Intervention for Reducing Sleep Disturbances After a 12-Time Zone Transition.

Hoshikawa, M, Uchida, S, and Dohi, M. Intervention for reducing sleep disturbances after a 12-time zone transition. J Strength Cond Res 34(7): 1803-1807, 2020-The purpose of this study was to examine the effect of an intervention consisting of bright light exposure, sleep schedule shifts, and ramelteon on sleep disturbances after a transition of 12 time zones. Two groups, which flew from Tokyo to Rio, participated in this study. The experimental group received the treatment, whereas the control group did not receive any treatment. The experimental group members were exposed to bright light at night and their sleep-wake schedules were gradually delayed for 4 days before their flight. They also took 8 mg of ramelteon once a day for 5 days from the day of their first flight. Both groups departed Tokyo at 14:05, transiting through Frankfurt and arriving in Rio at 05:05. In Rio, it was recommended that they go to bed earlier than usual if they experienced sleepiness. Nocturnal sleep variables measured by wristwatch actigraphy and subjective morning tiredness were compared between groups. Statistical analysis revealed shorter sleep onset latencies (SOLs) in the experimental group (p < 0.01). The SOLs in Rio were 7.7 ± 2.5 minutes for the experimental group and 16.3 ± 3.7 minutes for the control group (d = 0.89, effect size: large). Sleep efficiency for the first 3 nights in Rio was 88.5 ± 1.2% for the experimental group and 82.9 ± 3.0% for the control group (p < 0.01, d = 1.09, effect size: large). These results suggest that the intervention reduced sleep disturbances in Rio. Our intervention may increase the options for conditioning methods for athletic events requiring time zone transitions.

Senior Vipassana Meditation practitioners exhibit distinct REM sleep organization from that of novice meditators and healthy controls.

The present study is aimed to ascertain whether differences in meditation proficiency alter rapid eye movement sleep (REM sleep) as well as the overall sleep-organization. Whole-night polysomnography was carried out using 32-channel digital EEG system. 20 senior Vipassana meditators, 16 novice Vipassana meditators and 19 non-meditating control subjects participated in the study. The REM sleep characteristics were analyzed from the sleep-architecture of participants with a sleep efficiency index >85%. Senior meditators showed distinct changes in sleep-organization due to enhanced slow wave sleep and REM sleep, reduced number of intermittent awakenings and reduced duration of non-REM stage 2 sleep. The REM sleep-organization was significantly different in senior meditators with more number of REM episodes and increased duration of each episode, distinct changes in rapid eye movement activity (REMA) dynamics due to increased phasic and tonic activity and enhanced burst events (sharp and slow bursts) during the second and fourth REM episodes. No significant differences in REM sleep organization was observed between novice and control groups. Changes in REM sleep-organization among the senior practitioners of meditation could be attributed to the intense brain plasticity events associated with intense meditative practices on brain functions.

Temporal patterns of sleep latency in central hypersomnia and attention deficit hyperactivity disorder: a cluster analysis exploration using Multiple Sleep Latency Test.

Introduction: Excessive daytime sleepiness (EDS) is a crucial symptom that diminishes the quality of life. The primary causes of EDS are central hypersomnia, including narcolepsy type 1 (NT1), type 2 (NT2), and idiopathic hypersomnia (IH). EDS is often associated with other psychiatric disorders, particularly attention deficit hyperactivity disorder (ADHD). The Multiple Sleep Latency Test (MSLT) is the standard assessment tool for EDS. Although the MSLT yields numerous parameters, most are not employed in clinical practice. In this study, we leveraged novel MSLT parameters to discern central hypersomnia and ADHD presence. Our analysis focused on sleep latency variability and employed cluster analysis to identify unique temporal patterns. Methods: We examined the MSLT data from 333 patients; of these, 200 (aged 14-54, mean: 24.9 ± 8.1, years; 114 females) met the inclusion criteria comprising comprehensive data an Apnea-Hypopnea Index (AHI) below 5, and no prior diagnosis of sleep apnea syndrome. We employed a time-course cluster approach that specifically targeted sleep latency variability during the MSLT. Results: Considering both multiple clustering quality evaluations and the study's objectives, we identified 9 distinct clusters. Clusters 1 and 3 predominantly had MSLT-positive results; Cluster 2 was entirely MSLT-positive; Clusters 4, 5, 6, 8, and 9 were mainly MSLT-negative; and Cluster 7 had mixed results. The diagnosis of hypersomnia varied notably among Clusters 1, 2, 3, and 7, with Cluster 2 demonstrating a pronounced tendency towards NT1 and NT2 diagnoses (p < 0.005). However, no significant correlation was observed between ADHD diagnoses and specific sleep latency patterns in any cluster. Conclusions: Our study highlights the value of time-course clustering in understanding sleep latency patterns of patients with central hypersomnia.

