Pharmacological management of intra-operative miosis during cataract surgery.

Cataract surgery requires a well-dilated and stable pupil for a good outcome. Unexpected pupillary constriction during surgery increases the risk of complication. This problem is more pronounced in children. There are now pharmacological interventions that help tackle this unforeseen happening. Our review discusses the simple and quick options available to a cataract surgeon when faced with this dilemma. As cataract surgical techniques continue to improvise and get faster, an adequate pupil size is of paramount importance. Various topical and intra-cameral drugs are used in combination to achieve mydriasis. Despite good pre-operative dilation, the pupil can be quite unpredictable during surgery. Intra-operative miosis limits the field of surgery and increases the risk of complications. For example, if the pupil size decreases from 7 mm to 6 mm, this 1 mm change in pupil diameter will lead to a decrease of 10.2 mm2 in the area of surgical field. Making a good capsulorhexis with a small pupil can be a challenge, even for an experienced surgeon. Repeated touching of the iris increases the risk of fibrinous complications. Removal of cataract and the cortical matter becomes increasingly difficult. Intra-ocular lens implantation in the bag also requires adequate dilation. When dealing with challenging cases like lens subluxation, pseudo-exfoliation, and zonular dehiscence, a small pupil further increases the risk and adversely affects the surgical outcome. Hence, achieving and maintaining adequate mydriasis throughout surgery is essential. This review highlights the risk factors for small pupils during surgery and current management strategies.

Bilateral Transient Dilated and Fixed Pupils After Microvascular Decompression: Rare Clinical Experience.

Microvascular decompression (MVD) has a satisfactory safety, and it is the only surgical treatment for neurovascular compression diseases, such as hemifacial spasm, trigeminal neuralgia, and glossopharyngeal neuralgia, from the perspective of etiology. Bilateral dilated and fixed pupils have long been regarded as a sign of life threatening, which is common in patients with cerebral herniation due to cranial hypertension. However, transient dilated pupils after MVD have not been previously reported. Here, we presented 2 patients with bilateral transient dilated and fixed pupils after MVD and discussed the possible etiologies through the literature review. Physical examination of both patients showed bilateral pupils were normal and without a medical history of pupil dilation. They underwent MVD under general anesthesia and used propofol and sevoflurane. In both cases, the vertebral artery was displaced, and Teflon pads were inserted between the vertebral artery and the brain stem. Postoperation, we found transient bilateral mydriasis without light reflection in both patients. The emergency head computed tomography revealed no obvious signs of hemorrhage and cerebral herniation. About 1 hour later, this phenomenon disappeared. Therefore, the authors think if MVD is successfully carried out, bilateral transient mydriasis may not necessarily indicate brain stem hemorrhage, cerebral herniation, and other emergency conditions, which can be recovered within a short time. The causes could be related to stimulation of the sympathetic pathway in the brain stem during MVD and side effects of anesthetics.

Anisocoria and mydriasis after scalp nerve block: a case report.

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.

Risk factors for intraocular pressure elevation during the early period post cataract surgery.

PURPOSE: To assess the risk factors for intraocular pressure (IOP) elevation during the early period post cataract surgery. STUDY DESIGN: Retrospective study. METHODS: This study involved 1587 eyes that underwent cataract surgery at the Baptist Eye Institute, Kyoto, Japan between April 2020 and May 2021. In all subjects, risk factors for early postoperative IOP elevation (i.e., an increase of IOP of 10 mmHg or more at 1-day postoperative compared with that at baseline, or a postoperative IOP of 28 mmHg or more) were analyzed by multivariate logistic regression analysis. RESULTS: Of the 1587 treated eyes in this study, 100 (6.3%) experienced early-postoperative IOP elevation. Of those 100 eyes, 78.0% were men, 27.0% had an axial length (AL) of ≥ 26.5 mm, 23.0% had a history of glaucoma treatment, 11.0% had poor mydriasis and 10.0% had intraoperative floppy iris syndrome (IFIS). Multivariate analysis findings revealed that male [odds ratio (OR) 4.36; 95% confidence interval (CI) 2.63-7.23; P < 0.001], AL of ≥ 26.5 mm (3.11; 1.83-5.30; P < 0.001), a history of glaucoma treatment (2.83; 1.63-4.91; P < 0.001), poorly mydriasis (2.63; 1.16-6.01; P = 0.02), IFIS (4.37; 1.78-10.74; P = 0.001) and baseline high IOP (1.09; 1.01-1.18; P = 0.03) were associated with increased IOP during the early period post cataract surgery. CONCLUSIONS: The findings in this study reveal that male sex, high myopia, a history of glaucoma treatment, poor mydriasis, IFIS and baseline high IOP are risk factors for IOP elevation during the early period post cataract surgery.

Pourfour du Petit Syndrome: A Rare Association With Cluster Headache.

