[Clinical aspects of the abnormal pupillary response; shedding light on pupillary response]. / De pupil belicht.

Testing the pupillary response is a quick and valuable diagnostic measure for certain neurological and ophthalmological diseases in patients. The pupillary response can aid in localizing abnormalities in important parts of the visual system and brainstem, provided that the tests are executed and interpreted correctly. When an abnormal pupillary response is found, it is important to differentiate between an afferent problem (eyeball, retina, optical nerve), brain stem pathology, or an efferent problem (parasympathetic fibers of the oculomotor nerve, iris sphincter muscle). We describe the technique of the ophthalmological examination, the normal neurophysiology and the possible abnormal pupil responses in patients with intact and decreased consciousness.

Progression of Anterograde Trans-Synaptic Degeneration in the Human Retina Is Modulated by Axonal Convergence and Divergence.

In the visual pathway of patients with multiple sclerosis (MS), the inner nuclear layer (INL) of the retina is a tight barrier for retrograde trans-synaptic degeneration. In this observational, retrospective cross-sectional study, segmented macular spectral domain optical coherence tomography (OCT) volume scans were reviewed to investigate if this observation also holds true for anterograde trans-synaptic degeneration. Significant thinning was found in all retinal layers in patients with outer retinal diseases compared with the healthy controls, while there was no significant attenuation of the outer retina in patients with MS. In contrast to the tight barrier function observed with retrograde trans-synaptic degeneration, the INL appears to be more permissive for the propagation of anterograde trans-synaptic degeneration. We speculate that this may be due to the size of the area affected and be explained by convergence and divergence of axons within the retinal layers. These findings are likely relevant to future restorative stem cell treatment of the outer retinal layers, as time may matter.

The prevalence of microcystic macular changes on optical coherence tomography of the macular region in optic nerve atrophy of non-neuritis origin: a prospective study.

BACKGROUND: Microcystic macular changes, also called microcystic macular oedema, have recently been reported in patients with multiple sclerosis, particularly after optic neuritis. But it has since emerged that the finding is not specific for optic neuritis. This study was designed to prospectively investigate the prevalence of microcystic perifoveal changes in patients with optic atrophy not due to optic neuritis. METHODS: A prospective, cross-sectional study including 54 patients with a history of optic atrophy and 54 healthy control subjects. Spectral domain optical coherence tomography (SD-OCT) was used to scan the macular area and to measure the peripapillar retinal nerve fibre layer thickness. Scanning laser ophthalmoscopy (SLO) was used for imaging of the macular area. RESULTS: Microcystic macular changes were present in 11/54 patients (20.4%), 17/90 eyes with optic atrophy (18.9%) and absent in the normal eyes of patients with monocular optic atrophy and all healthy control eyes. No correlations were found with the age, duration of optic atrophy or severity of optic atrophy. Besides the known perifoveal (semi) circular abnormal reflexes on SLO imaging, we also noticed a more patchy pattern of low SLO reflections in some patients with optic atrophy. CONCLUSIONS: Microcystic macular changes are a frequent observation in patients with optic atrophy of another cause than optic neuritis. The cause of these abnormalities remains a matter of debate. It is important for clinicians to recognise these macular changes and to realise that the cause may lie remotely away from the macula.

Recurrent Optic Perineuritis after Intranasal Cocaine Abuse.

Recurrent optic perineuritis can be related to orbital inflammation. Here we present the case of a 46-year-old male patient in whom recurrent episodes of optic perineuritis were related to chronic osteolytic sinusitis following intranasal cocaine abuse. Magnetic resonance imaging (MRI) demonstrated optic perineuritis adjacent to a soft tissue mass that intruded the orbit from the nasal cavity. Computed tomography (CT) confirmed destruction of the medial orbital wall. Staphylococcus aureus was cultured and biopsy showed granulomatous tissue. Visual outcome was poor. We review the literature and discuss the diagnostic pitfalls and management implications in relation to optic (peri)neuritis originating from the nasal sinuses.

Angiotensin converting enzyme inhibiting therapy is associated with lower vitreous vascular endothelial growth factor concentrations in patients with proliferative diabetic retinopathy.

AIMS/HYPOTHESIS: Vascular endothelial growth factor (VEGF) is thought to be instrumental in the progression of diabetic retinopathy. Indications exist that the renin-angiotensin system is involved in VEGF overexpression. We assessed the vitreous VEGF concentrations in patients and related them to anti-hypertensive treatment, with special interest in the use of ACE-inhibitors. METHODS: Samples of vitreous fluid (10-80 microl) were obtained from 39 patients both with Type I (insulin-dependent) and Type II (non-insulin-dependent) diabetes mellitus and 11 non-diabetic patients undergoing intra-ocular surgery. The VEGF-A concentrations were assessed by immunoassay. RESULTS: Control patients and patients without proliferative diabetic retinopathy ( n = 8) had low and comparable VEGF concentrations (medians < 50 pg/ml). In contrast, patients with proliferative diabetic retinopathy ( n = 31) had high vitreous VEGF concentrations (median 1134 pg/ml), which showed a negative correlation with the use of ACE inhibiting medication (Spearman rank-R = - 0.54; p = 0.002, n = 13). Diastolic and systolic blood pressure did not differ significantly between the two subgroups with proliferative diabetic retinopathy, i. e. those patients receiving ACE-inhibition (medians 88/160 mm Hg, respectively) and the others (90/160). For the mostly used ACE-inhibitor in the proliferative diabetic retinopathy group, i. e. enalapril ( n = 8), a linear dose-effect relation was observed (-20 +/- 4 pg x ml(-1) x mg(-1) x day(-1); p = 0.024; coefficient +/- SEM). CONCLUSION/INTERPRETATION: Treatment with ACE-inhibitors attenuates retinal overexpression of VEGF-A in patients with proliferative diabetic retinopathy, probably by interference with a local effect of angiotensin II.

