Normal Light Reflex Research Articles

Transient Anisocoria during Medial Blowout Fracture Surgery.

Transient anisocoria is rare during blowout fracture reconstruction. We report a case of transient anisocoria occurring during medial blowout fracture reconstruction and review the relevant literature. A 54-year-old woman was struck in the face and was admitted for a medial blowout fracture of the left eye. During the operation, persistent bleeding occurred. To control this bleeding, a 1% lidocaine solution with 1:200,000 epinephrine was applied to the orbital wall with cotton pledgets. In total, 40 mL of local anesthetic was used for the duration of the operation. After approximately three hours of the surgery, the ipsilateral pupil was observed to be dilated, with sluggish response to light. By 3 hours after the operation, the mydriasis had resolved with normal light reflex. In conclusion, neurological and ophthalmologic evaluation must be performed prior to blowout fracture surgery. Preoperative ophthalmic evaluation is simple and essential in ruling out any preexisting neurologic condition. Moreover, surgeons must be aware of the fact that excessive injection of lidocaine with epinephrine for hemostasis during orbital wall surgery can result in intraoperative anisocoria. Anisocoria-related situations must be addressed in a proficient manner through sufficient understanding of the mechanism controlling the pupillary response to various stimuli.

Leber’s hereditary optic neuropathy with the 3434, 9011 mitochondrial DNA point mutation

Leber's hereditary optic neuropathy (LHON) contains several well-known mitochondrial DNA (mtDNA) point mutations. We report a case with characteristic clinical manifestations of LHON involving a possible new LHON point mutation. A 34-year-old man was diagnosed with LHON. The patient exhibited (1) sudden onset of bilateral visual loss, (2) normal light reflex, and (3) swelling of the peripapillary nerve fiber layer. After subsequent development of bilateral optic disc pallor, we concluded that the patient had LHON. mtDNA analysis was conducted using non-radioisotopic single-strand conformational polymorphism followed by direct sequencing. There was no change in the patient's visual acuity during the 26-month follow-up period. The mtDNA point mutations were found at T3434C, G3483A, and V9011A. The confirmed mtDNA substitutions included (1) A-G at nucleotide position 3434, (2) G-A at nucleotide position 3483, and (3) C-T at nucleotide position 9011. The amino acid code at the nucleotide positions 3434 and 9011 was phylogenetically highly conserved. The 3434 and 9011 mtDNA point mutations are candidates for a new LHON mutation.

Ipsilateral reversible diaphragmatic paralysis after pons stroke

Neurological disease may present with respiratory dysfunction. This presentation is also well recognized for stroke although the precise mechanisms responsible for respiratory problems are poorly understood. Diagnosis of respiratory dysfunction resulting from diaphragmatic paresis after stroke has been reported but few data are available about the effects of stroke on the diaphragmatic function. It is commonly thought that respiratory muscles are under bilateral hemispheric control although diaphragmatic excursion reduction and cases of diaphragmatic paralysis on the hemiplegic side have been reported in stroke patients [1, 2]. We report a case of a patient with unilateral diaphragmatic palsy contralateral to the hemiparetic side. A 65-year-old woman awoke with vomiting, dizziness and left hemiparesis. There was no history of recent trauma of the neck or the chest or recent surgery. On admission, her pulse rate was 80 beats/min, blood pressure was 110/60 mm Hg, and respirations were 15/min and regular. The patient denied dyspnea. The neurological examination showed a normal mental status. Her speech was dysarthric. The visual fields were intact; pupils were equal, with a normal light reflex; and ocular movements were full and smooth, without nystagmus. A mild left hemiparesis was present involving the face. There were no sensory deficits to touch, pain, temperature, vibration, or position sense. There was no ataxia on either side. No abnormality was demonstrated on brain computed tomography performed in the acute stage. Extensive laboratory investigations including hematological and biochemical parameters were unremarkable. Electrocardiogram, echocardiogram and carotid Doppler studies were normal. Chest radiograph revealed an elevated right hemidiaphragm (Fig. 1a). The brain magnetic resonance imaging (MRI) showed an area of increased signal intensity on T2 weighted or FLAIR images involving the paramedian region of the right pons (Fig. 2). The lesion showed focal restricted diffusion by using MRI diffusion-weighted imaging. The disturbance of neurological symptoms gradually improved. Complete resolution of diaphragmatic elevation and no hemiparesis were detected on day 60 of follow-up (Fig. 1b). The diaphragm is considered to contribute up to 60–70% of the total ventilation at rest, in both sitting and supine positions. Hemidiaphragmatic paralysis results in a vital capacity decrement of 10–30%, with the most substantial decrements seen in the supine position [3]. Breathing can be activated either automatically or volitionally [4]. The exactly cortical motor representation of respiratory muscles is not completely understood and there is no clear evidence of cerebral dominance for diaphragm function [5]. The descending pathways of the voluntary system are associated with the corticospinal tracts in the brainstem and upper cervical cord [6]. G. Moris M. Arias J. M. Terrero Neurology Service, Hospital San Agustin, Aviles, Asturias, Spain

