pupil abnormalities

Dr Stephen Best

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The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex

The size of the pupil is determined by the antagonistic action of the sphincter constrictor muscle vs the diffuse dilator pupillae

Parasympathetic vs Sympathetic innervation

Local factors may alter this

Pupil size is usually equal !!

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Miosis = small pupil

Mydriasis = large pupil

Anisocoria = difference in size

Polycoria = multiple apertures

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Light reflex – direct/consensual

Near reflex – miosis / accommodation / convergence

Relative afferent pupil defect

Pathologic pupil defects

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Topical medications – mydriatics/miotics/other agents

Trauma – traumatic mydriasis / sphincter rupture / surgical trauma / posterior synechia

Disease processes / iritis / uveitis / acute angle closure glaucoma

Systemic medications – narcotics = miosis

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Oculosympathetic paresis….interruption of the sympathetic supply along the three neuron pathway

Miosis

Ptosis

Apparent enophthalmous

Cutaneous anhydrosis

Other features – transient hyperaemia/iris hypopigmentation in congenital cases

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Diagnosis confirmed by topical cocaine test

Abnormal pupil fails to dilate whilst the normal pupil will dilate ( loss of noradrenaline at nerve junction )

Other associated clinical signs and symptoms….( headache / apical lung pathology / long tract neurology signs ) will determine appropriate investigations

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Postganglionic parasympathetic denervation

Glare / accommodative difficulties

Mydriasis

Light – near dissociation….slow constriction on prolonged near effort and slow re-dilation to distance

Usually young females – 90% unilateral initially , but often becomes bilateral

Decreased corneal sensation

Decreased deep tendon reflexes

Pupil becomes tonic with time….even miotic

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Oculosympathetic paresis….interruption of the sympathetic supply along the three neuron pathway

Miosis

Ptosis

Apparent enophthalmous

Cutaneous anhydrosis

Other features – transient hyperaemia/iris hypopigmentation in congenital cases

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Diagnosis confirmed by deinnervationhypersensitivity to weak cholinergic (pilocarpine 0.1%)……abnormal pupil will constrict whilst normal pupil remains un-effected

Aberrant re-innervation of pupillary sphincter muscle ….contractions of part of the pupil margin (vermiform movement)

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Pupil involved 3rd nerve palsy

Bilateral dilated pupils

Horner’s Syndrome

Adie’s Tonic Pupil

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The most common pupil abnormality is simple

Physiological Anisocoria

Benign!!!

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38 yr female

Severe burns- plastics admission for grafts

Early morning headaches

Some blurring of vision

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VA 6/12 OD, 6/9 OS

Pupillary examination – sluggish

Optic disc examination – abnormal

HVF= peripheral visual field constriction OU

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Neuro-imaging mandatory with papilloedemaRefer as appropriate

Note: PTC/BIH/IIH

Consecutive optic atrophy following resolution of papilleodema secondary to meningioma after neuro-surgical intervention

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should not be reproduced without written permission