Ipsilateral transient amaurosis, mydriasis and light reflex absence after subconjunctival local anesthesia with mepivacaine in three patients with refractory glaucoma - a case report.

BACKGROUND: The subconjunctival anesthesia with local anesthetics is considered as a low-risk procedure allowing ocular surgery without serious complications typical for retro- or parabulbar anesthesia, especially in patients with preexisting Optic Nerve damage. We report development of ipsilateral transient amaurosis accompanied with mydriasis and both, direct and consensual light response absence. CASE PRESENTATION: Three patients with advanced refractory glaucoma undergoing laser cyclophotocoagulation (CPC) for intraocular pressure lowering experienced these adverse effects just few minutes after subconjunctival injection of mepivacaine 2% solution (Scandicaine® 2%, without vasoconstrictor supplementation). The vision was completely recovered to usual values in up to 20 h after mepivacaine application. Extensive ophthalmological examination, including cranial magnetic resonance imaging (MRI), revealed no further ocular abnormalities, especially no vascular constriction or thrombotic signs as well as no retinal detachment. The oculomotor function remained intact. The blockade of ipsilateral ciliary ganglion parasympathetic fibers by mepivacaine may be the responsible mechanism. Systemic pathways as drug-drug interactions seem to be unlikely involved. Importantly, all three patients tolerated the same procedure previously or at a later date without any complication. Overall, our thoroughly elaborated risk management could not determine the causative factor explaining the observed ocular complications just in the current occasion and not at other time points. CONCLUSIONS: Doctors should be aware and patients should be informed about such rare complications after subconjunctival local anesthetics administration. Adequate risk management should insure patients' safety.

Maximum atropine dose without clinical signs or symptoms.

PURPOSE: Atropine 1% has been used to slow the progression of myopia; however, it has not gained worldwide clinical acceptance because it results in clinically significant pupillary mydriasis and accommodative paralysis. Lower concentrations of atropine (0.5 to 0.01%) have been reported to be associated with fewer symptoms, while still controlling myopia. It is the purpose of this study to find the highest concentration of atropine that does not result in significant symptoms from pupillary dilation and accommodative paralysis. METHODS: A 3 × 3 phase I clinical trial paradigm was used in 12 subjects, to determine the maximum dosage of atropine which could be prescribed without creating symptoms or clinical signs of insufficient accommodation or excessive pupillary dilation. Accommodation was measured by pushouts and pupillary dilation by photography. Prior to this study, we established the following criteria for comfort: 5D or more of residual amplitude of accommodation, less than or equal to a 3 mm pupillary difference between the eyes, and a report of minimal symptoms of near vision blur or outside photophobia. RESULTS: Our results indicate that atropine 0.02% is the highest concentration that did not result in clinical symptoms and findings associated with higher dosages. Mean pupillary dilation was 3 mm, and mean accommodative amplitude was 8 diopters with this concentration. Further, reduction of the concentration of atropine from 0.02 to 0.01% did not seem to result in a decrease in clinical signs or symptoms associated with atropine. CONCLUSIONS: Atropine 0.02% is the highest concentration that does not produce significant clinical symptoms from accommodation paresis or pupillary dilation. This would be an appropriate starting point in evaluating a low dosage of atropine to slow myopic progression.

Dilated and unreactive pupils and burst-suppression on electroencephalography due to buproprion overdose.

Burst-suppression pattern on electroencephalography (EEG) occurs upon dissociation of the cortex from underlying brain structures. Unless the pattern is a physiologic consequence of administered sedatives, this electroencephalographic pattern is indicative of a poor neurologic outcome and high mortality. We report a case of a 29-year-old female thought to be brain dead based on initial physical examination and EEG findings of burst-suppression, who was later found to have supratherapeutic serum levels of bupropion. This is the second documented case of burst-suppression pattern on EEG in a patient who overdosed on bupropion. We propose that burst-suppression in the setting of bupropion toxicity may revert with drug clearance.

