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.

Unilateral mydriasis following septoplasty with inferior turbinate reduction.

Nasal septoplasty and inferior turbinate reduction are common procedures performed in the treatment of nasal obstruction. These procedures are generally considered to be safe with minimal reported complications. Herein, we describe a case of a 43-year-old female who developed transient unilateral mydriasis following septoplasty with inferior turbinate reduction, likely due to the sympathomimetic agents used for vasoconstriction and mucosal decongestion.

Pourfour du Petit Syndrome Associated With Right Eye Pressure.

Pourfour du Petit (PDP) syndrome is a rare disorder characterized by ipsilateral mydriasis, eyelid retraction, and hemifacial hyperhidrosis caused by hyperactivity of the ipsilateral oculosympathetic pathway. A case is presented of PDP syndrome associated with likely ipsilateral occipital neuralgia. We review the causes and co-morbidities and the clinical features of PDP.

Postoperative Anticholinergic Poisoning: Concealed Complications of a Commonly Used Medication.

BACKGROUND: Scopolamine is a potent anticholinergic compound used commonly for the prevention of postoperative nausea and vomiting. Scopolamine can cause atypical anticholinergic syndromes due to its prominent central antimuscarinic effects. CASE REPORT: A 47-year-old female presented to the emergency department (ED) 20 h after hospital discharge for a right-knee meniscectomy, with altered mental status (AMS) and dystonic extremity movements that began 12 h after her procedure. Her vital signs were normal and physical examination revealed mydriasis, visual hallucinations, hyperreflexia, and dystonic movements. Laboratory data, lumbar puncture, and computed tomography were unrevealing. The sustained AMS prompted a re-evaluation that revealed urinary overflow with 500 mL of retained urine discovered on ultrasound and a scopolamine patch hidden behind her ear. Her mental status improved shortly after patch removal and physostigmine, with complete resolution after 24 h with discharge diagnosis of scopolamine-induced anticholinergic toxicity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although therapeutically dosed scopolamine transdermal patches rarely cause complications, incomplete toxidromes can be insidiously common in polypharmacy settings. Providers should thoroughly evaluate the skin of intoxicated patients for additional adherent medications that may result in a delay in ED diagnosis and curative therapies. Our case, as well as rare case reports of therapeutic scopolamine-induced anticholinergic toxicity, demonstrates that peripheral anticholinergic effects, such as tachycardia, dry mucous membranes, and hyperpyrexia are often not present, and incremental doses of physostigmine may be required to reverse scopolamine's long duration of action. This further complicates identification of the anticholinergic toxidrome and diagnosis.

[Severe Eyeball and Facial Skeletal Injuries Caused by Firefighting Sport]. / Schwerwiegende Augen- und Gesichtsskelettverletzungen beim Feuerwehrsport.

The aim of this work is to draw attention to possible injuries of the eye and the facial skeleton caused by firefighting sport. There was a group of 9 patients presented who were treated from 2006 to 2015 in the Department of Ophthalmology at the University Hospital in Pilsen and diagnosed with severe eyeball contusion after being hit by a jet of water and/or a water pipe. Three cases are presented in detail.

[Ocular complications of local anaesthesia in dentistry]. / Oculaire bijwerkingen van lokale anesthesie in de tandheelkunde.

An estimated 1 in 1,000 local anaesthetic injections in the maxilla or the mandible lead to unwanted effects on the ipsilateral eye. We have seen a case with diplopia and lateral rectus palsy following bimaxillary anaesthesia. A systematic literature review of reports on this type of complication resulted in a total of 144 documented cases published between 1936 and 2016. The most frequently reported symptoms included diplopia (72%), partial or full ophthalmoplegia (26%), ptosis (22%), mydriasis (18%), amaurosis (13%) and orbital pain (12%). This type of complication is best understood by pathophysiological hypotheses that include intra-arterial injection, intravenous injection, autonomic dysregulation, or deep injection and diffusion. If ocular symptoms appear after local intraoral anaesthesia, the patient should be reassured. In the case of diplopia, the eye should be covered with a gauze dressing, and the patient should be instructed about associated safety risks. If symptoms persist or when vision deteriorates, referral to an ophthalmologist is advisable.

