微视野仪在视功能评估中的应用

微视野仪是一种在直视眼底的条件下,能定量、定位地测量黄斑区域的视网膜光敏感度,同时可以全程记录被检查眼的固视轨迹,自动分析固视位置、固视稳定性,并能将微视野图与眼底像点对点重合,实现功能和结构上的组合。微视野仪的各项研究指标与主观视力有良好相关性,为定量评估视力提供了新手段,在法医学视功能的评定中将具有一定的应用潜力。本文综述了微视野仪的原理、方法及研究指标,并着重探讨微视野仪在视功能评估中的作用,以期为法医学视功能评估提供参考。     

劳动能力鉴定中无晶体眼的视觉功能评价

无晶体眼视觉功能的评价是劳动能力鉴定中经常遇见的问题。准确评价无晶体眼的视觉功能障碍程度,有利于保证鉴定意见的科学性和客观性。无晶体眼不仅影响视力,亦可影响视野,引起视野缺损。单眼无晶体者较双眼视力对称性降低更易引起立体视锐度的损害。总结多年劳动能力鉴定中涉及视觉功能障碍评定的实践经验,可以紧紧把握劳动能力鉴定标准中＂依视力递减受损百分比进行比较＂这个关键,利用改进的＂对比相乘法＂对无晶体眼的视觉功能进行有效评价。     

道路交通事故眼损伤伤残评定的标准化和规范化

GB18667-2002《道路交通事故受伤人员伤残评定》标准（以下简称“标准”）中有关眼损伤的条款较为原则和笼统。随着“标准”的广泛应用,加之法医学和临床眼科学技术的不断进步,对眼损伤后遗症的检验技术和认识水平已有较大的提高。建议采用视力表投影仪代替国际视力表进行行为视力检查,存在屈光不正的应了解屈光度后再检查其矫正视力;疑有伪盲或伪装视力降低时,可行伪盲试验或伪装视力降低的检验,视觉电生理技术是测试伪盲或伪装视力降低的有效方法。运用电脑视野计可进行视野检查,动态视野检查结果可通过视野有效值换算为残存视野半径（或直径）;视野检查存在一定的干扰因素,分析时应密切结合原发损伤及其他检查结果。对于遗留复视等双眼视障碍的,可采用同视机等检查方法,检验结果应考察功能障碍与眼肌等原发性损伤的符合性。泪器损伤后遗留溢泪症状的,应采用相应的检查方法证实泪道狭窄或梗阻。眼睑下垂及眼睑畸形分为轻度及重度;眼睑畸形包括闭合不全、眼睑缺损及眼睑外翻等情形。影响视力的外伤性白内障符合“标准”相关条款的规定。根据现行“标准”对道路交通事故所致眼损伤进行伤残评定,应进行视觉功能检测、眼球结构检查、伪盲试验及视觉电生理检测,最后综合病史材料及既往情况综合分析,得出评定结果。统一对现行“标准”的理解,规范检测手段和结果评价原则,有助于道路交通事故眼损伤伤残评定的标准化和规范化。     

眼外伤后眼压增高法医学鉴定32例分析

目的分析眼部钝性外伤后眼压增高的原因及其特点,探讨法医学鉴定要点。方法选取资料完整的眼部钝性外伤后眼压增高鉴定案例32例,总结其眼压增高出现及持续时间、眼压增高的程度、主要临床表现、临床治疗方法及愈后视力、视野检查结果,分析其中的相关性。结果本组眼外伤后眼压增高者的临床表现包括外伤性虹膜睫状体炎、前房积血、晶体脱位与玻璃体积血等。虹膜睫状体炎导致的外伤后眼压增高持续时间短、程度轻,多不遗留严重后遗症;前房积血、玻璃体积血及晶体脱位等引发的眼压增高,则与其本身伤情的严重和广泛程度密切相关。结论对于眼外伤后眼压增高的鉴定,应重视：（1）眼压增高出现和持续的时间、增高的程度;（2）相关的临床治疗经过;（3）愈后的视觉功能状况,包括视力和视野检查结果;（4）分析导致眼压增高的原因及其与外伤的关系。     

视力表投影仪视力与对比度视力的相关性

目的研究视力表投影仪视力(以下简称"投影仪视力")与对比度视力测量值的相关性,探讨对比度视力在眼损伤后法医临床学视觉功能障碍鉴定中的应用价值。方法征集中青年志愿受检者79人共129眼作为实验组,分别检查其投影仪视力与对比度视力。对比度视力中,视标对比度分别为100%、25%、10%。统计分析两组实验数据的相关性。结果投影仪视力与100%对比度视力具有一致性;随视标对比度的下降,视力值的大小下降;相同视标对比度下,投影仪视力与对比度视力的均值呈线性相关。结论投影仪视力和对比度视力密切相关,对比度视力可以在法医临床学司法鉴定实践中推广应用。     

