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Helmut Wilhelm - One of the best experts on this subject based on the ideXlab platform.
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The Swinging Flashlight Test - Flawed Execution and Interpretation in Ophthalmological Routine.
Klinische Monatsblatter fur Augenheilkunde, 2020Co-Authors: Flemming Beisse, Helmut Wilhelm, Alina Ring, Christina BeisseAbstract:Background The swinging flashlight Test is a standard diagnostic procedure to detect relative afferent pupillary defects. The advantages of the Test lie within its objectivity and minimal effort. However, its value depends on its correct execution and interpretation. This questionnaire-based survey investigates whether this is given among German speaking ophthalmologists. Methods A multiple-choice questionnaire with 14 questions on the use of the swinging flashlight Test was designed. It was presented to German speaking ophthalmology specialists (primary data) and orthoptists (secondary data) on specialist conferences or by telephone interviews. Results 249 ophthalmologists and 76 orthoptists participated in the survey. Only 2% of ophthalmologists answered all 14 questions correctly. On average 66% (range 29 - 100%) of the questions were answered correctly by the ophthalmologists. The question with the lowest result had a rate of 19%, the question with the highest result was correctly answered by 95%. The orthoptists achieved similar results. Conclusion The rate of correct answers appears disturbingly low. The swinging flashlight Test being a basic tool and an obligatory Test in a number of guidelines should rather be performed nearly error-free. In light of the high error rates, misdiagnoses and treatment errors must be feared. Better training seems necessary.
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Associating the magnitude of relative afferent pupillary defect (RAPD) with visual field indices in glaucoma patients.
The British journal of ophthalmology, 2012Co-Authors: Ulrich Schiefer, Helmut Wilhelm, Janko Dietzsch, B. Wilhelm, Klaus Dietz, A. Bruckmann, Veronique Kitiratschky, Kai JanuschowskiAbstract:Purpose To identify the variable with the strongest association between the magnitude of the relative afferent pupillary defect (RAPD) and visual field indices in patients with glaucomatous optic neuropathy. Methods Seventy-nine consecutive subjects with manifest glaucomatous optic neuropathy at least in one eye were enrolled in this retrospective study. RAPD was assessed with the swinging flashlight Test and quantified with a neutral density filter. Perimetry was performed using the fast thresholding strategy German Adaptive Threshold Estimation. The values of the central differential luminance sensitivity (DLS), of the MD (mean defect) and of the ‘loss volume’ (LVOL) based on the individually modelled 3D hill of vision—the latter two within the eccentricities of 10°, 20° and 30°, respectively—were entered into a linear regression model without intercept as a function of RAPD. Results An absolute value of RAPD of 0.3 log 10 units or more was present in 20 out of 79 glaucoma subjects (25%). The magnitude of RAPD was most closely associated with LVOL-30° (R 2 =0.77), followed by MD-30° (R 2 =0.73), MD-20° (R 2 =0.71), LVOL-20° (R 2 =0.67), MD-10° (R 2 =0.58), LVOL-10° (R 2 =0.54) and central DLS (R 2 =0.04). Conclusions The prevalence of RAPD in glaucoma patients is comparatively small (25%). The magnitude of RAPD in glaucoma subjects is associated most closely with the LVOL within 30° eccentricity (which is the maximum visual field region Tested in this study) and most loosely with central DLS, underscoring the impact of the entire (30°) visual field area on the afferent pupillary system.
