Comparison of the new self-contained darkroom refractive screener versus table-top autorefractor and cycloplegia retinoscopy in detecting refractive error.

PURPOSE: By comparing the results of the new self-contained darkroom refractive screener (YD-SX-A) versus table-top autorefractor and cycloplegic retinoscopy, to evaluate the performance of the YD-SX-A in detecting refractive error in children and adolescents and then judge whether it can be used in refractive screening. METHODS: Cross-sectional study. 1000 participants between the ages of 6 and 18 who visited the Optometry Center of the People's Hospital of Guangxi Zhuang Autonomous Region from June to December 2022 were selected. First, participants were instructed to measure their diopter with a table-top autorefractor (Topcon KR8800) and YD-SX-A in a noncycloplegic setting. After cycloplegia, they were retinoscopy by a professional optometrist. The results measured by three methods were collected respectively. To avoid deviation, only the right eye (1000 eyes) data were used in the statistical analysis. The Bland-Altman plots were used to evaluate the agreement of diopters measured by the three methods. The receiver operating characteristic (ROC) curves was used to analysis effectiveness of detecting refractive error of YD-SX-A. RESULTS: The average age of participants was 10.77 ± 3.00 years, including 504 boys (50.4%) and 496 girls (49.6%). When YD-SX-A and cycloplegia retinoscopy (CR) were compared in the myopia group, there was no statistical difference in spherical equivalent (SE) (P > 0.05), but there was a statistical difference in diopter spherical (DS) and diopter cylinder (DC) (P < 0.05). Comparing the diopter results of Topcon KR8800 and CR, the difference between each test value in the myopia group was statistically significant (P < 0.05). In the hyperopia group, the comparison between YD-SX-A and CR showed no statistically significant differences in the DC (P > 0.05), but there were significant differences in the SE and DS (P < 0.05). In the astigmatism group, the SE, DS, and DC were statistically different, and the DC of YD-SX-A was lower than that of CR and Topcon KR8800. Bland-Altman plots indicated that YD-SX-A has a moderate agreement with CR and Topcon KR8800. The sensitivity and specificity of YD-SX-A for detecting myopia, hyperopia and astigmatism were 90.17% and 90.32%, 97.78% and 87.88%, 84.08% and 74.26%, respectively. CONCLUSION: This study has identified that YD-SX-A has shown good performance in both agreement and effectiveness in detecting refractive error when compared with Topcon KR8800 and CR. YD-SX-A could be a useful tool for large-scale population refractive screening.

Etiology of white pupillary reflex in pediatric age group.

Background: Leukocoria means white pupil. Normal pupil appears black in children and adults. The typical red reflex is due to retro-illumination of choroidal vessels reflected via the retina, vitreous humor, crystalline lens, aqueous humor, pupil, and cornea. If there is interference in these structures, it would result in a changed red reflex, or leukocoria. Immediate family members are highly likely to detect the first indicator and the pediatrician or general ophthalmologist is usually the first to be visited. The aim of the study was to find out the prevalence of common causes of white pupillary reflex in children, to undertake early diagnosis and treatment, and to reduce morbidity and death. This study aimed to see how common it is for children to have a white pupillary reflex when they visit a pediatric ophthalmologist. Objective: Determine the incidence of conditions that cause a white pupillary reflex in children who visited Hayatabad Medical Complex Hospital in Peshawar. Materials and methods: This study was carried out in the Ophthalmology unit of HMC Hospital Peshawar, from January 2021 to December 2021. 168 patients were enrolled in the study. We included all patients of up to 10 years and both genders with the above findings. Workup for leukocoria was done to find the exact cause that included fundoscopy, B-Scan, MRI, and CT scans. Examination under anesthesia (EUA) was carried out for uncooperative children for detailed fundus examination. Patient data was recorded and a proforma was made to collect all the necessary information. Family history was taken in detail during this study. Results: The most common cause of aberrant pupillary reflex in children aged 1 to 10 years was cataract, 79.76 percent of patients having it. Retinoblastoma (12.5%), Coats disease (3.5%), retinal detachment (2.9%) and persistent hyperplastic vitreous (PHPV) (1.1%) were other notable causes found. Conclusion: Leukocoria is a critical clinical finding, and if parents or primary care physicians notice it, the patient requires a complete follow-up examination by a pediatric ophthalmologist to determine the etiology.

