Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 45109

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : March | Volume : 17 | Issue : 3 | Page : NC01 - NC03 Full Version

Correlation of Pupil Cycle Time and Postural Hypotension as a Marker for Diabetic Neuropathy

Published: March 1, 2023 | DOI:
Vasanthi B Kotian, Puneet Hegde

1. Professor, Department of Ophthalmology, KS Hegde Medical Academy, Mangalore, Karnataka, India. 2. Assistant Professor, Department of Ophthalmology, KS Hegde Medical Academy, Mangalore, Karnataka, India.

Correspondence Address :
Dr. Puneet Hegde,
Flat No. 403, Haribhakthi Apartments, Pintos Lane, Mangalore, Karnataka, India.


Introduction: Diabetic Neuropathy (DN) can involve autonomic nervous system like cardiovascular system and pupillary reflex. Cardiovascular DN can be measured by estimating the change in Blood Pressure (BP) based on position. Ocular DN can be evaluated by using Pupil Cycle Time (PCT), which is an early diagnostic tool to estimate ocular DN. It is a simple way to measure autonomic reflex activity and is a specific test to study parasympathetic function.

Aim: To assess the correlation of effects of postural hypotension and PCT on persistent diabetes.

Materials and Methods: The prospective cross-sectional study was conducted in Ophthalmology Out Patient Department (OPD) at KS Hegde Medical Academy, Mangalore, Karnataka, India, from January 1st 2019 to December 31st 2019. The study included 60 male patients between the age group of 40-60 years which were divided into two groups of 30 diabetics (Random Blood Sugar (RBS) >200 mg/dL, Fasting Blood Sugar (FBS) >126 mg/dL and Glycated Haemoglobin (HbA1c) >6.5%) and 30 non diabetics. The blood pressure of all the patients were recorded using a sphygmomanometer in sitting and standing positions. PCT was measured in both eyes using Haggstreit-type of slit lamp after the subject was seated in a dimly lit room after dark adaptation for 15 minutes.

Results: The mean age of patients in the diabetic group was 54±3.2 years and the non diabetic group was 52±2.7 years. The mean HbA1c of diabetics was 6.9±0.8%. The mean BP among diabetics in standing position was 133.86±29.34 mmHg systolic and 87.4±16.72 mmHg diastolic whereas in sitting position, it was 141.66±28.17 mmHg systolic and 85.26±13.39 mmHg diastolic. The mean BP among non diabetics in standing position was 129.46±24.84 mmHg systolic and 83.46±13.52 mmHg diastolic whereas in sitting position, it was 132.06±26.48 mmHg systolic and 81.26±11.45 mmHg diastolic. The mean PCT-I and PCT-II in diabetics was 1000.52±187.73 and 1006.09±199.45, respectively. The systolic and diastolic BP, both during sitting and standing postures, in diabetic patients were high. The mean PCT-I and PCT-II in non diabetics was 853.23±181.54 and 880.17±192.72, respectively. The PCT-I and PCT-II were found to be significantly high in diabetic patients as compared to controls. The PCT-I and PCT-II negatively correlated with both diastolic and systolic blood pressure in sitting and standing postures.

Conclusion: Prolongation of PCT in diabetics correlates significantly with evidence of autonomic neuropathy obtained from testing of postural BP variations. Patients whose cardiovascular reflexes are very abnormal tend to have pupils which cycle slowly.


Autonomic neuropathy, Haggstreit-type of slit lamp, Postural blood pressure

Autonomic innervations are possessed by almost every organ system in the body. Various quantitative investigation procedures have been developed for evaluation of autonomic activity which includes cardiovascular, sudomotor, gastrointestinal, renal, sexual and respiratory functions. DN is known to affect the cardiovascular, gastrointestinal and genitourinary systems (1). BP variations are also a common manifestation of autonomic neuropathy secondary to diabetes. Patients usually present with generalised weakness, decreased vision, fatigue and episodes of loss of awareness. These have been known to occur as a result of change in heart rate, pumping ability of the heart and resistance to splanchnic vessels. The major factor responsible for a decrease in BP is a decrease in catecholamine production while standing and failure of lower limb vessels to increase resistance when required (1).