Pourfour du Petit syndrome is an uncommon cause of eyelid retraction, associated with unilateral mydriasis and hemifacial hyperhidrosis. This syndrome is caused by hyperactivity of the ipsilateral oculosympathetic pathway and needs to be recognized because it has an opposite clinical presentation but the same topographic and diagnostic value as Horner syndrome. The authors report a rare case of Pourfour du Petit syndrome associated with cluster headache and discuss pathophysiological hypotheses, clinical presentation, complementary exams, pharmacologic testing, treatment options, and prognosis. Early detection of these symptoms may lead to swift diagnosis and treatment.

An uncommon case of intermittent Pourfour du Petit Syndrome associated with acute angle-closure glaucoma successfully treated by laser iridotomy.

PURPOSE: To describe a case of acute angle-closure glaucoma secondary to intermittent mydriasis related to Pourfour du Petit Syndrome caused by tracheal deviation. MATERIALS AND METHODS: A 70-year-old Caucasian woman visited the Emergency Room of the University Eye Clinic complaining of blurring of vision and difficulty to move superior eyelid in her right eye. Examination revealed reactive mydriasis, and upper lid retraction on the right side. The rest of the ophthalmological examination was normal, and a cranial computed tomography (CT) did not identify any abnormalities. A cervical CT showed the presence of an accentuated lateral right convex deviation of the trachea, attributable to a fibrothorax. A right Pourfour du Petit syndrome was suspected. Although the mydriasis had in the meantime vanished, the patient was admitted to the Neurological Clinic. RESULTS: Five days later she suffered acute pain in her right eye. Ophthalmological examination of the right eye revealed conjunctival hyperemia, marked corneal edema, reduced depth of anterior chamber, permanent mydriasis. As assessed by Goldmann applanation tonometry, intraocular pressure (IOP) was 48 mm Hg. Fundus examination was normal in both eyes. Gonioscopy revealed angle closure in all quadrants. Slit lamp examination of the contralateral eye was normal; IOP was 10 mm Hg. After hypotensive medical therapy, iridotomy with YAG laser was performed. Thereafter, IOP stabilized at 12 mm Hg. CONCLUSIONS: This is the first report in the literature of a case of acute angle-closure glaucoma secondary to mydriasis related to Pourfour du Petit Syndrome caused by tracheal deviation.

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.

Genetic and genomic analysis of classic aniridia in Saudi Arabia.

PURPOSE: To determine the genetic and genomic alterations underlying classic aniridia in Saudi Arabia, a region with social preference for consanguineous marriage. METHODS: Prospective study of consecutive patients referred to a pediatric ophthalmologist in Saudi Arabia (2005-2009). All patients had paired box gene 6 (PAX6) analysis (sequencing and multiplex ligation-dependent probe amplification analysis if sequencing was normal). If PAX6 analysis was negative, the following were performed: candidate gene sequencing (forkhead box C1 [FOXC1], paired-like homeodomain transcription factor 2 [PITX2], cytochrome P450, family 1, subfamily B [CYP1B1], paired-like homeodomain transcription factor 3 [PITX3], and v-maf avian musculoaponeurotic fibrosarcoma oncogene homolog [MAF]) and molecular karyotyping by array competitive genomic hybridization (250K single nucleotide polymorphism (SNP) arrays). RESULTS: All 12 probands (4 months-25 years of age; four boys and eight girls) had lens opacity and foveal hypoplasia in addition to no grossly visible iris. Four cases were familial. All cases were products of consanguineous unions except for three, one of which was endogamous. Heterozygous PAX6 mutations (including two novel mutations) were detectable in all but two cases, both of which were sporadic. In one of these two cases, the phenotype segregated with homozygosity for a previously-reported pathogenic missense FOXC1 variant (p.P297S) when homozygosity for chromosome 11q24.2 deletion (chr11:125,001,547-125,215,177 [rs114259885; rs112291840]) was also present. In the other, no genetic or genomic abnormalities were found. CONCLUSIONS: The classic aniridia phenotype in Saudi Arabia is typically caused by heterozygous PAX6 mutations, even in the setting of enhanced homozygosity from recent shared parental ancestry. For PAX6-negative cases, interaction between missense variation in an anterior segment developmental gene and copy number variation elsewhere in the genome may be a potential mechanism for the phenotype.

[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.

Pigment dispersion syndrome and pigmentary glaucoma--a major review.

Pigment dispersion syndrome (PDS) is an interesting condition that can lead to secondary open angle glaucoma. Pigmentary glaucoma is primarily a disease of young people, myopes and men. PDS is characterized by the presence of Krukenberg spindles, iris trans-illumination defects, trabecular meshwork pigmentation and backward bowing of the iris. Posterior bowing of the iris causes rubbing of the pigmented iris epithelium against lens structures, liberation of pigment and trabecular meshwork changes that result in reduced aqueous outflow with the risk of glaucoma. Peripheral laser iridotomy can reverse backward bowing of the iris and may prevent progression of pigmentary glaucoma.

