PUPILLARY PATHWAYS

AND REACTIONS
DR AARUSHI SAINI
• Size of Pupil is controlled by 2 muscles-

1. Sphincter Pupillae

2. Dilator Pupillae

• Size of the Pupil is a result of the opposing forces of these two

muscles.
 SPHINCTER PUPILLAE
• It forms a 1mm broad circular band in the pupillary part
of iris.
• It is supplied by cholinergic nerves of
PARASYMPATHETIC SYSTEM through the 3rd Cranial
Nerve.
Edingerwestphal nucleus (located in midbrain at the level of
superior colliculi)

Fibres emerge and run in the main trunk of 3rd nerve

Inferior Division of 3rd CN

Nerve to Inferior Oblique

Ciliary Ganglion(RELAY)

Short ciliary nerves

Pierce the sclera around optic nerveChoroidciliary body

Iris
 DILaTOR PUPILLAE
• Supplied by Adrenergic Fibres of Cervial Sympathetic nerve.
Posterior Hypothalmus

Medulla

Intermediolateral horn of Spinal Cord(C8-T2)=Ciliospinal Centre of

Budge

Stellate ganglion

Ansa Vieussens

Superior cervical ganglion

Carotid plexus

Skull
Pass into Ophthalmic Division of 5th Nerve(V1)

Long ciliary Nerve (Thus, avoiding relay in the

Ciliary ganglion)

Nerves enter the eye on each side of Optic Nerve

Move forward between choroid and sclera

Enter ciliary body

Iris
• Some fibres supply the mullers muscle in Upper and
lower lid
• Sudomotor Fibres course along the External Carotid to
innervate sweat glands of face.
 PUPILLARY REFLEXES
• LIGHT REFLEX

• NEAR RELFEX

• PSYCHOSENSORY REFLEX

• DARKNESS REFLEX
 LIGHT REFLEX
• When light enters one eye, the pupil of that eye contracts (Direct
Reflex) as well as that of the other eye (Consensual Reflex/Indirect
reflex).
• Contraction of both the pupils is identical in time, course and
magnitude.
• If both pupils are illuminated simultaneously, the response
Summates i.e. constriction is greater as compared to illumination of
only one pupil.
• Latent Period:0.2-0.5s (Less than latent period of constriction seen
in accommodation reflex)
 AFFERENT Pathway
Light falls on Retina(Initiated by Rods and Cones)
1ST
Optic Nerve O
R
Chiasma D
E
R
Optic Tract

Pretectal Nucleus

• Nasal fibres decussate and cross to the opposite Optic tract and
hence go to the contralateral Pretectal Nucleus.
• Temporal fibres go the ipsilateral Pretectal nucleus.
 Pretectal Nucleus 2ND
O
Internuncial Fibres R
D
E
EdengerWestphal Nucleus of BOTH sides R

• Internuncial fibres connect the Pretectal nucleus to the EDW

nucleus of both sides. Half fibres from Pretectal nucleus go
to the ipsilateral EDW nucleus and the rest half of the fibres
go to the contralateral side EDW nucleus.
• This forms the basis of consensual light reflex.
• Efferent Pathway- It consists of the parasympathetic pathway
which arises from the EDW nucleus.

• Normally, there is a tonic inhibitory input from cerebral cortex

to the EDW nucleus. A diminution of this input results in
pupillary constriction during sleep.

• Pupilloconstrictor fibres are situated on the surface of 3rd nerve

but their location on surface changes along it’s intracranial
course.
• Hence, unilateral deficits in pupilloconstriction can be helpful
in localizing cases of unilateral pathologies like tumours and
aneurysms.
 LESIONS OF
PUPILLOMOTOR FIBRES
• Between the brainstem and cavernous sinus, these fibres are
located superficially in superior median quadrant of the 3rd nerve.
• Blood supply from Pial blood vessels

• Main trunk gets blood supply from Vasa Nervorum.

