Iris Cerclage To Treat Persistent Mydriasis Following Acute Angle Closure Glaucoma Improves Visual Quality.

PRCIS: We developed a modified iris cerclage technique that improves best corrected visual acuity, pupillary parameters, self-assessed photophobia, and visual function index-14 questionnaire scores in patients with acute primary angle closure and permanent mydriasis after cataract surgery. PURPOSE: To evaluate the efficacy of a modified iris cerclage technique in patients with acute primary angle closure (PAC) and permanent mydriasis after cataract surgery. PATIENTS AND METHODS: Twelve eyes of 12 patients with acute PAC and permanent mydriasis at more than 3 months after phacoemulsification combined with intraocular lens (IOL) implantation underwent modified iris cerclage. Best corrected visual acuity (BCVA), intraocular pressure (IOP), pupil diameter, and visual function index-14 (VF-14) questionnaire and self-assessed photophobia scores before surgery and at 1 week, 1 month, and 3 months postoperatively were compared. Further, the postoperative pupil position morphology and complications were evaluated. RESULTS: BCVA improved from 0.48±0.23 preoperatively to 0.28±0.15, 0.27±0.15, and 0.26±0.14 at 1 week, 1 month, and 3 months postoperatively, respectively ( P =0.008). No significant difference was observed between the preoperative and postoperative IOP ( P =0.974). Pupil diameter improved from 6.34±0.51 mm preoperatively to 3.59±0.33, 3.59±0.34, and 3.58±0.32 mm at 1 week, 1 month, and 3 months postoperatively, respectively ( P <0.001). Self-assessed photophobia scores improved from 3.33±0.78 preoperatively to 0.83±0.72, 0.51±0.15, and 0.45±0.14 at 1 week, 1 month, and 3 months postoperatively, respectively ( P <0.001). VF-14 scores improved from 47.6±6.1 points preoperatively to 67.9±6.2, 72.1±6.1, and 73.5±6.0 points at 1 week, 1 month, and 3 months postoperatively, respectively ( P< 0.001). Postoperatively, all pupils were centered and round. No postoperative complications, such as iris-suture slippage, iridodialysis, or exposure of the IOL's optical zone edge, were observed. CONCLUSION: Modified iris cerclage creates a centered, precisely sized, round pupil. It improves visual quality in patients with acute PAC and permanent mydriasis after cataract surgery.

[Painful anisocoria in a five-year-old child: A rare diagnosis which must not be missed]. / Anisocorie douloureuse chez un enfant de cinq ans : un diagnostic rare à ne pas méconnaître.

Congenital ectropion uveae (CEU) is a rare anomaly of the embryonic development of the anterior segment of the eye. We report the case of a 5-year-old child with an undiagnosed CEU who was treated urgently for an acute angle closure attack. CASE DESCRIPTION: A 5-year-old child was referred urgently for evaluation of anisocoria with mydriasis of the right eye and severe headache. Brain imaging with contrast injection was initially performed in the pediatric emergency department and ruled out central nervous system pathology. The initial examination of the right eye revealed an intraocular pressure (IOP) of 37mmHg, corneal edema, congenital ectropion uveae, mydriasis with pupillary block, a closed angle on gonioscopy, and a clear lens. The examination of the left eye was unremarkable, with no visible CEU. The initial management consisted of medical treatment with topical glaucoma drops and miotics and acetazolamide at 10mg/kg/d. Re-evaluation under general anesthesia showed persistent mydriasis and no resolution of the pupillary block. Filtering surgery was performed in the absence of a complete response to medical treatment, allowing control of IOP without drops and complete regression of the corneal edema. DISCUSSION: CEU is a rare malformation, and pressure complications represent an insignificant proportion of pediatric glaucoma cases. The acute presentation of acute angle closure in this potentially blinding short-term setting, however, makes detection and management difficult in very young children in a great deal of pain. Only one similar case has been reported in the pediatric literature. CONCLUSION: Acute angle closure complicating CEU is exceptional and difficult to diagnose in a pediatric context. Parents of children with this predisposing condition should be informed of the need to consult urgently when clinical signs of elevated intraocular pressure appear.

Urrets-Zavalia syndrome following cataract surgery in dogs: A case series.