PCT is a simple and sensitive test to measure dysfunction of autonomic nervous system. PCT is the time that pupil takes to constrict and dilate once, when stimulated with a slit beam of light (2). Stimulation of parasympathetic nerves excites the sphincter pupillae which leads to miosis. On the other hand, stimulation of sympathetic nerves excites the dilator muscle and leads to mydriasis. Autonomic function of the iris can be assessed by the measurement of PCT (3).

Diabetic autonomic neuropathy occurs in approximately 50% of individuals with long standing type 2 diabetes mellitus (4). The development of autonomic neuropathy correlates with the duration of diabetes and glycaemic control; both myelinated and unmyelinated nerve fibers are lost. This is due to increased metabolic products produced by phosphorylation and subsequent glycolysis of increased intracellular glucose. Metabolites like sorbitol are produced which alters redox potential, generates reactive oxygen species and likely leads to other types of cellular dysfunction. Axonal degeneration of metabolic origin tends to evolve over several weeks to a year or more and demyelinating neuropathies develop in diabetic patients (4). Degenerating autonomic nerve endings in the iris have been observed. The diabetic iris actually shows an increased response to both cholinomimetic and sympathomimetic drugs which indicates denervation hypersensitivity (5).

The PCT is a novel method to investigate the effects of persistent diabetes and to correlate its effect on postural hypotension. The aim of this study was to assess the correlation of effects of postural hypotension and PCT on persistent diabetes.

Material and Methods

This prospective cross-sectional study was conducted in Ophthalmology OPD at KS Hegde Medical Academy, Mangalore, Karnataka, India, from January 1st 2019 to December 31st 2019. The study was conducted after obtaining an approval from the Institutional Ethics Committee (IEC) on November 22nd 2018 (INST.EC/EC/064/2018-19).

Sixty patients between the age group of 40-60 years which were divided into two groups of 30 diabetics and 30 non diabetics. The non diabetics included patients who presented to the eye OPD with ocular complaints. A written consent was obtained from all patients who participated in the study.

The diabetic patients were admitted for systemic control of blood sugars and were referred to the OPD for diabetic retinopathy evaluation.

Inclusion criteria: Group-1 included type-2 diabetic patients diagnosed as per World Health Organisation (WHO) criteria, (RBS >200 mg/dL, FBS >126 mg/dL and HbA1c >6.5%) (1) (WHO 1980 Technical report series 646) without any history of ketoacidosis, more than 10 years of diabetes and co-existence of neuropathy diagnosed clinically. Group-2 included normal subjects.

Exclusion criteria: Severe non proliferative and proliferative diabetic retinopathy, ocular disease and disorders known to affect autonomic function as well as peripheral nervous system like Systemic Lupus Erythematosus (SLE), Rheumatoid arthritis, Myasthenia gravis patients taking drugs like dopamine, adrenaline or dobutamine which could affect autonomic function were excluded from the study.

Sample size calculation: On the basis of the study conducted by Young JB and Landsberg L assuming 95% confidence level, 80% power, mean blood glucose levels (FBS) of 131±3.8 mg/dL in the diabetic group and 113±2.7 mg/dL in the non diabetic group, estimated effect size is 0.8, an estimated sample size of 30 in each group was calculated. Sample size was estimated using G*Power l (3).

Study Procedure

The blood pressure (systolic and diastolic) of the patients was measured using sphygmomanometer and a stethoscope. The patients were asked to stand for five minutes and the blood pressure was recorded and documented. Next, they were asked to sit for five minutes and the blood pressure was recorded and documented. The mean systolic and diastolic pressure of the patients in standing and sitting positions were calculated. Neuropathy with burning, tingling sensation and painful or numb feet was diagnosed clinically with 10 g Semmes-Weinston monofilament test and vibration test using a 128 MHz tuning fork. PCT was measured in both eyes using Haggstreit-type of slit lamp. The subject was seated in a dimly lit room after dark adaptation for 15 minutes. Then asked to gaze at a fixed point to get accurate measurement. A horizontal beam of light of width of 1 mm wide slit beam of moderate intensity was focused through the slit lamp, accurately on the inferior margin of the pupil. The beam of light was slowly elevated until it overlaped the pupil. The pupil-initiated cycle of constriction was when light entered through the pupil and dilatation was when light escaped. The stopwatch was incorporated to an oscillator of 1 KHz, which gave an accuracy of 1 millisecond. It was connected to a counter on which the number of cycles to be counted could be selected. The counter started the stopwatch at the beginning and end of the preselected number of cycles, which reduced human error to minimum. The stopwatch was calibrated on an oscilloscope. Count was performed in both right and left eyes. For the purpose of analysis, the longer cycle of the two estimated from each subject was considered. The oscillatory cycles were timed for 60 cycles (two 30 cycles). The time taken for single cycle from the first 30 cycles was recorded as PCT-I and from the next 30 cycles was taken as PCT-II.

