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13th Pupil Colloquium
100
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 3 (Shields). One of two surgical suites in the Wadsworth Building.
When Dr. Wadsworth stepped down from the chairmanship in 1978, Dr. Machemer, who had gained an interna tional reputation for his pioneering work in vitreoretinal surgery at the University of Miami, took over the challenge of a growing department. To him fell the re sponsibility of continuing the high quality of training and medical care that his two predecessors had established and to ex pand the research program, which Dr. Wadsworth had so capably started, in the Eye Center. Dr. Machemer met this challenge by further increasing the senior and resident faculty and by starting fel lowship programs. He added research faculty under the leadership of Gordon Klintworth, and equipped the Eye Cen ter with facilities that included labora-
Fig. 4 (Shields). Dyson Hickingbotham, ophthal mic instrument designer, in the biophysics laborato ry of the Wadsworth Building.
JULY, 1983
tories for electron microscopy, tissue culture, biochemistry, instrument de velopment (Fig. 4), and laser research. The reputation of the Duke University Eye Center is now reaching international proportions. The credit goes to no single person, but to the program's three lead ers and those who have worked with them to build on the accomplishments of their predecessors. Whatever the future may hold, however, the Joseph A. C. Wadsworth Building will stand as a trib ute to one man, whose foresight, abili ties, and determination were of para mount importance in the continuing growth of ophthalmology at Duke Univer sity. M. BRUCE S H I E L D S
13TH P U P I L C O L L O Q U I U M The 13th Pupil Colloquium was held at the Sunnybrook Medical Centre in To ronto. The hosts of the 13th colloquium were Jan S. C. Czarnecki and the Depart ment of Ophthalmology of the Sunnybrook Medical Centre. T. Suzuki and S. Ishikawa (Kitasato University) observed that the pupils of patients in Japanese leprosaria are some times exceptionally small and respond poorly to mydriatics, suggesting that some structural damage has been done to the iris. Films were shown of the unusual pupillary constriction to darkness in some patients with congenital stationary night blindness and congenital achromatopsia as described by Flynn and Barricks (M. Price and H. S. Thompson, Iowa City). Discussion from the audience suggested that this brief, bilateral pupillary con striction can also occasionally be seen in patients with congenital amaurosis of Leber, optic disk hypoplasia, bilateral optic neuritis, and dominant optic atro phy. No mechanism was offered. Langley and Anderson's iris sphincter
VOL. 96, NO. 1
MEETINGS, CONFERENCES, SYMPOSIA
denervation experiments in the cat were repeated by J. S. C. Czarnecki (Toronto) but no light-near dissociation could be demonstrated. Pupil size and reactivity were carefully observed in 52 patients with primary thalamic hemorrhage (H. Ishikawa, Nihon University). Evidence was presented sug gesting that the miosis, anisocoria, and weak light reactions observed were the result of damage to both the excitatory and the inhibitory fibers to the sphincter nucleus rather than to damage to the sympathetic pathways. Three prototype portable instruments were shown, each designed to automate the swinging flashlight test and balance the relative afferent pupillary defect by dimming the light shining in one eye by a known amount (J.S.C. Czarnecki, Toron to; L. Sheingorn, Rockville, Maryland; and E. S. Perkins, Iowa City.) There are some promising aspects to these devices: the light always points directly at the pupil, the switch from one eye to the other is instantaneous, and the swinging rate is constant. Such an instrument is guaranteed to raise the consciousness of the user so that smaller and smaller asym metries are considered noteworthy. The temptation to take one more technologi cal step is almost irresistible: these de vices will no doubt soon be able to vary the intensity of the stimulus automatical ly and to print out the size of the relative pupil defect. At the moment, hand-held neutral density filters and a good hand light are still the easiest way to estimate the pupil defect. This technique was used in 55 amblyopic subjects and a relative afferent pupillary defect of 0.3 or more was found in the amblyopic eye in more than one half of the subjects (J. Portnoy and H. S. Thompson, Iowa City). The use of a noncontact, air-blast to nometer did not appear to increase the corneal penetration of tropicamide 0.5%, phenylephrine 10%, or thymoxamine
101