Chemoattractant and neutrophil degranulation activities related to interleukin-8 in vitreous fluid in uveitis and vitreoretinal disorders.

PURPOSE: To investigate whether the cytokine interleukin-8 (IL-8), a strong chemoattractant and activator for neutrophils, is responsible for neutrophil infiltration and degranulation in the eye in uveitis. METHODS: IL-8 and elastase were measured with specific enzyme-linked immunoassays in vitreous fluid samples obtained from 69 patients with various uveitis entities. Vitreous fluid of nonuveitis patients and eye bank eyes served as controls. The chemotactic activity of vitreous fluid was tested with the Boyden chamber technique. RESULTS: IL-8 was detected in 45% of the vitreous fluid samples from uveitis patients and in 26% of vitreous fluid samples from nonuveitis patients. Vitreous fluid samples with IL-8 levels exceeding 100 pg/ml were chemotactic for neutrophils. This chemotactic activity could be blocked by 41% to 79% with a monoclonal anti-IL-8 antibody. Elastase levels in vitreous fluid of uveitis patients with detectable IL-8 were significantly higher than those in vitreous fluid samples with no detectable IL-8. CONCLUSION: These results indicate that IL-8 participates in the inflammatory processes in the eye by attracting and degranulating neutrophils. It is suggested that these processes contribute to the pathogenesis of tissue destruction in uveitis.

Analysis of IL-6 levels in human vitreous fluid obtained from uveitis patients, patients with proliferative intraocular disorders and eye bank eyes.

Several studies suggest a role for IL-6 in the pathogenesis of uveitis. Earlier we have shown that aqueous humour obtained from patients with uveitis contained raised levels of IL-6. In the study described here we investigated the IL-6 levels in vitreous fluid samples obtained from 75 uveitis patients with different uveitis entities. Vitreous samples from 14 patients with proliferative intraocular disorders (PID) and 29 eye bank eyes were used as controls. All the samples were tested in the IL-6 B9 bioassay as well as in a sensitive ELISA for IL-6. Raised IL-6 levels were detected in the vitreous fluid of uveitis patients as well as patients with PID, implicating IL-6 as a common inflammatory mediator. The highest mean level of IL-6 was found in the vitreous fluid of patients with acute retinal necrosis. The mean IL-6 levels measured by the ELISA were higher compared to the levels measured by the B9 bioassay. This may be caused by the presence of B9 bioassay inhibitory factors in the vitreous fluid of these patients.

Evulsion of the optic nerve.

Optic nerve evulsion is an uncommon traumatic event, which may result from various orbital or facial injuries. Two patients in whom clear media permitted prompt diagnosis are described. The possible mechanisms are not quite clear, but extreme rotation of the globe seems to play an important role.

Malignant optic glioma in adults. Case report.

Malignant optic glioma in adulthood is a rare tumor that causes early loss of vision and nearly always leads to death within a year. A case history is presented illustrating the clinical and neuroradiological characteristics of the malignant optic glioma in adults. A review of the literature is given.

Endophthalmitis after Nd:YAG laser capsulotomy.

A 63-year-old patient underwent a Nd:YAG laser capsulotomy, 5 months after an extracapsular cataract extraction. One day later endophthalmitis had developed. Staphylococcus epidermidis was cultured from the vitreous. We assume that this micro-organism, a pathogen of low virulence, had been sequestered in the capsular bag and was released into the vitreous after Nd:YAG capsulotomy.

Dacryocystography after paranasal sinus surgery.

The influence of nasolacrimal duct dissection and irradiation of the lacrimal system on lacrimal drainage were assessed. Findings at dacryocystography, in correlation with the results of dye tests and symptoms, are presented. Lacrimal drainage obstruction was demonstrated in one of 10 patients after paranasal sinus surgery not followed by irradiation and in four of 10 patients in which surgery was followed by irradiation.

Primary empty sella syndrome and benign intracranial hypertension.

The combination of the empty sella syndrome (ESS) and benign intracranial hypertension (BIH) is illustrated by two case histories. The causal relationship between the ESS and the BIH can be explained by two mechanisms. Raised intracranial pressure could produce a herniation of the subarachnoid cistern into the sella turcica, if the diaphragma sellae is incomplete. Alternatively an infarction in a pituitary adenoma could result in both an ESS and cerebrospinal fluid flow obstruction, which could lead to BIH.

Lacrimal gland enlargement as one of the ocular manifestations of Wegener's granulomatosis.

Wegener's granulomatosis is characterized by chronic, focal, necrotizing and granulomatous vasculitis. The localized form involves mainly the upper or lower respiratory tracts, or both. In the commoner generalized form, the kidneys are also affected. Literature findings suggest that ocular manifestations are a predominating sign in about 30% of cases. Ocular findings may include conjunctivitis, keratitis and sclerouveitis, pseudotumor of the orbit or proptosis. We report on a patient who showed bilateral episcleritis, keratitis, nasolacrimal duct obstruction and enlargement of the lacrimal gland. The latter finding was confirmed by CT scan.

One year's experience with the Pearce tripod posterior chamber intraocular lens.

Anatomical and functional results in 72 eyes after (extracapsular cataract extraction) and implantation of a Pearce vaulted tripod posterior chamber lens are analysed after a short follow-up period.