Pupillary Examination Research Articles

Neurosurgical Management of Traumatic Brain Injury

The neurosurgical management of traumatic brain injury (TBI) plays a critical role in ensuring acute survival and mitigating secondary brain damage, which significantly impacts patients' quality of life. TBI is defined as an external force impacting the skull, leading to brain injuries and subsequent functional impairments. It is a leading cause of mortality and morbidity, particularly among young individuals. The initial clinical examination is crucial, with external signs like scalp injuries, hematomas, nasal fluid leakage, skull deformities, and neurological deficits providing important clues to injury patterns. Pupil examination is particularly critical, as mydriasis coupled with reduced consciousness may indicate an acute life-threatening increase in intracranial pressure (ICP), necessitating immediate neurosurgical intervention. TBI assessment often utilizes the Glasgow Coma Scale (GCS), classifying injuries as mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS <9). Even mild TBI can lead to long-term complications. TBI should be viewed as a disease process rather than a singular event. Primary brain damage results from shearing forces on the parenchyma, manifesting as contusions, hematomas, or diffuse axonal injury. Secondary brain damage is driven by mechanisms such as inflammation and spreading depolarizations. Treatment aims not only to secure immediate survival but also to reduce secondary injuries, with ICP management being crucial. Neurosurgical interventions are guided by cranial pathologies, with options including ICP monitoring, burr hole trepanation, craniotomy. In severe TBI cases with refractory ICP elevation, decompressive craniectomy may be performed as a last resort, significantly reducing mortality but often resulting in high morbidity and vegetative states, necessitating careful consideration of indications.

Prolonged hourly neurological examinations are associated with increased delirium and no discernible benefit in mild/moderate geriatric traumatic brain injury.

Serial neurological examinations (NEs) are routinely recommended in the intensive care unit (ICU) within the first 24 hours following a traumatic brain injury (TBI). There are currently no widely accepted guidelines for the frequency of NEs. Disruptions to the sleep-wake cycles increase the delirium rate. We aimed to evaluate whether there is a correlation between prolonged hourly (Q1)-NE and development of delirium and to determine if this practice reduces the likelihood of missing the detection of a process requiring emergent intervention. A retrospective analysis of patients with mild/moderate TBI, admitted to the ICU with serial NEs, was performed. Cohorts were stratified by the duration of exposure to Q1-NE, into prolonged (≥24 hours) and nonprolonged (<24 hours). Our primary outcomes of interest were delirium, evaluated using the Confusion Assessment Method; radiological progression from baseline images; neurological deterioration (focal neurological deficit, abnormal pupillary examination, or Glasgow Coma Scale score decrease >2); and neurosurgical procedures. A total of 522 patients were included. No significant differences were found in demographics. Patients in the prolonged Q1-NE group (26.1%) had higher Injury Severity Score with similar head Abbreviated Injury Score, significantly higher delirium rate (59% vs. 35%, p < 0.001), and a longer hospital/ICU length of stay when compared with the nonprolonged Q1-NE group. No neurosurgical interventions were found to be performed emergently as a result of findings on NEs. Multivariate analysis demonstrated that prolonged Q1-NE was the only independent risk factor associated with a 2.5-fold increase in delirium rate. The number needed to harm for prolonged Q1-NE was 4. Geriatric patients with mild/moderate TBI exposed to Q1-NE for periods longer than 24 hours had nearly a threefold increase in ICU delirium rate. One of five patients exposed to prolonged Q1-NE is harmed by the development of delirium. No patients were found to directly benefit as a result of more frequent NEs. Prognostic and Epidemiological; Level IV.