Background: In human medicine, Urrets-Zavalia syndrome (UZS) is a well-recognized but uncommon postoperative complication characterized by a fixed dilated pupil, accompanied by iris atrophy and glaucoma. Although it was originally reported in 1963 after penetrating keratoplasty surgery for keratoconus, it has been associated with various ophthalmic procedures such as cataract surgery. The condition has not been previously published in the veterinary literature. Case Description: Three client-owned diabetic dogs that developed UZS´s triad after cataract surgery are described. Despite uneventful phacoemulsification in the six eyes, five developed moderate-to-severe postoperative ocular hypertension. Although intraocular pressure (IOP) spikes were initially controlled, fixed dilated pupils accompanied by iris atrophy and chronic ocular hypertension were seen in the five affected eyes. Aggressive medical and surgical management maintained vision in three of those eyes. In one eye, uncontrolled IOP led to blindness. Conclusion: This is the first published description of UZS in dogs, occurring after phacoemulsification. Although no exact, demonstrable causative element could be determined, we believe that should be considered a triggering condition for this syndrome, as it directly affects the ocular blood flow autoregulation and intrinsic uveal tissue integrity. Until the contrary is proved, diabetes mellitus might be considered as a risk factor for developing this syndrome after cataract surgery in dogs.

Iris cerclage pupilloplasty and IOL implantation for traumatic mydriasis and aphakia after the blunt trauma of the eye.

Four patients with traumatic mydriasis and aphakia following blunt injury of the eye globe were evaluated. Patients with severe glare and photophobia due to wide pupil diameter from 6.0 to 9.0 mm were managed by combined iris cerclage pupilloplasty and retropupillar iris-claw lens implantation. The postoperative anatomic results, visual acuity, subjective degree of glare, photophobia, as well as intraoperative and postoperative complications were evaluated. The mean follow-up time was 32.6 months. Best-corrected visual acuity improved in all patients from preoperative 20/60, 20/30, 20/25, 20/22 to postoperative 20/20, 20/22, 20/20, and 20/20 (Snellen charts). All eyes achieved satisfactory anatomic result with round pupil diameter 3.5-4.5 mm. Glare and photophobia disappeared in all patients. There were no intraoperative or postoperative complications. During the follow-up period, pupils remained round and iris-claw lenses well positioned, without tilting. Combined iris cerclage pupilloplasty with retropupillar iris claw lens implantation appears to be a safe and effective surgical technique in reducing pupil size and improving visual outcomes. It is also a cost- and time-effective procedure, providing great results with a single surgery.

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.

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.].

Unilateral mydriasis: a complication of spine surgery in prone position / Midríase unilateral: uma complicação da cirurgia de coluna em decúbito ventral

Abstract Prone position though 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 cause of anisocoria. Anisocoria partially improved but persisted till follow up.

Resumo O posicionamento em decúbito ventral, embora comumente usado para melhorar o acesso ao local cirúrgico, pode estar associado a uma variedade de complicações. Distúrbios ou perda visual no Perioperatório é uma complicação rara, mas devastadora, que está principalmente associada à cirurgia de coluna vertebral em decúbito ventral. Relatamos aqui o caso de um paciente de 42 anos de idade, ASA - II, que desenvolveu anisocoria com dilatação pupilar esquerda após microdiscetomia lombar em decúbito ventral. Após uma avaliação adicional do paciente, observamos que a paralisia segmentar dos músculos pupilares esquerdos seria a possível causa de anisocoria. A anisocoria melhorou parcialmente, mas persistiu até o acompanhamento.

Xtra focus pinhole IOL (Morchers GMBH) a novel approach to tackle irregular astigmatism and large pupillary defects with a single step surgery.

A 69-year-old patient presented to us with traumatic mydriasis with irregular pupil measuring 7 mm, with superior loss of iris tissue and large inferior peripheral iridotomy and pseudophakia. The patient had history of blunt trauma 3 years ago in a fire cracker injury. He was operated elsewhere primarily after the trauma for cataract surgery with intraocular lens implantation and had suboptimal visual outcome with glare and photophobia. He presented to us with irregular pupil and inferior iridectomy with pseudophakia. The uncorrected visual acuity was 20/150 improving to 20/50 with glasses. He had a history of cataract surgery with intraocular lens (IOL) implantation done elsewhere several years back. The patient was not a diabetic or hypertensive. There was a para central corneal scar causing irregular corneal astigmatism. Extra focus pinhole IOL was implanted in sulcus having a pinhole aperture 1.36 mm. Preoperative total corneal higher-order aberrations were 3.3 µ and total corneal coma was 0.97 µ. Postoperatively uncorrected distance visual acuity improved to 20/40 intermediate uncorrected visual acuity improved to 20/30 and uncorrected near visual acuity was J3.

Scopolamine Toxicity in an Elderly Patient.

