of topical GT exposure needed to be elicited with further questioning. Hand hygiene details were known for 12 patients, and all reported that they did not wash their hands after GT application. Six patients (37.5%) were soft contact lens users. One patient had possible exposure through a family member's use of the medication. Ocular symptoms were common (blurry vision [11 patients, 68.8%] and eye dryness [7 patients, 43.8%]), but systemic anticholinergic symptoms were uncommon (such as constipation [1 patient, 6.3%] and urinary symptoms [3 patients, 18.8%]).

CONCLUSIONS

Mydriasis associated with topical GT seems to be a consequence of local exposure rather than systemic toxicity. Because patients may not volunteer topical GT as a medication, eliciting a history of exposure often requires further specific questioning. Soft contact lens wear and poor postapplication hand hygiene seem to be associated with mydriasis in GT use.

A well-appearing infant with a sudden anisocoria

Case presentationA 10-month-old boy was admitted to the emergency department due to a sudden onset of left unilateral mydriasis (figure 1). His medical history was unremarkable. A minor head trauma 2 days before was reported, without alarming signs or symptoms. His mother was putting him to sleep, after coming back from work, when she noticed a different pupil size and promptly went to the ED with her husband. The parents denied any use of medications, including nebulised therapy or direct contact with plants. The child was well appearing and his vital signs were within the standard age limits. His extraocular motility was normal as well as the rest of his neurological and physical examination. Parents' behaviour was somehow remarkable. Even though the child was not suffering, the mother seemed very worried while the father was nervous and aggressive, repeatedly asking for a discharge.

Pupil-Involving Oculomotor Nerve Palsy Following Tonsillectomy and Adenoidectomy

Ocular complications of adenotonsillectomy are rare. The authors describe a 6-year-old boy who developed mydrasis and limitations of supraduction and infraduction after adenotonsillectomy. This was attributed to the hemorrhagic compression of the nerve in the cavernous sinus. This is the first report of pupil-involving oculomotor nerve palsy following adenotonsillectomy. [J Pediatr Ophthalmol Strabismus. 2019;56:e76-e78.].

Pupillary abnormalities in childhood - 2 case presentations

Anisocoria is a condition characterized by an unequal size of the eyes' pupils. There is a broad spectrum of aetiological factors including benign and also life- threatening situations. The most important point is the ability to find the anatomical location of the pathology. Understanding to the anatomical, physiological and pharmacological influences helps us to solve the diagnostic challenge. In the article authors present the issue of the anisocoria in the childhood through two case presentations. Causes of an unequal size of the eyes' pupils are in this two cases different. In both of the cases the anisocoria is temporary with spontaneous resolution without any therapy. Diagnostic challenge is well- described with the analysis of important Pilocarpin pharmacological tests. Pharmacological diagnostic tests are a very effective method to differentiate between the pharmacological mydriasis and the mydriasis caused by another factor. Strictly taken patient´s history with targeted questions searching for recent contact with some drugs, plants or medications is crucial. Sometimes it is necessary to consider an unusual diagnosis - benign episodic unilateral mydriasis.

Acute Anticholinergic Syndrome from Atropa Belladonna Mistaken for Blueberries

Purpose

To report the first case in the ophthalmic literature of acute anticholinergic syndrome after ingestion of Atropa belladonna mistaken for blueberries.

Methods

A 36-year-old woman presented to our ophthalmic emergency department with complaints of blurry vision, lightning flashes, disorientation, loss of balance, agitation, and anxiety for 24 hours. Ophthalmic examination revealed bilateral pupillary dilatation and paresis of accommodation. Additional symptoms of the anticholinergic syndrome were elicited on further questioning.

Results

Anticholinergic intoxication was suspected and the patient admitted to have eaten six “blueberries” found in the forest the previous day. The patient identified Atropa belladonna as the source of the berries she had eaten when shown photographs of the plant and its fruit. The recommendations of the Swiss Toxicological Information Centre were followed and physostigmine, the antidote for severe poisoning when 10 or more berries are ingested, was not administered.

Conclusions

Accidental ingestion of Atropa belladonna berries may cause patients to first consult an ophthalmologist. It is important to recognize the anticholinergic syndrome caused by such intoxication in order to make a proper diagnosis, avoid unnecessary testing, and provide expedient appropriate treatment when required.

