Korean J Ophthalmol.  2009 Dec;23(4):291-295. 10.3341/kjo.2009.23.4.291.

A Pharmacologic Pupillary Test in the Diagnosis of Diabetic Autonomic Neuropathy

• Kwon HJ
• Kim HY

• KMID: 754766
• DOI: http://doi.org/10.3341/kjo.2009.23.4.291

Abstract

PURPOSE
To screen for diabetic autonomic neuropathy of the pupil using 0.5% apraclonidine and 0.1% pilocarpine and to evaluate the early diagnostic value of this pharmacologic pupillary test by assessing the relationship between pupillary and cardiovascular autonomic neuropathies.
METHODS
A total of 22 diabetic patients were recruited. Baseline pupillary diameter (PD) and the difference in PD between the test eye and the control eye before and after instillation of apraclonidine and pilocarpine were measured. All patients also underwent cardiovascular autonomic function (CAF) testing.
RESULTS
Baseline PD in room light correlated with duration of diabetes mellitus (DM, p=0.049) and the presence of DM retinopathy (DMR, p=0.022). Eleven patients (50%) had positive apraclonidine tests, and two patients had positive pilocarpine tests. The patients who had positive pilocarpine tests also had positive apraclonidine tests. Patients who had a positive pupillary test had a significantly higher rate of positive CAF tests (p=0.032).
CONCLUSIONS
Pupillary autonomic neuropathy was related to the duration of diabetes and the degree of DMR. There was also a significant correlation between pupillary autonomic neuropathy and cardiovascular autonomic neuropathy (CAN). Also, sympathetic nerve dysfunction occurred prior to parasympathetic dysfunction in this study. A simple pharmacologic pupillary test can help manage complications in diabetic patients because patients with pupillary autonomic dysfunction have an increased risk of CAN.

Keyword

Apraclonidine; Autonomic neuropathy; Diabetes mellitus; Pilocarpine; Pupil

MeSH Terms

Adrenergic alpha-Agonists/administration & dosage/diagnostic use
Adult
Aged
Clonidine/administration & dosage/*analogs & derivatives/diagnostic use
Diabetic Nephropathies/*diagnosis/physiopathology
Diagnosis, Differential
Female
Follow-Up Studies
Humans
Male
Middle Aged
Miosis/*chemically induced/physiopathology
Miotics/administration & dosage/diagnostic use
Ophthalmic Solutions
Pilocarpine/administration & dosage/*diagnostic use
Pupil/drug effects/*physiology
Reproducibility of Results

Figure

• 

  Fig. 1 Baseline PD (mm) in room light according to severity of diabetic retinopathy (r=-0.48, p=0.022, Spearman correlation). PD=pupillary diameter; NPDR=non-proliferative diabetic retinopathy; PDR=proliferative diabetic retinopathy.

• 

  Fig. 2 Difference in PD between test eyes and control eyes following 0.5% apraclonidine instillation according to severity of diabetic retinopathy (r=0.548, p=0.008, Spearman correlation). PD=pupillary diameter; NPDR=non-proliferative diabetic retinopathy; PDR=proliferative diabetic retinopathy.

• 

  Fig. 3 Patient who had a positive pharmacologic test. (A) Baseline photograph. (B) After instillation of 0.1% pilocarpine in the left eye and 0.9% normal saline in the right eye. (C) After instillation of 0.5% apraclonidine in the left eye and 0.9% normal saline in the right eye.

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