ABNORMAL REACTIONS OF PUPIL

Lamyaa Anwar AlGhafli211523025

OBJECTIVES

1- Pupil.

2- Normal Pupil Reactions.

3- Anisocoria Vs Isocoria.

4- abnormally shaped pupil.

5- Abnormalities of pupil.

PUPIL

Hole located in the center of the iris of the

eye that allows light to strike the retina.

Control the amount of light entering the eye

via contraction (miosis) and dilation (mydriasis)

under the autonomic nervous system.

Normal size of pupil ranges from 1-8 mm.

NORMAL PUPIL REACTIONSMydriasis

“pupil dilate”

sympathetic activation

parasympathetic

relaxation

Miosis “pupil

constrict”

parasympathetic

activation

sympathetic relaxation

NORMAL PUPIL REACTIONS

Direct light response

Swinging flashlight test

light respon

se Accommodation

near respon

se

NORMAL PUPIL REACTIONS

ABNORMAL PUPILS

ABNORMALLY SHAPED PUPIL

Features:

Deviation from round pupil.

Differential diagnosis:

Congenital defects (eg, coloboma), iris inflammation or trauma.

A fixed oval pupil, severe pain, red eye, cloudy cornea and systemic malaise acute angle closure glaucoma.

ABNORMALITIES OF PUPIL

They include ocular disorders and

neurologic disorders.

Abnormalities of pupil

Isocoria with Normal Pupil

Size

Relative Afferent Pupillary Defect

Bilateral Afferent

Pupillary Defect

Anisocoria with Dilated Pupil in

the Affected Eye

Complete Oculomotor

Palsy

Tonic Pupil

Iris Defects

Following Eyedrop

Application

Anisocoria with a Constricted Pupil in the

Affected Eye

Horner Syndrome

Following Eyedrop

Application

Isocoria with Constricted

Pupils

Argyll Robertson Pupil

Bilateral Pupillary

Constriction due to

Pharmacologic Agents

Toxic Bilateral Pupillary

Constriction

Inflammatory Bilateral Pupillary

Constriction

Isocoria with Dilated Pupils

Parinaud Oculoglandular

Syndrome

Intoxication

Disorders

1-ISOCORIA WITH NORMAL PUPIL SIZEA- Relative Afferent Pupillary Defect

Causes: Unilateral sensory disorder such as retinal detachment, neuritis of the optic nerve, atrophy of the optic nerve, or retinal vascular occlusion.

B- Bilateral Afferent Pupillary Defect

Causes: Bilateral sensory disorder such as maculopathy or atrophy of the optic nerve.

2- ANISOCORIA WITH DILATED PUPIL IN THE AFFECTED EYEA- Complete Oculomotor Palsy

Causes:

1- Processes in the base of the skull such as tumors, aneurysms, inflammation or bleeding.

2- Processes in the area of the superior orbital fissure or apex of the orbit.

Diagnostic considerations:

1- Light reflexes: No constriction in the affected eye.

2- Near reflex: absent.

3- Impaired motility and double vision.

2- ANISOCORIA WITH DILATED PUPIL INTHE AFFECTED EYEB- Tonic Pupil

Causes:

Postganglionic damage to the parasympathetic

pathway, that occurs with DM, alcoholism,

viral infection and trauma.

Diagnostic considerations:

2- ANISOCORIA WITH DILATED PUPIL INTHE AFFECTED EYEC- Iris Defects

Causes:

Trauma, Secondary to acute angle closure glaucoma, Synechiae (post-iritis or postoperative)

D- Following Eyedrop Application

By asymmetrical supranuclear inhibition of the Edinger–Westphal nucleus.

3- ANISOCORIA WITH A CONSTRICTED PUPIL IN THE AFFECTED EYEA- Horner Syndrome

Causes: Damage to the sympathetic pathway.

1- Central (first neuron):

Tumors, Encephalitis

2- Peripheral (second neuron):

Same the central, Trauma ,Rhinopharyngeal tumors, Goiter, Aneurysm.

3- Peripheral in the strict sense (third neuron):

Vascular processes, Internal carotid aneurysm.

3- ANISOCORIA WITH A CONSTRICTED PUPIL IN THE AFFECTED EYE Clinical picture:

SAMPLE

3- ANISOCORIA WITH A CONSTRICTED PUPIL IN THE AFFECTED EYEPeripheral Horner syndrome.

On the affected side, there is slight mydriasis

On the unaffected side, there is significant mydriasis.

Central Horner syndrome.

On both, the pupils are dilated.

B- Following Eyedrop Application

Unilateral Administration of a Miotic as in Glaucoma Therapy.

4- ISOCORIA WITH CONSTRICTED PUPILSA- Argyll Robertson Pupil:

Causes:

The precise location of the lesion is not known.

Diagnostic considerations:

1- The pupil is not roundand and constriction is not

always symmetrical.

2- There is no reaction to darkness or pharmacologic stimuli.

4- ISOCORIA WITH CONSTRICTED PUPILSB- Bilateral Pupillary Constriction due to Pharmacologic Agents

Causes:

Morphine, Deep general anesthesia.

C- Toxic Bilateral Pupillary Constriction

Causes:

mushroom poisoning.

D- Inflammatory Bilateral Pupillary Constriction

Causes:

Encephalitis, Meningitis

5- ISOCORIA WITH DILATED PUPILSA- Parinaud Oculoglandular Syndrome

Causes:

Tumors such as pineal gland tumors.

Diagnostic considerations:

1- Fixed dilated pupils.

2- Normal near reflex.

3- Limited upward gaze and retraction nystagmus.

5- ISOCORIA WITH DILATED PUPILSB- Intoxication

Causes:

Atropine, spasmolytic agents, anti-Parkinson agents, antidepressants, botulism, carbon monoxide and cocaine.

C- Disorders

Causes:

Migraine, Schizophrenia, Hyperthyredosis, Hysteria, Epileptic seizure and Coma.

HTTP://WWW.IMEDICALAPPS.COM/

iRis interactive

SUMMARY

1- Isocoria: the problem in afferent pathway

Anisocoria: the problem in efferent pathway

2- Direct light response, Swinging flashlight test and accommodation test are important tests to assess the pupil.

3- Disorders cause isocoria: Argyll Robertson Pupil and Parinaud Oculoglandular Syndrome.

Disorders cause anisocoria: Complete Oculomotor Palsy, Tonic Pupil and Horner Syndrome.

RESOURCES

1- Ophthalmology A Pocket Textbook Atlas, Gerhard K. Lang, MD, Oskar Gareis, Gabriele E. Lang, Doris Recker, Peter Wagner, Second edition

2- Lecture Notes On Ophthalmology, BRUCE JAMES, CHRIS CHEW, ANTHONY BRON, Ninth Edition

3- http://www.patient.co.uk/doctor/pupillary-abnormalities