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| ORIGINAL ARTICLE |
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| Year : 1988 | Volume
: 36
| Issue : 3 | Page : 120-122 |
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Pupillary involvement in autonomic dysfunction-A study in chronic renal failure
A Chandra, SP Gour, MK Mitra, KC Garg, B Lal
In Medicine, 2A Shahmina Road, K.G. Medical College, Lucknow, India
Correspondence Address:
A Chandra
In Medicine, 2A Shahmina Road, K.G. Medical College, Lucknow
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 3255699 
The pupils are totally innervated by the Autonomic nervous system, but tests of pupillary abnormalities do not form an integral part of the battery of tests used for studying its dysfunction. We have studied the effects of ANS dysfunction of the pupil by the Adrenaline Test of Loewi and correlated it with the other tests based on Cardiovascular, and G.I.T. involvements. In all 11 out of 20 patients, with Chronic Renal Failure studied, had ANS involvement. There was statistically significant pupillary dilatation in 10 and in one case this was the only positive test. I.V. Atropine test was also positive in 10 out of the case 20. This suggests that the Adrenaline Test of Loewi is sensitive and should form an integral part of the battery of tests used for assessing .ANS' dysfunction in various disease settings as this study has shown in CRF. Keywords: ANS = Autonomic Nervous System GIT = Gastro Intesteinal Tract CRF = Chronic Renal Failure
How to cite this article:
Chandra A, Gour S P, Mitra M K, Garg K C, Lal B. Pupillary involvement in autonomic dysfunction-A study in chronic renal failure. Indian J Ophthalmol 1988;36:120-2 |
| Introduction | |  |
The pupils are exclusively dependent upon autonomic nerves for their size and reactions and their assessment can give us information about the integrity of the Automatic nervous system.
Hitherto a lot of attention has been paid to the cardiovascular, urinary and gastric components of ANS for assessment of dysfunction seen in diabetes, chronic renal failure and other diseases. The idea that autonomic dysfunction itself may cause ocular disease has been mooted [2]. Simple tests of autonomic dysfunction of the eye are not used widely. We have used the Adrenaline test of Loewi [7] to assess the pupillary reaction in patients with chronic renal failure, who are prone to develop peripheral neuritis and ANS dysfunction and have correlated these findings with other parameters of ANS dysfunction.
| Material and Methods | | |
Patients with chronic renal failure and controls of similar age and sex were studied. These controls had - no evidence of ANS, renal, cardiovascular or central nervous system involvement. Patients were included in this study if they satisfied the twin criteria of (1) Creatinine clearance of less than 88 ml/minute'and (ii) Had symptoms of uraemia for more than 3 months'. Patients with diabetes mellitus, congestive heart failure and those on anti-hypertensive therapy were excluded. The cases thus selected were grouped into 4 groups based on their endogenous creatinine clearance which reflects the glomerular filtration rate. Gr.1 (Normal controls) with creatinine of more than 88 ml/min; Gr II (Mild) with creatinine clearance of 41-88 ml/min; Gr. III (Moderate) with a clearance of 21-40 ml/min. and Gr. IV (Severe) with a rate of less than 20 ml/min.
All were subjected to detailed history-taking specially regarding postural syncope, diarrhoea, abnormal sweating, bladder dysfunction, impotence and other symptoms of ANS dysfunction along with clinical examination . Relevant investigations were done to confirm the diagnosis and rule out associated and precipitating causes.
Special Tests for ANS Dysfunction
(i) Adrenaline test of Loewi [7] - This test was performed in all cases under the same conditions of illumination. The size of the pupil was measured initially and then again at 15,30 and 45 minutes after instillation of 1:1000 adrenaline into the conjunctival sac every minute for 5 minutes. Normally there is no significant dilatation. The increase in size of the pupil was expressed as a percentage of the original size and a dilatation of more than +2 Standard deviation of controls was taken to be significant. As the mean of controls was 30+27.4 a dilatation of more than 80% was taken to be significant. (ii) Postural hypotension [4] a fall of 30 mm Hg or more is abnormal (iii) Sustained hand grip test [4] resulting in a rise of blood pressure of less then 10 mm was abnormal, more than 16 was normal and between 11 and 15 was taken to be borderline. (iv) Valsalva test [5]: Normal value 1.20, borderline value 1.11-1.19 and abnormal value 1.10 (v) intravenous atropine test [5] value less than 1.33 was abnormal (vi) Hollander's Insulin test [6]: A secretion of more than 20 m mol/litre was taken as abnormal.
| Observations and Results | | |
We have studied 20 cases of CRF and subjected them to various tests of ANS dysfunction. Seventy percent were males mostly in the 21-40 years age group. Clinical examination revealed that the main symptoms were suggestive of peripheral neuropathy in 8, impotence in 5, sweating abnormalities in 4, bladder dysfunction in 4, postural hypotension in 3, and intractable diarrhoea in 2 cases. The resting pulse rate was higher in severe cases of CRF (Gr. IV). The correlation of the pupillary test with the severity of CRF is shown in [Table - 1].
From this table it is clear that considered in totality the mean values were statistically,significantly different although the mild CRF cases (Gr. II) did not show this and there were very few cases in the severe group (Gr. IV). The following [Table - 2] compares the sensitivity and specificity of this Pupillary test with the other more commonly performed tests of ANS dysfunction.
[Table - 2] reveals that in all 11 of 20 cases showed one or more tests positive for ANS involvement. The Pupillary test and sustained l hand grip test were abnormal in 50% of cases whereas postural hypotension was found abnormal in only 3 cases. The I.V. Atropine test was positive in 10 cases.
| Discussion | | |
Study of Pupillary abnormalities have not usually formed a part of the battery of tests of ANS dysfunction in clinical setting. We have studied them in the clinical background of CRF and compared their use vis-a-vis the other tests. Only confirmed cases of CRF were taken and for comparison, normal controls of similar age and sex were studied. A careful exclusion of situation likely to affect the ANS was done by excluding cases of Diabetes mellitus, congestive heart failure and those on antihypertensive therapy.
The Adrenaline test of Loewi was performed in all cases and Pupillary dilatation was significantly higher in CRF compared to controls (P 0.01), mild CRF cases did not exhibit this degree of statistical significance and there were only a few cases in the severe grade. In one case the pupillary test abnormality was the sole positive test and of the 11 cases with positive tests 10 had a positive Adrenaline test of Loewi making it a very sensitive indicator of ANS dysfunction.
It is therefore recommended that examination of the pupil and its reactions should form an integral part of the battery of tests used to study ANS dysfunction.
| References | | |
| 1. | Black, Douglas: `Renal Disease' 4th edition - Blackwell Scientific Publications, Oxford, London, Edinburgh, Melbourne, Page 496-497. 1979  |
| 2. | Clark C.V. and Mapstone, Lancet, ii, 185-87, 1985 |
| 3. | Doolan P.D., Alpen E.L. and Thiel G.B., Amer. J. Med., 32,65, 1962. |
| 4. | Ewing D.J., Irwing J.B., Kerr F., Wildsmith J.A.W. and Clarke B.F., Clin. Sci. Mol. Med. 46:295, 1974. |
| 5. | Ewing D.J. and Winney R., Nephron 15: 424-429, 1975. |
| 6. | Hollander F., Gastroenterology 7, 607-614, 1946 |
| 7. | Loewi, 1921 and 1924 as quoted by Sir Stewart Duke Elder Textbook of Ophthalmology, Henry Kimpton, London Vol. XII, Page 605. 1971. |
[Table - 1], [Table - 2]
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