Bayesian calibration of simultaneity in tactile temporal order judgment.

Human judgment of the temporal order of two sensory signals is liable to change depending on our prior experiences. Previous studies have reported that signals presented at short intervals but in the same order as the most frequently repeated signal are perceived as occurring simultaneously. Here we report opposite perceptual changes that conform to a Bayesian integration theory in judging the order of two stimuli delivered one to each hand.

Diurnal repeated exercise promotes slow-wave activity and fast-sigma power during sleep with increase in body temperature: a human crossover trial.

The effects of exercise on sleep have been explored from various perspectives, but little is known about how the effects of acute exercise on sleep are produced through physiological functions. We used a protocol of multiple daytime sessions of moderate-intensity aerobic exercise and examined the subsequent effects on sleep structure, core body temperature (CBT), distal-proximal skin temperature gradient (DPG), and subjective parameters. Fourteen healthy men who did not exercise regularly were evaluated under the baseline (no exercise) and exercise conditions on a within-subject crossover basis. Under the exercise condition, each participant performed a 40-min aerobic workout at 40% of maximal oxygen intake, four times between morning and early evening. We observed a 33% increase in slow-wave sleep (SWS; P = 0.005), as well as increases in slow-wave activity (SWA; P = 0.026), the fast-sigma power/SWA ratio (P = 0.005), and subjective sleep depth and restorativeness the following morning. Moreover, both CBT and the DPG increased during sleep after exercise (P = 0.021 and P = 0.047, respectively). Regression analysis identified an increased nocturnal DPG during sleep after exercise as a factor in the increase in SWA. The fast-sigma/SWA ratio correlated with CBT. The performance of acute exercise promotes SWS with nocturnal elevation in the DPG. Both CBT and fast-sigma power may play a role in the specific physiological status of the body after exercise. NEW & NOTEWORTHY We used multiple daytime sessions of moderate-intensity aerobic exercise to examine the effects on the sleep structure, core body temperature (CBT), distal-proximal skin temperature gradient (DPG), and subjective parameters. Significant increases in slow-wave activity (SWA), CBT, DPG, fast-sigma power, and subjective parameters were observed during the night and the following morning. Nocturnal DPG is a factor in the increased SWA.

Large blunt scleral rupture without retinal detachment.

Eyes with scleral rupture after blunt trauma are often complicated by proliferative vitreoretinopathy. A 56-year-old man sustained blunt trauma to his left eye. Visual acuity was light perception. The fundus was obscured by hyphema. Computed tomography imaging and the presence of extensive subconjunctival hemorrhage suggested scleral rupture. Prompt primary surgery to repair a 25-mm scleral rupture was performed under general anesthesia. No retinal detachment developed. Two years postoperatively, visual acuity increased to 12/20. This case shows that retinal detachment and proliferative vitreoretinopathy may not complicate extensive scleral ruptures under certain circumstances.

[Biochemical and bacteriological investigation of six cases of purple urine bag syndrome (PUBS) in a geriatric ward for dementia].

AIM: Purple urine bag syndrome is a condition in which the urinary catheter bag turns purple. A tryptophan-indigo hypothesis has been proposed as the mechanism of PUBS, in which bacterial decomposition of tryptophan in gut associated with chronic constipation, bacterial overgrowth in the urinary tract and alkaline urine causes production of indigo and discoloration. We considered that further investigation of cases was needed. METHODS: We investigated 6 cases exhibiting PUBS (3 males and 3 females). RESULTS: All cases had chronic constipation. Oral ingestion was impossible in one case. PUBS disappeared after antibiotic treatment (3 cases) or spontaneously (one case). Alkaline urine and indicanuria were not found in all cases that showed the disappearance of PUBS. In bacterial culture of urine during the exhibition of PUBS, Enterococcus faecalis was isolated together with Morganella morganii (3 cases) and Pseudomonas aeruginosa (one case). Single infections by Klebsiella pneumoniae or Citrobacter species were also found. After disappearance of PUBS, infected bacterial species changed but no cases showed sterile urine. Urine and blood alpha-amino-n-butyric acid levels reduced after the disappearance of PUBS whereas tryptophan levels did not show related changes. In one case, blood protein concentration increased after the spontaneous disappearance of PUBS. Indicanuria and alkalization of urine from urinary catheter bag were more intense than of fresh urine. CONCLUSIONS: The present results generally support the 'Tryptophan-indigo hypothesis'. Furthermore, it was suggested that additional factors associated with the occurrence of PUBS are an environment that facilitates specific bacterial growth in a hospital as well as abnormal metabolism relating to alpha-amino-n-butyric acid and reduced protein synthesis in patients.