Benign Episodic Unilateral Mydriasis in a Flight Nurse

BACKGROUND

Benign episodic unilateral mydriasis is one cause of anisocoria. This phenomenon is thought to be related to an imbalance between the sympathetic and parasympathetic nervous systems. There is a documented association with migraines, but asymptomatic cases have also been reported. A challenge with all cases is the level of investigation required to exclude more sinister causes of nervous system dysfunction. In a dynamic flight environment, additional considerations need to be made, such as varying light levels and use of night vision devices.

CASE REPORT

A 27-yr-old woman on deployment to Afghanistan as a flight nurse presented to the role one clinic with right-sided mydriasis. The patient denied headache or any history of migraines. A dilated right pupil that was reactive to light was found on exam. Symptoms and exam findings resolved shortly after initial presentation. We consulted an ophthalmologist who requested patient transfer for review. He made a diagnosis of benign episodic unilateral mydriasis.

DISCUSSION

There are a variety of causes for anisocoria. A thorough history and examination are required to avoid unnecessary investigations that may not be locally available in the more austere deployed military settings. From an operational perspective, the decision needs to be made regarding the maintenance of flight status. Consideration needs to be given to patient care capability when treating a flight nurse. In cases of rapid resolution such as this, removal from operational status is not reasonable should a clinician be confident of the diagnosis.Schiemer A. Benign episodic unilateral mydriasis in a flight nurse. Aerosp Med Hum Perform. 2017; 88(5):500-502.

The Tuebingen Scotopic Threshold Test (TSTT)

Measurement of the dark-adaptation threshold plays a key role in the diagnosis and estimation of disease progression of many retinal disorders. Determining the threshold is, however, difficult to perform in young children. We present here a prototype for a dark adaptometer, the Tuebingen Scotopic Threshold Test aimed to ease measurement of photoreceptor thresholds in young subjects. The device consists of two 7 cm ×10 cm fields with either blue or yellow LEDs, for testing rod or cone sensitivity, respectively. Presentation of homogenous field patterns or a flickering stimulus is also possible. The luminance threshold is measured by the method of ascending limits and the stimulus luminance, data recording and analysis are computer controlled. Preliminary results for six adults and two older children were ascertained and the influence of pupil dilation, binocular presentation, and a flickering stimulus examined. The method provides credible and consistent evaluations of the absolute threshold.

Pathophysiology of dilatation of pupils due to scorpion and snake envenomation and its therapeutic value: Clinical observations

Dilated nonreacting pupils are routinely taken as a sign of irreversible brain damage. Alpha-receptor stimulation (scorpion sting) and presynaptic acetylcholine receptor blocker (krait bite) may result in dilation of pupils without involvement of the brain. This study was aimed to clinically evaluate the response of pupils in scorpion sting and krait bite. Victims of scorpion sting and krait bite were chosen from Raigad district. Scorpion sting and krait bite cases were admitted to hospital and were clinically evaluated in detail regarding neurological manifestations. Both cases had nonreacting dilation of pupils, complete neurological recovery accompanied with reverse of pupillary size and its response to light. In scorpion sting and krait bite poisoning, dilated nonreacting pupils are not the signs of irreversible brain damage.

Benign episodic mydriasis. Experience in a specialist neuro-ophthalmology clinic of a tertiary hospital

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.

[Alert patients with mydriasis and fixed pupils]

Mydriasis is a rare phenomenon in non-comatose patients, usually caused by toxic agents or oculomotor neuropathy. We describe two patients who presented with mydriasis at the outpatient clinic. The first patient was a 46-year-old woman with mydriasis, headache, ptosis, ophthalmoplegia and transient ataxia after an influenza vaccination. The second was a 47-year-old woman with mydriasis, ophthalmoplegia, ptosis and ataxia after she had used doxycycline for an upper respiratory tract infection. In both patients, GQ1b-antibodies were detected and both were diagnosed with Miller Fisher syndrome. The second patient was treated with immunoglobulins, the other patient improved spontaneously. Miller Fisher syndrome is characterised by a triad of ophthalmoplegia, ataxia and areflexia. An infection or vaccination may give rise to an auto-immune response with GQ1b-antibodies directed against gangliosides in peripheral nerve tissue. The Miller Fisher syndrome has a good prognosis with spontaneous recovery ensuing in most patients. Treatment with immunoglobulins is required in some patients.

[Abnormal pupils' reactions]

Examination of the pupils' light reaction and estimation of the pupils' diameter are the components of the routine physical examination of a patient. Disturbances in pupils' light reaction, unequal size of the pupils indicate damage of the nervous system and require careful diagnosis, both neurological and ophthalmological. Different aspects of anatomy, physiology and the most common pathological syndromes associated with disturbed pupils' light reaction and unequal diameters of the pupils were presented in the article. Early diagnosis and proper treatment can allow to improve prognosis in the analyzed patient group.