Predictors of surgical intervention and visual outcome in bacterial orbital cellulitis.

ABSTRACT: This study aims to identify predictive factors associated with surgical intervention and the visual outcome of orbital cellulitis and to evaluate the treatment outcomes.A retrospective study involving 66 patients (68 eyes; 64 unilateral and 2 bilateral) diagnosed with bacterial orbital cellulitis was conducted between November 2005 and May 2019.The mean (± standard deviation) age was 42.1 (± 25.8) years (range: 15 days-86 years). Sinusitis was the most frequent predisposing factor, occurring in 25 patients (37.9%), followed by skin infection in 10 patients (15.2%), and acute dacryocystitis in 9 patients (13.6%). Subperiosteal abscesses were found in 24 eyes and orbital abscesses in 19 eyes. Surgical drainage was performed in 31 eyes. Regarding the abscess volume for surgical drainage, a cut-off of 1514 mm3 showed 71% sensitivity and 80% specificity. There was significant improvement in visual acuity (VA) and decrease in proptosis after treatment (for both, P ≤ .001). Only pre-treatment VA ≤20/200 was a significant predictor for post-treatment VA of 20/50 or worse (adjusted odds ratio: 12.0, P = .003). The presence of a relative afferent pupillary defect was the main predictor of post-treatment VA of 20/200 or worse (adjusted odds ratio: 19.0, P = .003).The most common predisposing factor for orbital cellulitis in this study was sinusitis. VA and proptosis significantly improved after treatment. We found that the abscess volume was strongly predictive of surgical intervention. Pre-treatment poor VA and the presence of relative afferent pupillary defect can predict the worst visual outcome. Hence, early detection of optic nerve dysfunction and prompt treatment could improve the visual prognosis.

Síndrome de Marcus-Gunn / Marcus Gunn syndrome

Introducción: El síndrome de Marcus-Gunn se manifiesta con retracción o elevación del párpado ptótico ante la estimulación del músculo pterigoideo del mismo lado y el término "guiño mandibular" es inapropiado ya que el párpado no siempre desciende. Puede producirse en la apertura bucal, masticación, avance mandibular, al sonreír, silbar, bruxar, sacar la lengua, deglutir, chupar, cantar, en la contracción esternocleidomastoidea, maniobra de Valsalva, respirar o inhalar. Es congénito y de modalidad rara y autosómica dominante. Objetivo: Contribuir al conocimiento de esta rara enfermedad y a su relación con el ámbito odontológico. Presentación del caso: Se trata de un niño de 3 años diagnosticado de síndrome de Marcus-Gunn en el periodo neonatal, por la observación de la madre de una apertura palpebral izquierda durante la succión nutritiva. No presenta otras enfermedades ni antecedentes de interés. En la exploración extraoral se advierte una ptosis palpebral derecha y apertura palpebral izquierda en los movimientos mandibulares y deglución. La intensidad del reflejo se incrementa en estados de ansiedad derivados del tratamiento dental. Conclusiones: el síndrome de Marcus-Gunn es una entidad rara en pediatría, en la cual sus hallazgos clínicos determinan el diagnóstico. Teniendo en cuenta que en ocasiones presentan alteraciones oculares, nada nos hace sospechar la presencia de una enfermedad oral específica(AU)

