An assessment of gait and balance deficits after traumatic brain injury

Vascular dysregulation refers to the regulation of blood flow that is not adapted to the needs of the respective tissue. We distinguish primary vascular dysregulation (PVD, formerly called vasospastic syndrome) and secondary vascular dysregulation (SVD). Subjects with PVD tend to have cold extremities, low blood pressure, reduced feeling of thirst, altered drug sensitivity, increased pain sensitivity, prolonged sleep onset time, altered gene expression in the lymphocytes, signs of oxidative stress, slightly increased endothelin-1 plasma level, low body mass index and often diffuse and fluctuating visual field defects. Coldness, emotional or mechanical stress and starving can provoke symptoms. Virtually all organs, particularly the eye, can be involved. In subjects with PVD, retinal vessels are stiffer and more irregular, and both neurovascular coupling and autoregulation capacity are reduced while retinal venous pressure is often increased. Subjects with PVD have increased risk for normal-tension glaucoma, optic nerve compartment syndrome, central serous choroidopathy, Susac syndrome, retinal artery and vein occlusions and anterior ischaemic neuropathy without atherosclerosis. Further characteristics are their weaker blood–brain and blood-retinal barriers and the higher prevalence of optic disc haemorrhages and activated astrocytes. Subjects with PVD tend to suffer more often from tinnitus, muscle cramps, migraine with aura and silent myocardial ischaemic and are at greater risk for altitude sickness. While the main cause of vascular dysregulation is vascular endotheliopathy, dysfunction of the autonomic nervous system is also involved. In contrast, SVD occurs in the context of other diseases such as multiple sclerosis, retrobulbar neuritis, rheumatoid arthritis, fibromyalgia and giant cell arteritis. Taking into consideration the high prevalence of PVD in the population and potentially linked pathologies, in the current article, the authors provide recommendations on how to effectively promote the field in order to create innovative diagnostic tools to predict the pathology and develop more efficient treatment approaches tailored to the person.

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The primary vascular dysregulation syndrome: implications for eye diseases

### 3.1 - General Principles of Glaucoma Treatment

The purpose of this chapter is to give a summary overview and it is not meant to be an all-inclusive text



Figure 3.1. 
THE WHOM -TO -TREAT GRAPH The rate of ganglion cell loss and resulting functional decay is very different among different glaucoma eyes. Quality of life is clearly reduced when visual field defects become severe, cf. the severe functional impairment. Line A represents the effect of aging alone. In glaucoma loss of visual function is often much more rapid. An older patient, diagnosed late in life, with a moderate rate of progression (B) has a much lower risk of developing severe functional impairment than a younger patient with the same amount of field loss at diagnosis and rate of progression (C). A very slow rate of progression may be tolerated by the patient and treatment left unchanged (D), while a rapid rate of progression (E) needs a considerably lower target pressure .

It needs to be remembered that it is the extent of binocular visual field or the field of the better eye that largely determines the patient’s quality of life, while the rates of progression of each eye separately are needed to determine treatment .



To assess the likely Rate of Progression (RoP) is an important part of patient management and the measured rate is a very important factor that should determine target pressure and treatment intensity (See Ch. Introduction) [I.D]. Many studies have found that progression is usually linear1-4, but the goal of intensifying treatment is to decrease rate of progression.

Please observe that perimetric printouts of progression using the MD or VFI indices are age-corrected, so that a normal eye would not show any age-related deterioration over time.

The goal of glaucoma treatment is to maintain the patient’s visual function and related quality of life, …

/pdf/european-glaucoma-society-terminology-and-guidelines-for-35j13md8bp.pdf

European Glaucoma Society Terminology and Guidelines for Glaucoma, 4th Edition - Chapter 3: Treatment principles and optionsSupported by the EGS Foundation: Part 1: Foreword; Introduction; Glossary; Chapter 3 Treatment principles and options

This literature review looks at the current status of multifocal intraocular lenses (IOLs) in cataract surgery. The results of implantation of multifocal IOLs of diffractive, refractive, and hybrid diffractive–refractive design are described with regard to uncorrected near and distance visual acuity and spectacle independence. The occurrence of photic phenomena and contrast sensitivity loss with multifocal IOLs are also addressed. Financial Disclosure Neither author has a financial or proprietary interest in any material or method mentioned.

