Case report: Topical pilocarpine ameliorated the accommodation loss and pupillary dilation after micropulse transscleral laser treatment.

BACKGROUND: The present study elucidates a common significant postoperative complication of micropulse transscleral laser treatment (mTLT) and explores its potential management strategies for younger patients with good central vision. CASE PRESENTATION: Three younger Chinese glaucoma patients with good central vision maintained high intraocular pressures (IOPs) (36, 25, and 30 mmHg) on maximally tolerated topical anti-glaucoma medications. All patients were treated with mTLT because of a higher risk of complications with filtering surgery. After the procedure, their best-corrected visual acuities were not significantly changed, IOPs were significantly decreased, and the number of topical anti-glaucoma medicines was gradually decreased. However, all patients complained about reduced near visual acuity (NVA) for 1-5 months. Slit-lamp examination revealed pupillary dilation, and binocular accommodative function examination indicated accommodation loss. After treatment with 2% topical pilocarpine, all patients reported an improvement in NVA. Among them, we could observe pupillary constriction, recovery of accommodation function, and improved NVA, even discontinuation of pilocarpine in Patient 2. CONCLUSION: In younger patients with good central vision, topical pilocarpine might ameliorate accommodation loss and pupillary dilation after mTLT.

A retrospective evaluation of systemic and/or topical pilocarpine treatment for canine neurogenic dry eye: 11 cases.

OBJECTIVE: To assess the response to topical and/or systemic pilocarpine in dogs with neurogenic dry eye. METHOD: Medical records of dogs diagnosed with dry eye between 2015 and 2018 were reviewed. Cases were excluded if STT values were decreased bilaterally, if dogs were lost to follow-up, or if surgical measures (parotid duct transposition) were undertaken within thirty days of presentation. Dogs were on treatment with topical pilocarpine (0.1%, every 6 hours) and/or oral pilocarpine (starting dose 2%, one drop per 10 kg every twelve hours). RESULTS: Eleven cases were included in the study, seven females and four males with mean age of 10 years. Seven cases had xeromycteria, two cases had facial nerve paralysis, and one case had Horner's syndrome. Seven cases (63.6%) had successful outcome following pilocarpine treatment, return to normal STT (15-25mm/minute), in an average of 24 ± 5.1 days. Of these cases, five had both systemic and topical treatment, one had just topical treatment, and one had just systemic treatment. The average time to normal tear production on treatment with topical pilocarpine ± systemic was 23 days (range 9-48 days). The number of systemic drops until a positive response varied between individuals from 0.8drops/10kg to 7drops/10kg. CONCLUSION: Pilocarpine treatment (topical ± systemic) is an effective therapy for unilateral dry eye disease in cases suspected to be neurogenic in origin. Most cases responded within 30 days. Side effects included topical irritation to the ophthalmic solution and systemic effects from oral pilocarpine, such as diarrhea and regurgitation.

Small-aperture strategies for the correction of presbyopia.

PURPOSE OF REVIEW: The recent scientific literature provides evidence of long-term results with small-aperture corneal inlays, as well as new evidence from a multicenter postmarket study of small-aperture intraocular lenses (IOLs) and early reports of the use of topical agents for presbyopia correction through pupil constriction. The field of small-aperture optics is growing and changing rapidly. RECENT FINDINGS: This article reviews what is known to date about various small-aperture optics platforms, including a posterior chamber IOL, add on device, corneal inlay, contact lenses, and pupil-constricting drops. Additionally, the impact of small-aperture technologies on light perception and visual performance, as well as the relative merits of monocular versus binocular small apertures are discussed. SUMMARY: Small-aperture optics are a dynamic, physiologic solution to the problem of presbyopia. They are effective throughout the range of accommodation loss and in pseudophakia. Small-aperture optics offer an opportunity to improve vision in presbyopes with and without cataracts. In some forms, they may also be able to reduce the impact of aberrations or improve vision in eyes with corneal irregularities, scars, or iris damage.

Effect of intracameral carbachol in phacoemulsification surgery on macular morphology and retinal vessel caliber.

