Mydriasis Research Articles

Case report: Satralizumab as an adjunctive therapy for AQP-4 antibody and MOG antibody dual-negative optic neuritis in a third-trimester pregnancy case

The treatment of demyelinating optic neuritis (DON) in pregnant patients is challenging, especially when there is poor or no response to intravenous methylprednisolone pulse (IVMP) therapy or adjunctive treatments such as intravenous immunoglobulin (IVIG) therapy. We herein report a case of a 28-year-old pregnant woman who experienced sequential severe vision loss in both eyes. She presented to a local hospital with the main complaint of sudden, painless vision loss in the left eye and was diagnosed with DON in the left eye. However, she did not receive orbital MRI or IVMP therapy due to safety concerns. Upon admission to our hospital, her visual acuity was 20/30 in the right eye and there was no light perception in the left eye. Her right eye vision deteriorated rapidly, declining to 20/1,000 one day after the admission. The ophthalmic examination revealed a normal anterior segment and a swollen optic disk in the right eye and a dilated pupil with a relative afferent pupillary defect and a swollen optic disk in the left eye. The serological tests for common pathogens, including the aquaporin-4 antibody (AQP-4 Ab), myelin oligodendrocyte glycoprotein antibody (MOG-Ab), and other common autoantibodies, were all negative. The patient was clinically diagnosed with DON in both eyes and received 7 days of IVMP therapy and 4 days of IVIG therapy, but showed no visual improvement. A three-dose regimen of satralizumab 120 mg was then administered subcutaneously during the acute stage of DON, in combination with a slowly tapered oral methylprednisolone regimen. Moreover, 2 months after the first injection of satralizumab, the patient naturally gave birth to a healthy female infant weighing 2,305 g at 36 weeks and 1 day of gestation. Her visual acuity improved to 20/500 in both eyes and slightly increased to 20/320 in both eyes 2 months later. Her visual acuity remained stable during subsequent follow-up visits. The infant was fed formula milk powder and developed normally. No systemic or ocular side effects related to satralizumab therapy were observed in the patient or her fetus during the 9-month follow-up. Our findings in this case suggest that satralizumab may be a safe and efficient adjunctive therapy for pregnant patients with DON who poorly respond to IVMP and IVIG therapy, even in cases of dual-negative AQP-4 Ab and MOG-Ab.

Datura stramonium seed ingestion leading to unintentional poisoning in a 3-year-old Ethiopian toddler: case report

IntroductionDatura stramonium poisoning, resulting from the ingestion of seeds, leaves, or flowers of Datura stramonium, is a severe condition with significant risks, particularly for young children. Most documented cases of Datura stramonium poisoning in the literature involve teenagers who intentionally ingest the plant to induce hallucinogenic and euphoric experiences. This report presents a rare instance of unintentional Datura stramonium poisoning in a 3year-old Ethiopian toddler.Case presentationHe presented with symptoms consistent with anticholinergic toxidrome, including altered mental status, agitation, seizures, dilated pupils, and tachycardia. Laboratory tests, including complete blood count, liver function test, renal function test, electrolyte levels and cerebrospinal fluid analysis were normal. Results of blood toxicology screen were negative. Timely recognition and supportive care lead to a positive outcome.ConclusionThrough this report, we aim to add to the limited body of literature on Datura stramonium poisoning in toddlers and offer insights into its clinical course and management in paediatric patients.

Hyoscyamus niger poisoning in Sudan: A case report.

Hyoscyamus niger, commonly known as henbane, contains potent alkaloids that can cause anticholinergic toxicity when ingested. This case report describes a 35-year-old male gardener who presented with confusion, hallucinations, dry mouth, and dilated pupils after consuming parts of the plant. The patient was treated with rehydration, activated charcoal, and physostigmine, leading to rapid clinical improvement. This case highlights the importance of recognizing plant-based poisonings and the efficacy of physostigmine in managing anticholinergic syndrome. Public awareness and education on the dangers of unfamiliar plants are essential to prevent accidental ingestions.