Introduction: Marcus Gunn syndrome manifests with retraction or elevation of the eyelid ptotico while stimulation of the pterygoid muscle on the same side and the term jaw-winking is inappropriate because the eyelid does not always goes down. It can occur during mouth opening, mastication, mandibular advancement, while smiling, whistling, bruxing, sticking out the tongue, swallowing, sucking, singing, during the sternocleidomastoid contraction, the Valsalva maneuver, breathing or inhaling. This syndrome is congenital and rare, and of autosomal dominant modality. Objective: To contribute to the knowledge of this rare disease and its relationship with the odontologic field. Presentation of the case: 3 years old boy diagnosed with Marcus Gunn syndrome in the neonatal period by the observation of the mother of a left palpebral opening during the nutritive sucking. He does not present other diseases or a background of interest. In the extraoral exploration, it is noticed a right palpebral ptosis and a left palpebral opening in the jaw movements and in swallowing. The intensity of the reflex increases in anxiety states arising from the dental treatment. Conclusions: Marcus Gunn syndrome is a rare entity in pediatrics, in which its clinical findings determine the diagnosis. Taking into account that sometimes it presents ocular alterations, nothing makes us suspect the presence of a specific oral disease(AU)

Deep coma does not always predict poor outcomes among patients with polytrauma.

PURPOSES: This study aimed to clarify the prognosis of polytrauma patients presenting to the emergency department (ED) with a Glasgow Coma Scale score (GCS) of 3. METHODS: A trauma registry system has been established at our institution since 2009. The current study reviewed patients in the registry who presented to the ED with a GCS of 3 from January 2011 to December 2015. Surviving and non-surviving patients were compared to identify the prognostic factors of patient survival. The study also aimed to determine the factors contributing to patients who survived with a GCS > 13 at discharge. RESULTS: During the study period, 145 patients were enrolled in the study, 119 of whom (82.1%) did not survive the traumatic insult. Of the 26 survivors, 13 (9.0%) had a GCS of 14 or 15 at discharge. The multiple logistic regression revealed that a lack of bilateral dilated and fixed pupils (BFDP) (OR 5.967, 95% CI 1.780-19.997, p = 0.004) and a GCS > 3 after resuscitation (OR 6.875, 95% CI 2.135-22.138, p = 0.001) were independent prognostic factors of survival. Based on the multiple logistic regression, an age under 40 years (OR 16.405, 95% CI 1.520-177.066, p = 0.021) and a GCS > 3 after resuscitation (OR 12.100, 95% CI 1.058-138.352, p = 0.045) were independent prognostic factors of a GCS > 13 at discharge. CONCLUSION: Aggressive resuscitation still provided benefit to polytrauma patients presenting with a GCS of 3, especially those with a rapid response to the resuscitation. Young patients with a deep coma on arrival had a higher probability of functional recovery after resuscitation in the ED.

Pupillary autonomic dysfunction in patients with ANCA-associated vasculitis.

OBJECTIVE: To assess autonomic function by infrared dynamic pupillometry in patients with ANCA-vasculitis (AAV) in correlation to autonomic symptoms, disease specific clinical parameters and cardiovascular reflex tests. METHODS: Patients with AAV and healthy controls underwent pupillometry at rest and after sympathetic stimulation (cold pressor test). Three parasympathetic parameters (amplitude, relative amplitude, maximum constriction velocity) and one sympathetic parameter (late dilatation velocity) were assessed. Results were correlated with clinical parameters, symptoms of autonomic dysfunction (COMPASS31 questionnaire), heart rate variability during deep breathing test and blood pressure response to pain. RESULTS: 23 patients and 18 age-matched controls were enrolled. Patients had a smaller amplitude (1.44 vs. 1.70 mm; p = 0.009) and a slower constriction velocity (4.15 vs. 4.71 mm/s; p = 0.028) at baseline and after sympathetic stimulation (1.47 vs. 1.81 mm, p = 0.001; 4.38 vs. 5.19 mm/s, p = 0.006, respectively). Relative amplitude was significantly smaller in patients after sympathetic stimulation (28.6 vs. 32.5%; p = 0.043), but not at baseline. There was no difference in sympathetic pupillary response between the groups. In patients, parasympathetic pupil response was correlated negatively with age and positively with parasympathetic cardiac response. After adjusting for age, no significant correlation was observed with clinical parameters. However, there was a trend towards a negative correlation with disease duration, vasculitis damage index and CRP. CONCLUSION: Patients with AAV exhibit parasympathetic pupillary autonomic dysfunction. Although correlations were weak and not significant, pupillary autonomic dysfunction is rather linked to chronic damage than to active inflammation or symptoms of autonomic dysfunction.

