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The evaluation of pupillary function is a keystone in the neuro-ophthalmic assessment of patients. The diagnosis of an afferent or efferent pupillary disorder is crucial in the acquisition of a broad range of diseases of the brain or the peripheral nervous system. This "update" of pupillary disorders covers a major part of clinical conditions eye doctors have to expect in their daily practice. The significance of pupillary evaluation, however, extends far beyond the area of ophthalmology., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Dissociated vertical divergence (DVD) is frequently associated with the infantile strabismus syndrome. There are different theories on the pathomechanism of this disorder, but none of them is generally accepted. Some authors believe that the slow upward movement of the covered eye is due to a different illumination of both retinae and consequently an unequal activity of the oculomotor nerve's nuclei. In one hypothesis a predominance of crossing pupillary tract fibres from the pretectal area to motor and parasympathetic nuclei of the oculomotor nerve was supposed. The consequence of this abnormal pathway in the midbrain would be a pronounced contraction anisocoria in patients with DVD. In contraction anisocoria the directly illuminated pupil contracts more strongly than the contralateral pupil without any efferent defect. In a small study we compared direct and indirect pupillary light reflexes in 11 DVD patients and 10 normal subjects. We found no significant differences of contraction anisocoria between the two groups. The results do not support the hypothesis of a different pupillary tract pathway in the midbrain of patients with DVD., (Georg Thieme Verlag KG Stuttgart · New York.)

Optic neuritis and anterior ischaemic optic neuropathy (AION) present with acute visual loss. AION shows a swollen optic disc, in optic neuritis it may be swollen in one third of the patients. Optic neuritis patients complain usually about pain with eye movements. A tumour causes slowly progressive visual loss, mostly painless. In all these cases a relative afferent pupillary defect (RAPD) may be expected. If RAPD is missing, a problem of the optic media (retinoscopy, pinhole test), macular disease (micropsy, improvement with grey filters), amblyopia or non-organic visual loss can be causative. However, it has to be considered that a homonymous visual field defect may be perceived as an unilateral visual loss. Therefore visual field testing is necessary., (Georg Thieme Verlag KG Stuttgart · New York.)

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., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aims: The aim of this study was to evaluate the clinical features as well as the visual results and determine the prognostic factors after the removal of retained intraocular foreign bodies (IOFBs)., Patients and Methods: At our centre we conducted a non-randomised, non-comparative retrospective analysis of records of 31 patients with intraocular foreign bodies treated using pars plana vitrectomy and other conventional surgical techniques during a 3-year period between January 2006 and December 2008. Using the OTS classification for ocular injuries (United States Eye Injury Registry [USEIR]), we evaluated the visual outcome and various pre-, intra- and postoperative clinical factors., Results: Almost all patients (96.8 %) were male with a mean age of 32.29 years ± 13.38 SD (SD = standard deviation). The most common cause of ocular injury was hammering (58 %), in 27 cases the IOFB was magnetic. Follow-up ranged from 1 to 34 months with a mean of 4.5 months. In 30 eyes, the IOFBs could be removed during the first surgery. The average time between injury and surgery was 15.78 ± 23.45 SD hours for 27 patients (87.1 %). In 3 cases the intraocular foreign body (IOFB) was removed 7, 9, 14 days after the injury. In one case the IOFB was removed in a second surgery 40 days after the injury. In 23 cases we performed pars plana vitrectomy, for 8 patients we performed anterior segment surgery, in 21 cases the lens was also removed. At the time of surgery initial vitreous haemorrhage was present in 17 patients (54.8 %). OTS score for ocular injury was calculated as 2.45 ± 0.78 SD. Initial visual acuity was below 20 / 200 in 61.3 % of the cases. Subsequent to surgical treatment over a mean follow-up of 2.5 months, 25 patients (80.64 %) achieved a visual acuity of 20 / 200 or better (0.69 ± 0.35 SD). Best corrected visual acuity was significantly better for ocular injuries with a higher OTS score (p = 0.000095). Other significant factors for good visual outcome were good initial visual acuity (p = 0.002), the absence of vitreal haemorrhagies (p = 0.024) and small size of the IOFB (p = 0.043). Postoperative complications included retinal detachment (9.67 %), endophthalmitis (3.22 %) and PVR (3.22 %)., Conclusion: Acceptable visual results could be achieved after the removal of posterior segment IOFBs by vitrectomy. A reliable classification of ocular injuries may provide significant information about the prognosis of injuries with intraocular foreign bodies., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Pupillary research has received a new impetus since the discovery of the melanopsin containing ganglion cell subpopulation ipRGC (intrinsically photosensitive retinal ganglion cells). These specific ganglion cells have a maximum spectral sensitivity at 480 nm and affect predominantly the day-night cycle (inner clock) and the pupil reaction. They control above all the adjustment of the pupil width during continuous lighting, as well as during particularly bright and above all short wavelength light. Our results from blind patients with retinitis pigmentosa also showed clear pupil light reactions when examined with standard pupillographic equipment (CIP, AMTech, Dossenheim) with a yellow stimulus. These results are difficult to explain with the previous hypotheses. Up till now, there have been only few investigations in groups of patients with ophthalmological diseases. These studies indicate that with modified pupillographic stimuli, a clear distinction between lesions of the outer and inner retina is possible., Methods: It is of interest for future applied pupillary research to ascertain how the pupillary light reaction alters with the wavelength, duration and intensity of the light stimulus. For such studies it is necessary not only to use well-defined spectral stimuli but also to develop special recording techniques and methods of analysis., Conclusions: It is to be expected that the results of such research will have consequences not only for the differential diagnosis of pathologies of the outer and inner retina, but also on the functional testing of retinal implants. This article gives an overview of the current state of knowledge., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim of the Study: Colour comparison tests are a subjective supplement to the swinging flashlight test. We have investigated the specificity and sensitivity, compared 3 exactly defined different colours (red, green, blue), and looked for age relationships., Method: 101 patient with various unilateral optic neuropathies were compared to 103 age-correlated healthy controls in randomised order by letting the patient evaluate red, green and blue colour charts of 5.5 cm diameter., Results: The area under the receiver operator characteristics curve was 0.804 for red, 0.821 for green and 0.789 for blue, and for any of the 3 colours 0.835 (at least one colour was seen differently). Best results were obtained when even small differences in colour perception were considered as pathological. 29 healthy controls perceived colours differently in both eyes, 24 of those being older than 50 years. The specificity decreased with age, was significant for green and red, not for blue., Discussion: There were no significant differences between the 3 colours in all age groups. Evaluation of more than one colour does not increase the sensitivity significantly. Even small differences have to be considered as pathological to obtain the highest possible sensitivity. Test specifity decreases with age., (© Georg Thieme Verlag KG Stuttgart · New York.)