Association between pupillary examinations and prognosis in patients with out-of-hospital cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation: a retrospective multicentre cohort study

BackgroundIn some cases of patients with out-of-hospital cardiac arrest (OHCA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR), negative pupillary light reflex (PLR) and mydriasis upon hospital arrival serve as common early indicator of poor prognosis. However, in certain patients with poor prognoses inferred by pupil findings upon hospital arrival, pupillary findings improve before and after the establishment of ECPR. The association between these changes in pupillary findings and prognosis remains unclear. This study aimed to clarify the association of pupillary examinations before and after the establishment of ECPR in patients with OHCA showing poor pupillary findings upon hospital arrival with their outcomes. To this end, we analysed retrospective multicentre registry data involving 36 institutions in Japan, including all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. We selected patients with poor prognosis inferred by pupillary examinations, negative pupillary light reflex (PLR) and pupil mydriasis, upon hospital arrival. The primary outcome was favourable neurological outcome, defined as Cerebral Performance Category 1 or 2 at hospital discharge. Multivariable logistic regression analysis was performed to evaluate the association between favourable neurological outcome and pupillary examination after establishing ECPR.ResultsOut of the 2,157 patients enrolled in the SAVE-J II study, 723 were analysed. Among the patients analysed, 74 (10.2%) demonstrated favourable neurological outcome at hospital discharge. Multivariable analysis revealed that a positive PLR at ICU admission (odds ration [OR] = 11.3, 95% confidence intervals [CI] = 5.17–24.7) was significantly associated with favourable neurological outcome. However, normal pupil diameter at ICU admission (OR = 1.10, 95%CI = 0.52–2.32) was not significantly associated with favourable neurological outcome.ConclusionAmong the patients with OHCA who underwent ECPR and showed poor pupillary examination findings upon hospital arrival, 10.2% had favourable neurological outcome at hospital discharge. A positive PLR after the establishment of ECPR was significantly associated with favourable neurological outcome.

Актуальные вопросы стандартизации деятельности специалистов по подготовке выпускников к самостоятельной жизни и постинтернатному сопровождению (по итогам научно-практической конференции)

&lt;p&gt;The review article presents a discussion of some topical issues of standardization of activities to prepare orphans and children without parental care for independent living and their support after graduation from various forms of education. The focus is on children of the normotypical category and children with &amp;ldquo;special needs&amp;rdquo; &amp;ndash; with limited health and (or) disabilities, with mental development disorders, with socially significant diseases, who need to develop adherence to taking medication. The structure and content of the standards are considered, the forms and methods of preparing students for independent life and accompanying graduates are illustrated, including an analysis of organizational resources and evaluation criteria. The speakers noted the need to focus on developing skills that will be in demand in a new place of life after adulthood, as well as developing independence in performing daily life activities for special categories of graduates. The results of testing the tools for socio-psychological examination of pupils and graduates in various forms of living conditions, and certain effective practices (mentoring, training apartments, project activities, etc.) that contribute to the implementation of the provisions of the standard were presented.&lt;/p&gt;

Fundoscopic changes in preeclampsia and eclampsia and their association with fetal outcome

Abstract Introduction: Hypertensive disorder is a major cause of maternal and perinatal mortality and morbidity, with preeclampsia and eclampsia being the most common. Preeclampsia is characterized by endothelial dysfunction and vasospasm of vessels, which can be observed by an ocular fundus examination. The fundus usually develops changes such as hypertensive retinopathy, papilledema, exudative retinal detachment, and vitreous and preretinal hemorrhages. Retinopathy is associated with placental insufficiency and intrauterine growth retardation. Therefore, this study has been undertaken to assess the prevalence of retinal changes in preeclampsia and their association with fetal parameters. Objective: To study the fundus changes in preeclampsia. To study the relationship between fundus changes and fetal outcome with respect to various parameters like birth weight, APGAR score, stillbirth, and perinatal death. To study the relationship between fundus changes with respect to proteinuria and serum uric acid. Study Design: Observational study. Methodology: One hundred patients presenting to the department of obstetrics and gynecology diagnosed with preeclampsia at a tertiary care center were included in the study. The patient recruited underwent an ocular examination using Snellen’s chart, a pupillary examination, a slit lamp examination, and a dilated fundus examination. The retinopathy was graded according to Keith and Wagner’s classification. The fetal parameters considered were birth weight, APGAR score, stillbirth, and neonatal death. Results: Patients ages ranged from 25 to 30 years old, with an average of 23.28 ± 3.37. Average systolic and diastolic blood pressures were 156.9 ± 17.961 and 104.88 ± 13.58, respectively. All patients had normal anterior segments. Visual acuity was6/6 in most of the patients. Fundus changes were noted in 48% of patients. Based on retinopathy classification, we found 66.7% patients with Grade 1 and 27.1% patients with Grade 2 hypertensive retinopathy. Only 6.3% of patients presented with Grade 3 hypertensive retinopathy. There was a significant association between retinopathy and proteinuria (P = 0.003), serum uric acid (P = 0.002), and the fetal birth weight (P = 0.001). Conclusion: Our findings suggest that progressive fundal changes in preeclampsia indicate worsening of the pathophysiological status of pregnancy-induced hypertension (PIH) and help in management. The degree of hypertensive retinopathy in women with preeclampsia is a valid and reliable prognostic factor that serves as an indirect marker of the severity of PIH and fetal outcome. Fundus examination is a simple, noninvasive, and cost-effective procedure that could be the initial finding in an asymptomatic patient who may require immediate management, which may help in saving the lives of both the mother and the baby. Fundus evaluation is essential for all patients with PIH.