Relationship between abnormal pupillary reactivity and the outcome of a psychotropic drug overdose.

OBJECTIVE: The association between abnormal pupil reactivity (abnormal) and the outcome among patients with psychotropic drug overdose (OD) was retrospectively investigated. METHODS: The study included patients that had experienced an OD between January and December 2007. The subjects were divided into 2 groups, namely, abnormal and normal groups. RESULTS: There were 12 subjects in the abnormal and 74 subjects in the normal group. Glasgow Coma Scale in the abnormal was significantly smaller that that in the normal group. An average quantity of ingested tranquilizer per subject in the abnormal was significantly larger that those in the normal group. However, the duration of admission and survival rates between the two groups were not significantly different. CONCLUSION: The patients that experienced an OD, who demonstrated abnormal pupil reactivity, tended to have ingested larger amounts of drugs while also demonstrating severe unconsciousness. However, the patients with abnormal pupil reactivity had a favorable outcome.

Bilateral dilated nonreactive pupils secondary to rocuronium infusion in an ARDS patient treated with ECMO therapy: A case report.

RATIONALE: Pupil monitoring for neurologic examination has become a regular clinical practice during extracorporeal membrane oxygenation (ECMO) therapy. Sudden dilation of pupils always indicates a severe cerebrovascular event. However, bilateral dilated nonreactive pupils secondary to neuromuscular blockade are uncommon and widely ignored in adult acute respiratory distress syndrome (ARDS) patients. This is the first case report of bilateral dilated nonreactive pupils caused by rocuronium in an ARDS patient receiving ECMO treatment. PATIENT CONCERNS: Bilateral dilated nonreactive pupils were found in an ARDS patient who received V-V ECMO therapy. However, CT angiography did not indicate the occurrence of a cerebrovascular event. Drugs that could potentially result in dilated nonreactive pupils were checked. DIAGNOSIS: Bilateral dilated nonreactive pupils were caused by rocuronium infusion. INTERVENTIONS: Rocuronium infusion was stopped. OUTCOMES: Bilateral dilated nonreactive pupils were resolved 20 h after rocuronium infusion was stopped. LESSONS: Neuromuscular blockade should be taken into consideration when bilateral dilated nonreactive pupils are found in ARDS patients treated with ECMO therapy.

The synthetic cannabinoid 5F-MDMB-PICA: A case series.

5F-MDMB-PICA has been detected in products sold on the internet as well as in biological samples since 2016. It is associated with serious adverse health and behavioral effects and even death. Herein we report on twelve cases with proven 5F-MDMB-PICA consumption, including three fatalities, four cases of driving under the influence of drugs and five other criminal acts. In these cases, 5F-MDMB-PICA was detected in postmortem blood or serum. Concentrations ranged from 0.1-16ng/mL. In some blood (serum) and urine samples, the hydrolysis metabolite of 5F-MDMB-PICA (M12) could also be detected. In this case series, co-consumption with other drugs occurred in 9 of 12 cases, most commonly alcohol, cannabis and other contemporary SCs. In five cases, 4F-MDMB-BINACA was also detected. The described cases demonstrate various adverse effects that might be associated with 5F-MDMB-PICA. Observed physical adverse effects were mainly balance deficiencies and ocular effects such as reddened conjunctivae, glassy eyes and delayed or unresponsive pupil light reactions. Observed mental and behavioral effects were mainly changing moods, aggression, confusion, erratic behavior, mental leaps, disorientation, slowed reaction, logorrhea and slurred speech. Due to the fast changing market of synthetic cannabinoids, data on such new appearing substances are basically scarce. Because of the limited number of studies on pharmacological properties of synthetic cannabinoids, reports of findings in human samples along with corresponding case history descriptions can be valuable for the interpretation of upcoming routine cases.

Compressive optic neuropathy secondary to an allergic reaction to hyaluronidase. / Neuropatía óptica compresiva secundaria a reacción alérgica a hialuronidasa.