Examination of the pupil offers an objective evaluation of visual function as well as the vegetative pathways to the eye. Essential information is gathered within a short time. This makes pupillary inspection a valuable part of the routine ophthalmological, neurological and general medical examinations. Due to the proximity of pupillary pathways to various anatomic structures, pupillary dysfunction can be caused by a variety of disorders, some of which may be life threatening. The ophthalmologist plays a key role in detecting pupillary disorders and in directing further investigations. Therefore, one should have a good knowledge of the diagnostic significance of pupillary function and dysfunction., (© Georg Thieme Verlag KG Stuttgart · New York.)

Traumatic optic neuropathy is a severe complication of a head or face trauma. Diagnosis is established by analyzing pupillary responses to light. Fundus examination and orbital CT scan help to localize the site of the lesion and may show a fracture involving the optic canal. Surgical decompression or megadose steroids are therapeutic options. No therapeutic approach has proven with sufficient evidence to be effective. Spontaneous improvement is definitely possible. Based on experiences in single cases direct compression of the optic nerve by bone fragments or optic nerve sheath haemorrhage are as a rule treated surgically. In all other cases usually high dose steroids are given without proven effectiveness.

Background: A ciliary block is the rarer cause of angle block glaucoma. In order to choose the appropriate therapy, however, it is crucial to make the correct diagnosis. We report on a patient who suffered from recurrent increases of intraocular pressure while having renal dialysis. In his case the use of the Orbscan II made the differentiation between a pupillary and a ciliary block easier., Case Report: In addition to basic ophthalmological examinations we performed a topographic analysis using Orbscan II before and after renal dialysis. Since intraocular pressure rise during renal dialysis had been proven, iridotomies on both eyes and an iridectomy on the left one had been performed before the patient was referred to us. In spite of these open shunts we measured an increase of intraocular pressure values of 10 to 12 mmHg directly after renal dialysis had been completed. The anterior chamber became shallower both at its centre and the periphery, thus its volume diminished analogously. Measurements by the Orbscan II showed that the lens swelled up and was displaced anteriorly as well, so that a ciliary block mechanism had to be assumed., Conclusions: Since the Orbscan II is capable of collecting topometric data of the cornea, anterior chamber and also lens, it is helpful in differentiating a pupillary from a ciliary block in angle block glaucoma.

