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PubMed2004

Retinal microvascular changes and target organ damage in untreated essential hypertensives.

BACKGROUND AND PURPOSE: The clinical and prognostic significance of initial retinal alterations in hypertensive patients remains controversial. Therefore, we assessed the relationship of microvascular abnormalities with prognostically validated markers of target organ damage (TOD), such as left ventricular mass (LVM), carotid intima-media thickness (IMT) and microalbuminuria, in early stages of untreated essential hypertension. METHODS: A total of 437 consecutive, never-treated patients with grade 1 or 2 essential hypertension, referred to our outpatient clinic, underwent the following procedures: (1) clinical and routine laboratory examinations, (2) 24-h ambulatory blood pressure monitoring, (3) 24-h urine collection for microalbuminuria, (4) echocardiography, (5) carotid ultrasonography, (6) non-mydriatic retinography. Patients were divided into group I, with either a normal retinal pattern (n=65, 14.9%) or arteriolar narrowing (n=185, 42.4%) and group II with arteriovenous crossings (n=187, 42.7%). RESULTS: The two groups were similar for gender, body mass index, smoking habit, heart rate, clinic and ambulatory blood pressure (BP) values, while mean age was slightly but significantly higher in group II than in group I (47.6 +/- 10.7 versus 44.5 +/- 12.5 years, P=0.008). No differences occurred between the two groups in LVM index (101.8 +/- 18.5 versus 99.9 +/- 20.4 g/m), carotid IMT (0.67 +/- 0.12 versus 0.66 +/- 0.20 mm), urinary albumin excretion rate (14.4 +/- 27.7 versus 13.3 +/- 27.7 mg/24 h) as well as in the prevalence of LV hypertrophy (14.3 versus 14.0%), IM thickening and/or plaques (26.5 versus 27.2%) (both defined according to 2003 ESH-ESC guidelines) and microalbuminuria (10.1 versus 8.7%). Furthermore, the three different retinal artery patterns were similarly distributed among tertiles of LV mass index, IMT and urinary albumin excretion rate. CONCLUSIONS: These results show that: (1) a very large fraction (more than 80%) of untreated, recently diagnosed hypertensive patients have initial retinal microvascular abnormalities detectable by non-mydriatic retinography, (2) the presence of arteriovenous crossings is not associated with more prominent cardiac and extracardiac TOD, (3) fundoscopic examination has a limited clinical value to detect widespread organ involvement in early phases of grade 1 and 2 hypertension.

Adult↗
PubMed1991

Cost-effectiveness of strategies for detecting diabetic retinopathy.

A computer model has been developed to determine cost-effectiveness of screening and treatment for diabetic retinopathy from a societal viewpoint. This model was used to evaluate biannual and annual screening programs using ophthalmoscopy, fundus photography with a "nonmydriatic camera," and photography with a "mydriatic camera." Computations were performed for three subpopulations formed by patients with younger onset diabetes (age at diagnosis less than 30 years) of 5 years or more duration, with older onset diabetes (age at diagnosis greater than or equal to 30 years) who are taking insulin, and with older onset diabetes not taking insulin. Population characteristics are from a well-described southern Wisconsin population where data are available, but the computer model may be specialized to other population. Generally costs of screening programs appear to be recovered by avoided costs of blindness in the population subgroups taking insulin; however, the cost of screening programs generally are not recovered by avoiding costs of blindness in the older onset population subgroup not taking insulin. It was estimated that supplying annual examination with mydriatic fundus photography as a screening program to a cohort of 1,000 diabetics from the younger onset population who have been diagnosed at least 5 years and who are currently not receiving care might save 319 sight years over the lifetime of the cohort. This program will save 62 sight years in an older onset cohort who are taking insulin, and 21 sight years in the older onset population not taking insulin (all benefits are presented as present values computed with an annual discount rate of 5%). Other programs achieve slightly lower savings in each subpopulation.

Adult↗
PubMed1986

Does prior instillation of a topical anesthetic enhance the effect of tropicamide?