0.5%, judged by their pupillary actions (Q. A. Mekki and D. F. Edgar, London). A 15-year-old girl was described who seemed to show only the pupillary and accommodative signs of "cyclic oculomo tor spasms." There was no blepharoptosis and no diplopia (P. Bourgon and P. Laflamme, Montreal). Further evidence was offered that the pupils do not con strict to unpleasant stimuli; they dilate (S. R. Steinhauer, Pittsburgh). Type A (coronary prone) subjects cannot be dis tinguished from Type B subjects on the basis of their pupillary behavior (M. P. Janisse, Winnipeg). Pupillary responses to information-processing tasks suggest that schizophrenic subjects are marching to the beat of a different drummer (S. Steinhauer, Pittsburgh). Twenty-six cases were assembled of episodic pupillary distortion apparently resulting from segmental spasms of the iris dilator muscle. In most of these cases the pupil suddenly becomes misshapen so that it looks like a little black tadpole. The episodes last only a minute or two and sometimes occur many times a day and may go on for several weeks. Eleven of the patients had Homer's syndrome on the affected side, and eight had migraine (H. S. Thompson and D. Zackon, Iowa City). N. Sitaram (Detroit) is doing careful work on the effect of chronic antidepressant therapy on alphai receptor sensitivi ty by monitoring pupillary responses to phenylephrine. Clinical lore about diabetic pupils points to a weak or slow dilation to mydriatics and an occasional light-near dissoci ation, but recent work suggests that this may be in spite of an extrastrong dilation to directly acting adrenergic drugs (M. Hayashi and S. Ishikawa, Kitasato Uni versity; and S. E. Smith and S. A. Smith, London). The pupils of diabetic patients tend to be slightly smaller than normal and react a bit less to light than normal
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AMERICAN JOURNAL OF OPHTHALMOLOGY
subjects. This may result chiefly from concomitant parasympathetic damage (S. Smith, London) or primarily from me chanical abnormalities of the iris (S. Ishikawa, Kitasato University), or both. It seems generally agreed that diabetic au tonomie neuropathy is the major cause of these abnormalities. Of course, this neu ropathy may occur in the preganglionic path as well as the postganglionic neuron, thus preserving hydroxyamphetamine
JULY, 1983
mydriasis (S. Smith, London) or it may tend to involve chiefly the ciliary nerves, thus also numbing the cornea and per haps enhancing the corneal penetration of any medications placed in the conjunctival sac. The next meeting of the Pupil Collo quium will be held in the spring of 1985 at the University of Nebraska, Omaha, with Terry Cox as host. H. STANLEY T H O M P S O N
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 3 (Shields). One of two surgical suites in the Wadsworth Building.
When Dr. Wadsworth stepped down from the chairmanship in 1978, Dr. Machemer, who had gained an interna tional reputation for his pioneering work in vitreoretinal surgery at the University of Miami, took over the challenge of a growing department. To him fell the re sponsibility of continuing the high quality of training and medical care that his two predecessors had established and to ex pand the research program, which Dr. Wadsworth had so capably started, in the Eye Center. Dr. Machemer met this challenge by further increasing the senior and resident faculty and by starting fel lowship programs. He added research faculty under the leadership of Gordon Klintworth, and equipped the Eye Cen ter with facilities that included labora-
Fig. 4 (Shields). Dyson Hickingbotham, ophthal mic instrument designer, in the biophysics laborato ry of the Wadsworth Building.
JULY, 1983
tories for electron microscopy, tissue culture, biochemistry, instrument de velopment (Fig. 4), and laser research. The reputation of the Duke University Eye Center is now reaching international proportions. The credit goes to no single person, but to the program's three lead ers and those who have worked with them to build on the accomplishments of their predecessors. Whatever the future may hold, however, the Joseph A. C. Wadsworth Building will stand as a trib ute to one man, whose foresight, abili ties, and determination were of para mount importance in the continuing growth of ophthalmology at Duke Univer sity. M. BRUCE S H I E L D S
13TH P U P I L C O L L O Q U I U M The 13th Pupil Colloquium was held at the Sunnybrook Medical Centre in To ronto. The hosts of the 13th colloquium were Jan S. C. Czarnecki and the Depart ment of Ophthalmology of the Sunnybrook Medical Centre. T. Suzuki and S. Ishikawa (Kitasato University) observed that the pupils of patients in Japanese leprosaria are some times exceptionally small and respond poorly to mydriatics, suggesting that some structural damage has been done to the iris. Films were shown of the unusual pupillary constriction to darkness in some patients with congenital stationary night blindness and congenital achromatopsia as described by Flynn and Barricks (M. Price and H. S. Thompson, Iowa City). Discussion from the audience suggested that this brief, bilateral pupillary con striction can also occasionally be seen in patients with congenital amaurosis of Leber, optic disk hypoplasia, bilateral optic neuritis, and dominant optic atro phy. No mechanism was offered. Langley and Anderson's iris sphincter