109例外伤性视损害的法医学分析

目的对外伤性视力损害的类型,机制及法医学鉴定进行分析。方法收集109例外伤性视损害案例,回顾性分析其两眼视差、屈光参差、受伤眼别、视力分布等项目。结果男女比例5.8:1,多见于30~59岁;单、双眼受伤的比例17.17:1,故意伤害案左、右眼受伤的比例1.39:1;受伤眼115目,83目达低视力或盲程度;两眼视力之差≥3行视标的95人(87.16%);屈光参差2.25D~6.00D的9人,6.00D的23人。结论两眼视差、屈光参差等问题在鉴定实践中并不少见,但我国鉴定标准尚未涉及,建议制定相关标准时关注双眼整体功能。     

双眼视力及其伤残评价作用研究

目的研究双眼视力与两单眼视力的关系,及评价其视力伤残评价作用。方法年龄18~60岁患者1 006名,检测两单眼和双眼最佳镜片矫正视力。结果双眼视力可高于、等于和低于较好单眼矫正视力,三者分别占27.14%、70.78%和1.49%,统计显示两眼视差与双眼相互作用有一定关联(χ~2=54.939,P0.001,r=0.228)。33人单眼视力相同而双眼视力不同。结论双眼视力与两单眼视力、较好单眼视力既关联又有一定不确定性,双眼视力在视力伤残评价中具有特殊作用。     

Unexpected Serotonin Syndrome,Epileptic Seizures,and Cerebral Edema Following 2,5‐dimethoxy‐4‐bromophenethylamine Ingestion

4‐bromo‐2,5‐dimethoxyphenethylamine (2C‐B) is a designer drug. In Europe, 2C‐B is easily obtained and used for recreational purposes. It is known for its stimulating effects similar to those of 3,4‐methylenedioxymethamphetamine, although in higher doses it has more hallucinogenic effects. Here, we report a case of 2C‐B ingestion, confirmed by liquid chromatography‐tandem mass spectrometry, in an 18‐year‐old man. The neurological consequences were severe, including the development of serotonin syndrome and severe brain edema. Supportive therapy resulted in a stable condition, although, after several months, the patient still suffered from severe neurological impairment due to the drug‐induced toxicity. This case showed that 2C‐B could not be identified with the drugs of abuse screening routinely used in Dutch hospitals. The use of 2C‐B carries many risks, with potentially profound neurological damage, that both consumers and healthcare physicians are unaware of.     

Fatal Intoxication with Acetyl Fentanyl

Among the new psychoactive substances encountered in forensic investigations is the opioid, acetyl fentanyl. The death of a 28‐year‐old man from recreational use of this compound is reported. The decedent was found in the bathroom of his residence with a tourniquet secured around his arm and a syringe nearby. Postmortem examination findings included marked pulmonary and cerebral edema and needle track marks. Toxicological analysis revealed acetyl fentanyl in subclavian blood, liver, vitreous fluid, and urine at concentrations of 235 ng/mL, 2400 ng/g, 131 ng/mL, and 234 ng/mL, respectively. Acetyl fentanyl was also detected in the accompanying syringe. Death was attributed to recreational acetyl fentanyl abuse, likely through intravenous administration. The blood acetyl fentanyl concentration is considerably higher than typically found in fatal fentanyl intoxications. Analysis of this case underscores the need for consideration of a wide range of compounds with potential opioid‐agonist activity when investigating apparent recreational drug‐related deaths.     

Fatality from olanzapine induced hyperglycemia

A case history of a 31-year-old male schizophrenic patient is presented. The man was treated with olanzapine for three weeks before he died. After one week on a 10 mg daily dose of olanzapine, his fasting blood glucose was elevated to 11.3 mmol/L (203 mg/dL). In order to treat more aggressively his psychosis, the olanzapine dose was raised to 20 mg daily resulting in his fasting blood glucose climbing to 15.8 mmol/l (284 mg/dL). On the days preceding his death, he became progressively weaker, and developed polydipsia with polyuria. He had no personal or family history of diabetes mellitus and he was on no other medication at the time of his death. Postmortem blood, vitreous humor, and urine glucose concentrations were 53 mmol/L (954 mg/dL), 49 mmol/L (882 mg/dL), and 329 mmol/L (5922 mg/dL), respectively. Drug screen on urine and blood indicated only a small amount or olanzapine and no alcohols. Peripheral blood olanzapine concentration was within therapeutic limits, 45 ng/mL. Analysis of vitreous humor and urine revealed severe dehydration with small amounts of ketones. Death was attributed to hyperosmolar nonketotic diabetic coma, and olanzapine was felt most likely to be the cause. Another atypical neuroleptic, clozapine, has also been associated with the development and exacerbation of diabetes mellitus or diabetic ketoacidosis. We recommend including vitreous glucose and beta-hydroxybutyrate analysis as part of postmortem toxicology work up when the drug screen reveals the presence of either olanzapine or clozapine.     