Preinstillation of a topical anesthetic has been reported to increase the effect of subsequently applied mydriatics. We examined the effect of instilling 1 drop of proparacaine hydrochloride (0.5%) before applying 1 drop of tropicamide (1%). The results show that preanesthesia prolongs the mydriatic and the cycloplegic effects of tropicamide in eyes with either lightly or more heavily pigmented irides.

Accommodation, Ocular↗
PubMed1985

Comparison of the effects of chronic administration of ciclazindol and desipramine on pupillary responses to tyramine, methoxamine and pilocarpine in healthy volunteers.

Twenty-nine healthy volunteers participated in an experiment lasting for 8 weeks: Phase I (2 weeks)--pre-treatment control period; Phase II (4 weeks)--medication with either ciclazindol hydrochloride (50 mg twice daily), or desipramine hydrochloride (50 mg twice daily) or lactose placebo (twice daily) administered in a single-blind fashion; Phase II (2 weeks)--recovery. Experimental sessions took place twice weekly for the photographic assessment of resting pupil diameter, and for the assessment of one of the following pupillary responses: mydriatic response to methoxamine, mydriatic response to tyramine, miotic response to pilocarpine. Resting pupil diameter increased during medication with either ciclazindol or desipramine. Methoxamine-evoked mydriasis and tyramine-evoked mydriasis were antagonized by both ciclazindol and desipramine. Pilocarpine-evoked miosis was potentiated by both ciclazindol and desipramine. The steady-state plasma levels (mean +/- s.e. mean) of the antidepressants were: ciclazindol: 5.90 +/- 0.74 microM; desipramine: 0.60 +/- 0.17 microM. The antagonism of methoxamine-evoked mydriasis is likely to reflect the blockade of postsynaptic alpha 1-adrenoceptors in the iris by the antidepressants, whereas the antagonism of tyramine-evoked mydriasis may reflect both the blockade of uptake of tyramine into presynaptic adrenergic terminals and the blockade of postsynaptic alpha-adrenoceptors. There is no immediate explanation for the potentiation of pilocarpine-evoked miosis by the two antidepressants.

Adolescent↗
PubMed2006

Rapid and cost-effective method to assess vision disorders in a population.

PURPOSE: The aim was to develop a means of rapidly assessing eye health in a cost- and time-effective way to monitor changes over time. METHODS: Key features of the five main eye diseases that cause vision loss in Australia were assessed. Participation was volunteer-based from randomly selected Melbourne suburbs. Recruitment was by mail. Anterior segments and fundi were photographed with a digital non-mydriatic fundus camera. Visual fields were tested with Frequency Doubling Technology. A questionnaire collected information about demographics, general health and lifestyle. Findings from this rapid assessment were compared with those from a population-based study. RESULTS: A total of 1695 people, aged between 70 and 79 years (mean 74), were recruited. The rates and causes of visual impairment were similar between the rapid assessment method and the population-based study. Among the 134 people (8%) with visual impairment at presentation, 98 (73%) had undercorrected refractive error, 17 (13%) had age-related macular degeneration, 11 (8%) had cataract, 2 (2%) had diabetic retinopathy and 2 (2%) had glaucoma. Screening costs per participant were only about AU$145, compared with AU$433 in the Melbourne Visual Impairment Project (VIP). The application of Frequency Doubling Technology as well as the use of a non-mydriatic digital camera for fundus and lens photography resulted in an average examination time of less than half the time needed in the VIP. Data collection took 3 months rather than 4 years in the VIP. CONCLUSION: The rapid assessment method was efficient in time and cost and produced results comparable to a normal population-based survey. Repeating the study design for a similarly sampled group every 2 years would allow the assessment of changes in the prevalence of undiagnosed eye disease.

Aged↗
PubMedDate not supplied

Management of patients with narrow angles and acute angle-closure glaucoma.