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Relativer afferenter Pupillendefekt bei Glaukom
Klinische Monatsblatter fur Augenheilkunde, 2011Co-Authors: Karolína Skorkovská, Helmut Wilhelm, Holger Lüdtke, Barbara WilhelmAbstract:Ziel der Studie war festzustellen, wie haufig ein relativer afferenter Pupillendefekt (RAPD) bei Glaukompatienten ist und ob sein Auftreten mit dem Ausmas von Gesichtsfelddefekten und ihrer Seitendifferenz bei schwellennah-uberschwelliger Rasterperimetrie abhangt. Patienten und Methoden: Es wurden retrospektiv Patienten mit Offenwinkelglaukom aus der Glaukomsprechstunde der Universitatsaugenklinik Tubingen herausgesucht, bei denen die Pupillen im Rahmen einer Standarduntersuchung mit dem Swinging-Flashlight-Test untersucht wurden. Das zentrale 30Grad-Gesichtsfeld wurde mittels statischer Rasterperimetrie mit dem Tubinger Automatik-Perimeter oder dem Octopus-Perimeter untersucht. Die Gesichtsfeldbefunde und ihre Seitendifferenz wurden zwischen Patienten mit und ohne RAPD mit dem Wilcoxon-RangsummenTest verglichen. Ergebnisse: Nach der Berucksichtigung von Ausschlusskriterien wurden 100 Patienten mit primarem Offenwinkelglaukom in die Studie aufgenommen, 34 davon wiesen einen RAPD (34 %) auf. Fur die Gesichtsfeldanalyse konnten die Daten von 85 Patienten verwendet werden, da bei diesen eine identische perimetrische Strategie verwendet wurde. 25 Patienten davon hatten einen RAPD (29 %). Die berechneten Gesichtsfelddefektmase waren bei Patienten mit RAPD signifikant groser als bei Patienten ohne RAPD, ihre Gesichtsfeldbefunde also insgesamt fortgeschrittener. Auch die Seitendifferenz zwischen Gesichtsfeldern beider Augen war bei Patienten mit RAPD signifikant groser. Eine ROC(Receiver Operating Characteristics)-Kurve stellte dar, dass die Seitendifferenz im Gesichtsfeldbefund mit einer AUC (area under curve) von 0,81 ein guter Pradiktor fur den RAPD ist. Schlussfolgerung: Der RAPD tritt ungefahr bei einem Drittel der Patienten mit Offenwinkelglaukom auf. Er findet sich vorwiegend bei starker ausgepragten Gesichtsfeldausfallen und Gesichtsfeldausfallen mit einer grosen interokularen Differenz. Wir raten, den Swinging-Flashlight-Test in die Glaukomdiagnostik einzuschliesen.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 30deg. visual field was examined by means of static perimetry using the Tubinger 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.
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efficacy and tolerability of 0 2 brimonidine tartrate for the treatment of acute non arteritic anterior ischemic optic neuropathy naion a 3 month double masked randomised placebo controlled trial
Graefes Archive for Clinical and Experimental Ophthalmology, 2006Co-Authors: Barbara Wilhelm, Holger Lüdtke, Helmut WilhelmAbstract:Neuroprotection may be an option in ischemic optic nerve disease. There have been promising reports about the neuroprotective ability of topical brimonidine in animal studies. Therefore, we Tested whether 0.2% brimonidine tartrate could improve the outcome of patients with non-arteritic anterior ischemic optic neuropathy (NAION). The study was stopped after an interim analysis, having not proven its feasibility within practicable time frame. A 3-month, double-masked, placebo-controlled, randomised European multicenter trial conducted according to good clinical practice rules. Thirty-six patients (22 m, 14 f), older than 40 years with first eye involvement and typical signs of NAION were included in the study within the 1st week after visual loss (VA 0.05–1.0) and were randomized to treatment with either brimonidine 0.2% (Alphagan) or placebo. Visual acuity (VA, primary endpoint), visual field (VF, Humphrey 30–2 and Goldmann, quantified by a modified Esterman grid) and automated swinging flashlight Test (SWIFT) were performed at baseline, 2 weeks, 4 weeks and 12 weeks after first visit. Primary analysis aimed at intention-to-treat group (ITT, n=29), secondary analysis to the per protocol population (PP, n=25). Tolerability and safety were Tested in the safety group (n=36). A two-sample two-sided t-Test was used for statistical analysis (alpha level at 0.05). VA did not show statistically significant difference by treatment. There were non-significant trends for better visual field results in the brimonidine group. Adverse events consisting of local irritation were observed six times in the verum and three times in the placebo group. No serious adverse events occurred. In contradiction to an open-labeled, retrospective study published by Fazzone et al., the results of this trial did not indicate any harmful effect of brimonidine in patients suffering from NAION. However, a statistically significant advantage for the patients receiving brimonidine tartrate could not be shown.
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Efficacy and tolerability of 0.2% brimonidine tartrate for the treatment of acute non-arteritic anterior ischemic optic neuropathy (NAION): a 3-month, double-masked, randomised, placebo-controlled trial
Graefe's Archive for Clinical and Experimental Ophthalmology, 2006Co-Authors: Barbara Wilhelm, Holger Lüdtke, Helmut WilhelmAbstract:Introduction Neuroprotection may be an option in ischemic optic nerve disease. There have been promising reports about the neuroprotective ability of topical brimonidine in animal studies. Therefore, we Tested whether 0.2% brimonidine tartrate could improve the outcome of patients with non-arteritic anterior ischemic optic neuropathy (NAION). The study was stopped after an interim analysis, having not proven its feasibility within practicable time frame. Methods A 3-month, double-masked, placebo-controlled, randomised European multicenter trial conducted according to good clinical practice rules. Thirty-six patients (22 m, 14 f), older than 40 years with first eye involvement and typical signs of NAION were included in the study within the 1st week after visual loss (VA 0.05–1.0) and were randomized to treatment with either brimonidine 0.2% (Alphagan) or placebo. Visual acuity (VA, primary endpoint), visual field (VF, Humphrey 30–2 and Goldmann, quantified by a modified Esterman grid) and automated swinging flashlight Test (SWIFT) were performed at baseline, 2 weeks, 4 weeks and 12 weeks after first visit. Primary analysis aimed at intention-to-treat group (ITT, n =29), secondary analysis to the per protocol population (PP, n =25). Tolerability and safety were Tested in the safety group ( n =36). A two-sample two-sided t -Test was used for statistical analysis (alpha level at 0.05). Results VA did not show statistically significant difference by treatment. There were non-significant trends for better visual field results in the brimonidine group. Adverse events consisting of local irritation were observed six times in the verum and three times in the placebo group. No serious adverse events occurred. Conclusion In contradiction to an open-labeled, retrospective study published by Fazzone et al., the results of this trial did not indicate any harmful effect of brimonidine in patients suffering from NAION. However, a statistically significant advantage for the patients receiving brimonidine tartrate could not be shown.
