Bilateral tonic pupil during a migraine attack: a case report / Pupila tônica bilateral durante crise de enxaqueca: relato de caso

INTRODUCTION:Tonic pupil or Adie's pupil occurs due to parasympathetic denervation, and it is characterized by mydriasis with little or no response to light, with pupillary contraction to accommodation. It is caused by eye pathologies, such as infections, trauma, neoplasms, inflammatory diseases, and systemic diseases with autonomic dysfunction. Few cases have been reported of bilateral tonic pupils associated with migraine attacks. CASE REPORT: Our aimed to describe the case of a young female patient with a history of chronic migraine without aura, who presented acutely with bilateral pupillary mydriasis during a migraine attack, characterized as tonic pupil, and to discuss the possible causes of mydriasis during a migraine attack.

INTRODUÇÃO: A pupila tônica ou pupila de Adie ocorre devido à denervação parassimpática e é caracterizada por midríase com pouca ou nenhuma resposta à luz, com contração pupilar à acomodação. É causada por patologias oculares, como infecções, traumas, neoplasias, doenças inflamatórias e doenças sistêmicas com disfunção autonômica. Poucos casos foram relatados de pupilas tônicas bilaterais associadas a crises de enxaqueca. RELATO DE CASO: Nosso objetivo foi descrever o caso de uma paciente jovem, com história de enxaqueca crônica sem aura, que apresentou agudamente midríase pupilar bilateral durante uma crise de enxaqueca, caracterizada como pupila tônica, e discutir as possíveis causas da midríase durante uma crise de enxaqueca. ataque de enxaqueca.

Poder dióptrico del lente intraocular y dilatación en pacientes con catarata / Dioptric power of intraocular lens and dilatation in patients with cataract

ntroducción: la cirugía de catarata con implante de un lente intraocular es, hoy en día, el procedimiento quirúrgico más frecuente en todo el mundo. Su éxito depende de muchos factores, uno de los más importantes es el cálculo exacto del poder dióptrico del lente intraocular. Objetivo: comparar el cálculo del poder dióptrico del lente intraocular en los pacientes sin y con dilatación pupilar. Material y métodos: estudio longitudinal, en el que se determinó el cálculo del poder dióptrico del lente intraocular en pacientes con y sin dilatación pupilar. Las variables de estudio fueron: edad, género, ojo a estudiar, queratometría, longitud axial, profundidad de cámara anterior y poder dióptrico del lente intraocular. Se realizó estadística descriptiva y t de Student. Resultados: se estudiaron 37 pacientes, 23 mujeres y 14 hombres. La edad promedio fue de 68 ± 7.87 años. Se estudiaron 64 ojos, 30 fueron derechos y 34 izquierdos. Estadísticamente solo hubo diferencia significativa en K2 de la biometría ocular entre pacientes sin y con dilatación pupilar al obtenerse un valor de p ≤ 0.05. Conclusión: no existen cambios en el cálculo del poder dióptrico del LIO sin y con dilatación pupilar.

Background: Cataract surgery with intraocular lens implant is, nowadays, the most frequent surgical procedure in all the world. Its success depends on a lot of factors, one of the most important is the calculation of the exact dioptric power of intraocular lens. Objective: To compare the calculation of dioptric power of intraocular lens with and without dilatation in patients with cataract. Material and methods: Longitudinal study, the calculation of the dioptric power of the intraocular lens was determined in patients without and with pupillary dilation. The variables were age, gender, eye to study, keratometry, axial length, anterior chamber depth and dioptric power of the intraocular lens. Descriptive statistics and Student t test were performed. Results: There were 37 patients, 23 females and 14 males. The average age was 68 + 7.87 years. Sixty-four eyes were studied, 30 were right and 34 left. Statistically, there was only significant difference in K2 of the ocular biometry between patients without and with pupillary dilation when obtaining a value of p < 0.05. Conclusion: There are no changes in the calculation of the dioptric power of the Intraocular lens without and with pupillary dilation

Identificação da velocidade anormal da dilatação de pupila como biomarcador de lesão cerebral em pacientes neurocríticos / Identification of abnormal pupil dilation velocity as a biomarker of cerebral injury in neurocritically ill patients