Vision at high latitudes: High sensitivity without specific boreal adaptations in photoreception in reindeer (Rangifer tarandus L.)

Abstract The light climate at high latitudes, in particular the extended twilight of winter and the reduced diel variation in light level in midsummer and midwinter, potentially constrains visual function and the synchronisation of temporal organisation in polar species. In this paper, we describe the temporal pattern and variation in the spectral composition and brightness of skylight (daylight, twilight, moonlight, starlight, airglow and aurorae) at high latitudes and review photoreception of reindeer/caribou (Rangifer tarandus; ‘Rangifer’) which is one of the few polar resident species for which data are available. Experimental data indicate that the rods of Rangifer may be stimulated by levels of ambient light lower than those occurring during astronomical twilight (solar angle <−18°). Several features of the eyes of Rangifer contribute to their visual capability under extended twilight. These include transmission of UV through the optical media, which enables the animals to exploit the shorter wavelengths characteristic of twilight, and a shift in the peak spectral reflectance of the tapetum lucidum (TL) from around 640 nm in summer to around 450 nm in winter, which increases retinal illumination at short wavelengths. Enhanced sensitivity to short wavelengths is likely to enhance the contrast of some objects and hence the ability of Rangifer to discriminate forage plants and to detect other animals (conspecifics or predators) against a snowy background under low illuminance. There is, nevertheless, currently no evidence of any specific boreal adaptation in their visual system: (i) The eyes of Rangifer, and by inference the area of the dilated pupil, are no larger than expected based on the allometry of eye size in ruminants. (ii) There is no evidence of a change in the spectral sensitivity of photoreceptors associated with detection of UVa. (iii) Transmission of UV through the anterior eye is not unique to Rangifer. (iv) The blue shift in the reflectance of the winter TL appears to be a passive response to prolonged dilation of the pupil and there is no a priori reason not to predict the same response in other large ungulates exposed to low light levels. (v) There is no conclusive evidence of a seasonal shift in absolute retinal sensitivity in Rangifer. (vi) Weak circadian organisation in Rangifer has tentatively been linked to mutations within the circadian molecular clockwork but it remains unclear to what extent this represents a specific adaptation to high latitude. Read the free Plain Language Summary for this article on the Journal blog.

Drug Addiction Clinical Study Among Patients Admitted to the Alqana Center for Social Rehabilitation

Background: Drug addiction is a worldwide issue; 5.6% of the world's population aged 15 to 64 took drugs at least once in 2016. For the majority of medicines, younger individuals use them more than older people do. Drug abuse seems to be on the increase in several ASEAN (Association of Southeast Asian Nations) countries, particularly among young men aged 15 to 30. Illicit drug abuse account for around 14% of the overall health burden among young males. Younger individuals are also more prone to die from drug abuse issues. Aims of study is to assess the severity of problems related to drug addiction. in Baghdad city and to study epidemiological features of drug addiction among Patients Admitted to the Alqana Center for Social Rehabilitation. Patients and methods: An analytical cross-sectional study of 300 individuals diagnosed as a drug addiction patient according to the criteria established by the "Diagnostic and Statistical Manual of Mental Disorders", Fifth Edition, text revision, often called the DSM-V-TR or DSM-5-TR. From the medical department at Alqana Center for Social Rehabilitation in Baghdad. The research was carried out from 25/December/2023 to 30/June/2024. Results: the demographic characteristics of the study sample. In with a mean and a standard deviation (SD) of age of 29.33±18.68. Individuals aged 20-29 year had the highest proportion to addiction, with a rate of 42.7%. Conversely, 89.3% of the participants were male. The majority,86.7%, live in urban regions. The majority of patients had 51.7% unmarried, with only 36.0% being married and 12.3% was divorced. The main rate among drug addiction patients was 38.7% primary education ,33.0% secondary education, and 16.0% was illiterate patient, while lowest patient 12.3% at collage. According to the statistics in the table,76.3% of the participants were free business. 95.0% cigarette smoker. presented the result of psychological symptoms as show 93.0% of study addictive patient have mood swings, and in the same table the behavioral and social symptoms showed as 97.0% of study patient had poor performance and/or attendance at work or school. Also, physical symptoms of addiction showed as 74.7% of patient suffering from disrupted sleep patterns, including insomnia Regarding to the withdrawal symptoms of drug addiction presented in Table (3), results showed as 95.7% fatigue, 85.3% muscle pain or aches, 81.0% irritability and agitation, 76.0% trembling and tremors, 69.3% hunger, 50.7% anxiety, 36.7% sweating, 30.7% insomnia, 25.3% loss of appetite, 22.7% depression, 20.7% confusion, 22.3% nausea, 9.3% seizures, 8.0% dilated pupils, 3.3% vomiting, and 2.3% paranoia. Conclusion: the majority of addicted patient was male. the main symptoms were Poor performance and/or attendance at work or school and mood swing. The highly complication was fatigue. Regarding the way of addiction, the tablets is vast majority and enjoyment is the most common cause of addiction. Recommendations: It's possible that other important differences between the factors seen in this study would become clearer if multicenter study, the sample size was larger and the duration of the addiction study had been longer.