Multifocal intraocular lenses in cataract surgery: literature review of benefits and side effects.

Multifocal Intraocular Lenses: An Overview

Purpose To evaluate the optical and visual performance after implantation of refractive or apodized diffractive multifocal intraocular lenses (IOLs). Setting Military Health Service Institute, Warsaw, Poland. Methods Uncorrected distance visual acuity, best distance-corrected visual acuity, best distance-corrected near visual acuity, distance contrast sensitivity under photopic conditions (CSV-1000), residual refractive error, and wavefront aberrations (LADARWave Hartmann-Shack wavefront analyzer) were measured in 23 patients who had bilateral implantation of the AcrySof ReSTOR SN60D3 IOL and 23 patients who had bilateral implantation of the ReZoom IOL…. Results At the 6-month postoperative visit, the mean photopic uncorrected distance acuity was 0.03 ± 0.05 (SD) in the ReSTOR group and 0.02 ± 0.06 logMAR in the ReZoom group (both approximately 20/20) ( P = .569). In all patients, the mean photopic best distance-corrected acuity was 0.00 logMAR (approximately 20/20) and the mean photopic best distance-corrected near acuity at 35 cm was 0.10 logMAR. The photopic contrast sensitivity was within the standard normal range in both IOL groups. The difference in photopic contrast sensitivity between groups was statistically significant ( P P Conclusions AcrySof ReSTOR SN60D3 and ReZoom IOLs provided good visual performance at distance and near under photopic conditions. Optical quality measures were significantly worse in patients with ReZoom IOLs.

Apodized diffractive versus refractive multifocal intraocular lenses: optical and visual evaluation

Purpose To compare phacoemulsification parameters of torsional and longitudinal ultrasound modes. Setting Ophthalmology Department, Military Health Service Institute, Warsaw, Poland. Methods This prospective study evaluated eyes 1, 7, and 30 days after phacoemulsification with an Infiniti Vision System using the torsional or longitudinal ultrasound (US) mode. Cataract classification was according to the Lens Opacities Classification System II. Nucleus fragmentation was by the phaco-chop and quick-chop methods. Primary outcome measures were phaco time, mean phaco power, mean torsional amplitude, and aspiration time. Total energy, defined as cumulative dissipated energy (CDE) × aspiration time, and the effective coefficient, defined as aspiration time/phaco time, were also calculated. Results Four hundred eyes were evaluated. The CDE was statistically significantly lower in the torsional mode for nucleus grades I, II, and III (P .05). Aspiration time was statistically significantly shorter in the torsional mode than in the longitudinal mode for nucleus grades III and IV (P Conclusions Torsional phacoemulsification was more effective than longitudinal phacoemulsification in the amount of applied fluid and the quantity of US energy expended. With the torsional method, it was possible to maintain a constant ratio of amount of fluid flow to quantity of US energy used, regardless of nucleus density.

Comparison of torsional and longitudinal modes using phacoemulsification parameters

Aims To define parameters of autonomic nervous system activity in patients with normal tension glaucoma (NTG). Methods Ambulatory 24-h ECG (Lifecard CF) and 24-h blood pressure (BP) monitoring (SpaceLab 90207-30) were carried out in 54 patients with NTG (44 women, mean age 59.7) and 43 matched control subjects (34 women, mean age 57.0). Heart rate variability time and frequency domain parameters (low frequency (LF), high frequency (HF) and LF/HF ratio), BP variability (BPV), diurnal and nocturnal BP variables were compared between study groups. Results Patients with NTG demonstrated higher LF, LF/HF and lower HF values than control subjects for the 24-h, daytime and night-time periods. The mean 24-h, daytime and night-time LF/HF ratios were statistically higher in patients with glaucoma as compared to control subjects ((3.2±1.5 vs 2.2±0.8, p=0.0009), (3.5±1.7 vs 2.7±1.0, p=0.0173) and (2.6±1.7 vs 1.4±0.6, p=0.0001), respectively). There were no statistical differences in the mean BP during the whole day, daytime and night-time, and in BPV (10.4±1.9 vs 10.5±2.1, p=0.790) between study groups. No difference was also found in the percentage decrease in night-time mean BP (12.3% vs 13.6%, p=0.720). ‘Dippers’, ‘non-dippers’ and ‘overdippers’ with NTG showed significantly higher LF/HF ratio as compared to the same subgroups of control subjects. Conclusions The sympathovagal balance of autonomic nervous system in patients with NTG shifted towards sympathetic activity however with no change of 24-h pattern of BPV as compared to controls.