RESUMO Objetivo: Calcular as velocidades médias da dilatação de pupila para classificar a gravidade da lesão derivada da escala de coma de Glasgow, estratificada por variáveis de confusão. Métodos: Neste estudo, analisaram-se 68.813 exames das pupilas para determinar a velocidade normal de dilatação em 3.595 pacientes com lesão cerebral leve (13 - 15), moderada (9 - 12) ou grave (3 - 8), segundo a escala de coma de Glasgow. As variáveis idade, sexo, raça, tamanho da pupila, tempo de permanência na unidade de terapia intensiva, pressão intracraniana, uso de narcóticos, classificação pela escala de coma de Glasgow e diagnóstico foram consideradas confundidoras e controladas para análise estatística. Empregou-se regressão logística com base em algoritmo de classificação com aprendizado de máquina para identificar os pontos de corte da velocidade de dilatação para as categorias segundo a escala de coma de Glasgow. Resultados: As razões de chance e os intervalos de confiança desses fatores se mostraram estatisticamente significantes em sua influência sobre a velocidade de dilatação. A classificação com base na área sob a curva mostrou que, para o grau leve, na escala de coma de Glasgow, o limite da velocidade de dilatação foi de 1,2mm/s, com taxas de falsa probabilidade de 0,1602 e 0,1902 e áreas sob a curva de 0,8380 e 0,8080, respectivamente, para os olhos esquerdo e direito. Para grau moderado na escala de coma de Glasgow, a velocidade de dilatação foi de 1,1mm/s com taxas de falsa probabilidade de 0,1880 e 0,1940 e áreas sob a curva de 0,8120 e 0,8060, respectivamente, nos olhos esquerdo e direito. Mais ainda, para o grau grave na escala de coma de Glasgow, a velocidade de dilatação foi de 0,9mm/s, com taxas de falsa probabilidade de 0,1980 e 0,2060 e áreas sob a curva de 0,8020 e 0,7940, respectivamente, nos olhos esquerdo e direito. Esses valores foram diferentes dos métodos prévios de descrição subjetiva e das velocidades de dilatação previamente estimadas. Conclusão: Observaram-se velocidades mais lentas de dilatação pupilar em pacientes com escores mais baixos na escala de coma de Glasgow, indicando que diminuição da velocidade pode indicar grau mais grave de lesão neuronal.

ABSTRACT Objective: To calculate mean dilation velocities for Glasgow coma scale-derived injury severity classifications stratified by multiple confounding variables. Methods: In this study, we examined 68,813 pupil readings from 3,595 patients to determine normal dilation velocity with brain injury categorized based upon a Glasgow coma scale as mild (13 - 15), moderate (9 - 12), or severe (3 - 8). The variables age, sex, race, pupil size, intensive care unit length of stay, intracranial pressure, use of narcotics, Glasgow coma scale, and diagnosis were considered as confounding and controlled for in statistical analysis. Machine learning classification algorithm-based logistic regression was employed to identify dilation velocity cutoffs for Glasgow coma scale categories. Results: The odds ratios and confidence intervals of these factors were shown to be statistically significant in their influence on dilation velocity. Classification based on the area under the curve showed that for the mild Glasgow coma scale, the dilation velocity threshold value was 1.2mm/s, with false probability rates of 0.1602 and 0.1902 and areas under the curve of 0.8380 and 0.8080 in the left and right eyes, respectively. For the moderate Glasgow coma scale, the dilation velocity was 1.1mm/s, with false probability rates of 0.1880 and 0.1940 and areas under the curve of 0.8120 and 0.8060 in the left and right eyes, respectively. Furthermore, for the severe Glasgow coma scale, the dilation velocity was 0.9mm/s, with false probability rates of 0.1980 and 0.2060 and areas under the curve of 0.8020 and 0.7940 in the left and right eyes, respectively. These values were different from the previous method of subjective description and from previously estimated normal dilation velocities. Conclusion: Slower dilation velocities were observed in patients with lower Glasgow coma scores, indicating that decreasing velocities may indicate a higher degree of neuronal injury.

Influence of pupillary dynamics on the defocus curve of eyes implanted with diffractive multifocal lenses: a randomized study / Influência da dinâmica pupilar na curva de desfoco de olhos implantados com lentes multifocais difrativas: um estudo randomizado

ABSTRACT Purpose: To evaluate the influence of pupil dynamics on the defocus profile and area-of-focus of eyes implanted with a diffractive multifocal intraocular lens (IOL). Methods: This prospective randomized trial was conducted at the Department of Ophthalmology, School of Medicine of Ribeirão Preto, University of São Paulo, Brazil. Thirty-eight patients were randomly assigned to receive the multifocal SN6AD1 (n=20) or the aspheric monofocal SN60WF (aIOL) (n=18) IOLs bilaterally. Dynamic pupillometry, visual acuity for distance and near, corrected and uncorrected, and a defocus profile were assessed postoperatively. The area-of-focus was calculated using an empirical polynomial model of the defocus profile. Results: Sixteen patients (32 eyes) in the multifocal SN6AD1 group and 17 patients (34 eyes) in the aspheric monofocal SN60WF group completed the 1-year follow-up. There were no significant between-group differences in monocular uncorrected distance or near visual acuity. The defocus profiles of the mfIOL group showed a double peak, whereas those of the aspheric monofocal SN60WF group showed only one peak, which is typical for a monofocal intraocular lens. The area-of-focus of the aIOL group (4.66 ± 1.51 logMARxD) was significantly different from that of the multifocal SN6AD1 (1.99 ± 1.31 logMARxD). Pupil size at maximum contraction after exposure to a flash of 30 cd/m2 for 1 second was significantly correlated with a better area-of-focus in the multifocal SN6AD1 group (r=0.54; p=0.0017), whereas this was not the case in the aspheric monofocal SN60WF group. Conclusion: These findings indicate that in eyes implanted with an multifocal SN6AD1, the smaller the pupil size, the better is the area-of-focus and hence the better is the visual performance. This correlation was not found for the aspheric monofocal SN60WF.(AU)