OBJECTIVE: To investigate the effects of intracameral carbachol in phacoemulsification surgery on central macular thickness (CMT), total macular volume (TMV) and retinal vessel caliber (RVC). MATERIALS AND METHODS: In this prospective consecutive case series, 82 patients underwent uneventful phacoemulsification and in-the-bag intraocular lens implantation. Unlike patients in the control group (43 eyes), patients in the study group (42 eyes) were injected with intracameral 0.01% carbachol during surgery. Spectral-domain optical coherence tomography (OCT) was used to analyze the parameters of CMT, TMV and RVC. RESULTS: On the first postoperative day, mean CMT and TMV decreased markedly in the carbachol group, though these values did not change significantly in the control group. During follow-up visits, no statistically significant differences between the groups occurred regarding changes in mean CMT (p = 0.25, first day; p = 0.80, first week; p = 0.95, first month). However, change in mean TMV between groups on the first postoperative day was statistically significant (p = 0.01, first day; p = 0.96, first week; p = 0.68, first month). RVC values were similar on the preoperative and postoperative first days in both groups (p > 0.05). DISCUSSION: Results suggest that the effect of intracameral carbachol on macular OCT is related to pharmacological effects, as well as optic events (e.g. miosis). CONCLUSION: Intracameral carbachol given during cataract surgery decreases macular thickness and volume in the early postoperative period but does not exert any gross effect on RVC.

A history of glaucoma pharmacology.

The history of glaucoma pharmacology begins in 1862 with the isolation of physostigmine from the calabar bean. The discovery of epinephrine's intraocular pressure lowering capacity came along some 40 years later. During the 20th century, drug discovery and development accelerated, with the introduction of carbonic anhydrase inhibitors, beta blockers, and prostaglandin analogs. This survey of the history of glaucoma medications reviews some of the pivotal stories behind the development of the drugs that we use daily to manage our patients with glaucoma. In addition, some unmet needs that persist in glaucoma pharmacology are discussed.

Mydriasis associated with local dysfunction of parasympathetic nerves in two dogs.

In clinical practice, photophobia resulting from persistent mydriasis may be associated with dysfunction of ocular parasympathetic nerves or primary iris lesions. We encountered a 5-year-old Miniature Dachshund and a 7-year-old Shih Tzu with mydriasis, abnormal pupillary light reflexes, and photophobia. Except for sustained mydriasis and photophobia, no abnormalities were detected on general physical examination or ocular examination of either dog. We performed pharmacological examinations using 0.1% and 2% pilocarpine to evaluate and diagnose parasympathetic denervation of the affected pupillary sphincter muscles. On the basis of the results, we diagnosed a pupillary abnormality due to parasympathetic dysfunction and not to overt primary iris lesions. The test revealed that neuroanatomic localization of the lesion was postciliary ganglionic in the first dog.

[Glaucoma]. / Glaukom - Grüner Star.

Glaucoma is one of the most frequent causes of blindness in the world. Although there are several different subforms of glaucoma, their final common pathway is an atrophy of the optic disc leading to progressive visual field defects and finally total blindness. The loss of function in glaucoma is irreversible, i.e. early detection of the disease is the most important part of its therapy. Early detection, however, requires improved knowledge about the disease in the general population and the active help of all general practitioners, explaining their patients the insidious nature of the disease.

Efficacy of treatments for Demodex blepharitis: A systematic review and meta-analysis.

PURPOSE: We conducted a systematic review and meta-analysis to evaluate the efficacy of different treatment for Demodex blepharitis. Parameters studied were mites count, improvement of symptoms and mites' eradication, stratified on type of treatments and mode of delivery of treatments (local or systemic). METHOD: The PubMed, Cochrane Library, Embase, ClinicalTrials.gov, Google scholar and Science Direct databases were searched for studies reporting an efficacy of treatments for Demodex blepharitis. RESULTS: We included 19 studies (14 observational and 5 randomized clinical trials), for a total of 934 patients, 1741 eyes, and 13 different treatments. For mites count, eradication rate, and symptoms improvement, meta-analysis included fifteen, fourteen and thirteen studies, respectively. The overall effect sizes for efficiency of all treatments, globally, were 1.68 (95CI 1.25 to 2.12), 0.45 (0.26-0.64), and 0.76 (0.59-0.90), respectively. Except usual lid hygiene for mites count, Children's Hospital of Eastern Ontario ointment (CHEO) for both eradication rate and symptoms, and CHEO, 2% metronidazole ointment, and systemic metronidazole for eradication rate, all treatments were efficient. Stratified meta-analysis did not show significant differences between local and systemic treatments (1.22, 0.83 to 1.60 vs 2.24, 1.30 to 3.18 for mites count; 0.37, 0.21 to 0.54 vs 0.56, 0.06 to 0.99 for eradication rate; and 0.77, 0.58 to 0.92 vs 0.67, 0.25 to 0.98 for symptoms improvement). CONCLUSION: We reported the efficiency of the different treatments of Demodex blepharitis. Because of less systemic side effects, local treatments seem promising molecules in the treatment of Demodex blepharitis.