Statistical Analysis

Statistical analysis of the data was done using the software Statistical Package for the Social Sciences (SPSS) version 20.0 at 95% confidence level. Categorical variables were presented as percentage. Continuous variables were presented as Mean±Standard Deviation (SD). The comparison of BP and PCT in the diabetic and non diabetic group was done using the paired t-test. Correlation between PCT and blood pressure in sitting and standing positions was done using Karl Pearson’s Coefficient of correlation. A p-value of <0.05 was considered statistically significant.


The mean age of patients in the diabetic group was 54±3.2 years and the non diabetic group was 52±2.7 years (p=0.127). In the diabetic group, 20 (65%) were males and 10 (35%) were females whereas in the non diabetic group, 17 (57%) were males and 13 (43%) were females. The mean HbA1c of diabetics was 6.9±0.8%.

The study showed significant difference between the systolic blood pressure, diastolic blood pressure both during sitting posture and standing posture in control and diabetic patients (Table/Fig 1). In the same way, the PCT-I and PCT-II was significantly high (p=0.003 and p=0.0005, respectively) in diabetic patients as compared with the means of controls (Table/Fig 1).

PCT-I and PCT-II negatively correlated with both diastolic and systolic blood pressure in sitting and standing postures (Table/Fig 2),(Table/Fig 3), but these correlations were not found to be statistically significant.


The aim of this study was to compare the PCT of patients with type II diabetes and healthy control subjects and to analyse the effect of variables like age, sex, HbA1c levels and BP on PCT. Mean PCT was prolonged in diabetics when compared with control subjects. There was prolongation of PCT with increasing age, but the correlation of PCT with age could only be demonstrated in the control group, as diabetes, by itself, can prolong the PCT. A study conducted by Miller SD and Thompson HS found that beyond the age of 50 years, there was a lengthening of PCT (6), whereas Dustman RE and Beck EC found the same in a group of older subjects, with a mean age of 67 years (7).

In the present study, there was a tendency towards a lengthening of the PCT in control group with advancing age. This was comparable with the study conducted by Manor RS et al., which also showed the tendency for PCT to increase with age whereas the above findings were negated by Sood AK et al., who did not find any significant correlation between age and PCT (8),(9).

In this study, mean PCT of diabetic patients was 1003ms, whereas mean PCT of controls was 870ms with SD of 183.14ms and 194.36 ms, respectively. This increase in mean PCT, in diabetic group could also be due to increased distribution of elderly patients in the diabetic group, which was also observed in the study conducted by Manor RS et al., (8). The prolonged PCT in diabetics as compared to healthy normal subjects points towards a possibility of pupillary autonomic neuropathy as the probable explanation for this result. Similar finding was cited by many other studies like Smith SE et al., (10).

Martyn CN and Ewing D; Kim GC et al., concluded that PCT is prolonged in diabetics and correlates well with evidence of autonomic neuropathy (11),(12). PCT may be prolonged due to the inability of the iris smooth muscle to contract, which can happen due to structural abnormalities in iris muscle in diabetes. Ultrastructural studies have demonstrated abnormalities in the muscles of the diabetic iris, though these may be a consequence to damage to the innervating fibers. It is more likely that the prolongation of PCT is caused by an abnormality in the innervation of the iris than an abnormality in the smooth muscle. In this cross-sectional study, the PCT was significantly correlated with the duration of diabetes but not with postural changes in the BP whereas the study by Martyn CN and Ewing D showed prolongation of PCT in diabetics correlated well with the evidence of autonomic neuropathy obtained by testing BP (11). Patients whose BP was very abnormal tend to have pupils which cycle slowly. However, abnormal BP does not necessarily reflect autonomic dysfunction in other systems. The imperfect correlation of PCT with BP suggests that autonomic dysfunction in different organ systems does not tend to occur spontaneously. Various techniques have been used for recording and measuring pupillary reactions using infrared video camera and using computer software to analyse these images. These studies have shown association between abnormalities in pupil with autonomic and peripheral nerve dysfunction (13).