BACKGROUND: Acute closure of the anterior chamber angle can have catastrophic consequences for vision when it occurs in an unsupervised situation. Visual debilitation is much less likely to result when angle-closure occurs in a well-controlled environment that allows appropriate management. Therefore, it is desirable for optometrists to undertake a complete ocular health assessment, including mydriatic fundus examination, on patients who have narrow anterior chamber angles, provided that appropriate precautions and procedures are followed. CASE REPORT: We report on the case of a 59-year-old white female whose anterior chamber angles closed in response to mydriatic drops instilled during an optometric examination. Her optic discs and visual field results from before and four years after the angle-closure attack do not show any significant changes. CONCLUSION: We conclude that the optimal standard of care for patients presenting to an optometric practice, and who are subsequently found to have narrow anterior chamber angles, includes pupillary dilatation to allow stereoscopic visualisation of the optic nerve head. Precautions must be followed to ensure that, in the unlikely event of an ensuing angle-closure episode, the attack occurs under clinically supervised conditions.

Journal Article↗
PubMed1991

Screening for treatable diabetic retinopathy: a comparison of different methods.

The results of the screening of 3318 diabetic patients for sight-threatening diabetic retinopathy in three UK centres are reported. The aims of the study were to determine the extent of diabetic retinopathy in the screened population and to assess the relative effectiveness of different screening methods in appropriately referring cases from a diabetic population, in a context very close to a routine clinical service. Patients were assessed by ophthalmoscopic examination by an ophthalmological clinical assistant. The clinical assistants' referral grades formed the reference standard against which to assess the effectiveness of other screening methods including ophthalmoscopy by primary screeners who were general practitioners (GPs), ophthalmic opticians and hospital physicians, and the assessment by consultant ophthalmologists of non-mydriatic Polaroid fundus photography. The performance of primary screeners based on ophthalmoscopy ranged from a sensitivity of 0.41, with a specificity of 0.89, for one of the GP groups, to a sensitivity of 0.67, with a specificity of 0.96, for the hospital physician group. The performance of the non-mydriatic camera ranged from a sensitivity of 0.35, with a specificity of 0.95, to a sensitivity of 0.67, with a specificity of 0.98.

Aged↗
PubMed1988

alpha-Methyldopa produces mydriasis in the rat by stimulation of CNS alpha 2-adrenoceptors.

1. The effects of i.v. administration of alpha-methyldopa (MD) on rat pupil diameter were investigated. All experiments were carried out in rats in which vagosympathetic nerve trunks were sectioned bilaterally at the cervical level. 2. In anaesthetized rats MD produced a marked dose-related increase in pupil diameter. The onset of pupillary response to MD was gradual and reached maximal levels 2-3 h after administration. 3. Pretreatment with alpha 2-adrenoceptor antagonists yohimbine (1.5 mg kg-1, i.v.) or idazoxan (0.5 mg kg-1, i.v.) blocked the pupillary response to MD. In contrast, the alpha 1-antagonists prazosin (1.0 mg kg-1, i.v.) and phenoxybenzamine (1.5 mg kg-1, i.v.) did not significantly alter the pupillary effects of MD. 4. Selective enzymatic blockade with 3-hydroxy-benzyl-hydrazine (NSD-1015; 25 mg kg-1, i.p.), a dopa-decarboxylase inhibitor, as well as bis (4-methyl-homopiperazinyl-thiocarbonyl) disulphide (FLA-63, 5.0 mg kg-1, i.p.), a dopamine-beta-hydroxylase inhibitor, prevented the mydriatic effect of MD. 5. The above findings support the hypothesis that MD produces a clonidine-like CNS mydriasis in the rat. This effect appears to be mediated primarily by the MD metabolite, alpha-methylnoradrenaline. 6. These results indicate that MD produces mydriasis in the rat by a CNS action. The mydriatic action of MD appears to be produced by its metabolite alpha-methylnoradrenaline which in turn stimulates CNS postsynaptic alpha 2-adrenoceptors.

Adrenergic alpha-Antagonists↗
PubMed1991

Comparison of non-stereo polaroids and slides in detection of diabetic retinopathy.

