pupil - ssj,calicut medical college
TRANSCRIPT
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PUPILShruthi.s.jayaraj ,53rd
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PUPIL
• aperture of the diaphragm of eye (iris) that allows light to enter the retina
FUNCTION• Controls amount of light entering the eye –
influence of ANS
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Not all animals have circular pupil !!
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• Pupils are controlled by 2 muscles of ectodermal origin –
1. Sphincter pupillae2. Dilator pupillae
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• Circular fibres – parasympathetic supply – miosis
• Radial fibres – cervical sympathetic nerves – mydriasis
BALANCE OF TONE BETWEEN THE 2 ANTAGONIST MUSCLES MAINTAIN THE NORMAL PUPIL SIZE
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• TONE OF SPHINCTER MUSCLE > TONE OF RADIAL MUSCLE (keeps the pupil slightly contracted )
• Pupils are equal normally on both sides unequal anisocoria
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note1. normally there is one pupil. More than 1 pupil
is called polycoria
2.Pupil location almost central,slightly nasal..eccentric pupil is called correctopia
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• Pupil size varies depending on the background illumination (2-3 mm normally)
• Diameter affects the type of image formed
Note the size,shape & contour of the pupil.then test for reflexes
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PUPILLARY REFLEXES
PUPILS PARTICIPATE IN SEVERAL REFLEXES
• LIGHT REFLEXES – DIRECT,INDIRECT
• NEAR REFLEX
• PSYCHOSENSORY REFLEX
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Keep in mind!!
• Illumination of examination room should be low
• Patient should look into the distance• Light used should be focussed & bright
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• DIRECT & INDIRECT When light is shone in one eye,both the pupils
constrict.. Constriction of pupil to which light is shone is
direct light reflex and that of other is consentual ( indirect ) light reflex.
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• Using a bright focussed light• In a dark room• Finer examination – slit lamp
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Swinging flashlight test
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• If both optic nerves are intact, both pupils will be tightly constricted
(direct’ magnitude = concensual)
If one optic nerve damaged,both pupils dilate on showing the light to the diseased eye.
on swinging back to normal side,both pupils constrict
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• The dilatation or escape that occurs is called MARCUS GUNN PUPIL or AFFERENT PUPILLARY DEFECT.
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NEAR REFLEX
OCCURS ON LOOKING AT A NEAR OBJECT. IT HAS 2 COMPONENTS : CONVERGENCE REFLEX (contraction of pupil on convergence) ACCOMODATION REFLEX (constriction of pupil on viewing a near target)
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Convergence reflex
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Accomodation reflex
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PSYCHOSENSORY REFLEX
Refers to the dilatation of pupil in response to sensory and psychic stimuli
Complex, mechanism still not elucidated
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• Light reflexes • Near reflex OF PUPIL• Psychosensory reflexes
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PUPILLARY PATHWAY
SHORT CILIARY NERVES
N.TO INFERIOR OBLIQUE
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Pupillary pathway
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LESIONS IN THE PUPILLARY PATHWAY
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OPTIC NERVE
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1.OPTIC NERVE
• Abolition of direct reflex on affected side & consentual on opposite side
amaurotic pupil
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MEDIAL CHIASMA
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• Medial chiasma
bitemporal hemianopic paralysis
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LATERAL CHIASMA
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lateral chiasma
binasal hemianopic paralysis
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OPTIC TRACT
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• OPTIC TRACT
CONTRALATERAL HEMIANOPIC PARALYSIS (WERNICKE PARALYSIS) NO LIGHT REFLEX WHEN LIGHT IS THROWN ON
TEMPORAL HALF OF RETINA OF AFFECTED SIDE & NASAL HALF OF OPPOSITE SIDE
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PROXIMAL PART OF OPTIC TRACT
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• LESION OF PROXIMAL PART OF OPTIC TRACT – NORMAL PUPILLARY REACTIONS
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IN THE REGION OF BRACHIUM &
TECTUM
CONTRALATERAL HEMIANOPIC PARALYSIS
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CENTRAL DECUSSATION
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• BILATERAL REFLEX PARALYSIS• INACTIVITY TO LIGHT REFLEX WITH
RETENTION OF NEAR REFLEX !!
ARGYLL ROBERTSON PUPIL
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ARGYLL ROBERTSON PUPIL
• Pupil slightly smaller in size• Near reflex present but Light reflex absent i.e
there is light near dissociation• Both pupils are involved ,dilate poorly with
mydraiatics• Hallmark of tertiary syphilis (neurosyphilis)
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B/W DECUSSATION & CONSTRICTOR
CENTRE – UNILATERAL ARP
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PARTIAL LESION
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• Ipsilateral abolition of direct reflex,with retention of indirect
• Retention of both contralaterally
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NUCLEAR /EXTENSIVE
SUPRANUCLEAR LESION
Ipsilateral absolute pupillary paralysis
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3RD NERVE
Ipsilateral absolute pupillary paralysis
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CILIARY GANGLION
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Lesion at ciliary ganglion
• Light reflex absent,retention of near reflex (very slow) and tonic
ADIE’S TONIC PUPIL
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Adie’s pupil
Affected pupil is larger Usually unilateral a/w absent knee jerk ( HOLMES ADIE SYN) young women
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• adies’s pupil constricts with weak pilocarpine (.125 %) while normal pupil does not
denervated iris sphincter is supersensitive to topical parasympathomimetics
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OTHER CONDITIONS AFFECTING PUPILS….
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Ophthalmoplegia interna
• d/t lesion in 3rd nerve nucleus• paralysis of both sphincter pupillae & ciliary
ms• Dilated,immobile pupils• Meningitis,encephalitis,cerebral syphilis,
trauma affecting 3rd nerve and ciliary ganglion etc
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Unilateral dilatation may result from irritation of cervical
symapthetic nerves(swollen lymph nodes,cervical rib,apical
pneumonia,meningitis affecting lower cervical &upper thoracic ventral roots..)
IRRITATIVE DILATATION EVENTUALLY LEAD TO CONSTRICTION FROM
SYMPATHETIC PARALYSIS
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When all sympathetic function on one side is lost,it result in
• miosis,• slight enophthalmos horner syndrome• ptosis • anhydrosis on affected side
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HORNER’S
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