A Subjective Assessment of the Prevalence and Factors Associated with Poor Sleep Quality Amongst Elite Japanese Athletes.

BACKGROUND: The amount, quality, and timing of sleep are considered important for athletes' ability to train, maximize training responses, and recover. However, some research has shown that elite athletes do not obtain sufficient sleep. Based on this background, researchers recently started to assess and manage sleep in elite athletes. The purpose of this study was to clarify the prevalence of poor sleep quality and its associated factors amongst elite Japanese athletes. METHODS: Eight hundred and ninety-one candidates for the 17th Asian Games Incheon 2014, who were over 20 years old, participated in this study. They completed a questionnaire that included the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale, two-question case-finding instruments, and a checklist for sleep hygiene. Data from 817 of the 891 athletes (91.7%) with no missing values were analyzed. RESULTS: The mean time in bed was 7 h and 29 min. Two hundred and twenty-nine (28.0%) athletes showed a PSQI global score above the clinical criteria. A multiple logistic analysis revealed that sleep quality was significantly associated with five factors: "time in bed," "eating breakfast every morning," "avoiding the use of electronic devices (PC, smartphone, etc.) just before bedtime," "depressive mood", and "not thinking about troubles while in bed." Forty percent of athletes reported they had been informed by someone about "snoring loudly" and/or "leg twitching or jerking during sleep." CONCLUSIONS: The results of this study demonstrate that 28% of the athletes showed the PSQI score above the cutoff for poor sleep quality (> 5.5), which suggests that there may be a high prevalence of poor sleep quality in this population of athletes. To improve athletes' sleep, the five factors associated with sleep quality should be emphasized in athletes' sleep education. Furthermore, in medical evaluations of athletes, it may be desirable to include screening for sleep disorders.

High rebound mattress toppers facilitate core body temperature drop and enhance deep sleep in the initial phase of nocturnal sleep.

Recently, several new materials for mattresses have been introduced. Although some of these, such as low rebound (pressure-absorbing/memory foam) and high rebound mattresses have fairly different characteristics, effects of these mattresses on sleep have never been scientifically evaluated. In the current study, we have evaluated effects of a high rebound mattress topper [HR] on sleep and its associated physiology, and the effects were compared to those of a low rebound mattress toppers (LR) in healthy young (n = 10) and old (n = 20) adult males with a randomized, single-blind, cross over design. We found that sleeping with HR compared to LR induced a larger decline in core body temperature (CBT) in the initial phase of nocturnal sleep both in young (minimum CBT: 36.05 vs 36.35°C) and old (minimum CBT: 36.47 vs. 36.55°C) subjects, and declines in the CBT were associated with increases in deep sleep/delta power (+27.8% in young and +24.7% in old subjects between 11:00-01:00). We also found significantly smaller muscle activities during roll over motions with HR (-53.0 to -66.1%, depending on the muscle) during a separate daytime testing. These results suggest that sleeping with HR in comparison to with LR, may facilitate restorative sleep at the initial phase of sleep.

Changes in sleep quality of athletes under normobaric hypoxia equivalent to 2,000-m altitude: a polysomnographic study.

