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.

Urrets-Zavalia syndrome after Descemet membrane endothelial keratoplasty.

PURPOSE: To report a case of Urrets-Zavalia syndrome (UZS) after Descemet membrane endothelial keratoplasty (DMEK). METHODS: A 74-year-old woman with Fuchs endothelial dystrophy and inconspicuous ocular history developed UZS after DMEK surgery. The intraoperative and postoperative course is presented. RESULTS: After uneventful DMEK surgery, intraocular pressure was elevated up to 40 mm Hg on the first postoperative day. A small bleed from the peripheral wide-open iridectomy in the 12 o'clock position in the otherwise deep anterior chamber was observed. On the sixth postoperative day, a 4-mm-wide pupil, nonreactive to light, was noted. One year after surgery, the fixed medium mydriasis (4 mm) persisted and best-corrected vision was 0.1 logMAR. No pupillary reaction was noted after application of 0.2% or 2% pilocarpine. CONCLUSIONS: Filling the anterior chamber with air to secure fixation of a grafted Descemet membrane carries the risk of early acute postoperative ocular hypertension. This can lead to iris sphincter defects resulting in a fixed dilated pupil after DMEK surgery. Large patent iridectomy in the 12 o'clock position is insufficient to prevent this. Patients undergoing DMEK surgery should be informed about this potential complication.

Fixed mydriatic pupil associated with an intraocular pressure rise as a complication of the implant of a Phakic Refractive Lens (PRL).

We describe a case report of a patient that was implanted with a posterior chamber phakic intraocular lens (Phakic Refractive Lens, PRL) for the correction of moderate myopia and who developed postoperatively a fixed mydriasis compatible with an Urrets-Zavalia Syndrome (UZS). Specifically, a sudden acute increase of IOP in the left eye was observed in the immediate postoperative period. After IOP stabilization, the refractive result was good, but a fixed and mydriatic pupil appeared. This condition led the patient to experience visual discomfort, halos, and glare associated with high levels of higher-order aberrations in spite of the good visual result. A tinted-contact lens was fitted in order to minimize those symptoms. The UZS should be considered as a possible complication after implantation of posterior chamber phakic intraocular lenses.

[Ocular trauma. Blunt ocular trauma]. / Contusions oculaires à globe fermé

Ocular traumas represent a major public health problem with poorly understood ramifications at both the individual and community levels. Any of the ocular structures can be damaged in the case of closed globe injury. These lesions, often multiple, may appear immediately or in a delayed fashion. Classifications have been developed recently in order to better inform the patient of the visual prognosis. However, significant efforts are still needed, on the one hand, to assess and develop new therapies, and on the other hand, to implement effective policies to prevent ocular trauma.

Pre-hospital transcranial Doppler in severe traumatic brain injury: a pilot study.

BACKGROUND: Investigation of the feasibility and usefulness of pre-hospital transcranial Doppler (TCD) to guide early goal-directed therapy following severe traumatic brain injury (TBI). METHODS: Prospective, observational study of 18 severe TBI patients during pre-hospital medical care. TCD was performed to estimate cerebral perfusion in the field and upon arrival at the Level 1 trauma centre. Specific therapy (mannitol, noradrenaline) aimed at improving cerebral perfusion was initiated if the initial TCD was abnormal (defined by a pulsatility index >1.4 and low diastolic velocity). RESULTS: Nine patients had a normal initial TCD and nine an abnormal one, without a significant difference between groups in terms of the Glasgow Coma Scale or the mean arterial pressure. Among patients with an abnormal TCD, four presented with an initial areactive bilateral mydriasis. Therapy normalized TCD in five patients, with reversal of the initial mydriasis in two cases. Among these five patients for whom TCD was corrected, only two died within the first 48 h. All four patients for whom the TCD could not be corrected during transport died within 48 h. Only patients with an initial abnormal TCD required emergent neurosurgery (3/9). Mortality at 48 h was significantly higher for patients with an initial abnormal TCD. CONCLUSIONS: Our preliminary study suggests that TCD could be used in pre-hospital care to detect patients whose cerebral perfusion may be impaired.

[Abnormal pupils' reactions]. / Nieprawidlowe reakcje zreniczne.

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.

Hyponatraemia, rhabdomyolysis, alterations in blood pressure and persistent mydriasis in patients envenomed by Malayan kraits (Bungarus candidus) in southern Viet Nam.

Between 1998 and 2007, 42 patients admitted to Choray hospital, Ho Chi Minh City, and to two hospitals in adjacent regions in southern Viet Nam brought the Malayan kraits (Bungarus candidus) that had been responsible for biting them. Half of the patients had been bitten while they were asleep. Fang marks and numbness were the only local features of the bites. Common signs of neurotoxic envenoming included bilateral ptosis, persistently dilated pupils, limb weakness, breathlessness, hypersalivation, dysphonia and dysphagia. Thirty patients (71.4%) required endotracheal intubation of whom all but one were mechanically ventilated. Fourteen patients (33.3%) developed hypertension, 13 (31.0%) shock, 31 (73.8%) hyponatraemia (plasma sodium concentration < 130 mEq/l) and 30 (71.4%) showed evidence of mild rhabdomyolysis (peak plasma creatine kinase concentration 1375 +/- 140 micro/l). None developed acute kidney injury. All the patients were treated with a new monospecific B. candidus antivenom. There were no fatalities. Hyponatraemia has been reported previously in victims of Chinese kraits (Bungarus multicinctus) in northern Viet Nam and rhabdomyolysis in patients envenomed by B. niger in Bangladesh. These features of envenoming pose new problems for the management of krait bite cases in South east Asia and should stimulate a search for the causative venom toxins.