RESUMO Objetivo: Avaliar a influência da dinâmica pupilar na curva de desfoco de olhos implantados com lente intraoculares multifocais difrativas. Métodos: Estudo prospectivo e randomizado realizado na Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo - Departamento de Oftalmologia. Trinta e oito pacientes foram aleatoriamente designados para receber bilateralmente lentes intraoculares SN6AD1 (n=20) (mfIOL) ou SN60WF (n=18) (aIOL). Além da acuidade visual para longe e perto, corrigida e não corrigida, e curva de desfoco, foi ainda realizada pupilometria dinâmica. A área sob a curva de desfoco foi calculada usando um modelo polinomial empírico. Resultados: Um total de 16 e 17 pacientes (n=32 e 34 olhos) completaram 1 ano de seguimento nos grupos mfIOL e aIOL, respectivamente. Não houve diferenças significativas entre grupos para as acuidades visuais seja para longe ou perto. As curvas de desfoco do grupo mfIOL mostraram um pico duplo; enquanto o SN60WF mostrou apenas um pico, típico para uma lente intraoculares monofocal. A média da área sob a curva de desfoco do grupo aIOL foi (4,66 ± 1,51 logMAR.dp), e essa é estatisticamente significante diferente da métrica do grupo mfIOL (1,99 ± 1,31 logMAR.dp). A pupila na contração máxima após a exposição a um flash de 30 cd/m2 por 1 segundo foi significativamente correlacionada com uma melhor área de foco no grupo mfIOL (r=0,54; p=0,0017), essa relação não foi observada para o grupo aIOL. Conclusão: Estes dados indicam que quanto menor a pupila durante contração, melhor é a área sob a curva de desfoco e, portanto, o desempenho visual dos olhos implantados com essa mfIOL. Esta correlação não foi encontrada para lentes intraoculares monofocais.(AU)

Intraocular pressure and pupil diameter in healthy cats anesthetized with isoflurane and pre-medicated with isolated acepromazine or in combination with tramadol / [Pressão intraocular e diâmetro pupilar em gatos saudáveis anestesiados com isoflurano e pré-medicados com acepromazina isolada ou em combinação com tramadol]

The objective of this study was to determine changes on intraocular pressure (IOP) and pupil diameter (PD) in healthy cats anesthetized with isoflurane, and premedicated with acepromazine alone or in combination with tramadol. Thirty cats were allocated in two groups (n=15/each) and were treated with acepromazine (AG) or acepromazine/tramadol (ATG). PD and IOP were assessed before and following 30 (PM1), and 40 minutes (PM2) of treatments. Anesthesia was induced with propofol, and IOP and DP were recorded (A10) at 10 minute intervals until the end of anesthesia (A40). IOP decreased in AG and ATG, when comparing baseline with PM1. IOP decreased only in AG, in comparisons between baseline and PM2. During anesthesia, IOP did not change within and between groups. Comparisons between baseline with those recorded at PM1 and 2 showed that PD increased in the ATG. During anesthesia, PD decreased significantly in AG and ATG. Both protocols maintained the IOP within the reference range to perform corneal or intraocular surgery in healthy cats but did not sustain pre-anesthetic pupil dilation observed in ATG.(AU)

O objetivo do presente artigo é determinar possíveis alterações na pressão intraocular (PIO) e no diâmetro pupilar (DP) em gatos saudáveis anestesiados com isoflurano e pré-medicados com acepromazina isolada ou em combinação com acepromazina/tramadol. Trinta gatos saudáveis foram distribuídos aleatoriamente em dois grupos (n=15/cada) e tratados com acepromazina (GA) ou acepromazina/tramadol (GAT). DP e PIO foram avaliadas antes (basal) e após 30 (PM1) e 40 minutos (PM2) dos tratamentos. A anestesia foi induzida com propofol, e a PIO e o DP foram registrados (A10) a cada 10 minutos até o final da anestesia com isoflurano (A40). Ao se compararem os valores obtidos no basal com PM1, a PIO diminuiu em GA e GAT; com PM2, a PIO reduziu apenas no GA. Durante a anestesia, a PIO não diferiu dentro e entre os grupos. Comparações entre os valores basais e os registrados em PM1 e em PM2 mostraram que a DP aumentou significativamente no GAT. Durante a anestesia, o DP diminuiu significativamente em GA e GAT. Ambos os protocolos mantêm a PIO dentro dos valores de referência para realizar cirurgias corneanas ou intraoculares em gatos saudáveis, mas não sustentam a dilatação pupilar pré-anestésica observada em GAT.(AU)

The Canabrava Ring, an open ring-shaped pupil expander for cataract surgery associated with iris colobomata: a case report / Aplicação de anel expansor de pupila pequena em formato de anel aberto para cirurgia de catarata em coloboma de íris: relato de caso

ABSTRACT In this report, we describe a new pupil expander device that was used to obtain adequate pupil dilation and centering in a patient with an iris coloboma. Specifically, we describe the case of a patient with an iris coloboma; a Malyugin ring was inserted to facilitate dilation during phacoemulsifi­cation surgery. One of the scrolls did not engage which resulted in an uneven distribution of forces and an eccentric pupil. A Canabrava Ring was then implanted that promoted effective pupillary dilation and remained stable and effective throughout the surgical procedure.