Prevalence of Age-related Macular Degeneration among Elderly Bulgarian Population

Age-related macular degeneration (AMD) is the leading cause of blindness worldwide in an older patient population with the highest risk of disease development in individuals older than 65 years. This study aims to estimate the prevalence of AMD and its stages among the elderly population of Sofia city. An observational study among elderly Sofia citizens, held as prophylactic ophthalmological examinations was performed. The participants underwent full ophthalmic examination including autorefractometry, noncontact tonometry, best-corrected visual acuity measurement, biomicroscopy, and indirect ophthalmoscopy through a dilated pupil. Optical coherent tomography was performed in cases with difficulties to determine the stage of AMD or when the visual acuity did not correspond to the ophthalmoscopy findings. All participants were asked to fill in informed consent and a specifically structured questionnaire based on the modified Wolffson LVQOL questionnaire that was previously used in the study in Eastern Bulgaria (in 2014 by Nencheva). Overall 700 patients, with a median age of 74 years (69 to 96 years) met the inclusion criteria and were enrolled in the study. The prevalence of AMD, early, intermediate and late AMD was estimated as 26.1%, 14%, 6.6%, and 5.6%, respectively. Age was strongly associated with the prevalence of AMD and its stages. The ageing of the population in Bulgaria and worldwide and the large proportion of elderly persons, affected by AMD, emphasize the necessity of regular ophthalmological examinations of that part of the population. The timely diagnosis and treatment are very important for diminishing of blindness and visual impairment.

Description of a new method to calculate the equator of the crystalline lens using AS-OCT images: Accuracy in non-dilated measurements.

To establish a methodology for objectively estimating the Lens Equatorial Plane (LEP) from clinical images, comparing LEP with dilated versus non-dilated pupils. A cohort of 91 eyes from 60 patients undergoing preoperative assessments for cataract surgery was evaluated. Anterior Segment Optical Coherence Tomography (AS-OCT) images were analysed under conditions of pharmacologically induced pupil dilation versus a non-dilated pupil. Geometrical parameters, including LEP, intersection diameter (ID), lens thickness (LT), anterior and posterior lens thickness were automatically calculated by applying standard image processing techniques to clinical AS-OCT images. Significant differences in lens parameters, including LEP, were observed between dilated and non-dilated conditions (all p < 0.001). A strong linear correlation was found across all geometrical variables under both conditions (r[LEP] = 0.64, r[ID] = 0.78, r[LT] = 0.99, all p < 0.001); enabling reliable correction of these differences. The study introduces an objective methodology for LEP calculation, emphasising the need to consider the eye's physiological state during preoperative measurements. Incorporating LEP into future intraocular lens (IOL) power calculation formulas and replacing the habitual effective lens position may potentially improve the accuracy of IOL power estimation and thus postoperative visual outcomes.