https://bjo.bmj.com/content/bjophthalmol/96/5/624.full.pdf

Cardiac autonomic dysfunction in patients with normal tension glaucoma: 24-h heart rate and blood pressure variability analysis

PURPOSE: To study the distribution and mechanism of traumatic injuries to the nerves supplying the eye and muscles protecting the visual apparatus. METHODS: Brain autopsy was carried out in 12 consecutive patients who died within three days after closed head injury. A segment of the brainstem with the entire intracranial portion of nerves II-VII was dissected out in each case and fixed in formalin. The specimens were stripped of the leptomeninges and inspected thoroughly under magnification. RESULTS: Injuries to the nerves were seen in nine subjects. The oculomotor nerve was completely torn off from the midbrain unilaterally in three and bilaterally in two cases. In one patient only a portion of the superficial fibres on the medial aspect of the nerve was ripped out from the brainstem. In two patients the fourth nerve was ruptured. The root of the fifth cranial nerve was contused and the fibres between the brainstem and Gasserian ganglion crushed and separated in one case. Bilateral avulsion of the root of the sixth nerve from the brainstem was found in two cases. The initial segment of the facial nerve was crushed in two subjects. No visible injury to the optic nerves was found. CONCLUSIONS: Cranial nerves related to the visual system are subject to serious injury in a large proportion of cases of severe head trauma resulting from automobile accidents. In the majority of cases damage results from ripping the roots of these nerves out of the brainstem. Language: en

Cranial nerve II-VII injuries in fatal closed head trauma

Glaucoma is a group of eye diseases causing irreversible optic nerve damage. This review presents 4 elements of future glaucoma treatment strategies: baroprotection, vasoprotection, neuroprotection and gene therapy. New baroprotection includes compounds that alter the actin cytoskeleton (rho-kinase inhibitors, latrunculin, cytochalasin), new drugs that enhance aqueous outflow via the trabecular meshwork (statins, steroid antagonists) and via the uveoscleral route (EP2 agonists, 5-HT2 agonists), as well as new classes of components that suppress aqueous humor formation (cannabinoids). Vasoprotection includes blocking reperfusion injury (NOS-2 inhibitors, endothelin blockers, MMP-9 inhibitors). Concerning neuroprotection antiamyloids antibodies, erythropoietin and caspase inhibitors are discussed. Gene therapy may target various effectors: the trabecular meshwork (cytoskeleton regulatory proteins, miocyllin, MMPs), the ciliary body epithelium (genes modifying aqueous humor production, neuropeptides), the ciliary body cells (MMPs, genes of local PGs biosynthesis, ciliary muscle relaxants), the retinal ganglion cells (neurotrophin genes, anti-apoptotic genes), Muller cells (neurotrophins, GLAST) and conjunctiva (gene of chloramphenicol acetyltransferase, inhibitor p21). Experimental studies on the graft mesenchymal stem cells and mature retinal cells to replace the dead retinal ganglion cells are advanced. Immunotherapy, offering a vaccination, providing protection against loss of retinal ganglion cells, has been investigated.

Andrzej Stankiewicz

Papers

Apodized diffractive versus refractive multifocal intraocular lenses: optical and visual evaluation

Comparison of torsional and longitudinal modes using phacoemulsification parameters

Cardiac autonomic dysfunction in patients with normal tension glaucoma: 24-h heart rate and blood pressure variability analysis

Cranial nerve II-VII injuries in fatal closed head trauma

Future possibilities in glaucoma therapy.