RESUMO Neste relato, descrevemos um novo dispositivo expansor pupilar que foi usado obter adequada dilatação e centralização da pupila em um paciente com coloboma de íris. Especificamente, descrevemos um caso de cirurgia de facoemulsificação em um paciente com coloboma de íris associado à pupila pequena e que, previamente, tentou-se sem sucesso o uso do expansor Malyugin Ring, que provocou uma dilatação pupilar descentrada. Entretanto, com o uso do expansor de íris Canabrava Ring, a pupila permaneceu dilatada e centrada durante toda a cirurgia, permitindo a realização de um procedimento seguro.

Comparision effects of solifenacin, darifenacin, propiverine on ocular parameters in eyes: A prospective study

ABSTRACT Objective To evaluate the effects of solifenacin, darifenacin, and propiverine on nasal-, subfoveal-, temporal choroidal thicknesses (NCT, SFCT, TCT), intraocular pressure (IOP) and pupil diameter (PD). Materials and Methods Patients with overactive bladder (OAB) diagnosed according to The International Continence Society were administered with solifenacin, darifenacin or propiverine on a daily basis between November 2017 and May 2018. NCT, SFCT, TCT, IOP, and PD of these patients were measured and compared as initial, fourth and twelfth weeks. Results A total of 165 patients (330 eyes) with OAB were evaluated. Solifenacin (n=140) significantly reduced IOP from 17.30±2.72 mmHg to 16.67±2.56 mmHg (p=0.006) and 16.57±2.41 mmHg (p=0.002), at the fourth and twelfth weeks, respectively. Darifenacin (n=110) significantly reduced NCT from 258.70±23.96 μm to 257.51±22.66 μm (p=0.002) and 255.36±19.69 μm (p=0.038), at the fourth and twelfth weeks, respectively. Propiverine (n=80) significantly increased PD from 4.04±0.48 mm to 4.08±0.44 mm (p=0.009) and 4.09±0.45 mm (p=0.001), at the fourth and twelfth weeks, respectively. Conclusion These findings can help to decide appropriate anticholinergic drug choice in OAB patients. We finally suggest further well-designed randomized prospective studies with a larger population to evaluate the anticholinergic-related complications in eyes.

Centration in refractive surgery / Centralização em cirurgia refrativa

ABSTRACT The point of centration for refractive surgery is a theme of great importance that generates considerable discussion among specialists and surgeons in the field. Notably, any changes in light can alter the size of the pupil, and the visual axis of the fixation line to the fovea is unique in each patient. A variety of options have been described in the literature with respect to centration in refractive surgery, and the results differ among these methods. No consensus has been established regarding the ideal refractive surgery technique for evaluation of centration in each patient that will yield a satisfactory surgical result.

RESUMO O ponto de centralização da cirurgia refrativa é tema de grande importância e gera muita discussão entre especialistas e cirurgiões da área. Afinal, qualquer alteração na luz pode alterar o tamanho da pupila, além disso, o eixo visual da linha de fixação para a fóvea é particular em cada paciente. Existem opções para centralização em cirurgia refrativa com resultados diferentes na literatura. Ainda não há consenso sobre a melhor técnica em cirurgia refrativa que avalie cada caso específico visando um resultado cirúrgico final satisfatório.

Application of Eye Tracker in Lie Detection / 法医学杂志

Objective To investigate the application value of eye tracking in lie detection. Methods The 40 subjects were randomly divided into two groups. The pupil diameter, fixation duration, points of fixation and blink frequency of the subjects in the experimental group in observing target stimulation and non-target stimulation were recorded with eye tracker after they accomplished the mock crime. The eye movement parameters of subjects in the control group were directly collected. The differences in eye movement parameters of the experimental group and the control group in observing target stimulation and non-target stimulation were analyzed by t-test. Pearson coefficient analysis of correlation between eye movement parameters that had differences was conducted. The effectiveness of eye movement parameters to distinguish between the experimental group and the control group was calculated by the receiver operator characteristic （ROC） curve. Results Participants from the experimental group had shorter average pupil diameter, longer average fixation duration and fewer fixation points （P<0.05）, but the differences in blink frequency had no statistical significance. The differences in the above indicators of the control group in observing target stimulation and non-target stimulation had no statistical significance. The average fixation duration showed a negative correlation with fixation points （r=-0.255, P<0.05）; the average fixation duration showed a negative correlation with average pupil diameter （r=-0.218, P<0.05）; the fixation points showed a positive correlation with average pupil diameter （r=0.09, P<0.05）. The area under the curve of average pupil diameter, average fixation duration and fixation points was 0.603, 0.621 and 0.580, respectively. Conclusion The average pupil diameter, average fixation duration and fixation points obtained by the eye tracker under laboratory conditions can be used to detect lies.