Ophthalmic effects of Bitis atropos (Berg Adder) envenomation

Objective: Bitis atropos, commonly known as the Berg Adder, is a venomous viperid found in Southern Africa. Envenomation is rare, with reported cases primarily exhibiting cytotoxic, neurotoxic, and myotoxic effects, including severe systemic manifestations and ophthalmologic complications such as ptosis, mydriasis, and loss of accommodation. However, the underlying pathophysiology of these sequelae remains poorly understood. Case: We present the case of a 26-year-old male who suffered severe envenomation by a Berg Adder in the Limpopo Province, South Africa. Within minutes of the bite, the patient experienced hypoesthesia, progressive dyspnea, and loss of consciousness, followed by prolonged intensive care management. Ophthalmic examination revealed bilateral dilated pupils, right ptosis, and impaired accommodation, alongside generalized muscle weakness, anosmia, ageusia, and dysphagia. Despite the absence of antivenom, the patient’s condition showed gradual improvement over a 127-day follow-up period. Notably, the pupils exhibited denervation supersensitivity, similar to Adie’s tonic pupil, and responded well to low-dose pilocarpine. Conclusion: The clinical features observed, particularly the ophthalmoplegic triad, can be attributed to the effects of phospholipase A2 proteins in the venom, which disrupt cholinergic transmission at muscarinic receptors. This case underscores the complexity of Berg Adder envenomation and highlights the variability in recovery timelines for different neuro-ophthalmic effects. This case provides valuable insights into the pathophysiology and management of severe Berg Adder envenomation, emphasizing the role of targeted therapeutic interventions such as pilocarpine in mitigating long-term sequelae.

Pupil dilation reflects the social and motion content of faces.

Human facial features (eyes, nose, and mouth) allow us to communicate with others. Observing faces triggers physiological responses, including pupil dilation. Still, the relative influence of social and motion content of a visual stimulus on pupillary reactivity has never been elucidated. A total of 30 adults aged 18-33 years old were recorded with an eye tracker. We analysed the event-related pupil dilation in response to stimuli distributed along a gradient of social salience (non-social to social, going from objects to avatars to real faces) and dynamism (static to micro- to macro-motion). Pupil dilation was larger in response to social (faces and avatars) compared to non-social stimuli (objects), with surprisingly a larger response for avatars. Pupil dilation was also larger in response to macro-motion compared to static. After quantifying each stimulus' real quantity of motion, we found that the higher the quantity of motion, the larger the pupil dilated. However, the slope of this relationship was not higher for social stimuli. Overall, pupil dilation was more sensitive to the real quantity of motion than to the social component of motion, highlighting the relevance of ecological stimulations. Physiological response to faces results from specific contributions of both motion and social processing.

Pupil-Linked Arousal Modulates Precision of Stimulus Representation in Cortex.

Neural responses are naturally variable from one moment to the next, even when the stimulus is held constant. What factors might underlie this variability in neural population activity? We hypothesized that spontaneous fluctuations in cortical stimulus representations are created by changes in arousal state. We tested the hypothesis using a combination of fMRI, probabilistic decoding methods, and pupillometry. Human participants (20 female, 12 male) were presented with gratings of random orientation. Shortly after viewing the grating, participants reported its orientation and gave their level of confidence in this judgment. Using a probabilistic fMRI decoding technique, we quantified the precision of the stimulus representation in the visual cortex on a trial-by-trial basis. Pupil size was recorded and analyzed to index the observer's arousal state. We found that the precision of the cortical stimulus representation, reported confidence, and variability in the behavioral orientation judgments varied from trial to trial. Interestingly, these trial-by-trial changes in cortical and behavioral precision and confidence were linked to pupil size and its temporal rate of change. Specifically, when the cortical stimulus representation was more precise, the pupil dilated more strongly prior to stimulus onset and remained larger during stimulus presentation. Similarly, stronger pupil dilation during stimulus presentation was associated with higher levels of subjective confidence, a secondary measure of sensory precision, as well as improved behavioral performance. Taken together, our findings support the hypothesis that spontaneous fluctuations in arousal state modulate the fidelity of the stimulus representation in the human visual cortex, with clear consequences for behavior.