Akira Negi - One of the best experts on this subject based on the ideXlab platform.
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New insights into the study of optic nerve diseases
Nippon Ganka Gakkai zasshi, 2013Co-Authors: Akira NegiAbstract:Optical coherence tomography (OCT) provides a new dimenstion in ophthalmology because it allows evaluation of the pathology in vivo, and provides information to assist the management of macular disease and glaucoma. It is necessary to differentiate the diagnosis of glaucoma from diseases of the optic nerve and of the visual pathway. This study evaluates the usefulness of OCT in detecting disorders of the optic nerve and visual pathway. In addition, the pathogenesis of glaucomatous optic neuropathy (GON), the most common optic neuropathy, was investigated by focusing on the dynamics of aquaporin. I. Evaluation of optic nerve and visual pathway disorders by optical coherence tomography. The swinging flashlight Test is an easy, sensitive, objective Test to detect relative afferent pupillary defects (RAPD). The number of RAPD detected by the swinging flashlight Test was closely correlated with the ratio of retinal nerve fiber layer thickness (RNFLT) between the two eyes of 20 cases of unilateral optic atrophy. OCT could assess the amount of RAPD that reflected an asymmetrical functional disturbance of the optic nerves, as a structural difference. The time courses of RNFLT and ganglion cell complex (GCC) changes' were observed immediately following the time of injury in 4 cases of traumatic optic neuropathy. OCT revealed that both the RNFLT and GCC decreased rapidly from 2 weeks after the injury until 20 weeks later. The RNFLT decreased significantly in the horizontal direction in comparison to the perpendicular direction in 34 eyes from the cases of optic chiasm syndrome. This means that OCT could quantitatively detect the band atrophy of the optic disc in optic chiasm syndrome. Measuring the RNFLT showed a thinning of RNFLT in the perpendicular direction in comparison to the horizontal direction in ipsilateral eyes and thinning in the horizontal direction in comparison to the perpendicular direction in the contralateral eyes in optic tract syndrome. Measuring the GCC showed a thinning of the GCC in the temporal hemifield to the central fovea of the ipsilateral eyes, and thinning of the GCC in the nasal hemifield of the contralateral eyes. This means that OCT could detect the structural changes of hourglass atrophy in the ipsilateral eye and band atrophy in the contralateral eye at the optic disc as well as the homonymous hemianopia in the visual field. OCT was useful in evaluating the optic nerve and visual pathway disorders, but there were also some limitations. The thinning area of RNFLT measured by OPTVue and Cirrus were in entirely opposite directions in cases of optic chasm syndrome. The reason was attributed to the better performance of RTVue in measuring a thin RNFLT on the nasal side of the optic disc in comparison to Cirrus. The specific characteristics of the instruments should be considered when the results of OCT are evaluated. II. Dynamics of aquaporin in the optic nerve Aquaporin (AQP) is a membrane protein that forms a water channel to facilitate water crossing the plasma membrane. AQP-4 was originally thought to be expressed in the optic nerve, but it is expressed only in the retrobulbar medullated region of the optic nerve and the expression of AQPs in the optic disc has not been detected. This study investigated the expressions of AQPs in the optic nerve in rat, monkey and human. The results demonstrate that only AQP-9 was expressed at the unmedullated pre-lamina cribrosa and lamina cribrosa regions, and both AQP-4 and AQP-9 were expressed at the medullated retrobulbar region. Astrocytes were observed to express AQP-9, because AQP-9 immunoreactivity was identical to that of glial fibrillary acidic protein. Elevated intraocular pressure substantially reduced AQP-9 expression in the optic nerve, whereas expression of AQP-4 was not changed in rat eyes. The same phenomena were also observed in the monkey eye with ocular hypertension as well as human eye with glaucoma. AQP-9 is an aquaglyceroporin that allows solutes such as lactate rather than water to cross the cell membrane. The astrocyte-to-neuron lactate shuttle hypothesis has been proposed, in which lactate transported from astrocytes is used by neurons as an energy substrate. Reduction of AQP-9 expression in the optic nerve head under elevated intraocular pressures might be closely related to the pathogenesis of GON.
