The Pupil

 The normal pupillary diameter is about ((3–4 mm))

 Normal pupil (CRRR) is Central (slightly nasally) Rounded, Regular,
Reactive to light and to near object
 20% to 40% of normal patients have a slight difference in pupil size
(physiologic anisocoria), usually less than 1 mm.

 Function of pupil
1- Control the amount of light entering the eye
2- Decrease aberration by cutting peripheral ray

Light Reflex
When light fall on eye

Ipsilateral pupil constrict (Direct)

Other pupil constrict (Indirect, consensual)

Pathway

Stimulus Light

Receptor Rod & cones

Afferent Optic nerve, Optic chiasm, Optic tract

Center Edinger Westphal nucleus

Efferent 3rd cranial nerve ciliary ganglion Constrictor pupillae ms

Afferent
Optic nerve Optic chiasma Optic tract

Pretectal area synapse in Edinger – Westphal nucleus of same and

opposite side

Efferent
Oculomotor Ciliary ganglion Short ciliary nerve

Sphincter pupillae ms.

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(Indirect, consensual) reflex as result of cross of fiber at
1- in optic chiasm (nasal fiber of optic nerve)
2- in mid brain (Edinger – Westphal nucleus)

The Near Reflex

When the eyes look at a near object, three responses occur
((Accommodation, Convergence, and Miosis))
1- Accommodation is done by ciliary muscle
2- Convergence by medial recti
3- Miosis by sphincter pupillae

Pupillary Light-Near Dissociation

The light reflex normally produces more miosis than the near response. The
reverse is known as pupillary light-near dissociation.

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 Pupil defect
Manifestation
Argyll Robertson Is caused by Neurosyphilis and is characterized by the following:
pupils Involvement is usually bilateral but asymmetrical.
The pupils are small and irregular.
The light reflex is absent or very sluggish.
The near reflex is normal (light near dissociation).
The pupils are very difficult to dilate.
other causes( DM, multiple sclerosis, encephalitis, chronic alcoholism)

Holmes Adie Clinical features are as follows:

syndrome It is unilateral in 80%.
It typically affects healthy young Female and associated with Areflexia (loss
of all deep reflex)
The affected pupil is large ((dilated))
The light reflex is absent or very slow.
Constriction to near is very slow, Accommodation is slow.

Horner's unilateral condition due to damage of sympathetic supply caused by

syndrome (1) Pancoast's tumour of the lung (2) carotid and aortic aneurysms,
(3) lesions in the neck (e.g. trauma or surgery), (4) brain-stem vascular
(Oculo- disease or demylination, (5)congenital (6)idiopathic.
sympathetic (( Partial ptosis -Miosis -Anhydrosis -Enophthalmos -Heterochromia is
palsy) occasionally present if the lesion is congenital))
The pupillary reactions are normal to light and near.

Marcus Gunn Marcus Gunn pupil is known as the relative afferent papillary defect (RAPD)
pupil Is caused by an incomplete optic nerve lesion or severe retinal disease.
There is a paradoxical dilation of the pupil when the torchlight is swung
From the contralateral normal eye to the affected eye.
It is elicited with Penlight swinging Test (used for diagnosis)

Hutchinson pupil Due to subdural hematoma caused by trauma

Ipsilateral pupil Contra-lateral pupil

Early Constriction Normal

Advanced Dilated(not respond to light) Constriction
Late stage Dilated(not respond to light) Dilated(not respond to light)

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 Abnormal pupil size
Miosis
Physiological intense light , old age, near vision,
dark race, during sleep
Drugs local Pilocarpine, acetylcholine,
general anesthesia (stage III),
Morphine poison, hypermetropia
early alcohol intoxication
Ocular causes Corneal ulcer, Iridocyclitis, rapid
hypotony, surgery, blunt trauma,
Argyll Robertson pupil,
Hutchinson pupil in early stage,
Horner s syndrome
Other Pontine hemorrhage
Organophosphate poison
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Mydriasis
the dark , young age, excitement, fear
,pain
local phenylepherine, atropine,
homatropine, myopias
General anesthesia stage I, II, IV.
acute congestive glaucoma , blunt
trauma , optic nerve atrophy , ciliary
ganglion inflammation, surgical 3rd
cranial nerve palsy, Adie s syndrome,
Hutchinson pupil in advanced stage
Midbrain lesion
co poisoning
 Anisocoria
Definition Unequal size pupils between two eyes.
Causes -Drugs. (if used for one eye)
-Inflammation ( Iridocyclitis , post synechiae)
-Angle- closure glaucoma, unilateral Iris diseases {atrophy, Aniridia}.
- Trauma (Paralysis of dilator papillae, constricted pupillae)
-Horner s syndrome, Adie s syndrome, Surgical 3rd cranial nerve palsy

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 Leukocoria
Definition White pupil
Causes 1-Congenital cataract (Bilateral – Unilateral)
2-Retinoblastoma (Unilateral – Bilateral)
3-Retinopathy of prematurity (Bilateral)
4-Coat‘s disease (Exudative retinitis) (almost always Unilateral)
5-Persistent hyperplastic primary vitreous (PHPV) (Unilateral)
6-Toxocariasis (Unilateral)

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