Identification of Clinically Relevant Groups of Patients Through the Application of Cluster Analysis to a Complex Traumatic Brain Injury Data Set.

In neurological intensive care units (NICUs) we are collecting an ever increasing quantity of data. These range from patient demographics and physiological monitoring to treatment strategies and outcomes. The BrainIT database is an example of this type of rich data source. It contains validated data on 264 patients who suffered traumatic brain injury (TBI) admitted to 22 NICUs in 11 European countries between March 2003 and July 2005 [1, 6].

Surgical Management of Aneurysmal Hematomas: Prognostic Factors and Outcome.

From 1991 until 2013, 304 patients with intracranial hematomas from aneurysmal rupture were managed surgically in our department, constituting 17 % of all patients with aneurysmal rupture. Of them, 242 patents presented with isolated intracerebral hematomas (in 69 cases associated with significant intraventricular hemorrhage), 50 patients presented with combined intracerebral and subdural hematomas (in 11 cases associated with significant intraventricular hemorrhage), and 12 presented with an isolated subdural hematoma. The surgical procedure consisted of simultaneous clipping of the aneurysm and evacuation of the hematoma in all cases. After surgery, 16 patients (5 %) submitted to an additional decompressive hemicraniectomy, and 66 patients (21 %) submitted to a ventriculo-peritoneal shunt. Clinical outcomes were assessed at discharge and at 6 months, using the modified Rankin Scale (mRS); a favorable outcome (mRS 0-2) was observed in 10 % of the cases at discharge, increasing to 31 % at 6 months; 6-month mortality was 40 %. Applying uni- and multivariate analysis, the following risk factors were associated with a significantly worse outcome: age >60; preoperative Hunt-Hess grades IV-V; pupillary mydriasis (only on univariate); midline shift >10 mm; hematoma volume >30 cc; and the presence of hemocephalus (i.e., packed intraventricular hemorrhage). Based on these results, an aggressive surgical treatment should be adopted for most cases with aneurysmal hematomas, excluding patients with bilateral mydriasis persisting after rescue therapy.

Unilateral mydriasis after maxillary osteotomy: a case series and review of the literature.

PURPOSE: To present 4 cases of unilateral mydriasis associated with orthognathic surgery and to review the differential diagnosis and management related to this condition. MATERIALS AND METHODS: Four cases of unilateral mydriasis associated with orthognathic surgery were identified from the authors' institutional experience. All maxillary osteotomies performed by the authors' department from 2001 to 2013 were identified based on Current Procedural Terminology codes; 4 cases of unilateral mydriasis were found. Cases are presented and the literature is reviewed. RESULTS: Two male and 2 female patients with an age range of 16 to 34 years developed unilateral mydriasis after maxillary osteotomy; the estimated prevalence is 0.004%. Although the precise cause can be difficult to determine, in this series 1 case was attributable to swelling affecting contents of the superior orbital fissure, 1 was related to edema or medications, and 2 were pharmacologically induced. CONCLUSION: Although rare, a review of the differential diagnosis for and management of unilateral mydriasis associated with orthognathic surgery is pertinent to those who perform corrective jaw surgery.

Clinical analysis of transcranial orbitotomy approach on cranio-orbital tumors.