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quantification of retinal nerve fiber layer thickness reduction associated with a relative afferent pupillary defect in asymmetric glaucoma
British Journal of Ophthalmology, 2007Co-Authors: Yasuko Tatsumi, Makoto Nakamura, Miyuki Fujioka, Yoriko Nakanishi, Azusa Kusuhara, Hidetaka Maeda, Akira NegiAbstract:Aim: The relative afferent pupillary defect (RAPD) is an important clinical sign of asymmetrical retinal ganglion cell and axonal damage. Although glaucoma essentially affects bilateral eyes, a subset of patients manifests asymmetrical glaucomatous optic neuropathy (GON), which exhibits an RPAD in the more advanced eyes. However, the degree to which axonal loss occurs before an RAPD is clinically detectable has not been substantiated. The purpose of this study is to assess the relationship between the depth of a clinically detectable RAPD and the reduction ratio of retinal nerve fiber layer (RNFL) thickness in the more advanced eyes relative to that in the contralateral less advanced eyes of patients with asymmetrical GON. Methods: Enrolled were 29 consecutive glaucoma patients with the clinically detectable RAPD. An RAPD was quantified by placing log-scaled neutral density filters over the less advanced eyes while performing the swinging flashlight Test. Average RNFL thickness was determined using the Fast RNFL thickness programme of optical coherence tomography 3000. Correlation coefficient and Linear regression analyses were used in assessing the relationship between the RAPD and the ratio of RNFL thickness in the more advanced eyes relative to that in the less advanced. Results: RAPD ranged from 0.6 to 2.4 log units. The log-scaled RAPD had a statistically significantly inversed correlation with the average RNFL thickness ratio (r s = −0.729, p 2 = 0.557, p Conclusions: When an RAPD is clinically detected, the RNFL thickness in the more advanced eyes was in average reduced to about 73% of that in the less advanced.
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Quantification of retinal nerve fiber layer thickness reduction associated with a relative afferent pupillary defect
Graefe's Archive for Clinical and Experimental Ophthalmology, 2006Co-Authors: Yoriko Nakanishi, Yasuko Tatsumi, Makoto Nakamura, Azusa Nagai-kusuhara, Akira NegiAbstract:Background A relative afferent pupillary defect (RAPD) is known to develop only when more than 25% of retinal ganglion cells are ablated in monkeys’ eyes. However, there was no prior study to estimate biometrically the degree of retinal nerve fiber layer (RNFL) thickness reduction leading to the development of RAPD in live human eyes. The purpose of this study was to examine the correlation between the amount of RNFL thickness reduction and the depth of a clinically detectable RAPD in patients with unilateral optic atrophy. Methods Enrolled were 20 patients with optic atrophy of various etiologies. We quantified RAPD by performing the swinging flashlight Test with log-scaled neutral density filters placed over the unaffected eye. Average RNFL thickness was measured by OCT3000 with the average RNFL thickness program. Linear regression analysis was used in assessing the relationship between RAPD and the ratio of affected to unaffected average RNFL thickness. Results The mean of average RNFL thickness was 95.6±17.3 μm in the unaffected eyes and 50.7±19.3 μm in the affected eyes ( P
Ulrich Schiefer - One of the best experts on this subject based on the ideXlab platform.
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Assessment of functional and morphometric endpoints in patients with non-arteritic anterior ischemic optic neuropathy (NAION)
Graefe's Archive for Clinical and Experimental Ophthalmology, 2014Co-Authors: Christoph Kernstock, Flemming Beisse, Sarah Wiethoff, Andrea Mast, Elke Krapp, Regine Grund, Janko Dietzsch, Wolf Lagrèze, Dominik Fischer, Ulrich SchieferAbstract:Background The primary objective of this bi-center explorative pilot study was the quantitative assessment of visual field defects and retinal nerve fiber layer thickness (RNFT) over 6 months in patients with acute non-arteritic anterior ischemic optic neuropathy (NAION), in order to elucidate the natural course of NAION and provide a reference dataset for future treatment studies. Methods 16 patients (age 41–80 years, nine males, seven females) suffering from acute NAION and presenting within 7 days after onset of symptoms were included in this study. The following examinations were carried out at the initial visit (month 0) and at months 2, 4 and 6: entire (90°) visual field examination with automated static white-on-white perimetry, quantified by mean defect (MD); peripapillary retinal nerve fiber layer thickness (RNFT) measurement with spectral domain optical coherence tomography (SD-OCT); assessment of distant best correct visual acuity (D-BCVA) and a quantification of the relative afferent pupillary defect (RAPD) using the swinging flashlight Test with neutral density filters. Perimetric Mean Defect (MD) and RNFT values were each compared between the consecutive visits using the non-parametric Friedman Test. Results The initial MD was 6.2 dB (IQR 5.0–7.4) without significant changes further on. RNFT was 183 μm (IQR 148–252) initially, decreased significantly at month 2 (78 μm (IQR 71–93) and further at month 4 (64 μm (IQR 58–74) and 6 (61 μm (IQR 52–81), Friedman Test, p
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Associating the magnitude of relative afferent pupillary defect (RAPD) with visual field indices in glaucoma patients.