Copper foreign body in the lens without damage of iris and lens capsule

The objective is to report a rare case of asymptomatic penetrating injury with a copper foreign body found during an examination for cataract surgery. A case report. A 73-year-old woman had vision loss. Examination by pupil dilation disclosed a dark-brown metallic mass located under the anterior capsule of the lens, as well as nuclear sclerosis of the lens. Although no history of traumatic injury was reported by the patient, careful examination revealed a dot corneal opacity. This finding, and the past history of the patient that she had worked in the fabrication of copper wire, suggested previous penetrating injury. The iris had no scar. No inflammatory reaction was observed in the posterior segment of the eye. Phacoemulsification and implantation of an intraocular lens were performed. After continuous curvilinear capsulorrhexis (CCC), the foreign body was extracted with a microforceps. The anterior capsule overlying the foreign body was intact, with normal light reflex. Qualitative analysis showed that the foreign body extracted contained pure copper at the center. Nevertheless, visual acuity of the right eye improved from 20/50 to 20/20 without any copper-related retinal damage. In this case, copper localized under the anterior capsule of the lens had been able to stay in the eye without causing severe inflammatory reaction.

HEAD INJURY???BASEBALL

HISTORY: 19 year old collegiate baseball player participating in a summer baseball league was injured during pre-game batting practice. He was walking from the dugout to the field and did not notice another player warming up nearby. He was struck in the head by the player's wooden bat in the side of his head, above his ear. He was not wearing a batting helmet. He immediately fell to his knees but did not lose consciousness. Immediate medical attention was provided by the trainer. The patient was previously in good health and had no history of preexisting head injury. He did not complain of any parasthesias or neck pain. He did complain of immediate headache, blurred vision, ringing in his ears and feeling “tired.” He was transferred immediately by ambulance to the emergency. PHYSICAL EXAMINATION: The patient was awake and responded appropriately to questions. He was oriented to place but not time or date. His vital signs were stable. He could purposefully move all four extremities. He had no neck tenderness or muscle spasm. He had a normal cranial nerve examination including equal pupils, normal light reflexes and normal extra-ocular movements. Cerebellar signs were normal. He had a small scalp laceration but had no blood in his auditory canal. His fundus examination was normal bilaterally. DIFFERENTIAL DIAGNOSIS: Scalp laceration with contusion Skull fracture Epidural hematoma Concussive brain injury Acute subdural hematoma TESTS AND RESULTS: Plain radiographs—suggestive parietal skull fracture CT scan-nondisplaced parietal skull fracture with no evidence of intra-cranial bleeding Evaluation by neurosurgeon in emergency room FINAL/WORKING DIAGNOSIS: Skull Fracture TREATMENT: Supportive care and observation in hospital for 24h Concussive symptoms resolved over next 4–5 days No physical activity for two weeks then re-evaluated Allowed to return to baseball in two weeks by neurosurgeon Did not wear protective gear except batting and when base running Healed with no long term sequalae

Light reflexes of the fundus oculi. Paper on an atlas which appeared under this title in Russian by A.M. Vodovozov

This atlas is the first publication dealing with the clinical significance of the light reflexes of the fundus. The mechanism and the conditions for the occurrence of light reflexes in ophthalmoscopy are described. A classification of the light reflexes is presented, dividing them into normal and pathologic groups. The normal light reflexes - foveolar, macular, areal, paravasal, streaks of light on the vessels - and their abnormal variations in different diseases of the fundus are described. The pathologic light reflexes - fanlike, focal, peripapillary, linear, stationary, metallic, crystalline - and their diagnostic significance are discussed. Practical recommendations are given for assessing pathologic changes in the retina and the optic disk from the appearance of the light reflexes. Finally the manifestation of light reflexes as a characteristic of some diseases of the fundus is pointed out.