A 58 year-old woman presented with severe chemosis and ophthalmoparesis on her left eye 8hours after uncomplicated cataract surgery under sub-tenon anaesthesia. Recovery of extrinsic motility was observed after corticosteroid and antihistamine treatment, but a non-haemorrhagic papillary oedema and a concentric defect of visual field were found. It progressed to papillary atrophy with preserved central vision, but with a significant visual field constriction. The aetiological study revealed an allergy to hyaluronidase that was used as adjuvant to the anaesthesia. This complication needs to be promptly diagnosed and treated, as the swelling of the orbital tissues can cause damage to the optic nerve.

Teenagers with Jimson weed (Datura stramonium) poisoning.

We report 2 cases of teenagers who were poisoned with Jimson weed (Datura stramonium) and presented to the emergency department with a severe acute anticholinergic toxidrome after ingestion of several hundred seeds. The patients presented with visual hallucinations, disorientation, incomprehensible and nonsensical speech, and dilated sluggish pupils. Both patients required restraints for combativeness until adequate sedation with lorazepam and haloperidol was achieved. Jimson weed is found in southern Canada and the United States and can cause acute anticholinergic poisoning and death in humans and animals. The treatment of choice for anticholinergic poisoning is mainly supportive care and gastrointestinal decontamination with activated charcoal. Jimson weed intoxication should be considered in cases of patients presenting with unexplained peripheral and central anticholinergic symptoms including delirium, agitation and seizures, especially among younger patients and partygoers. It is important that health care professionals recognize that Jimson weed is a toxic, indigenous, "wild" growing plant, subject to misuse and potentially serious intoxication requiring hospitalization.

Outbreak of toxic anterior segment syndrome associated with glutaraldehyde after cataract surgery.

PURPOSE: To present clinical findings of a cluster of cases of toxic anterior segment syndrome (TASS) after uneventful phacoemulsification cataract surgery. SETTING: Department of Ophthalmology, Akdeniz University, Antalya, Turkey. METHODS: Six eyes of 6 patients developed TASS after uneventful phacoemulsification cataract surgery with implantation of a 3-piece acrylic IOL performed by 2 ophthalmologists on the same day. Clinical findings included corneal edema, Descemet's membrane folds, anterior chamber reaction, fibrin formation, and irregular, dilated, and unreactive pupils. RESULTS: Glutaraldehyde 2% solution was used inadvertently by the operating room staff who cleaned and sterilized reusable ocular instruments before autoclaving. None of the affected corneas improved. Additional surgical procedures were required and included penetrating keratoplasty, trabeculectomy, and glaucoma tube implantation. CONCLUSIONS: Glutaraldehyde in concentrations generally used for cold sterilization is highly toxic to the corneal endothelium. The operating room staff involved in sterilizing instruments should be well educated about and careful to follow the protocols to properly clean and sterilize reusable ocular instruments.

Unilateral fixed dilated pupil in a ventilated child with asthma.

An 11-year-old boy known to have asthma was referred to our intensive care unit (ICU) with progressive respiratory distress. He was sedated, paralysed, and intubated approximately 3 hours after arrival and nebulization with salbutamol and ipratropium was continued on the ventilator. About 16 hours later, he presented with transient unilateral fixed dilated pupils which resolved spontaneously without any neurological deficit. Computerized tomography scan revealed no signs of generalized cerebral oedema. Local contamination with ipratropium was most likely to be the cause of pupil dilatation, which could have occurred during connecting and disconnecting the nebulization system or through contaminated hands.

[Impairment of safety in navigation caused by alcohol: pupillography and measurement of pupil movements]. / Beeinträchtigung der Sicherheit im Schiffsverkehr durch Alkohol. Pupillographie und Augenbewegungsmessungen.