Bilateral mydriasis as the first manifestation of Miller Fisher syndrome

Miller Fisher Syndrome (MFS) is a rare variant of Guillain-Barré Syndrome (GBS), characterised by a unique clinical triad of ophthalmoplegia, ataxia, and areflexia. MFS, which was first described in 1956 by Charles Miller Fisher , is frequently preceded by an infection, usually respiratory or gastrointestinal, and is believed to be triggered by an autoimmune reaction targeting peripheral nervous system components. However the MFS is further categorised into incomplete forms which can be present without the classical triad, such as acute ophthalmoparesis, acute ataxic neuropathy, acute ptosis and acute mydriasis. We report a case of a 50-year-old man presenting with dilated and unresponsive pupils, which progressed rapidly to ophthalmoplegia, ataxia, and areflexia. Given the clinical history supported by the cyto-protein dissociation in cerebrospinal fluid, the patient was diagnosed to have MFS and successfully treated with intravenous immunoglobulin. This case underscores the importance of recognising atypical features of MFS, such as primary mydriasis, and highlights the variable clinical spectrum within the syndrome. Clinicians should maintain a high index of suspicion for MFS, particularly when faced with unusual neurological presentations, to ensure timely intervention and optimal patient outcomes.

The bigger your pupils, the better my comprehension: an ERP study of how pupil size and gaze of the speaker affect syntactic processing.

Gaze direction and pupil dilation play a critical role in communication and social interaction due to their ability to redirect and capture our attention and their relevance for emotional information. The present study aimed to explore whether the pupil size and gaze direction of the speaker affect language comprehension. Participants listened to sentences that could be correct or contain a syntactic anomaly, while the static face of a speaker was manipulated in terms of gaze direction (direct, averted) and pupil size (mydriasis, miosis). Left anterior negativity (LAN) and P600 linguistic event-related potential components were observed in response to syntactic anomalies across all conditions. The speaker's gaze did not impact syntactic comprehension. However, the amplitude of the LAN component for mydriasis (dilated pupil) was larger than for miosis (constricted pupil) condition. Larger pupils are generally associated with care, trust, interest, and attention, which might facilitate syntactic processing at early automatic stages. The result also supports the permeable and context-dependent nature of syntax. Previous studies also support an automatic nature of syntax (fast and efficient), which combined with the permeability to relevant sources of communicative information, such as pupil size and emotions, is highly adaptive for language comprehension and social interaction.

Epidural Blood Patch in Subdural Hematoma Due to Spontaneous Intracranial Hypotention: A Case Report and Literature Review