Body mass index and blood pressure correlate in nursery school children in Port Harcourt, Nigeria

Introduction: Blood pressure (BP) is a vital indicator of health in children and adults. The relationship between body mass index (BMI) and BP is well established in children; and BMI has been shown to maintain an independent relationship with BP even after controlling for many other variables that characterize individuals. High BMI significantly increases the risk of hypertension. Epidemiological studies in various countries have been conducted to determine the relationship between BP and BMI in children; similar comparative studies are lacking in Nigeria, thus necessitating this study.Aim: To determine the relationship between BMI and BP in nursery pupils in Port Harcourt.Methods: Multi-staged sampling technique was used to select 710 nursery pupils from 13 schools. Biodata was obtained using a selfadministered (parent) questionnaire. Height and weight measurement were taken, and BMI calculated. BP was measured using a mercury sphygmomanometer; and relevant data analysis done.Result: There were 710 pupils 365 (51.4%) males and 345(48.6%) females. Mean systolic BP was 93.2 ± 10.6mmHg (70­130 mmHg); while mean diastolic BP was 58.8 ± 8.0mmHg(40 ­ 88.7 mmHg). Mean BMI was 15.0 ± 1.8 kg/m2(9.1 - 25.5 kg/m2). There is a positive linear relationship between systolic and diastolic BP and BMI (correlation coefficient r = 0.03). Obese pupils had significantly higher BP rates (25%) (X2= 15.35, p =0.002). BMI and height were significant predictors of diastolic BP (p<0.001).Conclusion: There is a positive correlation between BMI and BP; and high BMI is an important predictor of high BP in nursery pupils in Nigeria

Urrets-Zavalia Syndrome Following Trabeculectomy

PURPOSE: We report a case of Urrets-Zavalia syndrome with a fixed dilated pupil after an uneventful trabeculectomy.CASE SUMMARY: Trabeculectomy was performed on a 51-year-old male who had a history of recurrent uveitis in the left eye, with uncontrolled intraocular pressure despite maximally-tolerated medial therapy. There was no unexpected event during surgery. Topical 1% atropine was used for only 2 days after surgery. In the early postoperative period, 1% prednisolone and 0.3% ofloxacin were given four times a day, then gradually reduced. One month later, only 1% prednisolone was given once a day. Intraocular pressure in his left eye was well controlled from 8–14 mmHg after surgery. One month after surgery, the pupils remained dilated. There was no reaction to topical 2% pilocarpine and no relative afferent pupillary defect or posterior synechia.CONCLUSIONS: Our case, although rare, suggests that Urrets-Zavalia syndrome should be considered in patients with well-controlled intraocular pressure after uneventful trabeculectomy.

Uso de retinógrafo portátil como ferramenta no rastreamento de retinopatia diabética / Use of a handheld fundus camera as a screening tool for diabetic retinopathy

Resumo Objetivo: Determinar a concordância do retinógrafo portátil Pictor Plus, na ausência de midríase, com a retinografia digital e avaliar a sua acurácia como método de rastreio da retinopatia diabética (RD). Métodos: Estudo transversal, mascarado para o observador, avaliando 100 olhos de 51 pacientes diabéticos. Foram realizadas retinografias com o Pictor Plus com e sem midríase, seguidos de retinografia convencional com o retinógrafo IMAGEnet por técnico treinado. As imagens obtidas foram analisadas por oftalmologista especialista em retina e classificadas normais, presença de edema macular diabético, retinopatia não proliferativa (inicial, moderada e grave) e retinopatia proliferativa, além de análise inviável. A concordância entre os resultados foi avaliada via coeficiente Kappa. As imagens foram agrupadas em normais e alteradas e estas em RD de alto risco e RD de baixo risco. Avaliou-se ainda a sensibilidade, especificidade, valores preditivos positivos e negativos, em relação à retinografia convencional. Resultados: Oitenta e nove por cento das imagens foram consideradas viáveis para classificação. Pouco mais de 31% dos olhos avaliados foram considerados como normais pelas três tecnologias. O exame com Pictor na ausência de midríase apresentou altos índices de sensibilidade e especificidade para a classificação normal (92,9% e 93,4%) e RD de alto risco (82,9% e 97,9%) e bons resultados para RD de baixo risco (75,0% e 87,0%). Conclusão: O Pictor Plus apresentou altos níveis de concordância com a retinografia digital ao discriminar exames normais de alterados e portadores de RD de baixo e alto risco. Foram verificadas ainda altas sensibilidade e especificidade desta ferramenta, se comparados à retinografia padrão.

Abstract Purpose: Determine the effectiveness of the use a portable handheld fundus camera as a screening method for diabetic retinopathy, compared to regular digital retinography. Methods: This is a cross-sectional, observer-masked study, evaluating 100 eyes of 51 diabetic patients undergoing a routine dilated retinography for diabetic retinopathy. Fundus images pre and post-dilation we captured by Pictor Plus (Volk Optical Inc., Mentor, USA), followed by routine digital retinography by IMAGEnet (Topcon Medical Systems, New Jersey, USA). All exams were performed by a trained technician on the same occasion. The images were analyzed and graded by a masked retina specialist and classified as normal, presence of diabetic macular edema, nonproliferative diabetic retinopathy (initial, moderate and severe) and proliferative diabetic retinopathy. The ungradable images were recorded and excluded from analyses. The agreement between results obtained by the three methods was evaluated via Kappa coefficient. Sensitivity, specificity, positive and negative predictive values in relation to IMAGEnet images were also determined. Results: Images were gradable in 89% of pre-dilation photos. Pictor Plus pre-dilation images had high sensitivity and specificity in identifying normal eyes (92.9% and 93.4%) and in vision-threatening DR (82.9% and 97.9%) both when compared to IMAGEnet results. Conclusion: Pictor can capture retinal images of sufficient quality to screen for DR with and without dilation. Single retinal images obtained using Pictor can identify eyes with vision-threatening DR with high sensitivity and specificity compared to routine IMAGEnet images.