The British journal of ophthalmology, 2012Co-Authors: Ulrich Schiefer, Helmut Wilhelm, Janko Dietzsch, B. Wilhelm, Klaus Dietz, A. Bruckmann, Veronique Kitiratschky, Kai JanuschowskiAbstract:Purpose To identify the variable with the strongest association between the magnitude of the relative afferent pupillary defect (RAPD) and visual field indices in patients with glaucomatous optic neuropathy. Methods Seventy-nine consecutive subjects with manifest glaucomatous optic neuropathy at least in one eye were enrolled in this retrospective study. RAPD was assessed with the swinging flashlight Test and quantified with a neutral density filter. Perimetry was performed using the fast thresholding strategy German Adaptive Threshold Estimation. The values of the central differential luminance sensitivity (DLS), of the MD (mean defect) and of the ‘loss volume’ (LVOL) based on the individually modelled 3D hill of vision—the latter two within the eccentricities of 10°, 20° and 30°, respectively—were entered into a linear regression model without intercept as a function of RAPD. Results An absolute value of RAPD of 0.3 log 10 units or more was present in 20 out of 79 glaucoma subjects (25%). The magnitude of RAPD was most closely associated with LVOL-30° (R 2 =0.77), followed by MD-30° (R 2 =0.73), MD-20° (R 2 =0.71), LVOL-20° (R 2 =0.67), MD-10° (R 2 =0.58), LVOL-10° (R 2 =0.54) and central DLS (R 2 =0.04). Conclusions The prevalence of RAPD in glaucoma patients is comparatively small (25%). The magnitude of RAPD in glaucoma subjects is associated most closely with the LVOL within 30° eccentricity (which is the maximum visual field region Tested in this study) and most loosely with central DLS, underscoring the impact of the entire (30°) visual field area on the afferent pupillary system.
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The pupillary light reflex pathway: cytoarchitectonic probabilistic maps in hemianopic patients.
Neurology, 2008Co-Authors: Eleni Papageorgiou, Luca Francesco Ticini, Gregor Hardiess, Frank Schaeffel, H. Wiethoelter, Hanspeter A. Mallot, S. Bahlo, B. Wilhelm, Reinhard Vonthein, Ulrich SchieferAbstract:Objective: The anatomy of the human pupillary light reflex (PLR) pathway is a matter of debate. The aim of this study was twofold: namely, to investigate the association of a relative afferent pupillary defect (RAPD) in acquired suprageniculate lesions with the location and extent of the cerebral lesions. Further, we suggest a new strategy of lesion analysis by combining established techniques with the stereotaxic probabilistic cytoarchitectonic atlas developed by the Julich group. Methods: Twenty-three patients with homonymous visual field defects participated in this study. The RAPD was quantified clinically by two independent examiners with graded neutral density filters (swinging flashlight Test). Using MRI in each individual, cerebral regions commonly affected in patients with a RAPD but spared in patients without a RAPD were determined and subsequently assessed by using cytoarchitectonic probabilistic maps. Results: A RAPD was present in 10/23 patients. Comparison of patients showing a RAPD vs those not showing a RAPD revealed that a region including the course of the optic radiation at its early beginning in the temporal white matter is commonly associated with a RAPD. Conclusions: It was demonstrated that the pupillary light reflex (PLR) depends on the input of suprageniculate neurons, thus supporting the involvement of a cortical pathway also. The site of integration of cortical signals in relation to the PLR into the pupillomotor pathway may be located suprageniculately in the vicinity of the lateral geniculate nucleus. Moreover, the suggested combination of established lesion analysis techniques with the probabilistic cytoarchitectonic atlas turned out to be a very helpful amelioration of stroke data analyses.