[Rare causes of childhood leukocoria]. / Les causes rares de leucocorie chez l'enfant.

PURPOSE: The purpose was to record the causes of leukocoria among children under 10years of age and to determine the proportion of rare causes of leukocoria. PATIENTS AND METHODS: This retrospective study was conducted over a period of ten years, from January 1, 2004 to December 31, 2013, in patients under 10years of age who were referred for leukocoria. RESULTS: Leukocoria represented one of the ten reasons for consultation among children under 10years of age. The mean age of our patients was 42.5months. In 76 % of cases, the leukocoria patients were children under 6years of age. Male patients were affected more commonly, with a sex-ratio of 1.5. Patients coming from Dakar and its suburbs represented two thirds of the total. Bilateral involvement represented 53.7 % of the total. Cataracts were responsible for 74.3 % of cases, retinoblastoma 20.58 %, retinal detachment 0.96 %, retinopathy of prematurity 0.96 %, pupillary membrane persistence 0.96 %, persistent hyperplastic primary vitreous 0.64 %, endophthalmitis 0.64 %, optic nerve coloboma 0.32 %, iris heterochromia 0.32 % and ametropia 0.32 %. DISCUSSION: The total percentage of rare causes was 5.12 % in our study, including one case of hyperopia. These etiologies, although rare, do exist. CONCLUSION: Rare causes of leukocoria require special attention. The discovery of leukocoria necessitates rigorous etiological work-up. Ametropia must be a diagnosis of exclusion.

The Integration of Occlusion and Disparity Information for Judging Depth in Autism Spectrum Disorder.

In autism spectrum disorder (ASD), atypical integration of visual depth cues may be due to flattened perceptual priors or selective fusion. The current study attempts to disentangle these explanations by psychophysically assessing within-modality integration of ordinal (occlusion) and metric (disparity) depth cues while accounting for sensitivity to stereoscopic information. Participants included 22 individuals with ASD and 23 typically developing matched controls. Although adults with ASD were found to have significantly poorer stereoacuity, they were still able to automatically integrate conflicting depth cues, lending support to the idea that priors are intact in ASD. However, dissimilarities in response speed variability between the ASD and TD groups suggests that there may be differences in the perceptual decision-making aspect of the task.

Pupillary Abnormalities in Descemet Membrane Endothelial Keratoplasty After Nearly Full Tamponade.

PURPOSE: To describe the incidence, risk factors, and management of pupillary abnormalities after anterior chamber (AC) full air or gas tamponade in Descemet membrane endothelial keratoplasty (DMEK) without pupillary block. METHODS: In this retrospective case series, clinical records of 25 patients (32 eyes) who underwent DMEK were reviewed for pupillary abnormalities and iris morphology. All patients had nearly full intracameral tamponade with air or 20% SF6 at the end of surgery without default air release postoperatively. RESULTS: Pupillary abnormalities ranging from mild ovalization to mid-mydriasis were seen in 56% of the cases. These abnormalities were not related to morphometric changes in the iris volume, or in the iris dilator or iris sphincter muscle, but were probably due to posterior synechiae. Combining DMEK and cataract surgery increases by 5-fold the odds of developing this complication. Surgical revision of the posterior surface of the iris and synechiolysis reversed these pupillary abnormalities. CONCLUSIONS: Nonischemic pupillary abnormalities can be seen in patients with DMEK using a nearly full air/gas tamponade in the AC after surgery despite patent iridectomy especially when combined with cataract surgery. Ensuring complete mydriasis in the immediate postoperative period and a free-floating bubble in the AC above the inferior pupillary margin may reduce its incidence.