Pupilometría: Conceptos Fisiológicos y Clínicos Aplicados al Paciente Neurocrítico / Pupillometry: Physiological and Clinical Concepts Applied to the Neurocritical Patient

En la Unidad de Cuidado Neurocrítico (UCN), el examen neurológico constituye un parámetro fundamental en la evaluación de la evolución de pacientes admitidos en esta unidad; uno de los principales elementos de esta inspección es la valoración de las pupilas, establecida por la estimulación del reflejo pupilar a la luz, ya sea de forma manual o mediante un pupilómetro para medir el diámetro pupilar y su reactividad, lo que se ha constituido como un primer y en algunos contextos casi que el único signo clínico que manifiestan los pacientes con traumas o lesiones encefálicas al momento que hay un empeoramiento del cuadro patológico, por lo que se ha propuesto como una herramienta eficaz para establecer un pronóstico y seguimiento en estos pacientes.

At the neuro-critical care units, the neurological examination constitutes a fundamental parameter in the evaluation of the evolution of patients admitted into these units. One of the main elements of this inspection is the assessment of the pupils, established by the pupillary light reflection stimulation, either manually or by means of a pupilometer to measure the pupillary diameter and its reactivity. It has been constituted as a first, and in some contexts, almost the only clinical sign manifested by patients with traumas or brain injuries at the time where there is a worsening of the pathological picture, so it has been proposed as an effective tool to establish a prognosis and follow-up in these patients.

Efficacy of preoperative nonsteroidal anti-inflammatory drug and the re-dilation technique in minimizing miosis after femtosecond laser in cataract surgery / Eficácia do AINE pré-operatório e da técnica de re-dilatação em minimizar a miose na cirurgia de catarata com laser de femtosegundo

ABSTRACT Purpose: To assess the efficacy of using a nonste­roidal anti-inflammatory drug preoperatively and of applying the re-dilation technique when necessary to minimize pupil size variation when comparing the degree of mydriasis before femtosecond laser pretreatment with that at the beginning of phacoemulsification. Methods: This retrospective study included patients who underwent cataract surgery using the LenSx (Alcon Laboratories, Inc., Fort Worth, TX). Our routine dilating regimen with flurbiprofen, tropicamide, and phenylephrine was used. The re-dilation technique was applied on eyes that manifested with a pupillary diameter that was smaller than the programmed capsulotomy diameter after laser pretreatment. The technique consists of overcoming pupillary contraction by instilling tropicamide and phenylephrine before phacoemulsification. Pupil size was assessed before femtosecond laser application and at the beginning of phacoemulsification. Results: Seventy-five eyes (70 patients) were included. Nine (12%) eyes underwent the re-dilation technique. There was no significant difference in mean pupillary diameter and mean pupillary area between the two studied surgical time points (p=0.412 and 0.437, respectively). The overall pupillary area constriction was 2.4 mm2. Immediately before opening the wounds for phacoemulsification, none of the eyes presented with a pupillary diameter <5 mm, and 61 (85.3%) eyes had a pupillary diameter >6 mm. Conclusion: Preoperative administration of nonsteroidal anti-inflammatory drug and the re-dilation technique resulted in no significant pupil size variation in eyes that were pretreated with the femtosecond laser, when comparing the measurements made before the laser application and at the beginning of phacoemulsification. This approach can avoid the need to proceed with cataract extraction with a constricted pupil.

RESUMO Objetivo: Avaliar a eficácia do uso de anti-inflamatório não-esteróide no pré-operatório e aplicação da técnica de re-dilatação quando necessária para minimizar a variação do tamanho pupilar ao comparar o grau de midríase antes do tra­tamento com laser de femtosegundo no início da facoemulsificação. Métodos: Esse estudo retrospectivo incluiu pacientes que foram submetidos à cirurgia de catarata usando o LenSx (Alcon Laboratories, Inc., Fort Worth, TX). Nosso regime de di­latação de rotina com flurbiprofeno, tropicamida e fenilefrina foi usado. A técnica de re-dilatação doi aplicada em olhos que se manifestaram com um diâmetro pupilar menor do que o diâmetro da capsulotomia programado após o pré-tratamento a laser. A técnica consiste em superar a contração pupilar pela instilação de tropicamida e fenilefrina antes da facoemulsificação. O tamanho pupilar foi avaliado antes da aplicação do laser de femtosegundo e no inicio da facoemulsificação. Resultados: Setenta e cinco olhos (70 pacientes) foram incluídos. Nove (12%) olhos foram submetidos à técnica de re-dilatação. Não houve diferença significativa no diâmetro pupilar médio e na área pupilar média entre os dois tempos cirúrgicos estudados (p=0,412 e 0,437, respectivamente). A constrição global da área pupilar foi de 2,4 mm2. Imediatamente antes de abrir as incisões para a facoemulsificação, nenhum dos olhos apresentava diâmetro pupilar <5 mm e 61 (85,3%) olhos apresentavam um diâmetro pupilar >6 mm. Conclusões: O administração pré-operatória de anti-inflamatório não-esteróide e da técnica de re-dilatação resultaram em uma variação significativa do tamanho pupilar em olhos que foram pré-tratados com laser de femtosegundo, comparando as medidas realizadas antes da aplicação do laser e no inicio da facoemulsificação. Essa abordagem pode evitar a necessidade de prosseguir com a extração da catarata com uma pupila contraída.

