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Pupil Anisokor Dr. Devi Edit
Pupil Anisokor Dr. Devi Edit
Pupil Anisokor Dr. Devi Edit
Introduction
The pupil is a hole located in the center of the
iris of the eye allows light to enter the retina
The iris is a thin strip of smooth muscle which
regulates the amount of light entering the eye
by controlling the size of the pupil
PUPILS FUNCTION
CONTROL OF PUPILS
Constricts
- Sphincter pupillae a circular group of smooth
muscle
- Parasympathetic fibres in the oculomotor nerve
through the ciliary ganglion via short ciliary nerve
Dilates
- Dilator pupillae a radial muscle group
- Sympatheric nerve from hypothalamus via the
carotid artery entering the globe through short ciliary
nerves
PUPILS
INNERVATION
Afferent Pupillary Pathway
- pupillary fibers follows the optic tract and
separate from the optic tract just anterior to the
lateral geniculate body.
- They then enter the midbrain, where they synapse
to pretectal nucleus.
- leave pretectal nucleus & distributes
approximately equally to both EndingerWestphal
nuclei
PUPILS SIZE
Pupil diameter
Anisocoria (pupillary
inequality)
Anisocoria
Worse in
light
Abnormality in the
iris sphincter
( constriction
failure )
Worse in
dark
Abnormality in
the Iris dilator
(dilatation
failure)
No difference in
light and dark
Physiological
Causes of
Anisocoria
Worse in
Bright Light
Large
Abnormal
PupilConstriction
Failure
Parasympatheti
c
Causes
pathway
3rd cranial nerve palsy
- Microvascular injury subarachnoid or
cavernous sinus.
- microvascular infarct : include
aneurysmal compression,
tumor, inflammation.
Adies tonic pupil
Causes of
Anisocoria
Worse in Dim
Light
Causes
Dilatation
Failure
Sympathetic
pathway
Physiologic :
- Commonest (20% of population)
- Pupillary function normal
- Degree of anisocoria remains the same in light
and dark
Horners pupil
Argyll Robertson Pupil
Approach
Examination
1. Examine the patients pupils under normal
room light conditions
Case Study
1. Horners Pupil
Oculosympathetic paresis
interruption of the sympathetic
supply along the three neuron
patway.
Miosis
Ptosis
Apparent enophalmos
Cutaneous anhydrosis
Other feature iris hypopigmentation
on congenital cases
Horners Syndrome
Anisocoria
28
In bright light
In dim light
29
30
Rontgen Thorax
31
CT Scan Thorax
Kesan
32
33
2. Oculomotor nerve
palsy
Partial pupil
involvement in
25-47% of
patients with
posterior
communicating
Case 1
A 55-year-old woman presented to the
Emergency Department with complaints of
headache, droopy eyelid and double vision, her
symptoms worsened and she began to develop
diplopia.
On exam, right-sided ptosis, a dilated pupil
with a sluggish light response, and a downward
and lateral deviation of the right eye.
The remainder of neurologic exam was within
normal limits.
Case 2
A forty-seven-year-old female patient with
sudden ptosis, dilated pupil and diplopia
without pain, three days prior. She had no
trauma or systemic disease history.
Approximately 30 prism diopters exotropia was
seen in the primary position. Anterior and
posterior segment examination was normal in
both eyes.