OBJECTIVE: To evaluate data in an interdisciplinary project (ophthalmology, forensic medicine, internal medicine, psychology,and nautical science) in order to identify critical blood alcohol limits in sea navigation. METHODS: A sea traffic simulator was employed for realistic nautical demands on 21 professional experienced skippers under sober and alcoholized conditions (target blood alcohol concentration: 1.0 per thousand ). After simulated navigation, pupil light reflex, spontaneous pupil movements,nystagmus,and saccades were evaluated by pupillography. Modification of the pupillograph enabled us also to measure optokinetic nystagmus. RESULTS: Evaluation of the pupil light reflex revealed obvious changes in the extent of relative contraction and in redilatation time under the influence of alcohol. Diminished vigilance could be observed in all of the skippers when optokinetic nystagmus was tested. CONCLUSION: The pupillograph represents a suitable device for measuring functions of the visual and vegetative systems. Thus, the impact of these functions on nautical capability can be demonstrated. If further investigations such as ophthalmological, medical, psychological, and nautical evaluations are taken into account, it could be determined that blood alcohol levels of 1.0 per thousand may exclude safe navigation.

Angle closure glaucoma following pupillary block in an aphakic perfluoropropane gas-filled eye.

We report the case of a 35-year-old aphakic patient who developed an intractable secondary glaucoma due to angle closure after pupillary block following the use of perfluoropropane (C3F8) gas at a nonexpansile concentration of 14%.

Purtscher-like retinopathy after retrobulbar injection.

Purtscher-like retinopathy occurred in a 46-year-old Chinese male who received 5 mL of 2% lignocaine, retrobulbar injection, and underwent pterygium excision with conjunctiva graft. The visual acuity improved spontaneously from 20/120 on the first postoperative day to 20/20 within 8 weeks. The disc swelling, veinous tortuosity, retinal whitening, and hemorrhage resolved with time. However, relative afferent papillary defect and an arcuate visual field deficit persisted. The mechanisms of this Purtscher-like retinopathy are postulated.

Quantitative analysis of changes of automated perimetric thresholds after pupillary dilation and induced myopia in normal subjects.

We quantitatively analyzed the changes of the (retinal) threshold sensitivities between normal status and dilated emmetropic status, and between dilated emmetropic status and -1.0D induced myopic status. Three consecutive visual field examinations by Humphrey Field Analyzer C-30-2 threshold test and STATPAC program were performed in 36 eyes of 21 normal subjects who ranged in age from 23 to 40 years. The results were as follows: 1) There was a statistically significant decrease (0.87 +/- 0.91dB)in the mean threshold sensitivity within the central 30 degrees at the dilated emmetropic status (27.90dB) as compared with the normal status (28.77dB)(p = 0.0001). 2) There was a statistically significant decrease(0.99 +/- 0.61dB) at -1.0D induced myopic status(26.91dB) as compared with the dilated emmetropic status(27.90dB)(p = 0.0001). 3) After dilation, the mean threshold sensitivity between 20 and 30 degrees of field showed statistically significant decrease as compared with those within the central 20 degrees of visual field(p < 0.05). In case of -1.0D induced myopia, there were uniform decreases in the mean threshold sensitivities within the central 30 degrees of visual field (p > 0.05). Therefore, we emphasize the importance of consistent pupillary size and correct refractive state in performing the serial automated visual field tests.

An ENU-induced mutation of Nrg1 causes dilated pupils and a reduction in muscarinic receptors in the sphincter pupillae.

