Page 919 - TNFlipTest

Toronto Notes 2019
Pupils
Ophthalmology OP29
Patient with Anisocoria
Relevant history and examination with specific attention to:
• History of ocular trauma
• Check old photographs (ptosis, ocular deviation, long standing anisocoria) • Use of topical medications
• Exposure to toxins and drugs
• Associated ocular and neurologic symptoms/signs
Which pupil is abnormal?
Examine pupils in light and dark
Anisocoria equal in light and dark
Brisk reaction to light
Anisocoria accentuated by darkness (small pupil abnormal)
Dilation lag Ptosis
Test with 10% cocaine
Anisocoria accentuated by light
(large pupil is abnormal)
Isolated Ptosis/Ophthalmoplegia Sluggish to light
Light near dissociation
Use of 0.1% pilocarpine Third nerve palsy
Small pupil does not dilate
Horner’s syndrome
Both pupils dilate symmetrically
Large pupil constricts
Large pupil does not constrict
Use of 0.1% pilocarpine
Minimal/no constriction
Pharmocologic anisocoria
Adie’s tonic pupil
Physiologic anisocoria Patient Must Fixate on Distant Target
Figure 21. Approach to anisocoria
Reproduced with permission from: Kedar S, Biousse V, Newman NJ. Approach to the patient with anisocoria. In: UpToDate, Rose, BD (editor), UpToDate, Waltham, MA, 2011. Copyright 2011 UpToDate, Inc. For more information visit www.uptodate.com.
Table 9. Summary of Conditions Causing Anisocoria
Features
ABNORMAL MIOTIC PUPIL (impaired pupillary dilation)
Site of Lesion
Midbrain Sympathetic system
Light and Accommodation
Poor in light; better to accommodation
Both brisk
Poor in light, better to accommodation
± fixed (acutely) at 7-9 mm
Fixed at 7-8 mm
Anisocoria
Greater in dark
Greater in light
Greater in light Greater in light
Mydriatics/Miotics
Dilates/Constricts Dilates/Constricts
Dilates/Constricts
Dilates/Constricts No effect
Effect of Pilocarpine
Constricts (hypersensitivity to dilute pilocarpine)
Constricts
Will not constrict
Argyll-Robertson Pupil
Horner’s Syndrome
Irregular, usually bilateral
Round, unilateral, ptosis, anhydrosis, pseudoenophthalmos
ABNORMAL MYDRIATIC PUPIL (impaired pupillary constriction)
Adie’s Tonic Pupil
CN III Palsy Mydriatic Pupil
Irregular, larger in bright light
Round
Round, uni- or bilateral
Ciliary ganglion
Superficial CN III Iris sphincter