This study evaluated the sleep quality of athletes in normobaric hypoxia at a simulated altitude of 2,000 m. Eight male athletes slept in normoxic condition (NC) and hypoxic conditions equivalent to those at 2,000-m altitude (HC). Polysomnographic recordings of sleep included the electroencephalogram (EEG), electrooculogram, chin surface electromyogram, and electrocardiogram. Thoracic and abdominal motion, nasal and oral airflow, and arterial blood oxygen saturation (Sa(O(2))) were also recorded. Standard visual sleep stage scoring and fast Fourier transformation analyses of the EEG were performed on 30-s epochs. Subjective sleepiness and urinary catecholamines were also monitored. Mean Sa(O(2)) decreased and respiratory disturbances increased with HC. The increase in respiratory disturbances was significant, but the increase was small and subclinical. The duration of slow-wave sleep (stage 3 and 4) and total delta power (<3 Hz) of the all-night non-rapid eye movement sleep EEG decreased for HC compared with NC. Subjective sleepiness and amounts of urinary catecholamines did not differ between the conditions. These results indicate that acute exposure to normobaric hypoxia equivalent to that at 2,000-m altitude decreased slow-wave sleep in athletes, but it did not change subjective sleepiness or amounts of urinary catecholamines.

Effect of shortened sleep on energy expenditure, core body temperature, and appetite: a human randomised crossover trial.

The effects of sleep restriction on energy metabolism and appetite remain controversial. We examined the effects of shortened sleep duration on energy metabolism, core body temperature (CBT), and appetite profiles. Nine healthy men were evaluated in a randomised crossover study under two conditions: a 3.5-h sleep duration and a 7-h sleep duration for three consecutive nights followed by one 7-h recovery sleep night. The subjects' energy expenditure (EE), substrate utilisation, and CBT were continually measured for 48 h using a whole-room calorimeter. The subjects completed an appetite questionnaire every hour while in the calorimeter. Sleep restriction did not affect total EE or substrate utilisation. The 48-h mean CBT decreased significantly during the 3.5-h sleep condition compared with the 7-h sleep condition (7-h sleep, 36.75 ± 0.11 °C; 3.5-h sleep, 36.68 ± 0.14 °C; p = 0.016). After three consecutive nights of sleep restriction, fasting peptide YY levels and fullness were significantly decreased (p = 0.011), whereas hunger and prospective food consumption were significantly increased, compared to those under the 7-h sleep condition. Shortened sleep increased appetite by decreasing gastric hormone levels, but did not affect EE, suggesting that greater caloric intake during a shortened sleep cycle increases the risk of weight gain.

Napping after complex motor learning enhances juggling performance.

The present study examined whether a nap after complex motor learning enhanced the following day's physical performance. Eighteen volunteers met the inclusion criteria and were assigned to either a nap (n=9; men=5; mean age=21.0±1.5) or no-nap group (n=9; men=5; mean age=21.9±0.3). Participants practiced juggling in the morning and were tested immediately afterwards. Participants of the nap group were given a 70-minute nap opportunity after juggling practice, while the no-nap group stayed awake. Juggling performance was then tested in the evening (retest-1) and the next morning (retest-2). Two-way analysis of variance (group: nap, no-nap×time: test, retest-1, retest-2) found there was a significant effect of test time and a significant group×time interaction. The juggling performance of both groups improved from test to retest-1, respectively. However, the juggling performance level of the nap group was higher than that of the no-nap group at the retest-1. As predicted, a nap promptly after learning motor skills was associated with subsequently improved performance. Moreover, the juggling performance of the nap group showed additional significant improvements in the retest-2. In the no-nap group, however, there were no significant improvements in the juggling performance after nocturnal sleep. These results demonstrate that the benefits of a nap following learning were further enhanced after nocturnal sleep. The present results may provide justification for introducing nap periods into daily athletic training as an active method to improve performance.

Theta EEG neurofeedback benefits early consolidation of motor sequence learning.

Procedural learning is subject to consolidation processes believed to depend on the modulation of functional connections involved in representing the acquired skill. While sleep provides the most commonly studied framework for such consolidation processes, posttraining modulation of oscillatory brain activity may also impact on plasticity processes. Under the hypothesis that consolidation of motor learning is associated with theta band activity, we used EEG neurofeedback (NFB) to enable participants to selectively increase either theta or beta power in their EEG spectra following the acquisition phase of motor sequence learning. We tested performance on a motor task before and after training, right after the NFB session to assess immediate NFB effects, 1 day after NFB to assess interaction between NFB effects and overnight sleep-dependent stabilization, and 1 week after the initial session, to assess the effects of NFB on long-term stabilization of motor training. We also explored the extent of the influence of single-electrode NFB on EEG recorded across the scalp. Results revealed a significantly greater improvement in performance immediately after NFB in the theta group than in the beta group. This effect continued for testing up to 1 week following training. Across participants, post-NFB improvement correlated positively with theta/beta ratio change achieved during NFB. Additionally, NFB was found to cause widespread band-power modulation beyond the electrode used for feedback. Thus, upregulating postlearning theta power may yield contributions to the immediate performance and subsequent consolidation of an acquired motor skill.