Diagnosis of Hemorrhagic Stroke in an Exhumed Brain After Three Years of Burial in a Deep Grave

Abstract: We present the forensic neuropathologic analysis of an exhumed decomposed brain following long‐term interment in a 50‐year‐old white woman, who had been buried for 34 months. Next of kin authorized exhumation of the body for an autopsy to determine the cause of death. The embalmed body was anatomically intact and revealed decompositional changes with mold colonies. Internal viscera showed intact histomorphology. The brain revealed diffuse congestive swelling and extracellular edema with dissecting parenchymal hemorrhage and hematoma originating from the left putamen and thalamus and extending to the left lateral ventricle. Excitotoxic neuronal injury as well as penumbric parenchymal changes was noted. Cause of death was determined to be a hypertensive cerebral parenchymal hemorrhage. This case and our previously reported case are sentinel cases, which should encourage and guide the forensic neuropathologic work‐up and investigation of causes of death in spite of long‐term burial in deep graves.     

Positional Asphyxia without Active Restraint Following an Assault

Deaths due to positional asphyxia are most often accidental, associated with alcohol and/or drug intoxication. A 19‐year‐old male is reported who was assaulted and placed in a head‐down position in the back of a car were he was later found dead. Brush abrasions indicated that he had been dragged to the vehicle. The head and right shoulder were wedged into the foot well with the body uppermost. At autopsy, there was marked congestion of the face, neck, and upper chest with conjunctival ecchymoses, bruising of the face and scalp, focal subarachnoid hemorrhage, minor cerebral contusion, and diffuse cerebral swelling with early hypoxic ischemic encephalopathy (HIE). Toxicology was negative. Death was attributed to HIE resulting from the unusual positioning of the body. Cases of positional asphyxia involving others may not always include restraint, and when encountered should initiate a careful evaluation of the possible events and lethal pathophysiological processes.     

Fatal acute alcohol intoxication in an ALDH2 heterozygote: a case report

On an evening in November, a 25-year-old man was found dead in his bedroom. There were many empty snap-out sheets for flunitrazepam tablets in the trash at his bedside. He had been beaten by a gang of young people earlier in the morning of the same day. At the medico-legal autopsy, although there were many bruises and/or abrasions on the whole body, only slight subdural hemorrhage was observed, and none of them was thought to be the cause of death. Flunitrazepam and its metabolites were not detected in his body fluid by gas chromatography-mass spectrometry (GC-MS). Marked lung edema and a severe congestion of organs were observed. His blood alcohol concentration from the femoral vein was 2.00 mg/ml. Fatal cases of acute alcohol intoxication usually have shown higher alcohol concentration (2.25-6.23 mg/ml). Although the genotype of aldehyde dehydrogenase 2 (ALDH2) has not previously been mentioned as a contributing factor in determining the cause of death, in this case the genotype of ALDH2 was ALDH2*1/2 and thus is important. Those who possess the ALDH2*2 gene show high concentrations of acetaldehyde (AcH) at even comparatively lower alcohol levels. Consequently, the cause of death was considered to be acute alcohol intoxication including AcH poisoning.     

高度近视者眼球结构及其功能变化的法医学意义

高度近视者眼球可发生一系列不可逆的组织形态学改变。其中,眼轴、角膜曲率、前房深度、眼底形态、黄斑神经上皮厚度等改变与眼球的屈光状态及视觉功能有着密切的关系,玻璃体混浊、玻璃体脱离、白内障、青光眼、后巩膜葡萄肿、视网膜脱离等并发症的发生率也随着近视屈光度数的加深而增高。越来越多的研究表明高度近视者视觉功能改变是上述多种结构变化共同作用的结果。因此有望通过应用多项检查方法观察高度近视者眼球的结构变化,并根据这些变化分析评估高度近视者视觉功能的损害程度,为法医学评价眼部外伤与疾病的关系以及眼外伤的司法鉴定提供支持和依据。     