We present a case of a 66-year-old female who was to undergo a scheduled operation and placed on our institution's ERAS (Enhanced Recovery After Surgery) protocol. The intraoperative course was unremarkable. The patient developed delayed emergence in the Post-Anesthesia Care Unit. On physical exam, the patient was noted to have a transdermal scopolamine patch adjacent to an area of skin breakdown. She also displayed signs of central anti-cholinergic toxicity including mydriasis and tachycardia. Following removal of the scopolamine patch and administration of physostigmine, her mental status returned to baseline. This interesting case highlights the importance of considering patient specific factors such as age when implementing ERAS protocols perioperatively. It also demonstrates the risks associated with scopolamine and the importance of risk/benefit analysis prior to administration.

[Unilateral mydriasis: a complication of spine surgery in prone position]. / Midríase unilateral: uma complicação da cirurgia de coluna em decúbito ventral.

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.

Aqueous humor misdirection syndrome after glaucoma filtering surgery in patient with bilateral acute iris transillumination (BAIT) syndrome. / Síndrome de misdirección del humor acuoso tras cirugía filtrante de glaucoma en paciente con síndrome de transiluminación aguda iridiana bilateral (BAIT).

CASE REPORT: Bilateral Acute Iris Transillumination (BAIT) is a disease characterised by bilateral acute, severe pigment dispersion of the iris, and pupil sphincter paralysis. The case is reported of a 51-year-old female who was diagnosed with BAIT syndrome, with refractory ocular hypertension in the left eye, and who needed filtering surgery. Aqueous misdirection was developed a week after surgery, then pars plana vitrectomy was performed and the complication was solved. CONCLUSION: This is the first case described in literature of aqueous humor misdirection syndrome secondary to glaucoma filtering surgery in a patient diagnosed of BAIT syndrome. This is a recently defined disease with a few cases currently described.

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.

Isoflurane-Associated Mydriasis Mimicking Blown Pupils in a Patient Treated in a Neurointensive Care Unit.

We report a misinterpretation of bilateral mydriasis as blown pupils related to elevated intracranial pressure (ICP) under volatile sedation with isoflurane (Anesthetic Conserving Device [AnaConDa], Hudson RCI, Uppland Vasby, Sweden) in a 59-year-old patient with a severe traumatic brain injury with frontal contusion. The patient showed bilateral mydriasis and a missing light reflex 8 hours after changing sedation from intravenous treatment with midazolam and esketamine to volatile administration of isoflurane. Because cranial computed tomography ruled out signs of cerebral herniation, we assumed the bilateral mydriasis was caused by isoflurane and reduced the isoflurane supply. Upon this reduction the mydriasis regressed, suggesting the observed mydriasis was related to an overdose of isoflurane. Intensivists should be aware of the reported phenomenon to avoid unnecessary diagnostic investigations that might harm the patient. We recommend careful control of the isoflurane dose when fixed and dilated pupils appear in patients without other signs of elevated ICP.

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.

Mydriasis revealing vascular and osteodural compression of the oculomotor nerve: An observational study on five cases.

PURPOSE: To describe a form of neurovascular compression of the third cranial nerve (CNIII) in idiopathic mydriasis, in which a neurovascular "conflict" exists between the oculomotor nerve, the posterior communicating artery and the clinoid process, using high-resolution magnetic resonance imaging (MRI) with fast imaging employing steady acquisition (FIESTA) sequences. METHODS: An 18-month prospective, observational and monocentric case series report was performed. MRI was performed on 5 consecutive patients with idiopathic, unilateral, persistent and nonreactive mydriasis (pure intrinsic palsy of the CNIII). Patients with diplopia, ptosis or ophthalmoplegia were excluded. Cerebral MRI focused on the CNIII pathway from the mesencephalon to the cavernous sinus entry, particularly on the cisternal segment: image acquisition was performed on a 3 Tesla MRI; the protocol included fast imaging employing steady acquisition (FIESTA) and three-dimension time of flight (3D TOF) sequences. RESULTS: All patients presented a neurovascular compression point, involving the CNIII clamped between a tortuous posterior communicating artery (PCoA) and the posterior clinoid process at the entrance of the cavernous sinus. No cases occurred in the root entry zone. There was no compression on the contralateral side. No tumors or aneurysms were found. Thus, the mydriasis was caused by CNIII compression. CONCLUSION: MRI, including FIESTA sequences, revealed a new type of neurovascular conflict between the CNIII, PCoA and posterior clinoid process in patients with incomplete oculomotor palsy. Non-aneurysmal CNIII compression should be considered as a differential diagnosis in the work-up of idiopathic mydriasis. The role of MRI in the work-up of anisocoria should be considered.