An unrousable patient in the recovery room
Tim French, Terry Wardle in The Problem-Based Learning Workbook, 2022
On examination of the patient, she had small equal pupils which had delayed response to light. The possible causes of miosis in this patient are: age, since nearly all elderly patients are miotic. Sluggish pupils may be found if there is coexisting cataract or glaucomaopioid toxicity, which classically causes ‘pinpoint pupils’metabolic comas, which cause the pupils to be normal or mildly contracted. Pupils are never pinpoint, unless there is coexisting opioid toxicity/pontine haemorrhage. However, in this patient, the delayed response to light is a significant indicator that this could be a metabolic coma. The delayed light reflex, or hyporeflexia, is classical of hypothyroidism. This would tie in with the clinical history of weight gain and lethargy. 0ne extreme manifestation of hypothyroidism is myxoedema coma.
Neurology
Ashley Bond in MRCP Part 2 Examination, 2017
Small pupil (miosis): senile pupilpontine haemorrhageHorner’s syndromeArgyll Robertson pupildrugs – opiates, Pilocarpinemyotonic dystrophyDM.
Neurological Examination of Malingering
Alan R. Hirsch in Neurological Malingering, 2018
Malingerers usually complain of defective vision, which may be divided into three classes: (1) total blindness in one eye, (2) partial blindness in one eye, and (3) total or partial blindness in both eyes (Singhal, 1972). During the examination, the physician should note any hesitation to be examined or argumentativeness, which can point to patients malingering about their vision loss. Visual loss is one of the toughest complaints to interpret in nonspecialized clinics or hospitals which do not have access to computer simulations for visual acuity. Pupillary constriction is based on the cranial nerve II and cranial nerve III being intact and functional. It is possible for patients to have an intact cranial nerve II and cranial nerve III and still have cortical blindness. Pupillary diameter is not under somatic control, but rather under sympathetic and parasympathetic control. Therefore, some patients may use medications that can cause either mydriasis or miosis. The important feature of this is that even with medication the pupils will still accommodate with light, so one would be able to differentiate between organic or inorganic disease. With cranial nerve III palsy, the pupil is enlarged and deviated inferiorly and temporally—without being able to react to light.
Novichok: a murderous nerve agent attack in the UK
Published in Clinical Toxicology, 2018
J. Allister Vale, Timothy C. Marrs, Robert L. Maynard
Sidell [15] has reviewed the features and treatment in two patients poisoned with sarin and soman, respectively, and Sidell [16] has reviewed the features of nerve agent poisoning, which can follow inhalation, ingestion or dermal exposure, although the onset of systemic toxicity is slower with the latter. Miosis, which can be painful and last several days, occurs rapidly after ocular exposure to a nerve agent and appears to be a very sensitive index of exposure [17]. Ciliary muscle spasm can impair accommodation, and conjunctival injection and eye pain can occur. Contact with liquid nerve agent can produce localized sweating and fasciculation, which can spread to involve whole muscle groups. Chest tightness, increased salivation, rhinorrhea and bronchorrhea occur within seconds or minutes of inhaling a nerve agent. In contrast, ingestion of food or water contaminated with a nerve agent can cause abdominal pain, nausea, vomiting, diarrhea and involuntary defecation, although the onset of symptoms may be delayed. Miosis can also occur as a systemic feature, although it more usually follows direct exposure. Abdominal pain, nausea and vomiting, involuntary micturition and defaecation, muscle weakness and fasciculation, tremor, restlessness, ataxia and convulsions can follow dermal exposure, inhalation or ingestion of a nerve agent. If exposure is substantial, death may occur from respiratory failure within minutes, whereas mild or moderately exposed individuals usually recover completely, although electroencephalogram abnormalities have been reported in those severely exposed to sarin in Japan [18,19].
Fixed-combination topical anti-hypertensive ophthalmic agents
Published in Expert Opinion on Pharmacotherapy, 2020
Lindsay Machen, Reza Razeghinejad, Jonathan S. Myers
Pilocarpine was one of the first medications found to have an impact on IOP [105]. Through its effects on the ciliary body muscle, pilocarpine increases outflow through the trabecular meshwork and reduces IOP. Locally, pilocarpine results in pupillary miosis, stimulation of accommodation, brow ache, and potential ocular surface desiccation and punctal scarring with prolonged use. A theoretical risk of retinal tear and detachment exists due to traction on the ciliary body and peripheral retina; retinal compromise is unlikely in patients without preexisting retinal pathology and rare in general [106]. A dilated and thorough retina exam may be prudent prior to initiation of miosis-inducing medications. Potential systemic side effects include hypersalivation, stomach cramping, and bradycardia in excessive doses. Combination agents containing pilocarpine are less frequently used today; however, they have been demonstrated to have a significant IOP lowering effect.
In Vivo Analysis and Comparison of Anterior Segment Structures of Both Eyes in Unilateral Herpetic Anterior Uveitis
Published in Ocular Immunology and Inflammation, 2021
Muhammet Derda Ozer, Muhammed Batur, Erbil Seven, Serek Tekin, Fatih Kebapci
Pilocarpine hydrochloride drops were administered to both eyes three times in 30 min to decrease iris surface irregularities before image acquisition. Pupillary miosis could not be achieved in the affected eye because of persistent pupillary dilation in some of the participants. Immediately after achieving pharmacological miosis, all patients underwent AS SD-OCT scanning in a dim light room illumination. An angle scan in the automatic real-time mode was selected to achieve enhanced quality imaging. All scans were measured in the high-resolution mode at a resolution of 10.84 µm/pixel on the X-axis and 3.87 µm/pixel on the Z-axis. Figures of the nasal and temporal angles (at the 3 o’clock and 9 o’clock positions) were obtained separately after the adjustment of the fixation to the nasal and temporal areas for analyzing the SCA. Eleven cross-sectional B-scans were obtained for each eye in the scleral enhanced depth imaging mode. If artifacts due to nictitation were noted, the examination was repeated up to three times in each eye. The nasal and temporal limbus images were preferred in this study because of the obstacles to obtain superior and inferior limbal scans.
Related Knowledge Centers
- Pupillary Response
- Mydriasis
- Anisocoria
- Ehlers–Danlos Syndromes
- Horner'S Syndrome
- Bleeding
- Pons
- Intracranial Hemorrhage
- Cluster Headache
- Ptosis