Spontaneous intracranial hypotension (SIH) is an orthostatic headache syndrome with variable symptoms and complications which is often misdiagnosed at initial manifestations. SIH results from spontaneous CSF leakage leading to brain sag. The typical findings on cranial MR imaging consist of subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperemia, and sagging of the brain. Subdural hematoma may occur as a result of tearing of bridging veins and usually develop into chronic subdural hematoma. The majority of patients with SDH due to SIH have chronic DSH and, therefore, rarely present with neurological deficits. Evacuation of SDH may be performed for large SDH with ME (mass effects), or when dilated or asymmetric pupil is present. However in most cases, evacuation of the hematoma is not necessary and may result in worsened outcomes. The epidural blood patch (EBP) is a treatment of choice. Fortunately, most of these subdural hematomas can be handled with treatment directed at the underlying spinal CSF leak without the need for surgery. We report the case of 42-year-old man with the chief complaint of orthostatic headache. He was admitted to neurology ward and after imaging studies, it was found that he has bilateral subdural hematoma. Due to the lack of history of trauma, underlying disease, and coagulation disorder, and considering the imaging findings, the patient was referred to the pain department to perform an epidural blood patch. After performing the epidural blood patch, the patient's pain was relieved immediately, and during a three-month follow-up period, the epidural hematoma was completely absorbed. Spontaneous intracranial hypotension (SIH) is a highly misdiagnosed and underdiagnosed disorder and requires a high index of suspicion for diagnosis. During the last decades, a much larger number of spontaneous cases are identified. Literature is a bit confusing, with some authors recommending evacuation of subdural fluid in cases of deteriorating consciousness and few others recommending EBP first even in patients with comatose state but epidural patch is often an important part of treatment.

Surgical approach to and morphology of visually significant persistent pupillary membranes.

To characterize the morphology of persistent pupillary membranes (PPMs) in pediatric patients and explore the corresponding surgical approaches. Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China. Prospective observational study. Consecutive pediatric patients with PPMs who underwent surgery from April 2020 to July 2022 were included. PPM morphology was assessed and categorized according to its anatomic relationship with crystalline lens and distribution of iris strands. The surgical approaches for different morphologies of PPMs were described in detail. The visual outcome and operation-related complications were recorded. 31 eyes from 19 patients were included with the mean age of 7.2 years. 3 morphological variants of PPMs were observed: type I (51.6%, 16/31), a spider-like appearance and no adhesion to the anterior lens capsule (ALC); type II (38.7%, 12/31), a loose central adherence to the ALC and partially thick iris strands attached to the iris collarette; type III (9.7%, 3/31), a tight central adherence to the ALC and only silk-like iris strands. Surgeries were performed with a natural pupil size in type I, while dilated pupil in the other types. The adhesions between PPM and the ALC were separated by viscoelastic injection in type II and by discission needles in type III. The corrected distance visual acuity was significantly improved from 0.34 ± 0.18 logMAR preoperatively to 0.17 ± 0.09 logMAR postoperatively ( P < .001). No operation-related complications were observed during 9.5-month follow-up. PPMs were categorized into 3 types according to their different morphologies, which helped to determine the best surgical strategy.

Intraoperative trypan blue central landmark and its use in capsulotomy and capsulorhexis centration.

To compare 3 capsulotomy centration methods. Private clinic, Zlin, Czech Republic. Prospective, consecutive case series. 180 eyes undergoing cataract surgery had anterior capsule staining with microfiltered 0.4% trypan blue solution before selective laser capsulotomy. The first 60 eyes (Group 1) had mydriatic dilated pupil centered capsulotomies. The next 60 eyes (Group 2) were centered on the trypan blue central landmark (TCL). The final 60 capsulotomies (Group 3) were centered on the patient fixated coaxial Purkinje reflex (CPR). Measurements between key anatomical landmarks and the TCL, CPR capsulotomies, and implanted intraocular lens (IOL) center were made. The TCL, observed in >94% of eyes in the study, coincided with the CPR with a displacement of <0.1 ± 0.1 mm. Group 1 capsulotomies were noticeably decentered on the IOLs by 0.3 ± 0.2 mm. The Group 2 symmetrical IOL relationship was maintained with a decentration of 0.15 ± 0.1 mm. Group 3 had a similar decentration with the IOLs with 0.15 ± 0.1 mm. Verification with IOLMaster 700 data and CALLISTO Eye System showed that the CPR and the TCL were coincident with the measured visual axis. The clearly visible TCL served as an alternate landmark to the patient fixated CPR, and being on the anterior capsule was not sensitive to tilt. Further patient compliance was not required. Both were superior to dilated pupil centration, to achieve symmetric IOL coverage. This has application for both capsulotomies and capsulorhexes.