This study suggested that measurement of PCT is particularly sensitive to dysfunction in the parasympathetic efferent limb of the pupil reflex arc and this measurement will also be a useful addition to the existing tests of autonomic dysfunction.


The PCT is observer dependent and may be artificially prolonged by undetected cycles and can be interrupted by frequent blinking. Also, changes in intensity of stimulus and fixation pattern can lead to changes in strength and duration of pupillary contraction, which can also alter PCT. Another limitation was that the PCT values may not be reliable if the patient has an afferent or efferent pupillary defect, which was not assessed during the study.


This study shows that iris is one of the structures which have innervation by autonomic nervous system and also how assessment of PCT can help to quantify the functioning of the pupil. It is a reliable and sensitive method which was a non invasive and easily performable. The study also suggests that measurement of PCT is useful to assess abnormalities in the parasympathetic system of light reflex in diabetics.


WHO expert committee on diabetes mellitus. Second Report. Geneva: WHO, 1980. Technical Report Series 646.
Purewal TS, Watkins TJ. Postural hypotension in diabetic autonomic neuropathy: A review. Diabet Med. 1995;12(3):192-200. [crossref] [PubMed]
Young JB, Landsberg L. Suppression of sympathetic nervous system during fasting. Science. 1976;196:1473-75. [crossref] [PubMed]
Karaçorlu MA, Sürel Z, Cakiner T, Hanyalog? lu E, Saylan T, Mat C. Pupil cycle time and early ocular involvement in ocular leprosy. Br J Ophthalmol. 1991;75:45-48. [crossref] [PubMed]
Haworth PA, Heron G, Whittaker L. The measurement of pupil cycling time. Graefes Arch Clin Exp Ophthalmol. 2000;238:826-32. [crossref] [PubMed]
Miller SD, Thompson HS. Edge-light pupil cycle time. Br J Ophthalmol. 1978;62:495-500. [crossref] [PubMed]
Dustman RE, Beck EC. The effects of maturation and ageing on the wave forms of visually evoked potentials. Electroencephalogr Clin Neurophysiol. 1969;26:02-11. [crossref] [PubMed]
Manor RS, Yassur Y, Siegal R, Ben-Sira I. The pupil cycle time test: age variations in normal subjects. Br J Ophthalmol. 1981;65:750-53. [crossref] [PubMed]
Sood AK, Mithal S, Elhence A, Maini A. Pupil cycle time. Indian J Ophthalmol.1985;33:41-43.
Smith SE, Smith SA, Brown PM, Fox C, Sönksen PH. Pupillary signs in diabetic autonomic neuropathy. Br Med J. 1978;2(6142):924-27. [crossref] [PubMed]
Martyn CN, Ewing D, Pupil cycle time- A simple way of measuring an autonomic reflex. J Neurol Neurosurg Psychiatry. 1986;49:771-74. [crossref] [PubMed]
Kim GC, Ahn KW, Jun YM. Pupil cycle time in diabetics. J Korean Ophthalmol Soc.1995;36(4):691-96. [crossref]
Friedman SA, Feinberg R, Podolak E, Bedell RHS. Pupillary abnormalities in diabetic retinopathy: A preliminary study. Ann Intern Med. 1967;67:977-83. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/59631.17564

Date of Submission: Aug 17, 2022
Date of Peer Review: Oct 04, 2022
Date of Acceptance: Jan 03, 2023
Date of Publishing: Mar 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Aug 18, 2022
• Manual Googling: Dec 06, 2022
• iThenticate Software: Jan 02, 2023 (9%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)