Pseudomyopia with paradoxical accommodation: a case report

Background Pseudomyopia is caused by increased refractive power by ciliary muscle spasm. Most patients cannot overcome pseudomyopia spontaneously; therefore, treatment of pseudomyopia is fastidious and needs a multidisciplinary approach. We report a case of unusual pseudomyopia with paradoxical accommodation, straining eyes to induce emmetropia at far distance and relaxing eyes to focus at near objects, contrary to physiological accommodation. Case presentation A 33-year-old woman experienced intermittent distant vision discomfort. This occurred at least a few hundred times daily. She could see near objects clearly; however, distant objects could be seen clearly only when she strained her eyes. Uncorrected distance visual acuity was 20/20 and manifest refraction (MR) in both eyes in the relaxed state was approximately − 2.5 D. MR changed to approximately − 0.5 D when she grimaced and strained her eyes when attempting to focus on distant letters. Her response was contrary to the physiological accommodative response. Cycloplegic refraction was approximately 0.0 D. Binocular autorefractor/keratometer was used to objectively evaluate her refractive response and pupil reaction according to accommodative stimulation. The IOL Master was used to evaluate the anterior chamber depth (ACD), lens thickness (LT), and pupil diameter with relaxed and strained eyes. For stepwise static accommodative stimuli (1–5 D), the refractive responses were correspondingly stepwise, similar to those elicited by healthy individuals. However, contrary to physiological accommodation, she strained her eyes to see distant objects and relaxed them to see near objects. There was no change in pupil diameter despite the accommodative stimuli being maximum. Biometry results showed that ACD deepened and LT flattened with eye strain, which were contrary to those during physiological accommodation. Conclusions We report a rare case with reverse of physiological accommodative response. When patients complain of unusual distant visual discomfort, pseudomyopia with paradoxical accommodation should be considered.

Cataract type and pupillary response to blue and white light stimuli

We evaluated the pupil reaction to blue and white light stimulation in 70 eyes with cataract and in 38 eyes with a selective blue-light filtering intra-ocular lens. The diameter of the pupil before stimulation was set as baseline (BPD) and, after a stimulus duration of 1 s, the post-illumination pupillary response (PIPR) was measured using an electronic pupillometer. The BPD showed no significant difference among three grades of nuclear sclerosis (NS). In contrast, the PIPRs differed significantly among the NS grades eyes including with and without subcapsular cataract (SC) and IOL eyes for white light (p < 0.05, Kruskal–Wallis test), but not for blue light. Subcapsular opacity did not affect the BPD or PIPR in all cataract grades for either light stimulus. The tendency of larger PIPR in the pseudophakic eyes than the cataract eyes for both lights, however significant difference was found only for white light (p < 0.05 for white light, p > 0.05 for blue light). Our study demonstrates retention of the PIPR for blue light, but not for white light in cataract eyes. We also confirmed that the pupillary response in pseudohakic eyes with a selective blue light-filtering intra ocular lens was greater than that in cataractous eyes for white light.

Assessing pupil reaction to light using ultrasound in a sick neonate with Hypoxic Ischemic Encephalopathy

Examining pupil reaction to light is an important component of the neurological examination in infants with hypoxic ischemic encephalopathy (HIE) to determine eligibility for therapeutic hypothermia (TH) and as part of serial neurological assessment for prognostication. Pupil examination can be challenging in critically ill infants with generalized edema. In this paper I report a simple technique using bedside point of care ultrasound to examine the pupil reaction to light in an infant with moderate HIE undergoing therapeutic hypothermia.

CHANGES IN BINOCULAR PUPILLOMETRY IN ATHLETES AFTER HIGH EXERCISE STRESS

Aim. The article deals with studying the changes in binocular pupillometry to establish vegetative activity in athletes after high exercise stress. Materials and methods. 25 male athletes aged 19–34 years with no health limitations participated in the study. We estimated a set of the commonly accepted parameters of pupillometry (pupil diameter, pupil reaction initiation time, pupil constriction diameter, pupil constriction velocity) by measuring pupil reaction to a light stimulus with the help of a non-contact pupilometer (KVAZAR, Moscow). The examination was conducted prior to physical stress and 5, 15, and 30 minutes after. Intertrack-750 treadmill (SchillerAG, Switzerland) was used for testing. Results. The results obtained in a pupillometric study prove that there is a predominance of the sympathetic component in athletes at maximal load accompanied by emotional stress. After physical stress accompanied by fatigue and nervous system exhaustion, there is a pronounced predominance of the parasympathetic component. Conclusion. The data obtained prove that binocular pupillometry can be effectively used in sports medicine to estimate vegetative tone and regulatory mechanisms in athletes.

Effect of Pre-Hospital Intubation in Patients with Severe Traumatic Brain Injury on Outcome: A Prospective Cohort Study

Secondary injuries are associated with bad outcomes in the case of severe traumatic brain injury (sTBI). Patients with a Glasgow Coma Scale (GCS) < 9 should undergo pre-hospital intubation (PHI). There is controversy about whether PHI is beneficial. The aim of this study was to estimate the effect of PHI in patients after sTBI. A multicenter, prospective cohort study was performed in Switzerland, including 832 adults with sTBI. Outcomes were death and impaired consciousness at 14 days. Associations between risk factors and outcomes were assessed with univariate and multivariate Cox models for survival, and univariate and multivariate regression models for impaired consciousness. Potential risk factors were age, GCS on scene, pupil reaction, Injury Severity Score (ISS), PHI, oxygen administration, and type of admission to trauma center. Age, GCS on scene < 9, abnormal pupil reaction and ISS ≥ 25 were associated with mortality. GCS < 9 and ISS ≥ 25 were correlated with impaired consciousness. PHI was overall not associated with short-term mortality and consciousness. However, there was a significative interaction with PHI and major trauma. PHI improves outcome from patients with sTBI and an ISS ≥ 25.

Tonic Pupil

A tonic pupil is caused by a lesion affecting the postganglionic parasympathetic innervation of the pupil. It can be an incidental finding on examination or associated with visual symptoms, such as photophobia. In this chapter, we begin by briefly reviewing the differential diagnosis of photophobia. We next review the characteristic features of tonic pupil, which include poor pupil reaction to light, segmental palsy of the iris sphincter muscle, accommodation palsy, and tonic pupil reaction to near. We then review the causes of tonic pupil, which include viral infections, trauma, orbital surgery, or neurologic diseases, such as Miller Fisher syndrome. We then go on to discuss the clinical features, diagnostic evaluation, and prognosis of idiopathic tonic pupil, which is also known as an Adie pupil. Lastly, we briefly discuss the management options for tonic pupil, which include use of sunglasses and dilute pilocarpine eye drops.