Objective Verification of Physiologic Changes during Accommodation under Binocular, Monocular, and Pinhole Conditions

BACKGROUND: To objectively investigate accommodative response to various refractive stimuli in subjects with normal accommodation. METHODS: This prospective, non-randomized clinical trial included 64 eyes of 32 subjects with a mean spherical equivalent −1.4 diopters (D). We evaluated changes in accommodative power, pupil diameter, astigmatic value, and axis when visual stimuli were applied to binocular, monocular (dominant eye, non-dominant eye, ipsilateral, and contralateral), and pinhole conditions. Visual stimuli were given at 0.25 D (4 m), 2 D (50 cm), 3 D (33 cm), and 4 D (25 cm) and accommodative response was evaluated using open view binocular autorefractor/keratometer. RESULTS: The accommodative response to binocular stimulus was 90.9% of the actual refractive stimulus, while that of the monocular stimulus was 84.6%. The binocular stimulus induced a smaller pupil diameter than did the monocular stimulus. There was no difference in accommodative response between the dominant eye and non-dominant eye or between ipsilateral and contralateral stimuli. As the refractive stimuli became stronger, the absolute astigmatic value increased and the direction of the astigmatism axis became more horizontal. Pinhole glasses required 10%–15% less accommodative power compared with the monocular condition. CONCLUSION: Binocular stimuli enable more precise and effective accommodation than do monocular stimuli. Accommodative response is composed of 90% true accommodation and 10% pseudo-accommodation, and the refractive stimulus in one eye affects the contralateral eye to the same extent. This should be taken into account when developing guidelines for wearing smart glasses while driving, as visual stimulation is applied to only one eye, but far distance attention is constantly needed. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03557346

Relationship between facial attractiveness and pupil diameter in young adults / Relação entre a atratividade facial e diâmetro pupilar em adultos jovens / Relación entre atratividad facial y diámetro de la pupila en adultos jóvenes

The objective of this study was to investigate whether there is a relationship between pupil diameter and facial attractiveness. Participated in the study 60 young adults (30 men and 30 women) between 18 and 26 years of age (M=20.65, SD=2.20). Ten different unfamiliar neutral faces (five men and five women) were used as stimuli. The pupil diameter of each face was manipulated with pupil diameters of 2, 3, 4, 5 and 6mm (10 faces x5 pupil diameters=50 stimuli). A two-step study was carried out with the same sample and the same sets of faces, seeking to understand the difference of responses between subjects of both sexes. In phase I, result indicated a significant difference in relation to the pupil diameter factor for both the men (ꭓ²=21.93, p<.05) and the women (ꭓ²=44.73, p<.05). In phase II, the results indicated significant differences in relation to the pupil size [F(1, 234)=19.06, p<0.05]. The post-hoc Tukey HSD test showed that both the men and the women differently judged the faces with a pupil diameter of 2mm in relation to the faces with pupil diameters of 3, 4, 5 and 6mm (p<.05). Also, a significant difference between the diameter of 5mm in relation to the diameter of 3mm (p<.05). In general, the results indicate that the pupil diameter is a structural component of the human face that plays an important role in the process of judging facial attractiveness.

O objetivo deste estudo foi investigar a relação entre o diâmetro da pupila e a atratividade facial. Participaram da pesquisa 60 jovens com idade entre 18 e 26 anos. Foram utilizadas dez faces de adultos jovens, manipulou-se o diâmetro de cada pupila com variações de 2, 3, 4, 5 e 6mm. Realizou-se um estudo em duas etapas: na fase I, o resultado indicou diferença significativa para o fator de diâmetro pupilar tanto para homens quanto para mulheres (p<0,05). Na fase II, os resultados indicaram diferenças significativas em relação ao tamanho da pupila (p<0,05). O teste post-hoc Tukey mostrou que tanto os homens quanto as mulheres avaliaram diferentemente as faces com diâmetro pupilar de 2mm (p<0,05). Em geral, os resultados indicam que o diâmetro da pupila é um componente da face humana que desempenha um importante função no processo de julgamento da atratividade facial.

El objetivo de este estudio fue investigar si existe una relación entre el diámetro pupilar y el atractivo facial. Participaron en la estudio 60 adultos jóvenes (30 hombres y 30 mujeres) entre 18 y 26 años de edad (M=20.65, DE=2.20). Se utilizaron como estímulos diez rostros neutrales desconocidos diferentes (cinco hombres y cinco mujeres). El diámetro de la pupila de cada cara se manipuló con diámetros de pupila de 2, 3, 4, 5 y 6mm (10 caras x5 diámetros de pupila=50 estímulos). Se realizó un estudio en dos etapas con la misma muestra y los mismos conjuntos de caras buscando entender la diferencia de respuestas entre sujetos de ambos sexos. En la fase I, el resultado indicó una diferencia significativa en relación al factor de diámetro de la pupila tanto para los hombres (ꭓ²=21.93, p <0.05) como para las mujeres (ꭓ²=44.73, p<0.05). En la fase II, los resultados indicaron diferencias significativas en relación al tamaño de la pupila [F(1, 234)=19,06, p<0,05]. La prueba post-hoc de Tukey HSD mostró que tanto los hombres como las mujeres evaluaron de manera diferente las caras con un diámetro pupilar de 2mm con respecto a las caras con diámetros pupilares de 3, 4, 5 y 6mm (p<0,05). Se observó una diferencia significativa entre el diámetro de 5mm en relación al diámetro de 3mm (p<0,05). En general, los resultados indican que el diámetro de la pupila es un componente estructural de la cara humana que desempeña una importante función en el proceso de juicio del atractivo facial.