The Pilocarpine Model of Temporal Lobe Epilepsy and EEG Monitoring Using Radiotelemetry System in Mice.

Temporal lobe epilepsy (TLE) is a common neurological disorder in adulthood. For translational studies of chronic epilepsy, pilocarpine-induced status epilepticus (SE) is frequently selected to recapitulate spontaneous recurrent seizures (SRS). Here we present a protocol of SE induction by intraperitoneal (i.p.) injection of pilocarpine and monitoring of chronic recurring seizures in live animals using a wireless telemetry video and electroencephalogram (EEG) system. We demonstrated notable behavioral changes that need attention after pilocarpine injection and their correlation with hippocampal neuronal loss at 7 days and 6 weeks post-pilocarpine. We also describe the experimental procedures of electrode implantation for video and EEG recording, and analysis of the frequency and duration of chronic recurrent seizures. Finally, we discuss the possible reasons why the expected results are not achieved in each case. This provides a basic overview of modeling chronic epilepsy in mice and guidelines for troubleshooting. We believe this protocol can serve as a baseline for suitable models of chronic epilepsy and epileptogenesis.

A Rare Case of Blebharitis: Phthiriasis Palpebrarum.

A six-year-old male patient was admitted to our hospital due to itching and scalding crusts that persisted 10-15 days in both eyes. Upon biomicroscopic examination, 5-6 semi-translucent, yellowish brown living lice attached to the upper eyelashes and a large number of eggs were observed. Following application of pilocarpine hydrochloride (Pilomann 2%, Bausch-Lomb) and topical proparacaine hydrochloride (Alcaine 0.5%, Alcon), the paralyzed parasites and eggs were manually removed by pulling with forceps. The lice were identified as adult forms of pubic louse, Pthirus pubis, and its eggs. The patient was treated with pilocarpine hydrochloride, which was applied thrice a day combined with pure vaseline. One week later, no lice or eggs were seen on the eyelashes.

Primary Sjogren syndrome diagnosed simultaneously with localized amyloidosis of the lacrimal gland: A case report.

INTRODUCTION: Amyloidosis accompanied by Sjögren's syndrome (SS) has been reported to occur primarily in the skin, lungs, tongue, and mammary gland. However, SS in association with secondary amyloidosis is rarely reported, and knowledge of its relevance is inadequate. Here we report a case of primary SS diagnosed simultaneously with localized amyloidosis of the lacrimal gland. CASE PRESENTATION: A 45-year-old woman complaining of a left eyelid mass was referred to the hospital and was diagnosed with localized amyloidosis after excisional biopsy. She was then referred to the rheumatology department for additional evaluation for amyloidosis. Subsequently, her diagnosis was primary SS based on the presented symptoms and results of the Schirmer test, serologic testing, and minor salivary gland biopsy. Pilocarpine (10 mg/d) and hydroxychloroquine (200 mg/d) were initiated for the treatment of SS. Six months after the initial diagnosis, the dry eyes and mouth did not worsen and no masses suggestive of localized amyloidosis were reported. CONCLUSION: This is a rare case of amyloidosis, localized to the lacrimal gland, with SS. Therefore, despite its rarity, physicians should be aware of the potential coexistence of secondary amyloidosis, even in the localized form, in patients with SS.

[Primary open angle glaucoma. Morphological bases for the understanding of the pathogenesis and effects of antiglaucomatic substances]. / Primäres Offenwinkelglaukom. Morphologische Grundlagen zum Verständnis der Pathogenese und der Wirkung antiglaukomatöser Substanzen.