Fundus photography plays an important role in detection and assessment of diabetic retinopathy. This study compared the detectability of diabetic retinopathy lesions on Polaroid prints and Ektachrome slides obtained with a non-mydriatic camera. The number of lesions detected with Ektachrome slides was higher compared to Polaroids. The method of viewing the Ektachrome slides was also shown to be important. Slides when projected onto a white screen revealed a higher number of lesions compared to the same slide viewed through a macroscope. If a non-mydriatic camera is used to screen diabetic retinopathy, judgement from a projected Ectachrome slide is recommended.

Adult↗
PubMed2004

Effect of mydriasis and different field strategies on digital image screening of diabetic eye disease.

AIMS: To assess the effects of (1) mydriasis and (2) single versus three field photography on screening for diabetic eye disease using digital photography METHOD: Slit lamp examination findings were compared to digital fundal photographs for the detection of any retinopathy and for referable retinopathy in 398 patients (794 eyes). A Topcon TRC-NW6S digital non-mydriatic fundus camera was used. Three photographic strategies were used: undilated single field, dilated single field, and dilated multiple fields. The photographs were presented in random order to one of two retinal screeners. For the single field photographs the screeners were masked to the use of mydriatics. In 13% of fundal photographs, grading was performed by both, rather than just one grader. RESULTS: Mydriasis reduced the proportion of ungradable photographs from 26% to 5% (p<0.001). Neither mydriasis nor three field photography improved the sensitivity or specificity for the detection of any retinopathy or of referable retinopathy when compared with undilated single field photography. The sensitivity and specificity for detecting referable retinopathy using undilated single field photography was 77% (95% CI 71 to 84) and 95 % (95% CI 93 to 97) respectively. Using dilated single field photography the figures were 81% (95% CI 76 to 87) and 92% (95% CI 90 to 94) respectively. Using dilated three field photography the figures were 83% (95% CI 78 to 88) and 93% (95% CI 91 to 96) respectively. Intergrader reliability for the detection of referable retinopathy in gradable photographs was excellent (Kappa values 0.86-1.00). CONCLUSIONS: Mydriasis reduces the technical failure rate. Mydriasis and the three field photography as used in this study do not increase the sensitivity or specificity of detecting diabetic retinopathy.

Adolescent↗
PubMed1991

Intraocular pressure and pupillary responses in patients with diabetes mellitus.

Intraocular pressure (IOP) and the mydriatic responses to darkness in 38 diabetic patients have been compared with those of a matched control group of normal subjects. Overall, the diabetic patients had a significantly higher mean IOP than the control group, but this difference was not found in a sub-group of 13 diabetic patients with evidence of autonomic neuropathy. Those diabetic patients with evidence of autonomic neuropathy had a smaller mydriatic response to darkness than the control group, and this test may usefully be added to standard tests of autonomic function in the diagnosis of autonomic neuropathy.

Adolescent↗
PubMed1992

Agents for the treatment of overactive detrusor. III. Synthesis and structure-activity relationships of N-(4-amino-2-butynyl)acetamide derivatives.

A series of N-(4-amino-2-butynyl)acetamides were synthesized and examined for their inhibitory activity on detrusor contraction and mydriatic activity as an index of anticholinergic side effect. Among those compounds synthesized, (+)-2-cyclohexyl-N-(4-dimethylamino-2-butynyl)-2-hydroxy-2-phenylacet amide hydrochloride ((+)-13b.HCl), 2-cyclohexyl-2-hydroxy-N-(4-methylamino-2-butynyl)-2-phenylacetamide+ ++ hydrochloride (13c.HCl), N-(4-dimethylamino-2-butynyl)-2,2-diphenyl-2-hydroxyacetamide hydrochloride (14a.HCl), and 2,2-diphenyl-N-(4-ethylamino-2-butynyl)-2-hydroxyacetamide hydrochloride (14b.HCl) showed equipotent inhibitory activity on detrusor contraction to oxybutynin (1) and less mydriatic activity. Further evaluation of these compounds as an agent for the treatment of overactive detrusor has been examined.