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Relative afferent pupillary defects in patients with geniculate and retrogeniculate lesions
Neuro-Ophthalmology, 1996Co-Authors: Helmut Wilhelm, Barbara Wilhelm, Dirk Petersen, Ulrike Schmidt, Ulrich SchieferAbstract:We reviewed the clinical findings and imaging studies of 43 patients with homonymous hemianopia and normal optic discs to discover differences between those with and those without relative afferent pupillary defect (RAPD). Methods: RAPD was determined by means of the swinging flashlight Test. Visual field defects had to be congruous and no visual loss attributable to retinal or optic nerve disease or other causes of RAPD such as amblyopia was accepted. The imaging studies were reviewed by a neuroradiologist unaware of the clinical findings. Patients with lesions involving the optic tract were excluded. The shape of the lesion was transferred onto standard diagrams of the cerebral imaging sections and the proximity to the lateral geniculate nucleus (LGN) was determined. Results: Sixteen of 43 patients showed RAPD contralateral to the lesion. In these 16 patients, the median distance between the lesion and the LGN was 4.5 mm (maximum distance 18 mm, 14 lesions being closer than 10 mm). In 27 patients withou...
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Differential diagnostic strategies in uncertain vision disorders
Der Ophthalmologe : Zeitschrift der Deutschen Ophthalmologischen Gesellschaft, 1993Co-Authors: E Zrenner, Helmut Wilhelm, Ulrich SchieferAbstract:The differential diagnosis of visual disturbances of unclear origin can cause major problems in ophthalmology, especially if there are no functional defects or if functional defects cannot be explained by morphological findings after an extensive regular ophthalmological investigation. The aim of this paper is to present strategies that allow subtle visual disturbances to be related to certain groups of functional defects. Especially simple investigations are emphasized that lead quickly to a well-founded possible diagnosis that helps both the ophthalmologist and patient save time and cost-consuming deviations. The key investigations are: (1) a symptom-oriented case history; (2) exclusion of refractive problems by pin-hole Test, retinoscopy and ophthalmometry; (3) the swinging flashlight Test; (4) ophthalmoscopy of the macula and optic disc; (5) visual field. A flow chart is presented that explains the strategy of additional special investigations based on the results of the key findings in order to approach quickly the cause of a visual disturbance. Some of the more common causes of visual disturbances of unclear origin are discussed, including some major therapeutic principles.
Barbara Wilhelm - One of the best experts on this subject based on the ideXlab platform.
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Relativer afferenter Pupillendefekt bei Glaukom
Klinische Monatsblatter fur Augenheilkunde, 2011Co-Authors: Karolína Skorkovská, Helmut Wilhelm, Holger Lüdtke, Barbara WilhelmAbstract:Ziel der Studie war festzustellen, wie haufig ein relativer afferenter Pupillendefekt (RAPD) bei Glaukompatienten ist und ob sein Auftreten mit dem Ausmas von Gesichtsfelddefekten und ihrer Seitendifferenz bei schwellennah-uberschwelliger Rasterperimetrie abhangt. Patienten und Methoden: Es wurden retrospektiv Patienten mit Offenwinkelglaukom aus der Glaukomsprechstunde der Universitatsaugenklinik Tubingen herausgesucht, bei denen die Pupillen im Rahmen einer Standarduntersuchung mit dem Swinging-Flashlight-Test untersucht wurden. Das zentrale 30Grad-Gesichtsfeld wurde mittels statischer Rasterperimetrie mit dem Tubinger Automatik-Perimeter oder dem Octopus-Perimeter untersucht. Die Gesichtsfeldbefunde und ihre Seitendifferenz wurden zwischen Patienten mit und ohne RAPD mit dem Wilcoxon-RangsummenTest verglichen. Ergebnisse: Nach der Berucksichtigung von Ausschlusskriterien wurden 100 Patienten mit primarem Offenwinkelglaukom in die Studie aufgenommen, 34 davon wiesen einen RAPD (34 %) auf. Fur die Gesichtsfeldanalyse konnten die Daten von 85 Patienten verwendet werden, da bei diesen eine identische perimetrische Strategie verwendet wurde. 25 Patienten davon hatten einen RAPD (29 %). Die berechneten Gesichtsfelddefektmase waren bei Patienten mit RAPD signifikant groser als bei Patienten ohne RAPD, ihre Gesichtsfeldbefunde also insgesamt fortgeschrittener. Auch die Seitendifferenz zwischen Gesichtsfeldern beider Augen war bei Patienten mit RAPD signifikant groser. Eine ROC(Receiver Operating Characteristics)-Kurve stellte dar, dass die Seitendifferenz im Gesichtsfeldbefund mit einer AUC (area under curve) von 0,81 ein guter Pradiktor fur den RAPD ist. Schlussfolgerung: Der RAPD tritt ungefahr bei einem Drittel der Patienten mit Offenwinkelglaukom auf. Er findet sich vorwiegend bei starker ausgepragten Gesichtsfeldausfallen und Gesichtsfeldausfallen mit einer grosen interokularen Differenz. Wir raten, den Swinging-Flashlight-Test in die Glaukomdiagnostik einzuschliesen.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 30deg. visual field was examined by means of static perimetry using the Tubinger 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.