Iris alterations after DSAEK. / Alteraciones iridianas tras Queratoplastia endotelial automatizada con stripping de la Descemet.

OBJECTIVE: To evaluate a series of case that developed iris changes after performing Descemet's stripping automated endothelial keratoplasty (DSAEK). METHODS: Retrospective study of eyes that developed iris abnormalities, such as pupil ovalisation, iris atrophy, iridocorneal synechiae, mydriatic pupil, and pigmentary changes after performing DSAEK in a tertiary hospital. RESULTS: In a series of the first 32 DSAEK procedures performed, new single or mixed iris alterations were observed in 12 eyes (37.5%). Iris-corneal synechiae were observed in 7 eyes, corectopias in 9 eyes, iris atrophy in 3 cases, and one case developed an areflexic mydriatic pupil. Long-term pigment dispersion at the edge of the lenticule was observed in 12 eyes. The alterations occurred after three months from the surgery. In the evaluation of the associated factors, malignant glaucoma had occurred in 1 case, 2 eyes had required a second surgery, one case by re-DSAEK, and the other one by removing the intraocular lens due to lens opacification. Two cases had a shallow anterior chamber. No relationship was found between the thickness of the peripheral lenticule and the presence of synechiae. CONCLUSION: Iris changes regarding DSAEK are possible. A discussion is presented on the relationship between increased intraocular pressure due to air in anterior chamber and its relationship with ischaemia and secondary alterations in the iris.

Prognostic factors associated with mortality in patients with severe trauma: from prehospital care to the Intensive Care Unit.

OBJECTIVE: To identify factors related to mortality in adult trauma patients, analyzing the clinical, epidemiological and therapeutic characteristics at the pre-hospital levels, in the Emergency Care Department and in Intensive Care. DESIGN: A retrospective, longitudinal descriptive study was carried out. Statistical analysis was performed using SPSS, MultBiplot and data mining methodology. SETTING: Adult multiple trauma patients admitted to the Salamanca Hospital Complex (Spain) from 2006 to 2011. MAIN VARIABLES OF INTEREST: Demographic variables, clinical, therapeutic and analytical data from the injury site to ICU admission. Evolution from ICU admission to hospital discharge. RESULTS: A total of 497 patients with a median age of 45.5 years were included. Males predominated (76.7%). The main causes of injury were traffic accidents (56.1%), precipitation (18.4%) and falls (11%). The factors with the strongest association to increased mortality risk (P<.05) were age > 65 years (OR 3.15), head injuries (OR 3.1), pupillary abnormalities (OR 113.88), level of consciousness according to the Glasgow Coma Scale ≤ 8 (OR 12.97), and serum lactate levels > 4 mmol/L (OR 9.7). CONCLUSIONS: The main risk factors identified in relation to the prognosis of trauma patients are referred to the presence of head injuries. Less widely known statistical techniques such as data mining or MultBiplot also underscore the importance of other factors such as lactate concentration. Trauma registries help assess the healthcare provided, with a view to adopting measures for improvement.

Autonomic complaints in patients with restless legs syndrome.