The dilated pupil: an update

The dilated pupil can present a significant challenge to the clinician. Although in most cases a complete history and physical examination is sufficient to make an accurate diagnosis, selected patients will require further investigation, including pharmacologic testing and neuroimaging. This review outlines the physiology, clinical features, and diagnostic approach to the most important causes of the dilated pupil. Particular attention is given to recent publications on this topic.

Sensitivity and specificity of digital retinal imaging for screening diabetic retinopathy

AIMS

To assess the effectiveness of a non-mydriatic digital camera (45 degrees -30 degrees photographs) compared with the reference method for screening diabetic retinopathy.

METHODS

Type 1 and 2 diabetic patients (n = 773; 1546 eyes) underwent screening for diabetic retinopathy in a prospective observational study. Hospital-based non-mydriatic digital retinal imaging by a consultant specialist in retinal diseases was compared with slit-lamp biomicroscopy and indirect ophthalmoscopy through dilated pupils, as a gold standard, previously performed in a community health centre by another consultant specialist in retinal diseases. The main outcome measures were sensitivity and specificity of screening methods and prevalence of diabetic retinopathy.

RESULTS

The prevalence of any form of diabetic retinopathy was 42.4% (n = 328); the prevalence of sight-threatening including macular oedema and proliferative retinopathy was 9.6% (n = 74). Sensitivity of detection of any diabetic retinopathy by digital imaging was 92% (95% confidence interval 90, 94). Specificity of detection of any diabetic retinopathy was 96% (95, 98). The predictive value of the negative tests was 94% and of a positive test 95%. For sight-threatening retinopathy digital imaging had a sensitivity of 100%.

CONCLUSIONS

A high sensitivity and specificity are essential for an effective screening programme. These results confirm digital retinal imaging with a non-mydriatic camera as an effective option in community-based screening programmes for diabetic retinopathy.

Disappointment of patients on antidepressant therapy after excimer laser treatment

We describe 2 patients who were receiving antidepressant therapy before excimer laser surgery, at the time of surgery, and after surgery. Both patients experienced the ocular side effects of antidepressant drugs, ie, symptoms due to dry eyes and mydriasis.

Unilateral Mydriasis without Ophthalmoplegia—A Sign of Neurovascular Compression?: Case Report

OBJECTIVE:

We aimed to demonstrate the use of neuroimaging studies in vascular compression of the oculomotor nerve.

CLINICAL PRESENTATION:

A 24-year-old woman was noted by her dentist to have anisocoria, with the left pupil being larger than the right. After detailed ophthalmologic and neurological examination, we proceeded to peform neuroimaging. T2-weighted images (2 mm) and constructive interference in steady-state (0.3 mm) images were utilized.

INTERVENTION:

Magnetic reasonance imaging showed that duplicated left superior cerebellar artery, a prominent posterior communicating artery, and a posterior cerebral artery combined to compress the superomedial portion of the left oculomotor nerve.

CONCLUSION:

With continued improvements in neuroimaging, we think that more cases of isolated cranial neuropathies previously labeled as “idiopathic” will be shown to result from vascular compression.

Topical Apraclonidine Testing Discloses Pupillary Sympathetic Denervation in Diabetic Patients

BACKGROUND

Autonomic denervation is common in diabetes mellitus (DM). Pupillary sympathetic denervation (PSD) has been found in Horner syndrome following instillation of apraclonidine 0.5%. We have applied this technique to investigate the prevalence of PSD in DM.

METHODS

Apraclonidine 0.5% was instilled in the eyes of 50 patients with DM and 30 age-matched and gender-matched subjects without DM (control subjects). Pupil diameters (PD) were measured before and 60 minutes after instillation. The duration of DM and the degree of diabetic retinopathy (DR) were recorded for each patient.

RESULTS

Apraclonidine instillation caused an average of 0.9 mm of mydriasis (range 0 to 4.5 mm) in DM and -0.1 mm miosis (range 0.5 to -1 mm) in control subjects (P < 0.001). Mydriasis of at least 1 mm was observed in 42% of DM patients. The change in PD was highly correlated with the duration of DM (r = 0.368, P = 0.008) and the presence of DR (r = 0.532, P < 0.001).

CONCLUSION

Apraclonidine testing, which is easy to perform and not distressing to the patient, identified PSD in nearly half of DM patients, the degree of mydriasis being correlated to the duration of DM and the presence of DR.