Feasibility of USG-Guided Objective Initial Assessment of Pupillary Size and Pupillary Reflexes Versus Clinical Examination in Patients With Altered Mental Status: A Cross-Sectional Study.

Pupillary assessment is an important part of the neurological assessment which provides vital information in critically ill patients. However, clinical pupillary assessment is subjective. The ultrasound-guided pupillary examination is objective. There are limited pieces of literature regarding its use in assessing patients with altered mental status. So, we studied the extent of agreement of B-mode ultrasound with clinical examination for assessment of the pupillary size and reflex in patients with altered mental status. The primary objective was to determine the extent of agreement between clinical examination and ultrasound-based examination for assessing pupillary reflex and size in patients with altered mental status in two settings (trauma and non-trauma patients). Exactly 200 subjects (158 males, mean [range] age 43.56 [18-92 years]) with no history of partial globe rupture or dementia were included in this cross-sectional study from March 2019 to March 2020. B-mode ultrasound was performed with the subject's eyes closed using a 7-12 MHz linear probe and a standardized light stimulus. ICC score, paired t-test, kappa, Wilcoxon signed-rank test, and Bland-Altman plots were used for statistical analysis. The clinical-USG agreement for pupillary light reflex examination (Pupillary Diameter [PD] at rest, after direct light stimulation [Dstim ] and consensual light stimulation [Cstim ]) was excellent (ICC, 0.93-0.96). The Kappa coefficient (0.74 ± 0.07) showed an agreement of 87.36% between clinical and USG examination for pupillary reflex (reactive or non-reactive). USG-guided pupillary examination proves to be a better adjunct to neurological assessment in patients with altered mental status.

Clinical indicators for diabetic eyecare delivered by optometrists in Australia: a Delphi study

ABSTRACT Clinical relevance Valid and updated clinical indicators can serve as important tools in assessing and improving eyecare delivery. Background Indicators for diabetic eyecare in Australia were previously developed from guidelines published before 2013 and then used to assess the appropriateness of care delivery through a nationwide patient record card audit (the iCareTrack study). To reflect emerging evidence and contemporary practice, this study aimed to update clinical indicators for optometric care for people with type 2 diabetes in Australia. Methods Forty-five candidate indicators, including existing iCareTrack and new indicators derived from nine high-quality evidence-based guidelines, were generated. A two-round modified Delphi process where expert panel members rated the impact, acceptability, and feasibility of the indicators on a 9-point scale and voted for inclusion or exclusion of the candidate indicators was used. Consensus on inclusion was reached when the median scores for impact, acceptability, and feasibility were ≥7 and >75% of experts voted for inclusion. Results Thirty-two clinical indicators with high acceptability, impact and feasibility ratings (all median scores: 9) were developed. The final indicators were related to history taking (n = 12), physical examination (n = 8), recall period (n = 5), referral (n = 5), and patient education/communication (n = 2). Most (14 of 15) iCareTrack indicators were retained either in the original format or with modifications. New indicators included documenting the type of diabetes, serum lipid level, pregnancy, systemic medications, nephropathy, Indigenous status, general practitioner details, pupil examination, intraocular pressure, optical coherence tomography, diabetic retinopathy grading, recall period for high-risk diabetic patients without retinopathy, referral of high-risk proliferative retinopathy, communication with the general practitioner, and patient education. Conclusion A set of 32 updated diabetic eyecare clinical indicators was developed based on contemporary evidence and expert consensus. These updated indicators inform the development of programs to assess and enhance the eyecare delivery for people with diabetes in Australia.