Transscleral Cyclopexy Using Partial-Thickness Scleral Flap for Repairing Cyclodialysis Cleft: a Case Report

PURPOSE: To report a case of a cyclodialysis cleft that was successfully managed with gonioscopically guided transscleral cyclopexy using partial-thickness scleral flap. CASE SUMMARY: A 44-year-old man complaining of blurred vision in the left eye after blunt trauma was referred to our hospital. The intraocular pressure (IOP) was 4 mmHg and the visual acuity was counting finger. Gonioscopy examination revealed cyclodialysis cleft from 3 to 6 o'clock and fundus examination revealed macular folds. After the failure of conservative medical therapy and laser photocoagulation, gonioscopically guided transscleral cyclopexy using partial-thickness scleral flap was performed. Four months later, the IOP was 18 mmHg, the visual acuity was 0.8, and fundus examination showed the disappearance of the macular folds. CONCLUSIONS: Transscleral cyclopexy using partial-thickness scleral flap is a safe and effective method to treat hypotony maculopathy due to cyclodialysis and to minimize pupil distortion.

Homonymous Quadrantanopia Caused by Occipital Lobe Ulegyria

PURPOSE: We report a case of homonymous quadrantanopia caused by occipital lobe ulegyria. CASE SUMMARY: A 23-year-female was referred to our clinic because of a visual field defect incidentally discovered during preoperative evaluation for refractive surgery at another clinic. However, she did not report any symptoms. She had no systemic diseases. Visual acuity was 20/20 in both eyes, and the color vision test was normal. Both pupils exhibited normal responses to light and near stimulations. In fundus examinations, the right optic disc was normal and the left contained drusen. Automated perimetry revealed right lower homonymous quadrantanopia with macular sparing. Brain magnetic resonance imaging revealed areas of ulegyria involving the left occipital lobe, consistent with the visual field defect. A follow-up visual field test performed 5 months later yielded the same result. CONCLUSIONS: Neuroimaging should be performed in patients with homonymous visual field defects to determine the location and etiology of the brain lesions. Occipital lobe ulegyria can cause homonymous quadrantanopia in the absence of any neurological problem.

An Unusual Case of Benign Episodic Bilateral Mydriasis

PURPOSE: Although benign episodic mydriasis has been rarely reported worldwide, most of the reports so far have occurred in unilaterally. To report an unusual case of benign episodic bilateral mydriasis. CASE SUMMARY: Nineteen-year-old woman who presented with intermittent dilation of both pupils two months ago. She had difficulty on reading and doing tasks because of her visual blur. This symptom usually lasted for 1–2 hours, occurred once every 2–3 days, most frequently during stressful situations. Headaches and dizziness accompanied the eye symptoms, and her pupils were both 5 mm in a lighted room and both 7 mm in a dark room. All tests, including brain magnetic resonance imaging, showed no abnormal findings. We diagnosed her as benign episodic bilateral mydriasis. The frequency of her symptoms decreased during the university vacation period. CONCLUSIONS: In the absence of ophthalmologic or neurologic abnormalities other than headaches in patients with transient mydriasis, benign episodic mydriasis should be considered as a differential diagnosis. Although benign episodic bilateral mydriasis has a unilateral predominance, for the first time the authors report that benign episodic mydriasis may occur in both eyes during same episode.

Iridocorneal Endothelial Syndrome with Features of Posterior Polymorphous Corneal Dystrophy

PURPOSE: To report a case of iridocorneal endothelial syndrome, which overlapped with some of the features of posterior polymorphous corneal dystrophy. CASE SUMMARY: A 61-year-old female presented with tearing pain and blurred vision in her left eye, which was aggravated in the morning. The symptom started approximately 1 year prior to her visit. At the initial visit, the visual acuities were 1.0 in both eyes and the intraocular pressures were normal. On slit-lamp examination, a single pair of horizontal parallel lines was observed at the central corneal endothelial layer in the right eye. In contrast, multiple pairs of oblique parallel lines were observed in the left eye. The lines of the lesions were more prominent and wavier in the left eye than those of the right eye. The overlying cornea was clear, and the corneal thicknesses were in the normal range in both eyes. Using a gonioscopic examination, localized peripheral anterior synechiae were observed only in the left eye. The pupil and iris were normal in both eyes. On specular microscopic examination, the corneal endothelial cell size in the right eye increased and the corneal endothelial density decreased to 668 cells/mm². In the left eye, multiple abnormal endothelial cells with dark-light reversal were observed. In conclusion, the patient was subsequently diagnosed with iridocorneal syndrome, rather than posterior polymorphous corneal dystrophy. CONCLUSIONS: Posterior polymorphous corneal dystrophy and iridocorneal endothelial syndrome may present with many similarities. Therefore, in cases of uncertain diagnosis, an understanding of the clinical features is important for proper diagnosis.