PUPILLARY PATHWAY,

PUPILLARY
ABNORMALITIES, RAPD

AFEEFA N A
15
 PUPIL AND ITS FUNCTIONS
• The pupil is the dark circular opening in the center of the iris and is where light enters
the eye. Size of pupil ranges from 2.5- 4 mm.
• Its constriction and dilatation is controlled by two muscles of ectodermal origin-
sphincter pupillae and dilator pupillae, respectively.
Functions
o Pupil movement in response to changing light intensity helps in optimizing retinal
illumination to maximize the visual perception.
o Improves the image quality of retina when steady state pupil diameter is small.
o Small pupil increases the depth of focus of the eye’s optical system similar to pinhole
effect of camera by limiting rays entering retina.
 PUPILLARY PATHWAY

• The pupillary light reflex neural pathway on each side has an afferent limb and two
efferent limbs. The afferent limb has nerve fibers running within the optic nerve (cn ii).
Each efferent limb has nerve fibers running along the oculomotor nerve (cn iii). The
afferent limb carries sensory input.
• Thus pupillary pathway has afferent and efferent pathways.
 AFFERENT PATHWAY
Rods and Cones Travels centrally
and Melanopsin Ganglion Cells along the optic
Ganglion Cells nerve

Midbrain from
Nasal fibres
Lateral Side of
Optic Tract decussate in
Superior
optic chiasma
Colliculus

The Accessory
New Relay motor nuclei of
Pretectal
fibres partially Edinger
Nucleus
cross over Westphal
Nucleus
 EFFERENT PATHWAY

The axons of Lie on the

Passes laterally to
Edinger Westphal superficial Located inferiorly
petroclinoid
Nucleus extend dorsomedial as it enters the
ligament and
into IIIrd Cranial aspect as it leave orbit
dorsum sellae
Nerve the brain stem

Via short ciliary Inferior division

Sphincter papillae Ciliary Ganglion
nerves of IIIrd nerve
 PUPILLARY REFLEX

• Light reflex
• Near reflex
• Psychosensory reflex
 LIGHT REFLEX
• Light reflex consists of simultaneous and equal constriction of pupils in response to
stimulation of one eye by light.
• Pupil constriction is elicited with extremely low intensities and is proportional within
limits to both intensities and duration of stimulus.
• Consists of direct and consensual or indirect reflex
o Direct reflex- When light is directed to one eye, constriction of pupil of the
corresponding eye occurs.
o Consensual reflex- When light is directed to one eye and we look on the other eye, we
can see constriction of pupil on other eye.
 NEAR REFLEX

• Two components
o Convergence reflex- convergence of visual axis and associated constriction of pupil
o Accommodation reflex- increased accommodation and associated constriction of pupil

• Near reflex triad consists of:

 Increased accommodation
 Convergence of visual axis
 Constriction of pupils
 PSYCHOSENSORY REFLEX

• Dilatation of pupil in response to sensory and psychic stimuli.

• Mechanism- Cortical one and apparently the pupil dilatation in these results from 2
components
o Sympathetic discharge to the dilator pupillae
o Inhibition of parasympathetic discharge to the sphincter pupillae
 PUPILLARY ABNORMALITIES

• Afferent pupillary defect

 Total Afferent Pupillary Defect (TAPD)
 Relative Afferent Pupillary Defect (RAPD)
 Wernicke’s hemianopic pupil

• Efferent pupillary defect

 Tonic Pupil
 Oculomotor Nerve Palsy

• Light near dissociation

 Argyll Robertson Pupil
 TOTAL AFFERENT PUPILLARY DEFECT
(TAPD)
• Absence of direct light reflex on affected side and absence of consensual light reflex on
normal side.
• When stimulated, both pupils do not react normally.
• Diffuse illumination- both pupils are equal in size.
• Near reflex is normal in both eyes.
 RELATIVE AFFERENT PUPILLARY DEFECT
(RAPD)
• A relative afferent pupillary defect (RAPD), also known as a Marcus Gunn pupil, is a
medical sign observed during the swinging- flashlight test, whereupon the patient’s
pupils dilate when a bright light is swung from the unaffected eye to the affected eye.
• RAPD cause a reduction in pupil contraction when one eye is stimulated by light
compared with when the opposite eye is stimulated by light.
• May be associated with visual field or electroretinographic asymmetries between the
two eyes.
• Asymmetrical differences in retinal appearance or optic nerve appearance may occur.
 GRADING SCALE OF RAPD
• Grade 1+ : A weak initial pupillary constriction followed by greater redilatation
• Grade 2+ : An initial pupillary stall followed by greater redilatation.
• Grade 3+ : An immediate pupillary dilatation.
• Grade 4+ : Immediate pupillary dilatation following 6 sec illumination
• Grade 5+ : Immediate pupillary dilatation with no constriction at all.

However, most subjective grading of RAPDs has serious limitations, such as some
large- scale errors that arise from age variations in pupil size and pupil mobility.
 MEASUREMENT OF RAPD- NEUTRAL
DENSITY FILTERS
• Estimation of amount of RAPD is in log units which provide an objective data.
• Done by placing neutral density filters (NDF) in front of better eye which provides
better idea of how much visual field damage is present.
• NDF balances asymmetry of pupils between two eyes.
• Accurate quantification of RAPDs is accomplished by determination of the log unit
difference needed to “balance” the pupil reaction between the two eyes.
• Loss of central 5° of visual field results in rapd of 0.3 log units
• Loss of entire central field 10° causes rapd of 0.6-0.9 log units.
 WERNICKE’S HEMIANOPIA PUPIL

• Cause- Optic tract lesion

• Light reflex- Ipsilateral direct & contralateral consensual absent when light shown in
temporal half of affected retina and nasal half of opposite side.
 EFFERENT PUPILLARY DEFECT
• Interferes with contraction or dilatation of pupil due to damage in midbrain, peripheral
nerves that supply iris muscles, or in the iris muscles causing ANISOCORIA.
• Anisocoria- Difference in size of the two pupils of 0.4 mm or greater.
• Anisocoria is of two types
1. Anisocoria equal in both dim and bright light
 Physiological or primary anisocoria- 20% of individuals, pupil diameter difference <1.0 mm
2. Anisocoria greater in bright light (if iris is dilated in sympathetic palsy)
 Mechanical anisocoria- Previous trauma/ surgery or inflammation
 Pharmacological anisocoria- unilateral use of medications like pilocarpine
 ADIE’S TONIC PUPIL
• Caused by denervation of post ganglionic supply of sphincter pupillae and ciliary
muscle.
• Typical cause is idiopathic.
• Usually unilateral.
• Typically affects young healthy females.
• Affected pupil is large and irregular.
• Light reflex is absent.
• Near reflex is slow and tonic.
• Accommodative paresis.
• May be associated with mild impairment of corneal sensations
• May be associated with absent knee jerk
 OCULOMOTOR NERVE PALSY

• Pupillary dysfunction associated with ptosis and limitation of extraocular activity.

• Pupil mid- dilated, maximum anisocoria occurs in bright light.
• Aneurysms at the junction of internal carotid and posterior communicating artery must
be excluded.
 LIGHT NEAR DISSOCIATION
• Condition where light reflex is absent or sluggish but near response is normal.

ARGYLL ROBERTSON PUPIL

o Caused by lesion in the region of tectum.
o Usually bilateral but asymmetrical.
o Pupil small in size and irregular.
o Light reflex is absent but near reflex is present
o Pupils dilate very slowly with mydriatics
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