![]() The relationship between inflammation, as opposed to infection, and progression of encephalopathy is similar to that observed in chronic liver disease. The incidence of both bacterial and fungal infection occurs in approximately one third of patients. Patients with acute liver failure have a marked propensity to develop renal insufficiency and hence impaired ammonia excretion. Ammonia plays a definitive role in the development of cytotoxic brain edema. The onset of encephalopathy can be rapid and dramatic with the development of asterixis, delirium, hyperreflexia, clonus, seizures, extensor posturing and coma. Neurological manifestations are primarily underpinned by the development of brain edema. ![]() In acute liver failure, some patients may develop cerebral edema and increased intracranial pressure although recent data suggest that intracranial hypertension is less frequent than previously described, complicating 29% of acute cases who have proceeded to grade 3/4 coma. It typically culminates in the development of liver dysfunction, coagulopathy and encephalopathy, and is associated with high mortality in poor prognostic groups. Once these are systematically excluded, benign episodic unilateral mydriasis should be considered a possibility.Acute liver failure is a disorder which impacts on multiple organ systems and results from hepatocellular necrosis in a patient with no previous history of chronic liver disease. 1 Adies pupil and trauma are other common causes. These pupils can be identified by their refusal to constrict with 1% Pilocarpine. 4 Pharmacological blockade is the most common cause of such a presentation. 1 We found only one report of an intracranial aneurysm causing internal ophthalmoplegia without extraocular muscle involvement. ![]() 3 In the absence of any other ocular abnormality, unilateral mydriasis is rarely due to an intracranial cause. A systematic approach is required to examine and investigate this condition. The cataracts in our patient were an incidental finding.Īnisocoria is often viewed as a worrying sign. 2 The dilated pupil is the only ocular finding. 2 The episodes may be accompanied by blurred vision, orbital pain, headache, or photosensitivity. The features of our patient were consistent with a rare but innocuous condition termed ‘benign episodic unilateral mydriasis.’ 2 The affected individuals, usually women, often have a history of migraine. Each time there were no other significant findings and pharmacological tests were negative. Three of these episodes were accompanied by headache and two by ocular pain. Over the next 2 years, this patient presented four times with similar episodes of unilateral mydriasis, twice affecting the left eye ( Figure 1b). The anisocoria spontaneously disappeared in 3 days. ![]() It was observed that 0.125% Pilocarpine did not constrict the pupil, whereas 1% Pilocarpine constricted both pupils well. There was no other ocular abnormality, except for the previously noted cataracts. There was no ptosis and full ocular motility. Her vision was unchanged from her last visit to the department. A detailed history revealed no trauma and no possibility of pharmacological dilation. Six months later, she was referred to us with a dilated left pupil. This was interpreted as an abnormally prolonged response to tropicamide drops. The right pupil, however, remained dilated ( Figure 1a). The abrasion healed in 2 days with vision improving to 6/18. Examination revealed bilateral congenital cataracts. Vision was 6/12 in the right eye and 6/36 in the left. She was systemically well, except the occasional classical migraine. ![]() A 39-year-old lady presented to the casualty with a traumatic corneal abrasion to the left eye. ![]()
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