Alkynes↗
PubMed1999

An anisocoria produces a small relative afferent pupillary defect in the eye with the smaller pupil.

OBJECTIVES: To determine whether an anisocoria can produce a relative afferent pupillary defect of clinical importance. MATERIAL AND METHODS: Anisocoria and relative afferent pupillary defect were measured with infrared videography in three clinical experiments: 1) every few minutes in eight normal subjects who remained in darkness as one pupil was dilating from mydriatic drops; 2) every 2 hours, for 8 hours in six normal subjects who remained in room light after one pupil was dilated with mydriatic drops; and 3) before and after dilation of one pupil in 24 patients with known afferent defects from optic nerve disease and who remained in room light. RESULTS: In the presence of an anisocoria, the relative afferent pupillary defect was almost always in the eye with the smaller pupil. The results of the three experiments were: 1) In darkness, the induced pupillary defect was found to be related to the ratio of the areas of the two pupils (R = 0.942), and 0.14 log unit of pupillary defect was produced in the eye with the smaller pupil for every millimeter of anisocoria. 2) In room light, the induced pupillary defect was in the eye with the smaller pupil but was less than in Experiment 1 and persisted throughout the 8 hours. This was presumably because the eye with the larger pupil had become more light adapted in the clinic light than the eye with the smaller pupil. 3) In room light, inducing an anisocoria in patients with preexisting afferent pupillary defect tended to shift the pupillary defect toward the eye with the smaller pupil (R = 0.68). CONCLUSIONS: Clinically, approximately 0.1 log unit of relative afferent pupillary defect is produced in the eye with the smaller pupil for every millimeter of anisocoria. Therefore, the anisocoria must be larger than 2 mm in diameter difference to induce a clinically significant relative afferent pupillary defect.

Anisocoria↗
PubMed2002

[A clinical study on laser peripheral iridoplasty for primary angle-closure glaucoma with positive provocative tests after iridectomy].

OBJECTIVE: To evaluate the therapeutic effects of laser peripheral iridoplasty for primary angle closure glaucoma with positive dark room and prone test after laser peripheral iridectomy. METHODS: A long-term prospective study of 56 eyes (34 cases) with primary angle-closure glaucoma was carried out. The patients presented with positive dark room and prone provocative test after laser peripheral iridectomy, and laser peripheral iridoplasty by Double-Frequency Nd:YAG laser was performed on them. Their extent of goniosynechia was less than 1/2 circumference of the anterior chamber angle. Forty-nine eyes (27 cases) of all those studied were acute angle-closure glaucoma and the other 7 eyes (7 cases) were chronic angle-closure glaucoma. The inferior peripheral anterior chamber depth, anterior chamber angle, the configuration of peripheral iris and intraocular pressure were observed carefully, and the dark room, prone and mydriatic provocative tests were performed. The postoperative follow-up ranged from 1 year to 4 years. RESULTS: The results showed that in all these cases, the peripheral anterior chamber depth was increased, the anterior chamber angle was widened on goniscope and the trabecular meshwork could be visualized widely in static state. All patients did not have ocular hypertension and damage of visual field in the follow up. Mydriatic, dark room and prone provocative tests following laser peripheral iridoplasty were negative. CONCLUSIONS: In some acute angle-closure glaucoma and chronic angle-closure glaucoma patients, the pupillary block is relieved by laser peripheral iridectomy, but provocative tests can also be positive because of the abnormal configuration of the peripheral iris. Pupillary dilation results in peripheral iris bunching, and the surface of the trabecular meshwork can be blocked, hypertension then occurs. But the laser peripheral iridoplasty can improve the shape of the peripheral iris effectively and it can prevent the disease from deteriorating. The goniscopic examination and provocative tests following laser peripheral iridectomy are very important and also effective in detecting this kind of glaucoma.

Adult↗
PubMed1990

Pupillary dynamics in patients with primary open angle glaucoma.

