review on pupils - neurological approach - by deepayan kar

8/12/2019 Review on Pupils - Neurological Approach - by Deepayan Kar

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Review on PupilsA Neuro-Optometric Viewpoint

Deepayan Kar et.al*

1stAugust, 2014

*1Supriyo Chatterjee DOS;2Debasis Dutta DO MS


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Financial DisclosuresNONEAcademic purposes only

Deepayan Kar 2014


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Discussion Outline

Basic facts

Pupillary Innervation: Pharmacokinetics

Intrinsic Muscles: Innervation Types

Light Reflex Pathway: Parasympathetic

Pupillo-Dilator Pathway: Sympathetic

Near Reflex: Triad Response

Anisocoria

Pupillary Reaction: Types

Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture

False RAPD: Causes

Pupillary Defects: Clinica

Horners Syndrome: Classic Triad Causes Features

Adies Tonic Pupil: Findings Diagnosis

Argyll-Robertson Pupil More Clinical Condition

Conclusion


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Discussion Outline

Basic facts






Anisocoria



False RAPD: Causes





Conclusion


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Pupil: Basic facts

Function of the pupil:Modifies amount of light entering the eye; increases

sensitivity of the eye

Increases depth of focus

Minimizes chromatic and spherical aberrations

Newborns and the elderly are miotic, withthe elderly having 1/3rd size of that of a 20

year old Pupils are mioticduring sleep, with blinking,

and with forced closure

larger pupil response foveal stimulation

Accomodation Convergence Pupillary

constriction


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Discussion Outline

Basic facts






Anisocoria



False RAPD: Causes





Conclusion


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Pupillary Innervation: Pharmacokin

imitate the effects of the parasympathetic nervous system (constrict)

Parasympathomimetics

imitate the effects of the active sympathetic nervous system (dilate)

Sympathomimetics

inhibit the action of the parasympathetic nervous system (dilate)

Parasympatholytics

inhibit the action of the sympathetic nervous system (constrict)

Sympatholytics


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Discussion Outline

Basic facts






Anisocoria



False RAPD: Causes




Argyll-Robertson Pupil

More Clinical Condition

Conclusion


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Intrinsic Muscles:Innervation


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Intrinsic Muscles:Innervation Ty

Types of

Innervation

Parasympathetic

Sphincterpupillae

Ciliary m.

Sympathetic

Dilator pupillae

IntrinsicMuscles


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Discussion Outline

Basic facts

Pupillary Innervation: Pharmacokinetics Intrinsic Muscles:

Innervation Types




Anisocoria



False RAPD: Causes






Conclusion


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Light Reflex Pathway: Parasympath

Afferent

Pathway

ganglion cell layer, through the optic nerve

chiasm:nasal fibers of each retina cross optic tract

pretectal nucleus

posterior commissure and terminate in the Edinger-Westphal nu

Efferent

Pathway

begins at the Edinger-Westphal nucleus oculomotor branch (CN III)

enters the orbitthrough the superior orbital fissure

ciliary ganglion

Sphincter pupillae (via short ciliary nerves)


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Light Reflex Pathway: Parasympath


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Light Reflex Pathway: In Action

Optic Nerve (II)

Optic Chiasm

Optic Tract

Pretectal Nucleus

Edinger-CNIII Nu

Ciliary G

SphinctSphincterp. (OS)


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Discussion Outline

Basic facts


Innervation Types




Anisocoria



False RAPD: Causes






Conclusion


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Pupillo-Dilator Pathway: Sympath

Significance: Horners syndrome (results from a lesion within the sympathetic pathway)


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Discussion Outline

Basic facts


Innervation Types




Anisocoria


Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture False RAPD: Causes






Conclusion


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Accommodation

Miosis

convergence

Initiated by the

to fixate a neaAfferent pathwa

to light reflex p

Efferent pathwpass to the occipital through the prestriatpremotor area of thefibres pass througradiata and internal coculomotor nucleus

Clinical significance Argyll-Robertson Pup

dissociation)

Parinaudssyndrome


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Near Reflex: Light-Near Dissociat

oabsence of a miotic reaction to light (both direct and co

with the preservation of a miotic reaction to near stim(accommodation-convergence)

Causes: syphilis (Argyll-Robertson), Adiespupil, Parinaudssyndrome, RAPD, physiolog

retinal disease, aberrant regeneration of CN 3, diabetes, myotonic dystrophy,alcoholism, herpes zoster ophthalmicus (HZO)