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efficacy and tolerability of 0 2 brimonidine tartrate for the treatment of acute non arteritic anterior ischemic optic neuropathy naion a 3 month double masked randomised placebo controlled trial
Graefes Archive for Clinical and Experimental Ophthalmology, 2006Co-Authors: Barbara Wilhelm, Holger Lüdtke, Helmut WilhelmAbstract:Neuroprotection may be an option in ischemic optic nerve disease. There have been promising reports about the neuroprotective ability of topical brimonidine in animal studies. Therefore, we Tested whether 0.2% brimonidine tartrate could improve the outcome of patients with non-arteritic anterior ischemic optic neuropathy (NAION). The study was stopped after an interim analysis, having not proven its feasibility within practicable time frame. A 3-month, double-masked, placebo-controlled, randomised European multicenter trial conducted according to good clinical practice rules. Thirty-six patients (22 m, 14 f), older than 40 years with first eye involvement and typical signs of NAION were included in the study within the 1st week after visual loss (VA 0.05–1.0) and were randomized to treatment with either brimonidine 0.2% (Alphagan) or placebo. Visual acuity (VA, primary endpoint), visual field (VF, Humphrey 30–2 and Goldmann, quantified by a modified Esterman grid) and automated swinging flashlight Test (SWIFT) were performed at baseline, 2 weeks, 4 weeks and 12 weeks after first visit. Primary analysis aimed at intention-to-treat group (ITT, n=29), secondary analysis to the per protocol population (PP, n=25). Tolerability and safety were Tested in the safety group (n=36). A two-sample two-sided t-Test was used for statistical analysis (alpha level at 0.05). VA did not show statistically significant difference by treatment. There were non-significant trends for better visual field results in the brimonidine group. Adverse events consisting of local irritation were observed six times in the verum and three times in the placebo group. No serious adverse events occurred. In contradiction to an open-labeled, retrospective study published by Fazzone et al., the results of this trial did not indicate any harmful effect of brimonidine in patients suffering from NAION. However, a statistically significant advantage for the patients receiving brimonidine tartrate could not be shown.
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Efficacy and tolerability of 0.2% brimonidine tartrate for the treatment of acute non-arteritic anterior ischemic optic neuropathy (NAION): a 3-month, double-masked, randomised, placebo-controlled trial
Graefe's Archive for Clinical and Experimental Ophthalmology, 2006Co-Authors: Barbara Wilhelm, Holger Lüdtke, Helmut WilhelmAbstract:Introduction Neuroprotection may be an option in ischemic optic nerve disease. There have been promising reports about the neuroprotective ability of topical brimonidine in animal studies. Therefore, we Tested whether 0.2% brimonidine tartrate could improve the outcome of patients with non-arteritic anterior ischemic optic neuropathy (NAION). The study was stopped after an interim analysis, having not proven its feasibility within practicable time frame. Methods A 3-month, double-masked, placebo-controlled, randomised European multicenter trial conducted according to good clinical practice rules. Thirty-six patients (22 m, 14 f), older than 40 years with first eye involvement and typical signs of NAION were included in the study within the 1st week after visual loss (VA 0.05–1.0) and were randomized to treatment with either brimonidine 0.2% (Alphagan) or placebo. Visual acuity (VA, primary endpoint), visual field (VF, Humphrey 30–2 and Goldmann, quantified by a modified Esterman grid) and automated swinging flashlight Test (SWIFT) were performed at baseline, 2 weeks, 4 weeks and 12 weeks after first visit. Primary analysis aimed at intention-to-treat group (ITT, n =29), secondary analysis to the per protocol population (PP, n =25). Tolerability and safety were Tested in the safety group ( n =36). A two-sample two-sided t -Test was used for statistical analysis (alpha level at 0.05). Results VA did not show statistically significant difference by treatment. There were non-significant trends for better visual field results in the brimonidine group. Adverse events consisting of local irritation were observed six times in the verum and three times in the placebo group. No serious adverse events occurred. Conclusion In contradiction to an open-labeled, retrospective study published by Fazzone et al., the results of this trial did not indicate any harmful effect of brimonidine in patients suffering from NAION. However, a statistically significant advantage for the patients receiving brimonidine tartrate could not be shown.
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Automatisierter Swinging-Flashlight-Test bei Patienten mit Sehnervenerkrankungen
Klinische Monatsblatter fur Augenheilkunde, 2001Co-Authors: Barbara Wilhelm, Helmut Wilhelm, Holger Lüdtke, Tobias Peters, Rüdiger Schmid, Eberhart ZrennerAbstract: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.