In patients with primary open angle glaucoma (POAG), the evaluation of neurological status is clinically important. A detailed analysis of the pupillary dynamics under the control of the autonomic nervous system was performed in patients with POAG. Pupil size and pupillary light reflex were measured by an infrared videopupillogram in 13 patients with POAG (from 25 to 67 years old) with good oculotensive controls without applications mydriatics nor miotics revealed. Pupillary light reflexes were analyzed by comparing the simulated patterns obtained after the studies with topical autonomic agents. Effects of topical adrenergics (dipivalyl epinephrine: DPE 0.025%) on the pupil were also investigated. Three types of autonomic abnormalities (cholinergic, adrenergic and physiological mydriatic reflex patterns) of the light reflex were detected in 11 eyes of 6 patients, and a normal pattern was found in only 2 eyes of one patient. Afferent pupillary defect (APD) pattern was detected in 13 eyes. Although APD was generally described as a reduced visual input, the degree of APD was not related to the stage of the visual field defect in POAG.

Adult↗
PubMed1990

Pupillary dilatation during cataract surgery--relative efficacy of indomethacin and flurbiprofen.

In a prospective, randomized, double-blind trial, we evaluated the relative efficacy of indomethacin and flurbiprofen when used as adjuvants to routinely used mydriatics for maintenance of pupillary dilatation in patients with heavily pigmented iris undergoing extracapsular cataract extraction. The drugs were administered orally as well as topically according to a fixed regimen. The pupillary diameters, measured with calipers at various surgical steps, were significantly larger at every step in the study groups in which either of the adjuvants had been used than they were in the control group (P less than .001). Flurbiprofen tended to help maintain a larger pupillary diameter in the later stages of surgery than indomethacin, but this difference was not statistically significant. We conclude that it is important to use prostaglandin synthetase inhibitors as adjuvants to routine mydriatics, and that flurbiprofen may be somewhat more effective than indomethacin in this capacity.

Cataract Extraction↗
PubMed1986

Effects of 0.1% cyclopentolate or 10% phenylephrine on pupil diameter and accommodation.

The mydriatic and cycloplegic effects of either one drop of 0.1% cyclopentolate or two drops of 10% phenylephrine were studied over a period of up to 6 hours after drug instillation, using 5 subjects aged between 25 and 43 years. The extent of mydriasis was determined from the horizontal diameter of the pupil. Dynamic accommodation responses were monitored with an infra-red, continuously recording optometer. Static measurements of the accommodation response/stimulus curve were made with a laser optometer. With either drug, dilation of the pupil occurred more rapidly than recovery of normal pupil diameter. Both drugs caused alterations in the dynamic and static accommodation responses. Response times were generally slowed, and the slope of the accommodation response/stimulus curve and the amplitude of accommodation were reduced. The time course of these changes was broadly similar to that of the pupil dilation. Cyclopentolate hydrochloride was more efficient as a mydriatic but exercised a greater unwanted cycloplegic effect.

Accommodation, Ocular↗
PubMed1982

[Pupillometry, a clinical-pharmacologic model; statement of its strengths and limitations].

A new non-invasive clinical pharmacological model, developed at out Institut, is reported. The principle of the model is the photographic determination of the diameter of the pupil before and after administration of drugs active at the pupilr muscle. The area of the pupilla as a parameter of drug effect can be predicted mathematically. With the reported model the area under the area time curve, the pupillar index and the mean myotic or mydriatic time is determined. The area under the curve gives information about the extent of the drug effect. The pupillar index takes the maximum diameter into account and is even more sensitive than the area under the curve, correcting steep and flat profiles of the area time curve. The mean mydriatic or myotic time gives a robust measurement concerning the duration of the drug effect. To prove the relevance of our model we used treptilamine hydrochloride in four different formulations orally and intravenously. The results show: 1. The model is appropriate to show the effect of drugs on the smooth pupillar muscle concerning rate and extent; 2. The drug treptilamine hydrochloride does change the diameter of the pupils; 3. The drug is active after oral application.

Bridged-Ring Compounds↗