BACKGROUND: Data regarding autonomic function in restless legs syndrome (RLS) are limited to heart rate and blood pressure changes in cases with periodic limb movements (PLMS). METHODS: We compared autonomic symptoms of 49 subjects with RLS vs 291 control subjects using the Scales for Outcome in Parkinson disease-Autonomic (SCOPA-AUT) questionnaire, consisting of 23 items in six domains scored from 0 to 3. The total score and domain scores were transformed to 0-100 points. Subjects with neurodegenerative disorders (i.e., dementia, Parkinsonism) were excluded. RESULTS: The RLS group was younger (mean±standard deviation, 77.9±8.0 vs 80.5±7.9years; P=.03) and included more women (84% vs 69%; P=.04). The mean SCOPA-AUT total score was higher in the RLS group compared with the control group (20±11 vs 16±9; P=.005). Additionally the RLS group had abnormalities in gastrointestinal, cardiovascular, and pupillomotor domains. When comparing the percentage of subjects with any complaint on individual questions (score of ⩾1), the RLS group had a greater number of subjects with sialorrhea, constipation, early abdominal fullness, lightheadedness when standing, and heat intolerance. CONCLUSIONS: Autonomic complaints, especially gastrointestinal, cardiovascular, and oversensitivity to light, were significantly increased in subjects with RLS. Causes for autonomic dysfunction in RLS require further investigation.

[Impact of follow-up loss over visual deficiency in open-globe ocular trauma]. / Impacto de la pérdida de seguimiento sobre la deficiencia visual en trauma ocular con globo abierto.

INTRODUCTION: Open-globe ocular trauma causes visual deficiency; calculating the magnitude of the latter often misses the estimation in patients without follow-up. AIM: to identify the modification of the postoperative proportion of visual deficiency in open-globe ocular trauma, which would introduce considering the proportion estimated in patients without follow-up. METHODS: Non-interventional, retrospective, longitudinal, analytical study. Visual outcome in eyes with open-globe trauma, with and without follow-up, was calculated using the Ocular Trauma Score. The observed postoperative proportion of visual deficiency was identified in eyes with follow-up; in eyes without follow-up, the postoperative proportion of visual deficiency was estimated using an analysis of scenarios: best (Ocular Trauma Score), mean (that of eyes with follow-up) and worst (last observation/no visual improvement). The estimated proportion of visual deficiency was added to that observed in eyes with follow-up, and the resulting proportion was compared with that expected in the sample, using the Ocular Trauma Score (χ(2)). RESULTS: 104 eyes, 70 without follow-up and 34 without it. In eyes with follow-up the expected proportion of visual deficiency was 58.6%, and the observed one was 71.4% (p = 0.1); the estimated proportion of visual deficiency in eyes without follow-up was 76.5%. The resulting postoperative proportion of visual deficiency in the sample would be 73.1%, which would overcome that expected by the Ocular Trauma Score (59.6%, p = 0.04). CONCLUSIONS: In open-globe ocular trauma, the efficacy of surgery to reduce the proportion of visual deficiency would decrease with regard to the standard expected by the Ocular Trauma Score, if the deficiency estimated in eyes without follow-up were considered.

[Relative afferent pupillary defect in glaucoma]. / Relativer afferenter Pupillendefekt bei Glaukom.

BACKGROUND: The aim of this retrospective study was to estimate the frequency of relative afferent pupillary defect (RAPD) in glaucoma and whether its occurrence relates to the severity of the visual field defect and its side asymmetry as detected by standard automated perimetry. PATIENTS AND METHODS: Among patients with primary open angle glaucoma examined at the glaucoma unit of our university eye hospital patients were identified in whom a swinging-flashlight test as part of their routine examination was carried out. The central 30° visual field was examined by means of static perimetry using the Tübinger Automatic Perimeter or the Octopus Perimeter. The visual field findings and their side difference were compared between patients with and without RAPD by means of the Wilcoxon rank-sum test. RESULTS: After having taken into consideration the inclusion criteria, 100 glaucoma patients were included in the study, 34 of them had an RAPD (34 %). For the visual field analysis only the data of 85 patients, who received the same perimetric strategy, were used. 25 of them had an RAPD (29 %). The calculated visual field scores in patients with RAPD were significantly higher than those in patients without RAPD (p < 0.01), that means their visual field loss was generally more advanced. Also the side difference in visual field of both eyes was significantly greater in patients with RAPD (p < 0.01). A receiver operating characteristics (ROC) curve showed that the side difference in visual field defect is a good predictor for RAPD with an area under curve (AUC) of 0.81. CONCLUSION: RAPD can be diagnosed in about one third of patients with primary open angle glaucoma. It can be found especially with more advanced visual field defects and visual field defects with greater side asymmetry. Its absence does not mean that there is no visual field defect at all. We advise to include the swinging-flashlight test in glaucoma diagnostics.