Prognostic Factors of Mortality and Functional Outcome for Acute Subdural Hematoma: A Review Article.

Acute subdural hematoma (ASDH) is the most frequent intracranial traumatic lesion requiring surgery in high-income countries. To date, uncertainty remains regarding the odds of mortality or functional outcome of patients with ASDH, regardless of whether they are operated on. This review aims to shed light on the clinical and radiologic factors associated with ASDH outcome. A scoping review was conducted on Medline database from inception to 2023. This review yielded 41 patient series. In the general population, specific clinical (admission Glasgow Coma Scale [GCS], abnormal pupil exam, time to surgery, decompressive craniectomy, raised postoperative intracranial pressure) and radiologic (ASDH thickness, midline shift, thickness/midline shift ratio, uncal herniation, and brain density difference) factors were associated with mortality (grade III). Other clinical (admission GCS, decompressive craniectomy) and radiologic (ASDH volume, thickness/midline shift ratio, uncal herniation, loss of basal cisterns, petechiae, and brain density difference) factors were associated with functional outcome (grade III). In the elderly, only postoperative GCS and midline shift on brain computed tomography were associated with mortality (grade III). Comorbidities, abnormal pupil examination, postoperative GCS, intensive care unit hospitalization, and midline shift were associated with functional outcome (grade III). Based on these factors, the SHE (Subdural Hematoma in the Elderly) and the RASH (Richmond Acute Subdural Hematoma) scores could be used in daily clinical practice. This review has underlined a few supplementary factors of prognostic interest in patients with ASDH, and highlighted two predictive scores that could be used in clinical practice to guide and assist clinicians in surgical indication.

Clinical profile and visual outcome in patients with traumatic optic neuropathy.

To analyze the visual outcome in patients with traumatic optic neuropathy (TON) with respect to different treatment modalities, to study the correlation of initial visual loss with the final visual outcome, and to find out the predictor of final visual outcome in patients with indirect TON. A retrospective analysis of 36 eyes with TON was done. Data on clinical profile, including demographics, mode of trauma, best corrected visual acuity (BCVA), pupillary reflex examination, and anterior and posterior segment examination, was collected. Presence and location of orbital and cranial fractures were identified from computed tomography scan. Visual outcomes following steroid therapy, optic nerve (ON) decompression, and in untreated patients were analyzed. Pre- and post-treatment BCVA were divided into three groups based on logarithm of the minimum angle of resolution (logMAR) as follows: group A: 3, group B: 2.9-1.3, and group C<1.3. BCVA values at follow-up visits were taken as the primary outcome measure. Association between various risk factors and final visual outcome in patients with indirect TON was also analyzed. Out of 34 patients whose 36 eyes were studied, three (8.8%) patients were females and 31 (91.2%) patients were males. Most common mode of trauma was road traffic accident (RTA; 91.2%), which was followed by fall (8.8%) and assault (2.9%). Pre- and post-treatment BCVA values of 36 eyes were compared, and improvement in BCVA after treatment was found to be statistically significant. Also, 28.6% of patients with presenting BCVA of no light perception showed improvement compared to 94.1% and 100% in groups B and C, respectively. Orbital wall fractures were seen in 80.5% (n = 29) of the patients, with lateral wall fracture being the most common (58.3%) followed by medial wall (33.3%), roof (27.7%), floor (27.7%), and optic strut (5%). Baseline BCVA had significant association with final vision improvement. Lateral wall fracture was the most common fracture associated with indirect TON. Patients treated with high-dose corticosteroids, irrespective of the time of presentation, had a better visual outcome.