我国视损伤残疾评定标准问题研究

视损伤评价是制定视损伤残疾标准、统一标准适用的基础。由于基本问题缺乏界定与研究,导致我国残疾标准制定困难、理解适用混乱,影响了鉴定意见的科学性。应解决视功能含义、确定视残疾与个体残疾的关系、拣选检验指标、开展视残疾生存质量调查和一体评价视损伤等主要问题,加强残疾理论与法学、临床医学等其他学科的交叉研究,建立适合我国社会发展需求的残疾评价体系,促进残疾评定的科学化和标准化。     

应用微视野仪对眼底损伤者进行视敏度的评估

目的探讨眼底损伤者的微视野检测指标与视敏度的相关性,及微视野仪评估视功能的应用价值。方法应用MP-1型微视野仪,对100名眼底损伤者进行视网膜光敏感度、固视稳定性检查,获得黄斑中心2°视网膜平均光敏感度、全视野视网膜平均光敏感度、固视中心2°固视率、固视中心4°固视率等微视野检测指标数值,将其与视敏度进行Spearman相关分析及多元回归分析。结果黄斑中心2°视网膜平均光敏感度、全视野视网膜平均光敏感度、固视中心2°和4°固视率与视敏度均呈正相关,其相关系数分别为0.676、0.693、0.670、0.665（p〈0.05）。散点图显示各微视野指标与视敏度间具有直线相关趋势,由此得出多元线性回归方程为：Y=2.543＋0.043×X2＋0.017×X4（X2全视野视网膜平均光敏感度,X4固视中心4°固视率）。结论微视野检测指标与视敏度之间有良好的正相关性,具有法医学应用价值。     

Sudden Death by Spontaneous Epiglottic Hematoma Secondary to High Blood Levels of Warfarin

A 67‐year‐old man was found dead, at his home. On external examination, we found a voluminous purplish black ecchymosis of the anterior neck area. On internal examination, we found a voluminous epiglottis hematoma completely obstructing the upper airway. It was associated with other sites of intra‐abdominal hemorrhage. Toxicological studies revealed the presence of warfarin at a concentration of 8.4 mg/L in peripheral blood, which supposes an INR well above 4.5. To conclude, we supposed death was due to asphyxia secondary to a spontaneous epiglottic hematoma caused by a high blood concentration of warfarin. Hemorrhage in the epiglottis is very rare. To our knowledge, our patient is the only case of “sudden death” reported with spontaneous epiglottic hematoma due to high blood concentration of warfarin. In forensic practice, an anterior neck ecchymosis, without trauma, may suggest hemorrhage into soft airway tissues. Pathology findings make it possible to exclude exogenous trauma.     

Causality and Causation in Law, Medicine, Psychiatry, and Psychology: Progression or Regression?

In this article, I review recent developments in the areas of law, medicine, psychiatry, and psychology concerning causality and causation. I analyze the validity of the 2008 edition of the American Medical Association (AMA)’s guides to the evaluation of permanent impairment and its accompanying volume on causation. I conclude with recommendations for a synthetic approach to causality in the legal field and a more consistent model of impairment in the mental health one. The AMA’s book on medical causation needs careful revision.     

Enucleation in psychosis associated with aqueductal stenosis

Reports of self-enucleation are frequent in medical literature, but cases of enucleation towards another are rare. We report the case of a man, 20 years of age, who suffered from psychosis with hydrocephalus and aqueductal stenosis that required a forensic psychiatric investigation to ascertain whether he was of unsound mind when he assaulted and enucleated the right eye of an officer and led to the surgical enucleation of the victim's left eye. Based on his clinical interviews and hospitalization record, we conclude that at the time of the assault, he was suffering from a delusional disorder with religious and demonic content, visual and auditory hallucinations, illusion phenomena, delusional interpretations, imaginative elements, a feeling of terror, and command hallucinations that compelled him to perform the act of aggression.     

Severe Retinal Hemorrhages with Retinoschisis in Infants are Not Pathognomonic for Abusive Head Trauma

The combination of subdural hemorrhage (SDH), retinal hemorrhage (RH), and encephalopathy, or the presence of severe retinal hemorrhages alone in infants, is often attributed to and has been stated to be pathognomonic for abusive head trauma (AHT) or shaken baby syndrome. These beliefs have been challenged, because the same constellation of findings has been identified in accidental head injuries and natural diseases, and most if not all of the studies that support the concept of diagnostic specificity have serious flaws in their methodology. Presented here are two cases of severe retinal hemorrhages with retinoschisis associated with subdural hemorrhage in a natural disease and with severe cerebral edema in an accidental head injury. These cases challenge the dogma that severe retinal hemorrhages with retinoschisis are pathognomonic for AHT.