Retinoblastoma: a recent experience at the National University Hospital, Singapore.

INTRODUCTION: Retinoblastoma is a very rare disease. There were 30 cases of retinoblastoma diagnosed and treated at National University Hospital (NUH). MATERIALS AND METHODS: A retrospective chart review was performed on the medical records of 30 patients who were diagnosed with retinoblastoma between 1995 and 2008 at the Department of Paediatrics, National University Hospital, Singapore. RESULTS: The median age at diagnosis was 1.6 years (range, 0-5.9) with a median follow-up of 1.8 years (range, 0.1 to 11.6). The median time from presenting signs to the time of diagnosis was 5.2 months (range, 0-25.2). Common presenting signs of retinoblastoma were identified; the most common of which were leukocoria (50.0%), squinting (13.3%), poor vision (10.0%), strabismus (6.6%) and unknown (33.3%). Of the 30 patients, 10 were from Singapore whilst the other 20 patients were from the surrounding countries. Twelve patients had bilateral disease at the time of diagnosis, while 18 had unilateral disease. Staging information was available in 27 patients. Enucleation was performed in 25 of 30 patients. Radiation therapy was given in 3 patients in 1995 (bilateral disease), 2001 (bilateral disease) and 2003 (unilateral disease). At the time of analysis, 19 patients were alive with no evidence of disease. Overall 5-year survival for the cohort was 88.1% [95% confidence interval (CI), 88.0-100] and event-free survival for the whole cohort was 74.2% (95% CI, 55.8-92.6). CONCLUSION: In our limited experience, the importance of collaboration and standardisation of the staging system, raising awareness and education of primary healthcare providers and parents are strongly stressed.

Management of traumatic brain injury: first link in chain of survival.

Traumatic brain injury is a significant cause of morbidity and mortality. The prehospital care of the patient with a traumatic brain injury is critical to maximizing the chances for a good outcome. Prehospital management of the traumatic brain injury patient is directed toward preventing and limiting secondary brain injury while facilitating rapid transport to an appropriate facility capable of providing definitive neurocritical care. Key points in management include the assessment of oxygenation, blood pressure, and mental status (as measured with the Glasgow Coma Scale) and the pupillary examination. Treatment strategies are directed toward maintaining adequate oxygenation and perfusion and treating herniation. Judicious use of temporary hyperventilation and hypertonic saline are considerations. This review provides the most recent evidence regarding the treatment of traumatic brain injury in the prehospital setting and introduces areas in need of future research.

Rapid assessment of avoidable blindness in Kunming, china.