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Relative afferent pupillary defects in patients with geniculate and retrogeniculate lesions
Neuro-Ophthalmology, 1996Co-Authors: Helmut Wilhelm, Barbara Wilhelm, Dirk Petersen, Ulrike Schmidt, Ulrich SchieferAbstract:We reviewed the clinical findings and imaging studies of 43 patients with homonymous hemianopia and normal optic discs to discover differences between those with and those without relative afferent pupillary defect (RAPD). Methods: RAPD was determined by means of the swinging flashlight Test. Visual field defects had to be congruous and no visual loss attributable to retinal or optic nerve disease or other causes of RAPD such as amblyopia was accepted. The imaging studies were reviewed by a neuroradiologist unaware of the clinical findings. Patients with lesions involving the optic tract were excluded. The shape of the lesion was transferred onto standard diagrams of the cerebral imaging sections and the proximity to the lateral geniculate nucleus (LGN) was determined. Results: Sixteen of 43 patients showed RAPD contralateral to the lesion. In these 16 patients, the median distance between the lesion and the LGN was 4.5 mm (maximum distance 18 mm, 14 lesions being closer than 10 mm). In 27 patients withou...
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Retinal nerve fiber layer loss in glaucoma patients with a relative afferent pupillary defect.
Investigative ophthalmology & visual science, 2010Co-Authors: Shenton S. L. Chew, Greg D. Gamble, William J. Cunnningham, Helen V. Danesh-meyerAbstract:PURPOSE To assess the amount of structural loss (retinal nerve fiber layer [RNFL] thickness loss, macular thickness [MT] and volume [MV] measured by optical coherence tomography [OCT]) and functional loss (visual acuity [VA], visual field mean deviation [MD], brightness sensitivity, and red perception) necessary for a relative afferent pupillary defect (RAPD) to manifest in patients with glaucoma. METHODS In this case-control study, 50 glaucoma patients were prospectively enrolled: 25 with RAPD and 25 without. The presence of an RAPD was determined and quantified using the Swinging-Flashlight Test, with neutral-density filters. A separate examiner, masked to the pupillary findings, assessed participants for brightness sense, red perception, VA, MD, RNFL thickness, MT, and MV. RESULTS Differences in RNFL thickness (P < 0.0001), brightness sense (P = 0.0007), red perception (P = 0.030), and MD (P < 0.0001) were found between control and RAPD patients, but not in visual acuity or macular OCT parameters. An absolute difference in RNFL thickness of 14.6 μm or greater, intereye difference of 9.5 dB or greater, and brightness of less than 64% in the weaker eye, were all associated with 100% specificity of RAPD presence. When RNFL thickness was reduced to 83% of the less advanced eye, the sensitivity and specificity of RAPD presence were 72% (95% confidence interval [CI], 0.51-0.88) and 100% (95% CI, 0.86-1.00), respectively. CONCLUSIONS An RAPD was clinically detected in all participants in whom RNFL thickness decreased to 83% of that in the less advanced eye. Subjective brightness is the most accurate clinical surrogate for detecting an RAPD in patients with primary open-angle glaucoma.
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Brightness sensitivity and color perception as predictors of relative afferent pupillary defect.
Investigative ophthalmology & visual science, 2007Co-Authors: Helen V. Danesh-meyer, Taras Papchenko, Peter J. Savino, Greg D. GambleAbstract:PURPOSE. To characterize the relationship between brightness sensitivity and color perception and relative afferent pupillary defect (RAPD) in patients with optic neuropathy. METHODS. The "swinging flashlight Test" was used to diagnose RAPD, the degree of which was quantified by neutral density filters, in 325 consecutive patients in a case-control study. A separate examiner, masked to the pupillary findings, then assessed participants for Ishihara color plate reading, brightness sense, and red perception. The latter two were quantified by asking the patient to score (out of 100%) brightness (of a light source) or redness (of an object) of the two eyes relative to each other. Pearson correlation coefficients and receiver operating characteristic (ROC) curves were calculated. RESULTS. Brightness sense (r = - 0.79; 95% confidence interval [CI], -0.84 to -0.73; P < 0.0001), red perception (r = -0.73; 95% CI, -0.79 to -0.65; P < 0.0001), and Ishihara color plate reading (r = -0.68; 95% CI, -0.79 to -0.66; P < 0.0001) were each strongly and highly significantly correlated with the diagnosis and degree of RAPD. Brightness sense and red perception were each able to discriminate almost all the area under ROC for the diagnosis of RAPD (area of 0.99; 95% CI, 0.98-1.00; P < 0.0001; area of 0.93; 95% CI, 0.90-0.96; P < 0.0001, respectively). Sensitivity and specificity of brightness sense in detection of RAPD were 99% (95% CI, 0.97-1.00) and 95% (95% CI, 0.91-0.98), respectively. The red perception Test was only slightly less accurate. CONCLUSIONS. Rapid, simple assessments of brightness sense and color perception provide accurate methods to facilitate the diagnosis of optic neuropathy and may prove to be valuable in screening for optic neuropathy or alternatives to the swinging flashlight Test.