The pathogenesis of glaucomatic illnesses is poorly understood. An increase in ocular pressure can be caused by an increase in the secretion of aqueous humour or a reduction in its outflow. In the elderly, outflow is reduced while at the same time less aqueous humour is produced. This balance is easily disturbed, so that age represents a risk factor for glaucoma in addition to increased ocular pressure. Therapeutic possibilities involve, on the one hand, reducing the secretion of aqueous humour, for example using, beta blockers, carbonic anhydrase inhibitors and clonidine. On the other hand, aqueous humour outflow can also be influenced by drugs. Conventional outflow is increased by the administration of miotics. The uveoscleral outflow can be increased by prostaglandin derivates. Drugs which only influence trabecular outflow are not yet available. Future therapeutic possibilities involve new aspects of the pathophysiology, e.c. the use of growth factors, free radical scavenging enzymes and choroidal blood flow.

Unilateral dysphotopsia after bilateral intraocular lens implantation using the AR40e IOL model: case report.

The authors report a recent complication during the postoperative period of cataract surgery. A patient was submitted to cataract surgery in both eyes with IOL implantation (Sensar) inside the capsular bag. The postoperative period of right eye was uneventful, however, in the left eye the patient noted a dark shadow at the temporal visual field at the first postoperative week. This diagnosis was confirmed with the presence of a temporal scotoma revealed by the computerized visual field (first reported in this study) and also reducing the pupil area with miotic drops. The treatment of this complication was performed by using brimonidine tartrate and after 6 months this symptom completely disappeared as confirmed by the computerized visual field. The treatment should be based on reducing the pupil area with miotic drops and we also recommend to observe these cases until the 6th postoperative month before indicating an IOL exchange since the capsular edge that overlaps the IOL may opacify creating an optical barrier reducing or eliminating negative dysphotopsia.

Cataractous changes due to posterior chamber flattening with a posterior chamber phakic intraocular lens secondary to the administration of pilocarpine.

OBJECTIVE: To present the first reported case of cataract formation as a consequence of instillation of pilocarpine in an eye with a posterior chamber phakic intraocular lens (IOL). DESIGN: Interventional case report. INTERVENTION: A 46-year-old man received a hyperopic implantable collamer lens (ICL) bilaterally. MAIN OUTCOME MEASURES: Determination of best-corrected visual acuity (BCVA); contrast sensitivity testing with and without glare; and intraocular pressure (IOP), specular endothelial cell, and slit-lamp examinations were performed serially. In addition, the distance between the ICL and crystalline lens was measured with optical coherence tomography. RESULTS: Both eyes underwent uneventful ICL implantation for the correction of a manifest spherical equivalent of +7 diopters (D) in the right eye and +7.1 D in the left eye. The left eye was followed for 2 years without developing complications. The right eye, however, showed on the first postoperative day a fleckenlike opacification on the anterior pole of the crystalline lens after instillation on the operative day of 2% pilocarpine in an attempt to accelerate recovery from unwanted pupil dilation causing patient complaints of glare disability after surgery. Optical coherence tomography demonstrated complete contact of the ICL with the natural lens 24 hours postoperatively. Serial IOP measurements were always within the normal limits. The instillation of 1% cyclopentolate resulted in an increase in the ICL vault that measured 132 mum 24 hours later. Three days after the completion of a 3-day course of topical 1% cyclopentolate, the opacification was less dense and demarcated, and a 124-mum vault was measured. Three months postoperatively, the cataract was associated with a 3-line loss of BCVA and considerable degradation of the contrast sensitivity, especially at higher spatial frequencies and with a glare source, and corneal endothelial cell changes were within normal limits. One year after ICL implantation, the right eye had to undergo phacoemulsification and IOL implantation, which were uneventful. CONCLUSIONS: Posterior chamber flattening with resulting crystalline lens opacification can occur immediately after the instillation of pilocarpine in an eye with a hyperopic ICL. Therefore, caution should be taken with the administration of cholinergic agonists such as pilocarpine in patients with phakic IOLs, at least if they are hyperopic ICLs.

The rising cost of glaucoma drugs in Ireland 1996-2003.