Objective: The aim of this study was to compare the accuracy and the reproducibility of scotopic pupil measurements using 2 different methods., Methods: Scotopic pupil diameter was measured in 56 eyes of 28 volunteers and the results were compared between the green light test at the slit lamp (Haag-Streit, Switzerland) and the automatic measurements of the wave-front analyser WASCA (Carl-Zeiss-Meditec) by 2 independent examiners. Non-parametric sign test as well as All Pairwise Multiple Comparison Procedures (Student-Newman-Keuls method) were performed for the comparison of means for each individual eye as well as the results of both eyes tested by both examiners., Results: Mean age of the subjects was 34.9 years. The colour of iris was green or blue in 22 cases and brown in 6 cases. REPRODUCIBILITY: For the green light test we found for the first investigator in the right eye a mean pupil diameter of 6.58 mm (SD 0.68). The measurement of the second investigator for the same eye was 6.64 mm (SD 0.61). The left eye values were as follows: 6.36 mm (SD 0.68) and 6.75 mm (SD 0.68). For WASCA we found for the first investigator in the right eye 6.33 mm (SD 0.64) vs. 6.30 mm (SD 0.64) for the second investigator, in the left eye 6.39 mm (SD 0.69) vs. 6.36 mm (SD 0.60). There was a statistically significant difference between the two investigators when the green light test was used (6.47 mm vs. 6.69 mm for both eyes). No difference was found using the WASCA integrated pupillometer (6.35 mm vs. 6.33 mm). There was a significant difference between the means of combined data for both measurement methods: 6.58 mm for the green light test (SD 0.57) vs. 6.34 mm for WASCA (SD 0.62)., Conclusions: The integrated pupillometry of the WASCA analyser showed better reproducibility of measurements than the green light test. The green light test measures a slightly larger diameter (in the mean by 0.25 mm) than WASCA. Because of the fair and clinically sufficient reproducibility as well as virtually non-existing additional costs the green light test can be strongly recommended to referring ophthalmologists and low-volume refractive surgeons.

Background: In the first seconds after switching off the lights, Horner pupils often show a dilation lag. This dilation lag is diagnostic for Horner syndrome. We investigated whether the visibility of the dilation lag can be improved by increasing the amplitude of pupil dilation., Patients and Methods: In four patients with pharmacologically confirmed Horner syndrome pupil sizes were registered bilaterally simultaneously with an infrared camera. Dilation lag was induced by switching off the light while the patient was fixating at distance or by turning off the light and changing fixation from near to far at the same time. An increase of anisocoria of 0.5 mm or more within the first 4 seconds was interpreted as dilation lag., Results: Dilation lags were seen in one patient with both methods, in two patients only with the second method, and in one patient with neither method., Conclusions: Dilation lag visibility can be improved by asking the patient to change fixation from near to far at the moment when the lights are switched off.

Background: The aim of the study was to compare different methods for pupillometry, namely the Goldmann perimeter (gp), the Colvard pupillometer (cp) and the Procyon Video pupillometer (pvp). For the pvp three different illuminations were available: mesopic high, mesopic low, and scotopic., Patients: The size of the pupil was measured in 100 eyes (50 healthy subjects) with the three different methods. We examined 29 females (58 %) and 21 males (42 %) with an average age of 25.16 years, ranging from 18 to 30 years., Results: For the Goldmann perimeter, a mean pupil diameter of 4.39 mm +/- 0.62 mm was found under mesopic conditions (1.40 lux). For the Colvard pupillometer for scotopic conditions (0 lux), a mean pupil diameter of 6.80 mm +/- 0.81 mm was found. For pvp the pupil diameter ranged from 7.06 mm +/- 0.71 mm for scotopic (0.04 lux), over 6.24 mm +/- 0.80 mm for mesopic low (0.40 lux) to 4.65 mm +/- 0.73 mm for mesopic high conditions (4.00 lux)., Conclusion: The comparison of the results showed a high correlation between the Goldmann perimeter and the Procyon Video Pupillometer for mesopic high with a minimum difference of 0.25 +/- 0.69 mm. By addition of 2.67 mm to the mesopic measurement of the Goldmann perimeter, the results for the Procyon Video pupillometer at the scotopic level, by addition of 2.4 mm the scotopic measurement of the Colvard pupillometer could be achieved.