Paying attention to the clinical significance of pupil abnormalities

Pupil abnormalities may be physiological, pathological or pharmacological. It can indicate the underlying disease of the visual afferent system or visual efferent system. Examination of the pupils is therefore a part of eye examination. Insufficient knowledge and inconsistent methods in the pupillary examination by some ophthalmologists lead to mistakes or unreliable results, hampering the disease diagnosis and clinical assessment. This article emphasizes the significance of pupillary examination outcomes, advocates for standardized examination methods, and highlights the need to enhance the awareness of pupillary abnormalities, aiming to provide a guide on how to recognize and interpret the clinical implications of pupillary abnormalities, and to offer valuable insights for clinical practice.

Perceived Utility of Intracranial Pressure Monitoring in Traumatic Brain Injury: A Seattle International Brain Injury Consensus Conference Consensus-Based Analysis and Recommendations.

Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed. To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion. We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression. Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations. Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.

Assessment of altered mental status in the Emergency Department using quantitative pupillometry: a prospective cohort study (P7-4.006)

<h3>Objective:</h3> To assess whether quantitative pupillometry (QP) can distinguish between Emergency Department (ED) patients presenting with altered mental status (AMS) of primary neurologic versus non-neurologic etiology. <h3>Background:</h3> The rapid assessment of patients with AMS in the ED remains a major clinical challenge. Pupillary examination can aid in clinical decision making, yet is limited by interrater reliability. QP offers automated measurement of pupillary characteristics and may support the standardization of patient assessment. However, few studies have investigated the role of QP to aid in ED-based assessment of patients with neurologic presentations. <h3>Design/Methods:</h3> Between December 2021 and October 2022, 218 patients presenting with AMS were screened in two large, urban EDs. QP data were collected using an FDA-approved pupillometer (NeurOptics, Irvine, CA) and included pupil diameter, percentage constriction, latency/velocity of constriction, and dilation velocity. Final diagnoses were obtained from discharge summaries. Patients with intoxication or multiple causes of AMS were excluded. AMS was grouped as primary neurologic (ischemic stroke, intracranial hemorrhage, or seizure) or non-neurologic (infectious, metabolic, or psychiatric) in etiology. QP data were also collected from 56 nonaltered control patients. <h3>Results:</h3> 73 patients were included (29 and 44 patients with primary or non-neurologic AMS, respectively). Mean age was 64 years (SD 19.7) and 59.7% were female. A single-factor ANOVA test revealed statistically significant differences between the two AMS cohorts and controls; patients of either AMS category had lower percent constriction, constriction velocity, and dilation velocity than controls (p&lt;0.05). However, when a two-tailed T test was performed comparing primary versus non-neurologic AMS etiology, pupillary characteristics were indistinguishable (p=NS). <h3>Conclusions:</h3> QP use was feasible in the ED setting. While QP returned significantly different pupillary values in AMS patients versus controls, QP could not differentiate between broad categories of AMS. Further investigation with more specific patient cohorts is required further assess QP use in the ED. <b>Disclosure:</b> Miss Alexis has nothing to disclose. Mr. Fernandez-Penny has nothing to disclose. Benjamin Abella has nothing to disclose.

Clinical Practices Following Train-The-Trainer Trauma Course Completion in Uganda: A Parallel-Convergent Mixed-Methods Study