High frequency activities in the human orbitofrontal cortex in sleep-wake cycle.

We recorded human orbitofrontal electrocorticogram during wakefulness and sleep in epileptic patients using subdural electrodes. During wakefulness and rapid eye movement (REM) sleep, we observed beta activity in the raw orbitofrontal signals. Power spectral analysis demonstrated beta enhancement during wakefulness and REM sleep when compared to slow wave sleep (SWS). During the phasic REM periods, the beta power was significantly lower than during the tonic REM periods. Gamma enhancement manifested itself in four out of six subjects during the phasic periods. This study is the first that has focused on electrical activity in the human orbitofrontal cortex. Although the role of the orbitofrontal cortex during sleep still remains unclear, high frequency activities give us important suggestions in elucidating the human sleep mechanism.

Effects of alcohol on thermoregulation during mild heat exposure in humans.

We investigated the effects of alcohol on thermoregulatory responses and thermal sensations during mild heat exposure in humans. Eight healthy men participated in this study. Experiments were conducted twice for each subject at a room temperature of 33 degrees C. After a 30-min resting period, the subject drank either 15% alcohol (alcohol session) at a dose of 0.36 g/kg body weight or equal volume of water (control session). Skin blood flow and chest sweat rate in the alcohol session significantly increased over those in controls 10 min after drinking. Deep body temperature in the alcohol session started to decrease 20 min after the onset of sweating and eventually fell 0.3 degrees C lower than in the controls. Whole body hot sensation transiently increased after alcohol drinking, whereas it changed little after water drinking. The increased "hot" sensation would presumably cause cool-seeking behavior, if permitted. Thus, alcohol influences thermoregulation so that body core temperature is lowered not only by automatic mechanisms (sweating and skin vasodilation) but also behaviorally. These results suggest that decreases in body temperature after alcohol drinking are not secondary to skin vasodilation, a well-known effect of alcohol, but rather result from a decrease in the regulated body temperature evidenced by the coordinated modulation of various effectors of thermoregulation and sensation.

Effects of Five Nights under Normobaric Hypoxia on Sleep Quality.

PURPOSE: The purpose of this study was to evaluate the effects of five nights' sleep under normobaric hypoxia on ventilatory acclimatization and sleep quality. METHODS: Seven men initially slept for six nights under normoxia and then for five nights under normobaric hypoxia equivalent to a 2000-m altitude. Nocturnal polysomnograms (PSGs), arterial blood oxygen saturation (SpO2), and respiratory events were recorded on the first and fifth nights under both conditions. RESULTS: The hypoxic ventilatory response (HVR), hypercapnic ventilatory response (HCVR), and resting end-tidal CO2 (resting PETCO2) were measured three times during the experimental period. The duration of slow-wave sleep (SWS: stage N3) and the whole-night delta (1-3 Hz) power of nonrapid eye movement (NREM) sleep EEG decreased on the first night under hypoxia. This hypoxia-induced sleep quality deterioration on the first night was accompanied by a lower mean and minimum SpO2, a longer time spent with SpO2 below 90% (<90% SpO2 time), and more episodes of respiratory disturbance. On the fifth night, the SWS duration and whole-night delta power did not differ between the conditions. Although the mean SpO2 under hypoxia was still lower than under normoxia, the minimum SpO2 increased, and the <90% SpO2 time and number of episodes of respiratory disturbance decreased during the five nights under hypoxia. The HVR increased and resting PETCO2 decreased after five nights under hypoxia. CONCLUSIONS: The results suggest that five nights under hypoxia improves the sleep quality. This may be derived from improvements of respiratory disturbances, the minimum SpO2, and <90% SpO2 time.

Theta oscillation in the human anterior cingulate cortex during all-night sleep: an electrocorticographic study.