OBJECTIVE: To estimate the magnitude and causes of visual impairment (VI) in people aged > or = 50 years in Kunming using the Rapid Assessment for Avoidable Blindness methodology, and to assess the prevalence of a pupillary defect in participants diagnosed as cataract visually impaired. DESIGN: Population-based cross-sectional survey. PARTICIPANTS: We enrolled 2760 residents of Kunming prefecture in southwest China, >50 years of age. METHODS: Forty-six clusters of 60 people were selected based on population proportional to size. Households from each cluster were selected using compact segment sampling (CSS) or quota sampling when CSS was not feasible. Visual acuity (VA) was assessed using a tumbling E chart. Lens status and cause of VI were determined by ophthalmologists using direct ophthalmoscopy through a dilated pupil where necessary. The pupillary reaction was assessed on undilated pupils when VI was detected. MAIN OUTCOME MEASURES: Prevalence of blindness (VA<3/60), severe VI (SVI) (VA<6/60), and VI (VA<6/18) using presenting VA (PVA). The causes of blindness and VI and prevalence of a pupillary defect in the cataract visually impaired were also assessed. RESULTS: Of 2760 enumerated residents, 2588 were examined. The sample prevalence of bilateral blindness was 3.7% (95% confidence interval [CI], 2.8-4.6%). The prevalence of SVI was 3.0% (95% CI, 2.2-3.8%), and of VI was 9.1% (95% CI, 7.5-10.7%). The main cause of blindness was cataract (63.2% of blindness), followed by nontrachomatous corneal scar (14.7%), glaucoma (7.4%), and other posterior segment disease/neurologic disorders (4.2%). A pupillary defect was detected in 16% of those diagnosed with cataract VI. The cataract surgical coverage in the bilaterally blind was 58.9%, and 45% of operated eyes had good outcome with available correction (VA>6/18). The main barrier to cataract surgery was cost. CONCLUSIONS: Cataract remains the most important cause of preventable blindness in this poor region of China, and affordable provision of surgery would help to address this problem. Some cases of cataract blindness may not be preventable owing to preexisting comorbidity, as detected by the presence of a pupillary defect.

The prevalence of relative afferent pupillary defects in normal subjects.

BACKGROUND: Observational and pupillographic studies of small numbers of normal subjects have shown that a small (<0.3 log units) relative afferent pupil defect (RAPD) is present in a minority. We have extended the investigation of the prevalence of RAPD to a larger number of normal subjects. METHODS: A total of 102 subjects were examined by observation and pupillography. The swinging flashlight test was performed using neutral density filters for quantification. During the pupillographic procedure, light-emitting diodes were placed in front of each eye, alternately flashing for 2.5 seconds with a 0.5 second break. A binocular real-time pupillometer recorded the direct and consensual pupillary responses. After artefact detection and removal, the amplitudes of pupillary response were determined and plotted against stimulus intensity. The means of the direct and the consensual responses were used for automated calculation of RAPD. RESULTS: By observation, there was no RAPD in 87 (85%) subjects; there was an RAPD of 0.15 log units in 13 (13%), and an RAPD of 0.3 log units in 2 (2%). By pupillography, there was an RAPD of 0.07 log units in 53 (52%) subjects, an RAPD between 0.08 and 0.22 log units in 43 (42%) subjects, and an RAPD between 0.23 and 0.39 log units in 6 (6%) subjects. CONCLUSIONS: Observation and pupillographic measurements of the swinging light test in a large normal subject cohort has confirmed that an RAPD is present in a small minority but that it does not exceed 0.39 log units. The RAPD in these subjects may be explained by inaccuracy of measurement or by asymmetries in the connections between visual pathways and pretectal nuclei in the midbrain.

Bilateral tonic pupils: Holmes Adie syndrome or generalised neuropathy?

AIM: To compare the pupil signs in patients with bilateral pupillotonia caused by Holmes-Adie syndrome or generalised peripheral neuropathy. METHODS: Infrared video pupillographic techniques were used to measure a number of pupil variables in patients with Holmes-Adie syndrome, generalised neuropathy (various aetiologies) and healthy age-matched control subjects. RESULTS: Regardless of aetiology, the patients generally had pupil signs typical of pupillotonia (small dark diameters, large light diameters, tonic near responses, attenuated light responses with light-near dissociation, and sector palsy). However, significant differences were found in the prevalence and magnitude of several pupil variables in the two patient groups. In particular, sector palsy and anisocoria exceeding 1 mm (in the light) were seen much more commonly in Holmes-Adie patients than patients with generalised neuropathy. The presence of both these pupil signs can be used to distinguish between these diagnoses with a sensitivity of 58% and a specificity of 90%. CONCLUSIONS: The tonic pupils of patients with Holmes-Adie syndrome are significantly different to those found in patients with generalised neuropathy; recognition of these differences may allow distinction between these diagnoses.