BACKGROUND: N-ethyl-N-nitrosourea (ENU)-induced mutagenesis is a powerful tool for the study of gene function and the generation of human disease models. A large number of mouse mutants obtained by ENU-induced mutagenesis with a variety of phenotypes have been recovered. However, after genetic confirmation testing, only approximately 50% of the abnormal phenotypes were found to be heritable. METHODOLOGY/PRINCIPAL FINDINGS: A mouse mutant, Dp1, with a dilated pupil phenotype was induced with an N-ethyl-N-nitrosourea (ENU) mutagenesis strategy. Sequence analysis for Nrg1 reveals a G>A base substitution that flanks exon E59, encoding for an EGFß domain, in the 5' splice donor site. The mutation affects but does not abolish the splicing of EGFß-type Nrg1 mRNA in Dp1 mice and produces several different transcripts by activating other, cryptic splice sites. These types of protein isoforms are expected, and the result shows that, in the mutant, the effect is a decrease in but not an elimination of the high affinity EGFß-type Nrg1 isoforms. This is partially compensated for by an increase in expression of the low affinity alpha forms or inactive proteins, suggesting that the mutation results in a hypomorphic allele. Interestingly, genetic model testing shows that Dp1 is a mutation that results in a dilated pupil phenotype that is inherited with very low penetrance when heterozygous and with complete penetrance when homozygous. Pharmacological and immunohistochemical tests show a reduction of muscarinic (M) receptors in the sphincter pupillae of Dp1 mice, which is a major cause of dilated pupils. CONCLUSIONS/SIGNIFICANCE: This study is the first report of an Nrg1 mutation being associated with a dilated pupil phenotype and the reduction of M receptors. This report may help in establishing more mutant mouse lines and models of human genetic disease and can be applied to other organisms. Dp1 mice are a valuable resource for the further clarification of Nrg1 biological function.

Reflejo pupilar mesópico en pacientes tratados con fluoxetina / Mesopic pupillary reflex in patients treated with fluoxetine

INTRODUCCIÓN: Actualmente el tratamiento de enfermedades mentales mediante antidepresivos es muy frecuente. Los inhibidores selectivos de la recaptación de serotonina son los antidepresivos más prescritos a nivel mundial y han sido asociados con alteraciones en la acomodación o la pupila. El objetivo de este estudio es evaluar los efectos de la fluoxetina sobre el reflejo pupilar y la acomodación en población joven. METODOLOGÍA: El grupo de estudio contó con siete pacientes diagnosticados de depresión y tratados con fluoxetina; como grupo control se incluyeron 22 sujetos. Se evaluaron los reflejos pupilares y el estado acomodativo mediante el pupilómetro Power Refractor II. Se midieron 5 fases de 3 segundos cada una. En la fase 2 se produjo un deslumbramiento con una luz blanca. RESULTADOS: Para el diámetro pupilar se han obtenido valores máximos y mínimos mayores en el grupo de pacientes tratados con fluoxetina que en el control en todas las fases de medida. Para el grupo control se observa una contracción pupilar máxima en la fase de deslumbramiento, sin embargo, en el grupo de estudio se observa en la fase tras el deslumbramiento. En cuanto a la acomodación no se obtuvieron diferencias significativas entre ambos grupos. CONCLUSIONES: En pacientes tratados con fluoxetina existen alteraciones pupilares observándose diámetros pupilares mayores y menor velocidad de contracción pupilar. La falta de resultados concluyentes en cuanto a la acomodación no significa que no existan cambios relacionados con esta, cuya detección requerirá de futuros estudios utilizando diferentes metodologías y con un tamaño muestral mayor

INTRODUCTION: currently the treatment of mental illness by antidepressants is very frequent. Selective serotonin re-uptake inhibitors are the most prescribed antidepressants worldwide and have been associated with alterations in accommodation or pupil. The objective of this study is to evaluate the effects of fluoxetine on the pupillary reflex and the accommodation in young population. METHODOLOGY: The study group included seven patients diagnosed with depression and treated with fluoxetine; 22 subjects were included as a control group. The pupillary reflexes and the accommodative state were evaluated using the Power Refractor II pupilometer. Five phases of 3 seconds each were measured. In phase 2 there was a glare with a white light. RESULTS: For the pupil diameter, maximum and minimum values were obtained in the group of patients treated with fluoxetine than in the control in all the measurement phases. For the control group, a maximum pupillary contraction is observed in the glare phase, however, in the study group it is observed in the phase after glare. As for the accommodation, there are no significant differences between the two groups. CONCLUSIONS: In patients treated with fluoxetine there are pupillary alterations like a bigger pupillary diameters and slower pupillary contraction. The lack of conclusive results in terms of accommodation does not mean that there are no changes related to it, whose detection requires future studies with different methodologies and with a larger sample size