Long-term results of anterior chamber iris claw intraocular lens implantation in children with ectopia lentis in Marfan syndrome

PurposeTo report the long-term clinical and endothelial cell count (ECC) results of lensectomy with primary anterior chamber iris claw lens implantation in the eyes of patients ≤18-year-old with ectopia lentis due to Marfan syndrome. MethodsThe medical records of Marfan patients operated on at a single institution from September 2007 to August 2020, with minimum follow-up of 2 years, were reviewed retrospectively. The following data were analyzed: sex, age at surgery, indication for surgery, the position of the lens in relation to the undilated and dilated pupil, corneal endothelial cell counts (ECC), peri- and postoperative complications, pre- and postoperative best-corrected visual acuity. ResultsA total of Forty-two eyes of 23 patients (12 girls and 11 boys) were included. At least two or more postoperative ECCs were collected from 33 eyes (17 patients). Median age at IOL implantation was 6.1 years (range, 1.8-18). Median overall follow-up time was 6.2 years (range, 2-13.5). Median ECC follow-up time was 6.2 years (range, 2-10). Mean best-corrected visual acuity was 0.71 ± 0.38 logMAR before surgery and 0.02 ± 0.25 logMAR at final follow-up. The mean annual ECC decline was 0.71% ± 2.24. Total cell loss from first to last postoperative measurement was 150 cells ± 394 cells/mm2 (4.81%). Pre- and first postoperative data were available for 17 eyes of 10 patients, with a mean cell loss before and directly after surgery of 269 ± 268 cells (7.94%). Surgery related complications were iris bombé due to blockage of peripheral iridectomy in 3 eyes and claw dislocation due to direct impact trauma in 3 eyes. ConclusionsIn our large, pediatric study cohort, anterior chamber iris claw IOL implantation resulted in an excellent visual outcome and normal endothelial cell loss compared with normative data. Safety measures are recommended to avoid traumatic dislocation of IOLs.

Isolated ectopia lentis with partial anterior dislocation and pupillary block: a case report

BackgroundEctopia lentis is the dislocation of the natural crystalline lens and usually presents in the setting of trauma or other systemic diseases. Herein, we describe a case of an otherwise healthy four-year-old boy with isolated ectopia lentis whose partial lens dislocation was captured on a smartphone by the patient’s father several days prior.Case presentationA four-year-old boy with no past medical, developmental, or trauma history presented with bilateral partial anterior lens dislocation with pupillary block. Initial ophthalmic evaluation two months prior was notable for uncorrected visual acuity at 20/100 OD, 20/250 OS, bilateral iridodenesis, and partially dislocated lenses inferonasally OD and inferiorly OS on slit lamp. Genetic testing found no abnormalities. Ten months later, the patient developed sudden onset of left eye pain. A dislocated lens and temporarily dilated left pupil were captured on a smartphone by the patient’s father. He was evaluated 3 days later after a second episode and found to have hand motion vision OS, a fixed 8 mm left pupil with the crystalline lens subluxed into the pupil space and accompanying intraocular pressure OS of 40 mmHg. The lens was surgically removed with a limited anterior vitrectomy. Four and a half years after surgery, visual acuity was 20/125 OS with aphakic correction. The right eye eventually underwent prophylactic lensectomy and was 20/30 in aphakic correction.ConclusionsThis report presents a unique presentation of isolated ectopia lentis with anterior lens dislocation and pupillary block and illustrates the role of smartphone photography in assisting in the triage of eye emergencies.

Comparison of Full-Field Stimulus Threshold Measurements in Patients With Retinitis Pigmentosa and Healthy Subjects With Dilated and Nondilated Pupil.