[Paradoxal gazous embolism in hepatic trauma. Contribution of hyperbaric oxygenotherapy]. / Embolie gazeuse peropératoire chez un traumatisé hépatique. Intérêt de l'oxygénothérapie hyperbare.

A young man was admitted for a polytraumatism associating head trauma and blunt abdominal trauma with hepatic injury. He was managed with a damage control surgery with a perihepatic packing. During the second look surgery, he developed a paradoxal gazous embolism by air aspiration in the sus-hepatic vein. This has never been described before in such traumatism. The patient presented a respiratory distress, a circulatory shock due to right infarction and an intracranial hypertension with bilateral mydriasis. He was immediately treated by hyperbaric oxygenotherapy. The evolution was good and he recovered without sequelae.

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.

Fixed dilated pupil after penetrating keratoplasty for macular corneal dystrophy and keratoconus.

PURPOSE: To identify predisposed eyes, risk factors, and protective measures and to evaluate methods of treatment for fixed dilated pupil after penetrating keratoplasty (PKP) for macular corneal dystrophy (MCD) and keratoconus. DESIGN: Retrospective observational case series. METHODS: A retrospective review was conducted of the charts of 195 patients who had PKP for MCD and of 1800 patients who had PKP for keratoconus at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia. The review included an evaluation of the preoperative and intraoperative data and the postoperative course. In addition, clinical examinations at the last visit and photographs of the cornea, pupil, iris, and lens were analyzed. RESULTS: Twenty-one eyes of 18 patients had fixed dilated pupil after PKP; 15 eyes of 12 patients had MCD, and six eyes of six patients had keratoconus. A rise in intraocular pressure (IOP) during the procedure was seen in five patients (23.8%). Fixed dilated pupil was documented on the first and second postoperative days and the second postoperative week in 17 (80.9%), one (4.8%), and three (14.3%) eyes, respectively. Six eyes (28.6%) of six patients had severe eye inflammation. Only one eye (4.8%) regained partial reactivity of the pupil on follow-up visits. Seven eyes (33.3%) experienced lens changes; nine eyes (42.8%) had elevated IOP on the first postoperative day, and none of the eyes had chronic glaucoma. CONCLUSION: Inflammatory and multifactorial pathologic condition can cause fixed pupil after PKP. Atropine use, keratoconus, and high IOP are not constant findings in this syndrome. Awareness of the risk factors of fixed dilated pupil will help prevent against its occurrence.

[Emergency unilateral mydriasis]. / Mydriase unilatérale aux urgences.

UNLABELLED: 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.

Acute onset of a bilateral areflexical mydriasis in Miller-Fisher syndrome: a rare neuro-ophthalmologic disease.

Miller-Fisher syndrome (MFS) is characterized by variable ophthalmoplegia, ataxia, and tendon areflexia. It seems to be a variant of Guillain-Barré syndrome (GBS), but unlike in GBS, there is a primitive involvement of the ocular motor nerves, and in some cases there is brainstem or cerebellum direct damage. The unusual case of MFS in the current study started with a bilateral areflexical mydriasis and a slight failure of accommodative-convergence. Ocular-movement abnormalities developed progressively with a palsy of the upward gaze and a bilateral internuclear ophthalmoplegia to a complete ophthalmoplegia. In the serum of this patient, high titers of an IgG anti-GQ1b ganglioside and IgG anti-cerebellum. anti-Purkinje cells in particular, were found. The former autoantibody has been connected to cases of MFS, of GBS with associated ophthalmoplegia, and with other acute ocular nerve palsies. The anti-cerebellum autoantibody could explain central nervous system involvement in MFS. The role of these findings and clinical implications in MFS and in other neuro-ophthalmologic diseases are discussed.

[Acute self-induced poisoning with carbamazepine]. / Intoxication aiguë volontaire par la carbamazépine.

OBJECTIVE: We report the epidemiological, clinical, toxicological and therapeutic aspects of acute voluntary intoxication with carbamazepine. PATIENTS AND METHODS: The study included 17 cases of acute carbamazepine intoxication in patients hospitalized in our toxicology unit. RESULTS: Neurological signs predominated at admission, mainly agitation or coma associated with seizures. Mydriasis and cardiovascular signs were frequent. Blood chemistry most frequently showed hyponatremia. Mean serum carbamazepine level admission was 24 mg/l (range 4 ñ 12 mg/l). Ten patient required respiratory assistance for 28 +/- 17 hours. Symptomatic treatment and gastric lavage (+activated carbon) provided favorable outcome. CONCLUSION: Acute carbamazepine intoxication is seen with increasing frequency. Severity is related to the degree and duration of the coma, respiratory depression, seizures, cardiovascular disorders, and metabolic abnormalities. Symptomatic and specific treatment with activated carbon are required.