Unilateral hyperhydrosis in Pourfour du Petit syndrome.

Upper limp hyperhydrosis is an idiopathic disease with bilateral involvement. However, Pourfour du Petit syndrome, the opposite of Horner syndrome, may result in unilateral upper limb hyperhydrosis. It occurs following hyperactivity of the sympathetic cervical chain as a consequence of irritation secondary to trauma. We report herein two cases with Pourfour du Petit syndrome showing unilateral upper limb hyperhydrosis. The patients presented with right-sided mydriasis and ipsilateral hemifacial hyperhydrosis. The onset of disease was followed by a trauma in both patients. They underwent upper thoracic sympathectomy with favorable outcome. A history of an antecedent trauma in patients with unilateral upper limb hyperhydrosis and anisocoria may imply a possible diagnosis of Pourfour du Petit syndrome.

Avaliaçäo da freqüencia cardíaca e da pressäo arterial em pacientes adultos após instilaçäo ocular de fenilefrina 10 por cento / Assessment of heart rate and blood pressure after ocular instillation of 10 por cento phenylephrine

Objetivo: Tem-se por objetivo avaliar possíveis alteraçöes cardiovasculares, tais como as da pressäo arterial e freqüência cardíaca, produzidas pela instilaçäo tópica de fenilefrina 10 por cento.Local: Serviço de Oftalmologia do Hospital Regional de Säo José -Homero de Miranda Gomes, Säo José, SC.Métodos: Sessenta pacientes adultos atendidos na emergência oftalmológica do Hospital Regional Säo José com indicaçäo de exame sob midríase foram divididos em dois grupos de 30, aleatoriamente.No primeiro foi instilada 1 gota de fenilefrina 10 por cento em cada olho e no segundo, utilizado como controle, 1 gota de tropicamida (mydryacil) também em ambos os olhos.Todos os pacientes em estudo tiveram sua freqüênia cardíaca e pressäo arterial monitoradas em 5 tempos distintos (pré, 1 minuto após, 5 minutos após e 30 minutos após a instalaçäo da droga) com auxílio de um esfigmomanômetro eletrônico (marca Omron, USA).Resultados: Näo houve diferença entre a idade, sexo e raça nos grupos estudados.a freqüência cardíaca média inicial foi de 79, 65(ñ11, 51) batimentos por minuto, sem diferença entre os grupos, näo sendo observada alteraçäo da freqüencia durante o acompanhamento(P>0.05).A pressäo diastólica média inicial foi de 92, 16(ñ17, 70)mmHg näo existindo diferença entre os grupos, sendo observada uma diminuiçäo significativa desta, nos dois grupos em estudo, a partir do 15º minuto(P<0.05).Conclusäo: Observou-se que a instalaçäo de uma gota de fenilefrina a 10 por cento em cada olho näo produziu alteraçöes na freqüência cardíaca ou pressäo arterial sistêmica em pacientes adultos.

[Cataract extraction after angle closure glaucoma]. / L'opération de la cataracte après glaucome par fermeture de l'angle.

The best therapeutic approach to angle closure with cataract is phacoemulsification and foldable implant. The surgery is performed as soon as the acute crisis is over. Both dispersive and cohesive visco-elastic substance are used in the narrow anterior chamber. Poor mydriasis is best managed by means of iris hooks.

[Pourfour du Petit syndrome]. / Síndrome de Pourfour du Petit.

The Pourfour du Petit's syndrome is characterized by the unilateral appearance of mydriasis, lid retraction and exophthalmos. It suggests the existence of a localized oculosympathetic hyperactivity. It tends be to caused by injuries that suppose a stimulus of the sympathetics fibers at level of the proximal portion of the first dorsal root or in the cervical sympathetic chain. We report the clinical case of a young patient who developed a Pourfour du Petit's syndrome secondary to a small condrosarcoma of the proximal portion of the first rib. The observation of this syndrome is exceptional but its knowledge permits, by the great topographic value that possesses, a rapid identification of the causative injury.

[Optic neuropathies and peripheral oculomotor disorders in patients with AIDS]. / Neuropatías ópticas y trastornos oculomotores periféricos en pacientes con SIDA.

In patients with the acquired immunodeficiency syndrome (AIDS) there is an 8% incidence of neuro-ophthalmological changes. The commonest of these neuro-ophthalmological changes are: 1) Cranial nerve pareses 2) Optic neuropathy and 3) Pupil disorders. The cranial nerve pareses are usually combined, rather than single, and are due to intraparenchymatous lesions (toxoplasmosis or lymphoma) or to meningitis (tuberculous or lymphoma). The optic nerve changes tend to be papillitis due to CMV or optic neuropathy due to syphilis or to cryptococcal meningitis. Among the pupil changes, Bernard-Horner syndromes due to sympathetic involvement, Argyll-Robertson pupils due to mesencephalic tectal lesions and mydriasis associated with the common oculo-motor nerve have been described.