BACKGROUND: Glaucoma affects approximately 2% of the population in developed countries and is estimated to affect 67 million people worldwide. The authors investigated the effect of the introduction of new medications on the volume and cost of drugs for glaucoma in two countries, Northern Ireland (NI, population approximately 1.7 million) and the Republic of Ireland (ROI, population approximately 3.9 million) in the 8 years from 1996 to 2003. They also looked at the surgical rates for glaucoma within the same time period for the two countries. METHODS: A retrospective analysis was performed of drug costs, prescribing data, and operation rates for glaucoma in Ireland from January 1996 to December 2003. Information regarding costs and volume were obtained for each type of glaucoma drug and these were then grouped into the glaucoma treatment subsections as found in the British National Formulary. The drug information was obtained from the Central Services Agency in NI and IMS Health in the ROI and included both public and private prescriptions. The information on surgical rates for glaucoma was obtained from the Department of Health and Social Services in NI and the Hospital In-patient Enquiry (HIPE) data national files in the ROI. RESULTS: There was a 30% increase in prescription items for glaucoma in NI and a 59% increase in the ROI from 1996 to 2003. The costs increased more rapidly than the number of items: 227% in the ROI and 78% in NI from January 1996 to December 2003. In the ROI, there was an average 19% year on year increase in costs. In NI, new drugs accounted for 40% of the quantity of prescription items for glaucoma and 63% of the market cost in 2003. In the ROI new drugs accounted for 57% of the quantity and 77% of the market cost for glaucoma in 2003; prostaglandin analogue drugs alone accounted for 53% of the cost. The number of trabeculectomies performed decreased by more than 60% in both countries. CONCLUSION: Volume and cost of glaucoma drugs increased dramatically in both NI and the ROI from 1996 to 2003, probably the result of a combination of changing demographics and a changing approach towards the management of patients with glaucoma and ocular hypertension. In 2003 in the ROI, prostaglandin analogues were the most commonly prescribed class of drug for patients with glaucoma and/or ocular hypertension causing a profound rise in drug expenditure.

An uncommon presentation of acute angle closure glaucoma.

Acute angle closure glaucoma is an ocular emergency that is treatable with prompt and appropriate intervention. Recognition of this disease entity is sometimes difficult. We report a case of bilateral acute angle closure glaucoma in a 55-year-old, otherwise healthy individual, and discuss the different ways the condition may present. The anatomic and pathophysiologic progression leading to an event of angle closure is discussed and treatment modalities available to the Emergency Physician are presented.

Glaucoma pharmacotherapy: implications for flying fitness.

The objective of lowering the intraocular pressures remains the main-stay of therapy in the management of glaucoma, and may be achieved by medication, laser, or surgery. For many years the pharmacotherapy available, while quite effective, were few in number; principally timolol, pilocarpine, and oral acetazolamide. Through extensive research in glaucoma treatment, ophthalmologists now have access to a dozen different medications to treat glaucoma. This has invariably led to a decrease in the need for laser or surgery to control the intraocular pressures, and the number of glaucoma operations performed has progressively declined over the past few years. However, aviation medicine practitioners need to be aware of the potential adverse effects of these medications as some of these undesirable side effects may render the drugs unsuitable for aircrew.

[Ocular hypertension and glaucoma]. / Hipertensiunea oculara si glaucomul.

PURPOSE: To examine the relationship of ocular hypertension (O.H.) and primary open angle glaucoma (P.O.A.G.) with reference of two patients which presented papillo-campimetry changes after 38 and respectively 24 years after O.H. was diagnosed (at levels between 30 and 45 mm Hg). The ratio IOP/F (feeding of the papilla and retina) is time depending, e.g. IOP x T/ F x 1/T. Because in the O.H.T.S. values of Goldmann applanation tonometry was not corrected by the central corneal thickness; and also SWAP technique was not available by that time, the author considers confirmation of POAG at the term of 5 years as high as 14,6-24,6%. Thus, the O.H. must be named as pre-campimetry glaucoma, when the IOP exceeds 25-26 mm Hg.

Medical Treatment of Primary Canine Glaucoma.

Glaucoma is a painful and often blinding group of ocular diseases for which there is no cure. Although the definition of glaucoma is rapidly evolving, elevated intraocular pressure (IOP) remains the most consistent risk factor of glaucoma in the canine patient. Therapy should be aimed at neuroprotection. The mainstay of therapy focuses on reducing IOP and maintaining a visual and comfortable eye. This article discusses the most current ocular hypotensive agents, focusing on their basic pharmacology, efficacy at lowering IOP, and recommended use in the treatment of idiopathic canine glaucoma.