BackgroundDespite the growth of trauma training courses worldwide, evidence for their impact on clinical practice in low- and middle-income countries (LMICs) is sparse. We investigated trauma practices by trained providers in Uganda using clinical observation, surveys, and interviews.MethodsUgandan providers participated in the Kampala Advanced Trauma Course (KATC) from 2018 to 2019. Between July and September of 2019, we directly evaluated guideline-concordant behaviors in KATC-exposed facilities using a structured real-time observation tool. We conducted 27 semi-structured interviews with course-trained providers to elucidate experiences of trauma care and factors that impact adoption of guideline-concordant behaviors. We assessed perceptions of trauma resource availability through a validated survey.ResultsOf 23 resuscitations, 83% were managed without course-trained providers. Frontline providers inconsistently performed universally applicable assessments: pulse checks (61%), pulse oximetry (39%), lung auscultation (52%), blood pressure (65%), pupil examination (52%). We did not observe skill transference between trained and untrained providers. In interviews, respondents found KATC personally transformative but not sufficient for facility-wide improvement due to issues with retention, lack of trained peers, and resource shortages. Resource perception surveys similarly demonstrated profound resource shortages and variation across facilities.ConclusionsTrained providers view short-term trauma training interventions positively, but these courses may lack long-term impact due to barriers to adopting best practices. Trauma courses should include more frontline providers, target skill transference and retention, and increase the proportion of trained providers at each facility to promote communities of practice. Essential supplies and infrastructure in facilities must be consistent for providers to practice what they have learned.

Protecting Sleep Hygiene in the PICU: A Quality Improvement Project.

To increase the number of nights without sleep interruptions for routine tasks in recovering PICU patients. Prospective quality improvement project. Single-center, free-standing, tertiary children's hospital. Patients admitted to the PICU for greater than 72 hours and eligible for early mobilization. A multidisciplinary sleep hygiene team was created to improve sleep hygiene in critically ill patients eligible for early mobilization. This team rewrote local nursing policies to avoid routine tasks between 11 pm and 5 am . The team provided periodic control chart updates to staff detailing progress made protecting sleep. Discussions of sleep hygiene were added to the daily goal sheet and a sleep hygiene order set was created. Finally, the PICU quality dashboard was modified to show whether a sleep hygiene order set was initiated in eligible patients. Routine tasks were defined as daily chest radiographs, baths, routine tracheostomy care, central line dressing changes, twice daily medications, weights, and Foley care. After a year of data collection, avoidance of routine pupillary examinations was added to the sleep protection criteria. Baseline data was collected for 2 months prior to the creation of the sleep hygiene team. Screening of eligible patients occurred 1 week each month. The data were analyzed utilizing control charts. Baseline data demonstrated 32% of PICU patients without sleep interruptions. The centerline increased to 58% after the initial interventions but dropped to 33% after inclusion of pupillary checks. Following the introduction of the daily goal sheet, sleep hygiene order set, and tracking on the quality board, 49% of patients went without interruptions. The initiation of a sleep hygiene team along with retiming routine tasks, daily discussions on rounds with the daily goal sheet, introduction of a sleep hygiene order set, and transparent tracking improved the percentage of patients with protected sleep.

Prevention campaign for amblyopia and other eye disorders among schoolchildren

AbstractPurpose: This is a retrospective longitudinal observational study to detect amblyopia and other visual anomalies (refraction, strabismus, pathologies…) in 3, 4 and 5‐year‐old schoolchildren. Amblyopia is a disorder of sight in which the brain fails to fully process input from one eye and over time favours the other eye. It results in decreased vision in an eye that typically appears normal in other respects. Early detection improves treatment success. There is currently an early detection program but according to a recently published study, does not have good compliance or appropriate material.Methods: The study was carried out with children aged 4–6 years from 4 different schools, collecting 491 children with the corresponding informed consent of their parents. The study was divided into two phases, first an optometrist performed an external examination, red reflex, pupillary examination, ocular motility, cover test and photoscreening with a portable autorefractometer. And if any anomaly is detected in the second phase, it would be explored by an ophthalmologist who would also perform stereopsis tests, visual acuity, dilated refraction, eye fundus, and diagnosis and treatment.Results: 491 children were included in this study, visual anomalies were detected in 96, of which 60 were studied in our center. It was detected 47% who had refractive problems, 5% strabismus and 0% opacities. Extrapolating it to the total number of patients seen, 9% had refractive problems and 1% strabismus.Conclusions: Amblyopia has a prevalence of 6% in the population. Its treatment is relatively simple with glasses and patches at a low cost. There is a prevalence of 5%–7.5% of amblyopia in &lt;6 years, 1%–3% strabismus in &lt;6 years as well as 1 of 3 school failure is caused by visual problem.Paediatric check‐up or other check‐ups that these schoolchildren do not detect this type of condition. Therefore, the Campaign for the Prevention of Amblyopia and Other Visual Anomalies idea should be implemented in all the Autonomous Communities.Reference1. Eileen E Birch. Amblyopia and binocular vision. Prog Retin Eye Res. 2013; 33: 67–84.