Aim of the Study: The swinging flashlight test is an objective method to diagnose a lesion of the anterior visual pathways. However, errors and faults may easily alter the test's results. Hence, the value of the swinging flashlight test depends highly on the examiner's skills. Therefore an automated and objective procedure was developed which is independent from the examiner., Methods: A binocularly measuring instrument adapted for video pupillography was supplied with two arrays of light emitting diodes in front of each eye of the subject. By means of this illumination, pupillary light reflexes are elicited alternately. Pupil size is registered continuously, and after artifact elimination, the response amplitudes of the pupils are determined as a mean of right and left pupil. Responses elicited via right and left eye are compared. By varying the stimulus intensity it is possible to measure the amount of the relative afferent pupillary defect. The procedure was tested in 31 patients with optic nerve disorders., Results: The measurements were easily feasible, stable and reliable. Correlation between the relative afferent pupillary defect detected manually by grey filter compensating and with the automated procedure proved to be high. Both variables correlated highly significant with a Spearman rank coefficient of 0.65. If the clinical test is regarded as the golden standard, the automated swinging flashlight test is able to detect 85% of the relative afferent pupillary defects > or = 0.3 logE and 94% of the defects > or = 0.6 logE., Conclusion: The automated swinging flashlight test can be recommended to exclude influences by the examiner or if the exact amount of the relative afferent pupillary defect is desired, e.g. when monitoring therapeutic effects in optic nerve diseases. Furthermore, an automated swinging flashlight test could serve as a screening test.

Background: The term "hippus" describes pupillary oscillations of variable amplitude and frequency and may be physiological or part of a pathological entity. Thus, pupillary hippus is often the target of extensive clinical investigation., Case Report: A 9-year-old boy was seen in our emergency room in March 1998. Examination showed distinct pupillary oscillations in the absence of any other pathological findings. We presented the patient to a pediatric neurologist. Apart from a history of enuresis and of motor tics in the neck region, the present neurological examination was normal., Conclusions: Even a pronounced hippus may be physiological and does not necessarily require extensive diagnostic investigations.

Aim: To examine effects of diabetes mellitus on the pupillary light reflex it was analysed using a new compact integrated infrared pupillograph (CIP). PATIENTS AN METHODS: We examined 52 patients with diabetes mellitus and 21 control subjects. The initial pupillary diameter was diminished in the group of the diabetics. This was the only parameter that was significantly diminished in the group of all patients with diabetes mellitus. The maximal constriction velocity, the maximal velocity of the first part of the redilation, the reflex amplitude and the latency time were significantly reduced only in those patients showing also signs of autonomic neuropathy of the cardiovascular system. The amplitude and the velocities however, measured as part of the initial pupillary diameter showed no significant reduction., Conclusion: This leads to a very crucial question when examining the pupillary reflex of diabetics. Which alterations are due to the pathological small pupil and which are directly due to autonomic neuropathy. This study shows that the diminished pupillary diameter after adaptation to the dark is an early sign of autonomic neuropathy; other alterations in the pupillary reflex can be seen after other symptoms of the autonomic neuropathy are shown as well.

Unlabelled: The purpose of this study was to test for correlation between relative afferent pupillary defect (RAPD) and visual acuity, central differential light threshold and visual field defect measured by suprasthreshold automated grid perimetry., Methods: In 98 patients with optic neuropathies of different origin (inflammatory, ischemic, or compressive) in addition to a standard ophthalmological examination, static perimetry of the 30 degrees visual field with a dense grid of test spots, including measurement of the central differential light sensitivity, was done by means of the Tübingen Automated Perimeter. RAPD was tested using the swinging flashlight test quantified with neutral density filters., Results: Visual acuity and central differential light sensitivity correlated only weakly with the RAPD. The visual field showed a better correlation (coeff. of corr. for all patients 0.58, for patients with optic neuritis 0.64. for patients with AION 0.53 and for patients with compressive neuropathies 0.84). One test spot not seen in perimetry corresponded to an RAPD of about 0.01 log-units., Conclusions: The results confirm those from previous studies obtained by threshold perimetry. The RAPD is a good parameter for the severity of an optic nerve lesion, especially of compressive origin.

1. Disorders of the parasympathetic outflow (iris sphincter muscle disorders): lesions of the oculomotor nerve, tonic pupil, Adie's pupil syndrome. 2. Disorders of the sympathetic outflow (iris dilator muscle) Horner's syndrome (neuron I, II, III). 3. The afferent pupillary defect (lesions of the optic nerve, the chiasm and the optic tract): amaurotic pupil rigidity, amblyopic pupil disturbance, bitemporal pupil rigidity, homonymous hemianopic pupil rigidity, Argyll-Robertson pupil.

In 1958 Ross described a triade consisting of tonic pupils, hyporeflexia and sudomotor denervation. Etiology and pathogenesis are unknown. 14 cases of Ross' syndrome have been mentioned in the literature up to now. Three additional cases are demonstrated.