Posterior communicating artery aneurysm
was seen in enhanced MRI and MRI
angiography
Traumatic Pupil
Contusion Injury of the eye may
cause :
Miosis
may be due to
sphincter spasm
seen with iritis
Mydriasis
May be due to contusion
injury (or actual rupture)
of
the
iris
sphincter
muscle :
a. Irregular pupil
b.Poorly responsive to 2%
Ocular Trauma
Trauma Examination
Visual acuity
Pupil testing
Eye movement
Visual field
Palpasi eyelid and orbital margins
Pupil large
degreasing reactiont to
light and near, irreguler pupil ( spinter
damage)
Thank
Iris anatomy
normal
YE
S
Supersensitive to 0,1
% pilocarpine
NO
YES
Adie tonic
pupil
YES
NO
Suspect
pharmacologic
mydriasis
Traumatic
iridoplegia, iris
ischemia, siderosis
Constricts with
1,0 % pilocarpine
Iris damage
NO
Third-nerve
palsy
Pharmacologic
al mydriasis
Symptoms of a
ruptured aneurysm
Sudden onset of
a severe
headache
Nausea and
vomiting
Stiff neck
Transient loss of
vision or
consciousness
Risk factors
for
aneurysm rupture
include:
- Smoking,
- High blood pressure,
- Alcohol
- Genetic
factors
(family inherited)
- Atherosclerosis(hard
ening
of
the
arteries)
- Oral contraceptives
Angiogram is an invasive
procedure, where a catheter is
inserted into an artery and
passed through the blood
vessels to the brain.
Magnetic resonance imagi
ng
(MRI) scan is a noninvasive
test, which uses a magnetic
field. An MRA (Magnetic
Resonance Angiogram) is the
same non-invasive study.
Horner
Syndrome
1,0 %
hydroxyampheta
mine
Small pupil
unchanged
Third-order
neuron Horner
Syndrome
Anisocoria same in
dim and in bright
light
YES
Physiologic
anisocoria
Anisocoria greater in
dim light
Dilator muscle
working right
No or unsure
Cocaine
Both eyes dilate
Anisocoria
> 1.0 mm
Horner
Syndrome
rFunctional or
mechanical
restriction to
dilatation
Synechiae, uveitis,
miotic drops, old
Adie pupils
Mechanical /
pharmacologic
miosis
Horners
syndrome
CN3 palsy
Right horners
syndrome : miosis with
approximately 2mm
Right horners
syndrome : the right
pupil failed to dilate
while the left eye
dilated to 7 mm with
10% cocain.
Physical Examination
horner
Measurement of pupillary diameter in dim
and bright light and the reactivity of the pupils
to light and accommodation
Examination for dilation lag of the pupil
immediately after the room lights are dimmed
Examination of the upper lids for ptosis
Examination of the lower lids for upside-down
ptosis (eg, the position of the lower lid with
respect to the inferior limbus)
Treatment
Treat the underlying disorder if
possible.
Ptosis surgery may be performed as
needed.
Sinister Pupils
Associated with
motor nerve
palsies
Oculomotor
nerve
palsy
(diplopia/ptosis)
pupil is LARGE
Horners Syndrome
(ptosis)
Pupil is SMALL
Marcus Gunn Pupil
Associated with
visual loss
Compresive optic
neuropathy
Argyll Robertson
Pupil
Tertiary syphilis involving the central nervous
system.
small pupils (<2mm), often irregular.
Do not react to light, but the near response and
subsequent redilation are normal and brisk.
Are seen in widespread autonomic neuropathies
such as bilateral tonic pupils (chronic), diabetes,
chronis alcoholism, as well as in encephalitis,
following panretinal photocoagulation
Argyll Robertson
Pupil
Small, irregular pupils that do not react to light,
but do to near.
Dilate poorly in the dark and in response to
mydriatic agents,
including cocaine and paredine.
May be unilateral and thus imitate the miosis of
Horners
syndrome (more marked anisocoria in the dark and
after
cocaine or paredrine.
Approximately 20 % of patients with neurosyphilis
will
demonstrate the above pupillary phenomena.
Another 50% of patients with neurosyphilis will
demonstrate
Clues to the
cause of the
Horners
syndrome are
based on the
location of the
lesion
Algorithm number 2
For patients with an abnormal
light reaction and whose
anisocoria is greatest in bright
light conditions => the larger
pupil is the abnormal pupil
(constriction problem with the
larger pupil)
Findings
Tonic pupil
3rd nerve
palsy
Mydriatic
eyedrops
Parinaud
syndrome
Argyll
Robertson
pupil
Sympathomim
etic drugs
+
+
+
+
+
+
+
(-) +
(-) +