The common protocol of full-field stimulus threshold (FST) testing recommends pupil dilation. The aim of this study is to investigate the difference between FST measurements with dilated and nondilated pupils in healthy subjects and patients with retinitis pigmentosa (RP). Twenty healthy subjects and 20 RP patients were selected. One pupil of each subject was dilated; the other eye was measured in physiological width of the pupil. The FST was conducted using Diagnosys Espion E2/E3 with white, blue, and red stimuli. Statistical analysis was conducted with a mixed-model analysis of variance and a paired t-test. The statistical analysis revealed a significant difference between measurements of dilated and nondilated pupils with the following: blue stimuli for all subjects and groups except those with highly progressed RP; white stimuli for all tested subjects in total, for RP patients with better-preserved visual field (VF), and rod-mediated FST response; and red stimuli for RP patients with better-preserved VF and rod-mediated FST response. On average, the difference between the FST values for RP patients were -3.2 ± 3dB for blue, -2.3 ± 2.9dB for white, and -0.83 ± 3dB for red stimuli. The correlation between the FST values of dilated and nondilated pupils with all three stimuli was linear. Current recommendations are to perform FST with dilated pupils. However, based on this study's findings, pupil dilation can be omitted for clinical diagnostics or rough follow-ups. Our data provide useful information for the clinical use of FST.

Calculation of solar ultraviolet influx in the eye considering the field of view and pupillary dilation due to sunglasses

The media and even the specialized literature report that the ultraviolet (UV) protection for sunglasses is critical, on the grounds that sunglasses can have a counter effect if the lenses do not provide adequate UV protection. They reason that the primary and natural mechanism is that the pupil of the eye contracts to attenuate radiation and protect the inner eye under sun exposure. Therefore, if dark lenses do not provide appropriate UV protection, there is an increased UV incidence in the inner eye due to pupil dilation, which enhances the adverse effects and impacts the ocular tissues more severely than in situations without UV protection. However, no existing literature properly quantified or supported this argument. In this work, the influx of solar UV throughout the pupil of the eye was calculated in two situations: when a person wear sunglasses and when he/she does not. In both situations, the pupil dilation and the field of view (squint) were considered with their dependence on the brightness of the ambient, calculated by modeling the solar irradiation. Finally, it was assessed whether sunglasses with poor UV protection actually increase the UV influx throughout the dilated pupil compared to the non-dilated pupil. A set of 214 sunglasses lenses were tested and the results show that pupil dilation does not play an important role in the UV influx throughout the pupil. It was observed that the FOV is the main player, surpassing the pupil size contribution by up to 314.3%, disproving the common explanation. Because of the major role of the FOV, our results show that sunglasses with UV-A protection below 86% may have a slight potential to increase hazards to the eye compared to not wearing sunglasses at all. These results can have direct impact on sunglasses standards regarding the UV protection linked to the category of the lenses.

Treatment of Anticholinergic Delirium with Oral Rivastigmine: A Case Report

BackgroundAnticholinergic toxicity is commonly encountered in the emergency department. However, the availability of physostigmine, a central acetylcholinesterase inhibitor used to reverse anticholinergic delirium, has been significantly limited due to national drug shortages in the United States. Several articles have explored the viability of rivastigmine as an alternative treatment for these patients. Case ReportA 33-year-old male presented to the emergency department after a suspected suicide attempt. The patient was found with an empty bottle of diphenhydramine at the scene. On arrival, he was tachycardic, delirious, with dilated and nonreactive pupils and dry skin. As the clinical picture was highly suggestive of anticholinergic toxicity, the patient was treated with oral rivastigmine at a starting dose of 4.5mg to reverse his anticholinergic delirium. Though requiring a repeat dose, his delirium resolved without recurrence.Why Should an Emergency Physician Be Aware of This? Oral rivastigmine has been successfully applied here and in other case reports to reverse anticholinergic delirium with the benefit of prolonged agitation control. Emergency physicians may consider this medication in consultation with a specialist, with initial doses starting at 4.5 to 6 mg, if encountering anticholinergic delirium when physostigmine is not available.