Ten epileptic patients each with subdural electrodes surgically attached to the anterior cingulate cortex (ACC; two cases), the orbitofrontal cortex (OFC; seven cases), or both (one case) were included in this study. We recorded each patient's ACC or OFC electrocorticogram (ECoG) during the time period that the patient was awake and naturally asleep. We performed a Fast Fourier Transformation (FFT) power spectral analysis on each ECoG to examine its frequency component. We found that the ACC showed regular and continuous theta oscillation (5-7Hz) during wakefulness and rapid eye movement (REM) sleep, but not during slow wave sleep. Theta waves observed in REM sleep were not as distinct as those found in wakefulness. We also discovered that the orbitofrontal signals represented spectral peaks in the theta band only during wakefulness. This suggests the coexistence of theta oscillation in the ACC. Considering our previous observations of gamma and beta oscillations in the human hippocampus, we hypothesize that the human limbic system manifests two oscillatory activities. The results obtained in this study suggest that electrophysiological activity in the ACC could be related to particular psychological functions in wakefulness and in REM sleep. These results are useful in elucidating the human brain mechanism.

Sleep spindles in human prefrontal cortex: an electrocorticographic study.

To investigate the sleep spindle activity of the human prefrontal cortex (PFC), we simultaneously recorded whole nights of polysomnographic and electrocorticographic (ECoG) activities during the natural sleep of epileptic patients. Subjects were nine patients with intractable epilepsy who had subdural electrodes surgically attached to the orbital (seven cases), medial (three cases), or dorsolateral (two cases) PFC, and in one case to the frontal pole. To examine spindle frequencies, fast Fourier transformation (FFT) and auto-correlation analyses were performed on the PFC ECoG and Cz EEG data, primarily on epochs of stage 2 sleep. Lower sigma band ECoG oscillations of about 12 Hz were widely distributed across all prefrontal cortical areas including the frontal limbic regions, but none of the PFC sigma frequency peaks coincided with the faster (about 14 Hz) Cz EEG sleep spindles. Combining our results with anatomical and electrophysiological facts, it is suggested that the thalamofrontal circuit involving the rostral reticular and the mediodorsal nucleus of the thalamus is responsible for the generation of 12 Hz frontal spindles in humans.

Delta and theta power spectra of night sleep EEG are higher in breast-feeding mothers than in non-pregnant women.

The power spectra of night sleep EEGs of 12 breast-feeding 9-13 week postpartum mothers were analyzed and compared with those of 12 non-pregnant women. The power spectra in the delta and theta frequency range during NREM sleep for breast-feeding mothers were significantly higher than those for non-pregnant women. In addition, the all-night sleep patterns of the mothers were classified into two groups - interrupted sleep due to taking care of their infants and non-interrupted sleep - in order to observe the influence of partial sleep deprivation. The power spectra in the delta and theta frequency range were not significantly different between them. This result suggests that increased delta and theta power spectra during postpartum sleep do not result from partial sleep deprivation. The role of prolactin in breast-feeding mothers' sleep is also discussed.

Cancer-associated retinopathy associated with invasive thymoma.

PURPOSE: To report a case of cancer-associated retinopathy associated with invasive thymoma. DESIGN: Interventional case report. METHOD: A 41-year-old Japanese woman was observed between February 1998 and May 2001. Ophthalmologic examinations and systemic examinations were performed. The patient received treatment including corticosteroid pulse therapy, plasmapheresis, and thymectomy. RESULTS: The patient developed progressive visual dysfunction including bilateral visual acuity loss, concentric contraction of visual fields, and color vision loss. In both eyes, retinal vessel attenuation and retinal pigment epithelium degeneration were observed with fundus ophthalmoscopy and fluorescein angiography. Response in electroretinogram was reduced, suggesting both rod and cone dysfunction. Autoantibody against 23-kD cancer-associated retinopathy (CAR) antigen (antirecoverin antibody) was detected in the patient's serum. A mediastinal tumor that was histopathologically diagnosed as invasive thymoma was detected and was surgically resected. During more than 3 years of follow-up, no other malignancy was detected despite extensive systemic evaluation. The patient also suffered from subclinical myasthenia gravis. Although temporary improvement of visual function was observed after treatment with steroid pulse therapy and plasmapheresis' light perception of each eye was lost in the end. CONCLUSIONS: The patient was diagnosed as having CAR. Invasive thymoma was considered to be the causative tumor because there had been no evidence that suggested other systemic malignancy during more than 3 years of follow-up.