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Is it a Tonic Pupil?Valérie Biousse, MD
Neuro-Ophthalmology. Emory Eye CenterEmory University. Atlanta, GA. USA
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Disclosures
lNo relevant disclosureslConsultant for GenSight Biologics
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Anisocoria
Big Pupil Problemvs.
Small Pupil Problem
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Physiologic Anisocoria
l10-20% of population has 0.4mm of anisocoria
lNormal light, near and dark reactions
Light
Dark
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Anisocoria. Ocular causes
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Angle closure glaucoma Iris tear
Traumatic mydriasisOcular siderosis (L)
ICE syndrome
IOLIris nevusUveitis
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The small pupil is abnormal lThe anisocoria is greater in the dark
than in the light¡Poor pupillary dilation on the abnormal side¡Abnormality of the sympathetic system.
Dark
Light
Right eye Left eye
Lightpointed here
Lightpointed here
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Horner Syndrome lAbnormality of the sympathetic system
Light
Dark
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Congenital Horner Syndrome
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Horner’s Syndrome: Localization
1: 1st order neuron: brainstem/ spine
2: 2nd order neuron: brachial plexus/ lung apex
3: 3rd order neuron: carotid dissection
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Horner + VIth = Cavernous Sinus
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The big pupil is abnormal lThe anisocoria is greater in the light
than in the dark¡Poor pupillary constriction on the abnormal side¡Abnormality of the parasympathetic system.
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Pharmacologic MydriasislVery large pupillDoes not react to light or nearlPoor constriction with Pilocarpine 1%
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Pharmacologic MydriasisSphincter blockers• Belladonna alkaloids• Atropine• Scopolamine• Tropicamide• Cyclopentolate• Anticholinergic inhalants• Gentamycin• Lidocaine
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Pharmacologic Mydriasis
Dilator Stimulators• Epinephrine• Phenylephrine• Ephedrine• Hydroxyamphetamine• Cocaine• Ocular decongestants• Adrenergic inhalants
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Tonic Pupil
l Initially large, irregular, tonic redilation
l Good near response
l Sensitivity to dilute pilocarpine (0.125%)
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l Light response
l Near response
Tonic Pupil
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l Light response
l Dilute pilo
Tonic Pupil
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l Sectoral paralysis, segmental contraction
l Loss of pupillary ruff
l Vermiform movements of iris
Tonic Pupil
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l Usually no cause¡Diabetes¡Viral infection (zoster,
HIV)¡Syphilis¡Local orbital process
l If isolated, no workup
Tonic Pupil
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Third Nerve Palsyl Dilated pupil
l Poorly reactive to light
l Always with ptosis/diplopia
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PCOM Aneurysm / Pituitary Apoplexy
Right gaze Left gaze
Down gaze
Up gaze
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Anisocoria :RememberlNo anisocoria w/ afferent defect
lCarotid dissection (Horner)
lPosterior communicating artery aneurysm and pituitary apoplexy (IIIrd n. palsy)
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