• Surgical Lesions-Aneurysms, trauma, uncal herniation involve

pupil by compressing pail blood vessels and superficially located
pupillary fibres
• Medical lesions-Diabetes and Hypertension involve
microangiopathy of vasa nervorum affecting the main trunk but
sparing the pupillomotor fibres.
 NEAR REFLEX
• Near Reflex occurs on looking at near objects.

• It includes-

1. Increased Accomodation -Accomodation Reflex

2. Convergence of eyes
Convergence Reflex
3. Miosis
• Vision is not a prerequisite

• It is a synkinesis rather than a true reflex i.e. Voluntary muscle

movement causing simultaneous involuntary contraction of
other muscle.
 CONVERGENCE REFLEX
AFFERENT PATHWAY EFFERENT PATHWAY

• Not fully elucidated. EDW nucleus

Afferent from Medial Recti 3rd Nerve (Similar to Light

reflex)
3rd Nerve
Accessory Ganglion
Mesencephalic Nucleus of 5th Nerve
Sphicnter Pupillae
Convergence Centre in Tectal/Pretectal
Region(Located Ventrally)

Internuncial Fibres

EDW nucleus
 ACCOMODATION
RELFEX
Retina Occipitomesencephalic Tract
Optic Nerve Pontine Centre
Chiasma EDW Nucleus of both sides
Optic Tract 3rd Nerve
Lateral Geniculate Body Ciliary ganglion and Accesory
Optic Radiation Ganglion

Striate Cortex Sphincter Pupillae and Ciliary

Muscles
Parastriate Coretx
 PSYCHOSENSORY
RELFEXES
• Refers to dilatation of Pupil in response to sensory and psychic
stimuli. (Pain, emotional states, excitement)
• Not seen in newborns, but appears in first few days of life and
develops fully by age of 6m.
• Mechanism and pathway is complex and has not been elucidated
completely.
• General view is that the mechanism of reflex is Cortical based.

• Sensory stimulation causes first rapid dilatation of pupil due to

increased sympathetic discharge and then second rapid onset dilatation
which is slow to disappear due to inhibition of parasympathetic
discharge.
 DARKNESS REFLEX
• When a person goes from a lighted area to darkness, the
pupils dilate.
• Mechanism-

1. Abolition of light reflex with relaxation of sphincter

2. Contraction of dilator pupillae

DEFECTS IN PUPILLARY
PATHWAYS
 Absolute Afferent pupillary
defect
• Amaurotic Pupil

• Complete Optic nerve lesion

• Both pupils are equal in size in diffuse illumination

• Near reflex is normal in both eyes

• Stimulation of affected eyeNo response in either eye

• Stimulation of normal eye Response in both eyes

 RELATIVE AFFERENT
PUPILLARY DEFECT
• Marcus Gunn Pupil

• Causes-

1. Incomplete optic nerve lesion

2. Severe retinal disease

• Stimulation of normal eyeBoth eyes react briskly

• Stimulation of diseased eyeWeak constriction (appears as

dilatation in Swinging flash light test)

Stimulus delivered to constriction mechanism is reduced.

 WERNICKE’S
HEMIANOPIC PUPIL
• It indicates lesion of the optic tract.

• Light reflex(ipsilateral direct and contralateral

consensual) is absent when light is thrown on temporal
retina of affected side and nasal half of retina of opposite
side.
 Horner syndrome
• Oculosympathetic Palsy

• Sympathetic Supply has 3 neurons-

1. HypthalamusIntermediolateral Horn of Spinal Cord

2. Intermediolateral Lateral HornSuperior Cervial Ganglion

[PREGANGLIONIC] Closely related to Apical Pleura where it can
be damaged by Bronchogenic Carcinoma(Pancoast Tumour) or during
neck surgeries.