AIMS: The aims of this study were to investigate 21 cases of transcranial orbitotomy for cranio-orbital tumors and evaluate the clinical value of the surgical approach. METHODS: A retrospective study was done on 21 patients with cranio-orbital tumors. According to the tumors' location, shape, boundary, and invasion on the images, coronal scalp flap approach, subfrontal approach, or pterion approach for transcranial orbitotomy was performed. RESULTS: The surgical route was coronal scalp flap approach in 7 cases (including 3 cases combined with lateral orbitotomy), subfrontal approach in 6 cases, or pterion approach in 8 cases (including 1 case combined with evisceration of orbit). Tumors were en bloc resection in 4 cases, block resection or curettage in 13 cases, and incomplete resection in 4 cases. Postoperatively, the mean reduction in exophthalmos was 4 mm; maximum reduction was 11 mm. Ocular movement restriction was made better in 10 of 14 patients, whereas there was no change in 4 of 14 patients. Ophthalmoplegia occurred in 2 cases, complete ptosis occurred in 3 cases, and mydriasis occurred in 3 cases. No vision loss or cerebrospinal fluid leak was observed. Fourteen patients were followed up, including 2 patients with metastatic carcinoma who died dead because of systemic metastasis; 2 patients had a recurrence (schwannoglioma and meningioma). No recurrence was found in the other 10 patients. CONCLUSIONS: Cranio-orbital tumors can be removed effectively through transcranial orbitotomy, whereas operative approach is convenient to the surgical procedure and can offer better exposure. Being familiar with the tumors' location, adhesion, and invasion, coupled with the skilled surgical techniques, would improve the results and reduce serious complications.

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.

Unilateral mydriasis as the primary sign of neurosyphilis.

Syphilis can mimic most ocular disorders, and there is no characteristic to distinguish ocular syphilis from other eye diseases. We report a rare case of a 41-year-old man who presented with an Adie's-like pupil as the only feature of neurosyphilis. The patient met the criteria for the diagnosis of neurosyphilis by the finding of positive cerebrospinal fluid-Venereal Disease Research Laboratory (CSF-VDRL) and CSF-Treponema pallidum particle agglutination tests. The patient was then treated with 2 g intravenous ceftriaxone per day for 15 days because of penicillin allergy. Nine months after anti-syphilitic treatment alone, the diameter of the patient's left pupil reduced from 10 to 5 mm. The CSF-VDRL test was negative. It is highly recommended that any patients with ocular disease that does not respond to the routine treatment should undergo syphilis evaluation to avoid misdiagnosis.

Transient ipsilateral mydriasis during correction of left blowout fracture.

Mydriasis, either bilateral or unilateral, seldom occurs during reconstruction of periorbital fracture. Anisocoria, a unilateral mydriasis, requires more urgent assessment than bilateral mydriasis does. Pharmacologic agents, local anesthetic infiltration, as well as direct or indirect oculomotor nerve damage are possible causes of unilateral mydriasis. Few cases have been reported about intraoperative temporary ipsilateral mydriasis during correction of blowout fracture. We have experienced an unusual case of anisocoria and report the case with literature reviews.

Optic neuritis and mydriasis after vaccination: a case report.

BACKGROUND: Optic neuritis (ON) is an inflammatory demyelinating condition of the optic nerve, with various causes. Its incidence is higher in children and young adults than in older adults of both genders, but is more common in women than in men. ON is rarely associated with mydriasis, and it is seldom triggered by vaccines against tetanus and diphtheria. CASE REPORT: A 36-year-old Caucasian woman presented with bilateral ON that had started 18 days after administration of a booster dose of the double adult vaccine (dT) against diphtheria and tetanus. Bilateral mydriasis persisted after treatment and clinical resolution of the ON. She experienced severe headache, blurred vision, decreased visual acuity in the right eye and bilateral mydriasis, a diagnosis confirmed by imaging tests. Treatment with oral corticosteroids resulted in rapid resolution of the neuritis; however, mydriasis persisted for several months. CONCLUSION: This study describes a very unusual case of bilateral ON associated with prolonged mydriasis after vaccination against tetanus and diphtheria that regressed after treatment with oral corticosteroids. Prolonged mydriasis was the manifestation that differed from the other cases previously described.

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.