[Pupillary disorder after use of asthma spray aerosol]

A 46-year-old patient was referred as an emergency case to our neuro-ophthalmologic department, because her left pupil was mydriatic and unreactive since the morning of the same day. This pupil did not constrict normally on application of 1 % pilocarpin eye drops. Thus the diagnosis of a medication-induced mydriasis was established. The causative agent proved to be an aerosol, containing ipratropium bromide used for asthma treatment.

Validity of simple measurement to diagnose pupillary dilation

STUDY OBJECTIVE

The aim of the study was to compare the validity of 3 methods of detecting pupillary dilation: bright-light measurement, room-light measurement, and gestalt judgment.

METHODS

In reach volunteer, by random assignment, placebo was instilled in one eye and dilute phenylephrine in the other. Emergency care providers judged whether each pupil was dilated and measured it in bright light (>54,000 lux) and in room light (2700-5400 lux) while the other eye was covered. Test characteristics for measurement were determined according to published cut-points, and measurement methods were compared using receiver operating curve analysis.

RESULTS

There were 136 pupillary assessments-68 in placebo and 68 in phenylephrine eyes. Compared with gestalt judgment, bright-light measurement had higher specificity (0.94 vs 0.68) but lower sensitivity (0.43 vs 0.79). Bright-light measurement was more discriminating than room-light measurement.

CONCLUSION

Bright-light measurement has higher specificity, but lower sensitivity, than gestalt judgement, and is superior to room-light measurement.

Inferior Oblique Paresis, Mydriasis, and Accommodative Palsy as Temporary Complications of Sinus Surgery

A 15-year-old boy had temporary hypertropia, supraduction deficit, ipsilateral mydriasis, and accommodative paresis after bilateral endoscopic ethmoidectomy, bilateral partial inferior turbinectomy, septoplasty, and Caldwell-Luc procedures for chronic sinusitis. Postoperative imaging did not disclose any intra-orbital abnormalities. The patient was treated with oral prednisolone 70 mg/day on a tapering schedule. Within two months, the ophthalmic abnormalities had resolved. This is the second report to describe such findings, which are attributed to damage of the inferior division of the third cranial nerve secondary to manipulation of adjacent ethmoid tissues.

Anticholinergic toxicity associated with lupin seed ingestion: case report

We describe a case of acute poisoning in a 51-year-old female patient who presented to the Emergency Department with weakness, anxiety, dry mouth, bilateral mydriasis and lid drop. In differential diagnosis, botulism, Guillain-Barré syndrome and myasthenia gravis were considered, as well as cerebral haematoma because of a cranial injury a week before. Symptoms, which resolved within 12 h without any therapy, were instead related to the ingestion of lupin seeds.

Adult-onset acquired oculomotor nerve paresis with cyclic spasms: relationship to ocular neuromyotonia

PURPOSE

To describe the characteristics and significance of acquired oculomotor nerve paresis with cyclic spasm.

METHOD

Retrospective case series of two patients with a history of previous skull base irradiation for intracranial tumor who developed double vision and were found to have oculomotor nerve paresis with cyclic spasm. Both patients underwent a complete neuroophthalmologic assessment, including testing of eyelid position, pupillary size and reactivity, and ocular motility and alignment during both the paretic and spastic phases of the condition.

RESULTS

Both patients developed unilateral lid retraction and ipsilateral esotropia with limitation of abduction during the spastic phase of the cycle, with ipsilateral ptosis, exotropia, and variable limitation of adduction during the paretic phase. The cycles were continuous and were not induced or altered by eccentric gaze.

CONCLUSIONS

Cyclic oculomotor nerve paresis with spasms may occur years after irradiation of the skull base. This condition is different from the more common ocular motor disturbance that occurs in this setting-ocular neuromyotonia. However, in view of the similarity between these two disorders, it seems likely that they are caused by a similar peripheral mechanism.

[Mydriasis not reacting to light during an uneventful esophagectomy--drug-related side effect of Akrinor?]

We present a 72 year old patient who underwent an esophagectomy uneventfully. At the end of the procedure the anaesthetist diagnosed a mydriasis not reacting to light. The mydriasis lasted for 3 hours. 30 minutes after diagnosis a cranial computed tomography scan showed no abnormalities. The tracheal tube was removed after 16 h of artificial ventilation, the patient was awake and responded to questions. The neurological examination was normal, as well as the control CT scan. With regard to a mydriasis the following differential diagnosis have to be considered: cerebral ischemia, cerebral hematoma, metabolic encephalopathy, shock, and a drug side effect. We state that an alpha-mimetic effect of the drug mixture Akrinor, the patient had received shortly before diagnosis of the mydriasis, is the most likely explanation. One 2 mls syringe contents of 200 mg norephedrine-ethyl-theophylline and 10 mg noradrenaline-ethyl-theophylline.