VOL. 96, NO. 1
MEETINGS, CONFERENCES, SYMPOSIA
denervation experiments in the cat were repeated by J. S. C. Czarnecki (Toronto) but no light-near dissociation could be demonstrated. Pupil size and reactivity were carefully observed in 52 patients with primary thalamic hemorrhage (H. Ishikawa, Nihon University). Evidence was presented sug gesting that the miosis, anisocoria, and weak light reactions observed were the result of damage to both the excitatory and the inhibitory fibers to the sphincter nucleus rather than to damage to the sympathetic pathways. Three prototype portable instruments were shown, each designed to automate the swinging flashlight test and balance the relative afferent pupillary defect by dimming the light shining in one eye by a known amount (J.S.C. Czarnecki, Toron to; L. Sheingorn, Rockville, Maryland; and E. S. Perkins, Iowa City.) There are some promising aspects to these devices: the light always points directly at the pupil, the switch from one eye to the other is instantaneous, and the swinging rate is constant. Such an instrument is guaranteed to raise the consciousness of the user so that smaller and smaller asym metries are considered noteworthy. The temptation to take one more technologi cal step is almost irresistible: these de vices will no doubt soon be able to vary the intensity of the stimulus automatical ly and to print out the size of the relative pupil defect. At the moment, hand-held neutral density filters and a good hand light are still the easiest way to estimate the pupil defect. This technique was used in 55 amblyopic subjects and a relative afferent pupillary defect of 0.3 or more was found in the amblyopic eye in more than one half of the subjects (J. Portnoy and H. S. Thompson, Iowa City). The use of a noncontact, air-blast to nometer did not appear to increase the corneal penetration of tropicamide 0.5%, phenylephrine 10%, or thymoxamine
101
0.5%, judged by their pupillary actions (Q. A. Mekki and D. F. Edgar, London). A 15-year-old girl was described who seemed to show only the pupillary and accommodative signs of "cyclic oculomo tor spasms." There was no blepharoptosis and no diplopia (P. Bourgon and P. Laflamme, Montreal). Further evidence was offered that the pupils do not con strict to unpleasant stimuli; they dilate (S. R. Steinhauer, Pittsburgh). Type A (coronary prone) subjects cannot be dis tinguished from Type B subjects on the basis of their pupillary behavior (M. P. Janisse, Winnipeg). Pupillary responses to information-processing tasks suggest that schizophrenic subjects are marching to the beat of a different drummer (S. Steinhauer, Pittsburgh). Twenty-six cases were assembled of episodic pupillary distortion apparently resulting from segmental spasms of the iris dilator muscle. In most of these cases the pupil suddenly becomes misshapen so that it looks like a little black tadpole. The episodes last only a minute or two and sometimes occur many times a day and may go on for several weeks. Eleven of the patients had Homer's syndrome on the affected side, and eight had migraine (H. S. Thompson and D. Zackon, Iowa City). N. Sitaram (Detroit) is doing careful work on the effect of chronic antidepressant therapy on alphai receptor sensitivi ty by monitoring pupillary responses to phenylephrine. Clinical lore about diabetic pupils points to a weak or slow dilation to mydriatics and an occasional light-near dissoci ation, but recent work suggests that this may be in spite of an extrastrong dilation to directly acting adrenergic drugs (M. Hayashi and S. Ishikawa, Kitasato Uni versity; and S. E. Smith and S. A. Smith, London). The pupils of diabetic patients tend to be slightly smaller than normal and react a bit less to light than normal
102
AMERICAN JOURNAL OF OPHTHALMOLOGY
subjects. This may result chiefly from concomitant parasympathetic damage (S. Smith, London) or primarily from me chanical abnormalities of the iris (S. Ishikawa, Kitasato University), or both. It seems generally agreed that diabetic au tonomie neuropathy is the major cause of these abnormalities. Of course, this neu ropathy may occur in the preganglionic path as well as the postganglionic neuron, thus preserving hydroxyamphetamine
JULY, 1983
mydriasis (S. Smith, London) or it may tend to involve chiefly the ciliary nerves, thus also numbing the cornea and per haps enhancing the corneal penetration of any medications placed in the conjunctival sac. The next meeting of the Pupil Collo quium will be held in the spring of 1985 at the University of Nebraska, Omaha, with Terry Cox as host. H. STANLEY T H O M P S O N