Dexmedetomidine and Other Analgosedatives Alter Pupil Characteristics in Critically Ill Patients.

OBJECTIVES:In critically ill patients with neurologic disease, pupil examination abnormalities can signify evolving intracranial pathology. Analgesic and sedative medications (analgosedatives) target pupillary pathways, but it remains unknown how analgosedatives alter pupil findings in the clinical care setting. We assessed dexmedetomidine and other analgosedative associations with pupil reactivity and size in a heterogeneous cohort of critically ill patients with acute intracranial pathology.DESIGN:Retrospective cohort study.SETTING:Two neurologic ICUs between 2016 and 2018.PATIENTS:Critically ill adult patients with pupil measurements within 60 minutes of analgosedative administration. Patients with a history of intrinsic retinal pathology, extracranial injury, inaccessible brain imaging, or no Glasgow Coma Scale (GCS) data were excluded.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:We used mixed-effects linear regression accounting for intrapatient correlations and adjusting for sex, age, GCS score, radiographic mass effect, medication confounders, and ambient light. We tested the association between an initiation or increased IV infusion of dexmedetomidine and pupil reactivity (Neurologic Pupil Index [NPi]) and resting pupil size (mm) obtained using NeurOptics NPi—200 (NeurOptics, Irvine, CA) pupillometer. Of our 221 patients with 9,897 pupil observations (median age, 60 [interquartile range, 50–68]; 59% male), 37 patients (166 pupil observations) were exposed to dexmedetomidine. Dexmedetomidine was associated with higher average NPi (β = 0.18 per 1 unit increase in rank-normalized NPi ± 0.04; p < 0.001) and smaller pupil size (β = –0.25 ± 0.05; p < 0.001). Exploratory analyses revealed that acetaminophen was associated with higher average NPi (β = 0.04 ± 0.02; p = 0.02) and that most IV infusion analgosedatives including propofol, fentanyl, and midazolam were associated with smaller pupil size.CONCLUSIONS:Dexmedetomidine is associated with higher pupil reactivity (high NPi) and smaller pupil size in a cohort of critically ill patients with neurologic injury. Familiarity with expected pupil changes following analgosedative administration is important for accurate interpretation of pupil examination findings, facilitating optimal management of patients with acute intracranial pathology.

Neurological Pupil Index for the Early Prediction of Outcome in Severe Acute Brain Injury Patients.

In this study, we examined the early value of automated quantitative pupillary examination, using the Neurological Pupil index (NPi), to predict the long-term outcome of acute brain injured (ABI) patients. We performed a single-centre retrospective study (October 2016–March 2019) in ABI patients who underwent NPi measurement during the first 3 days following brain insult. We examined the performance of NPi—alone or in combination with other baseline demographic (age) and radiologic (CT midline shift) predictors—to prognosticate unfavourable 6-month outcome (Glasgow Outcome Scale 1–3). A total of 145 severely brain-injured subjects (65 traumatic brain injury, TBI; 80 non-TBI) were studied. At each time point tested, NPi <3 was highly predictive of unfavourable outcome, with highest specificity (100% (90–100)) at day 3 (sensitivity 24% (15–35), negative predictive value 36% (34–39)). The addition of NPi, from day 1 following ABI to age and cerebral CT scan, provided the best prognostic performance (AUROC curve 0.85 vs. 0.78 without NPi, p = 0.008; DeLong test) for 6-month neurological outcome prediction. NPi, assessed at the early post-injury phase, has a superior ability to predict unfavourable long-term neurological outcomes in severely brain-injured patients. The added prognostic value of NPi was most significant when complemented with baseline demographic and radiologic information.