[Emergency unilateral mydriasis]

UNEQUAL PUPILS: Or anisocoria is frequent and can be physiological, benign or life threatening. VARIATIONS IN THE PUPIL: Constriction depends on the parasympathetic system and dilatation on the sympathetic system. IN PARASYMPATHETIC DISORDERS: Peripheral or central neurological causes can be distinguished, among which acute cerebral lesions with compression of the trunk are the most dramatic. Differential diagnosis can be made by studying the local causes, which may represent ophthalmologic emergencies (acute glaucoma or lesions of the retina). AMONG THE SYMPATHETIC DISORDERS: Claude-Bernard-Horner's syndrome is the most classical example. Other particular cases exist, such as Adie's pupil, affecting young women (1/20,000), associating mydriasis and occasionally tendinous areflexia. Diagnosis is generally confirmed by the ophthalmologist, following a normal or evocative of the disease neurological examination.

IN PRACTICE

Rapid but careful clinical examination permits orientation of the diagnosis and appropriate treatment.

Neonatal mydriasis: intravenous lidocaine adverse reaction

Lidocaine (a sodium channel blocker) serves as an antiepilepsy drug in neonates. We present a neonate with a seizure disorder who acutely developed pupillary mydriasis secondary to lidocaine overdose. We suggest adding this side effect to the list of untoward effects of lidocaine and to the differential diagnosis of fixed dilated pupils in neonates treated with lidocaine.

Fixed dilated pupil (Urrets-Zavalia syndrome) after air/gas injection after deep lamellar keratoplasty for keratoconus

PURPOSE

To describe three cases of fixed dilated pupil and presumed iris ischemia (Urrets-Zavalia syndrome) after anterior chamber air/gas injection after deep lamellar keratoplasty for keratoconus.

METHODS

Interventional case series. Three eyes of three patients with keratoconus underwent deep lamellar keratoplasty and intraoperative or postoperative injection of air/gas in the anterior chamber to appose the host-donor lamellar graft interface.

RESULTS

Urrets-Zavalia syndrome was diagnosed on clinical grounds in three cases and was associated with the Descemet membrane microperforation intraoperatively and introduction of air/gas into the anterior chamber intraoperatively or postoperatively.

CONCLUSION

A fixed dilated pupil is an uncommon complication of penetrating keratoplasty for keratoconus that can also develop after deep lamellar keratoplasty. Leaving an air or gas bubble in the anterior chamber of a phakic eye after deep lamellar keratoplasty is a risk factor and should therefore be avoided.

Dorsal midbrain syndrome secondary to a pineocytoma

BACKGROUND

Dorsal midbrain syndrome is a triad of signs consisting of vertical gaze palsy, light-near dissociation of the pupils, and convergence retraction nystagmus. Associated findings may also be present. The most-common etiologies are pineal gland tumors and midbrain infarction. Pineal gland tumors are rare tumors that show a predilection for males. The specific tumor reported herein, a pineocytoma, shows no gender predilection and is most common in mid- to late adulthood.

CASE REPORT

A 38-year-old Native American man came to us with signs and symptoms consistent with dorsal midbrain syndrome. A neurological evaluation revealed the presence of a pineocytoma, which was later excised unsuccessfully. An explanation of the findings associated with dorsal midbrain syndrome is provided.

CONCLUSION

Patients who demonstrate signs consistent with dorsal midbrain syndrome should be referred for a neurological evaluation--including an MRI--to rule out any midbrain lesion.

Dilated pupil during endoscopic sinus surgery: what does it mean?

Endoscopic sinus surgery has become the standard of care for the surgical management of chronic sinus disease. Sinus disease and its surgical treatment carry the risk of orbital complications, irrespective of the approach. Orbital complications associated with sinus surgery include nasolacrimal duct damage, extraocular muscle injury, intraorbital hemorrhage/emphysema, and direct optic nerve damage, resulting in blindness. The finding of an unequal pupil at the end of a procedure would be a cause of considerable concern, but it is most likely due to the topical contamination of the eye with a mydriatic pharmacological agent commonly used in endoscopic sinus surgery.