3. Superior Cervical GanglionPlexus around ICAV1

NerveNasociliary and Long ciliary nerveDilator
Pupillae and Ciliary Body [POSTGANGLIONIC]
 CENTRAL
Brainstem Disease-Stroke,
tumour, demyelination
Syringomyelia
Cervical Spinal cord lesion
Diabetic autonomic
neuropathy
PREGANGLIONIC POSTGANGLIONIC
Pancoast tumours ICA dissection
Carotid and aortic Nasopharyngeal tumour
aneurysms/dissections Cavernous sinus mass
Thoracic spinal cord Otitis media
lesions
Thyroid tumours,enlarged
lymph nodes, trauma, post
surgery
 PRESENTATION

• Mild Ptosis (1-2mm) due to weakness of Mullers Muscle

• Miosis due to unopposed action of Sphincter Pupillae
• Anisocoria which is accentuated in dim light
• Pupillary Constriction to light and near stimuli is normal
• In congenital cases, Heterochromia is seen.
• Anhydrosis (if lesion is below Superior Cervical ganglion)
• Enophthalmos
 PHARMACOLOGICAL TESTS
APRACLONIDINE 0.5/1%
• It is an alpha adrenergic agonist
• Horner PupilDilates
• Normal PupilUnaffected
• Explanation: Alpha-1 receptors are upregulared in denervation of
dilator Pupillae

COCAINE 4%
• It blocks reuptake of Nordrenaline secreted at postganglionic
nerve endings which leads to accumulation of NA.
• Normal Pupil-Dilates
• Horner Pupil-No dilatation as there is no secretion of NA from
nerve endings.
PHENYLEPHRINE 1%
• Used to Distinguish pre and post ganglionic lesions
• Normal/Central or Pre Ganglion Horner Pupil-Not dilate
• Post ganglionic Horner Pupil-Dilates and improvement in ptosis
• Explanation-Dilator pupillae develops denervation
hypersensitivity to adrenergic neurotransmitters
• Adrenaline 0.1% has similar effect

HYDROXYAMPHETAMINE 1%
• It potentiates the release of NA from functional Post ganglionic
nerve endings.
• Normal/Pre Ganglionic Horner Pupil-Dilates
• Post ganglionic pupil-Doesn’t Dilate
 ADIE’s tonic PUPIL
• Caused by denervation of post ganglionic parasympathetic supply to
sphincter pupillae and ciliary muscles.
• Site of dysfunction- Ciliary Ganglion

• Affects young women, unilateral in 80%

• Presentation- Large Pupil, Anisocoria, Direct and indirect light reflex

of the same eye are absent/sluggish, Vermiform Iris movement due to
partial sphincter paralysis, blurring of near vision due to impaired
accomodation, near reflex is slow and tonic.
• Pilocarpine 0.1-0.125% Instillation- Leads to constriction of abnormal
pupil due to denervation hypersensitivity.
 ARGYLL ROBERTSON
PUPIL
• Seen in neurosyphillis

• Lesion in dorsal midbrain that impairs pupillary light reflex pathway but
spares more ventral pupillary near reflex pathway-Light Near
Dissociation.
• Damage to internuncial neurons.

• Bilateral involvement

• Dim Light-Both pupils are small and irregular

• Birght Light- Pupils don’t constrict

• On Accomodation- Both pupils constrict

• Pilocarpine 0.1%-No constriction (Differentiates from Tonic Pupil)

 OTHER CAUSES OF LIGHT-
NEAR DISSOCIATION
• Bilateral Complete Afferent pathway defect-B/L optic atrophy,
Retinal detachment
• Midbrain lesions(Tectal/dorsal midbrain pupils)-Tumours like
Pinealomas manifesting as Parinaud Syndrome, vascular lesions,
encephalitis.
• 3rd Nerve palsy with aberrant regeneration of medial rectus
innervation into sphincter innervation pathway(Pseudo Argyll
Robertson Pupil)
• Peripheral neuropathies in Diabetes, Alcoholism, Amyloidosis
Thank you