Inter-device reliability of the NPi-200 and NPi-300 pupillometers

The pupillary evaluation is an essential part of the neurological examination. Research suggests that the traditional examination of the pupil with a handheld flashlight has limited interrater reliability. Automated pupillometers were developed to provide an objective scoring of various pupillary parameters. The NPi-200 pupillometer is used for quantitative pupillary examinations, the NPi-300 was launched in July 2021 with enhanced features. The purpose of this study is to compare results from the NPi-200 to the NPi-300 to ensure that data are translatable across both platforms. This study examines the inter-device reliability of the NPi-200 compared to the NPi-300 in two cohorts: 20 patients at risk for cerebral edema and 50 healthy controls. Paired assessments of the devices were made from all participants. Each assessment included bilateral PLR readings within a 5-minute interval. Data showed high agreement between the two devices for the Neurological Pupil Index (NPi) reading (k = 0.94; CI: 0.91–0.99) and for pupil diameter assessment (k = 0.91; CI: 0.87–0.96). There is a very high level of agreement between the NPi-200 and NPi-300 among healthy controls and critically ill patients. Clinicians and researchers can interpret the results from either device equally.

Analysis of clinical features of tacrolimus-induced optic neuropathy.

Tacrolimus is associated with optic neuropathy. The clinical features of tacrolimus-induced optic neuropathy (TION) are unclear. The purpose of this article is to explore the clinical features of TION. TION-related case reports were collected and analysed by searching Chinese and English databases from 1989 to 31 December 2021. Twelve males and 7 females were included, with a median age of 54years (range 23-66). TION onset time ranged from 2months to 16years after administration, and the main clinical features were blurred vision (4 cases), decreased visual acuity (7 cases), decreased visual acuity (5 cases), grey films (3 cases), visual field damage (3 cases) and headache (2 cases). Fifteen patients developed bilateral optic neuropathy. Ophthalmological examination showed visual acuity ranging from 20/25 to blindness, pupillary examination revealed relative afferent pupillary defect in 9 patients and marked decrease in colour vision in 15 eyes. The optic disc showed pallor (10 cases), oedema (8 cases), atrophy (4 cases) and haemorrhage (2 cases). After discontinuation or dose reduction of tacrolimus, symptoms improved in 10 patients, 1 patient recovered completely, and 4 patients did not recover. TION presents diverse clinical manifestations. TION should be promptly identified and treated to prevent severe and permanent vision loss.

Pilot Study of Smartphone Infrared Pupillography and Pupillometry.

PurposeTo describe and validate a novel portable smartphone-based infrared pupillographer.Materials and MethodsA prototype infrared smartphone pupillographer device was custom designed for this project. Infrared video and photo pupillography were attempted on 12 patients with different clinical pupillary examination findings. Captured pupillography media files were assessed by three masked investigators, and the agreement between their qualitative clinical evaluation was tested against the evaluation of the neuro-ophthalmologist who performed the real-time examination and pupillography. Quantitative measurements of the pupillary diameter were performed by three investigators using a custom designed smartphone application on three different smartphones and on a personal computer. Measurements obtained by the three investigators using the smartphone and the desktop computer were compared.ResultsInfrared video pupillography of high quality was successfully captured for light and near pupillary reflexes, and infrared still photographs were obtained in light and dark conditions in 23 eyes of the 12 patients. Examination findings included relative afferent pupillary defect (n = 5), normal pupillary examination (n = 4), anisocoria (n = 2), and relative afferent pupillary reflex by reverse (n = 1). There was 100% agreement in the qualitative pupillary evaluation of the masked investigators compared with real time clinical examination. Quantitative measurements of pupillary size obtained on the smartphone and desktop computer showed excellent agreement among the three investigators with intraclass correlation (ICC) coefficient ranging from 0.982–0.986 (P<0.001) and 0.995 (P<0.001) for the smartphone and the desktop computer groups, respectively. Level of agreement ranged between −0.27 and 0.32. Mean pupil diameter errors were 0.03 ± 0.15 mm between groups (P = 0.248).ConclusionThis pilot study demonstrates the feasibility of smartphone-based infrared pupillography for high quality photo and video documentation of pupillary examination at the bedside and in the clinic with accurate and reproducible measurements of the pupillary size in light and dark conditions.