DDx: Abnormal Light and Near Response: Pharmacologic, trauma, CN 3 palsy


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Discussion Outline

Basic facts


Innervation Types




Anisocoria Pupillary Reaction: Types







Conclusion


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Anisocoria

asymmetric in size of pupils

Physiologic anisocoria commonand normal variant in up to 20% of the population variation should be no more than 1mm both eyes should react to light normally

Can be dangerous! if a manifestation of Horner's syndrome (e.g. carotid dissection) or from d

the third nerve (e.g. aneurysmal expansion)

Consider further workup such as imaging if anisocoria is suspected to be frpathologic process


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Discussion Outline

Basic facts


Innervation Types











Conclusion


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PupillaryLight Reflexes

Direct Consensual


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Discussion Outline

Basic facts


Innervation Types











Conclusion

Relative Afferent Pupillary Defe


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Relative Afferent Pupillary Defe(RAPD): Marcus-Gunn Pupil

Occurs in:

large retinal lesion asymmetric optic nerve disease

chiasm lesion

optic tract lesion (contralateral RAPD)

Swinging Flashlight Test

RAPD: Clinical


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RAPD: ClinicalPicture

large relative afferent pupildefect of the right eye OD

Normal direct+consensualreflex OU in unaffected eye

No direct/ consensual reflexOU in effected eye

Deepayan Kar 2014

h d


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Whydoes RAPD occur?

RAPD Negative OS RAPD Positi


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Yanoff, Myron, Jay S. Duker, andJames J. Augsburger. "The Pupils:Randy H. Kardon." Ophthalmology.

3rd ed. Vol. 1. Edinburgh: MosbyElsevier, 2009

Lowenstein O Loewenfeld IE In: Davs


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Lowenstein O, Loewenfeld IE. In: DavsThe eye, vol 3. New York: Academic Pre

Dark-adapted normal suflashes,b, of increasing into the right eye to produ

pupillary constriction. Ladecreases with intensity were recorded simultaneinfrared pupillography d

pupil tracing (solid line) tracing (broken line) mov

Reactions of the pupil to different intensities. At ththere was a short pupil lithe pupil dilated (escapestimulus. At the brighter contractions were larger sustained, also exhibiting(hippus).

P ill hi d t ti RA


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Pupillographic demonstration: RA

F l RAPD C


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False RAPD: Causes

amblyopia previously patched eye

tilted light source directed off the macula

What about Efferent Pupillary Defects (EPD)? CN III nerve palsy

internal ophthalmoplegia

Di i O tli


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Discussion Outline

Basic facts








Pupillary Defects: Clini

Horners Syndrome:

Classic Triad Causes Features



More Clinical Condition Conclusion

P ill D f t Cli i l C diti


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Pupillary Defects: Clinical Conditi

Horners syndrome

Adies Tonic Pupil

Argyll-Robertson pupils

Disc ssion O tline


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Discussion Outline

Basic facts









Horners Syndrome:

Classic Triad Causes Features




Horners Syndrome: Classic Tria


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Horner s Syndrome: Classic Tria

Loss of sympatheticinnervation causing the

clinical triad of:

Ptosis

(drooping eyelid)

Miosis

(pupillary constriction)

An

(decre(ipsilateral blepharoptosis)

Horner's Syndrome: Causes


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Horner s Syndrome: Causes

carotid artery dissection

pancoast tumors, nasopharyngial tumors

lymphoproliferative disorders

brachial plexus injury cavernous sinus thrombosis

fibromuscular dysplasia

Denervation

(sympathetic

CAD

Horners Syndrome:


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o e s Sy d o e:Features

Miosis Ptosis Anhydrosis

Site of lesion can be life threatening!

CAA: enlargement of the lumen of the carotid

artery demonstrated in the carotid angiogramDeepayan Kar 2014

Horners Syndrome:


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yFeatures

Miosis Ptosis Anhydrosis

Use pharmacologic testing!

MRI: bright signal in the wall of the

carotid artery resulting from blood

Carotid


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ArterialDissection

Discussion Outline


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Discussion Outline

Basic facts


Innervation Types




Anisocoria








Adies Tonic Pupil


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Adie s Tonic Pupil

Dilated, tonic pupil due to postganglionic parasympathetic pupillomotor da

90% women (2040 years of age)

80% unilateral

benign condition

Pathology: loss of ganglion cells in ciliary ganglion

degenerated axons in short ciliary nerves (affects sphincter mu

Denervation (parasympath

Adies Tonic Pupil: Findings


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Adie s Tonic Pupil: Findings

Initially, pupil is dilated, poorlyreactive and sluggish

Later becomes miotic; segmentalcontraction of pupil (vermiform

movements)

Light-near dissociation with slow(tonic) redilation after near stimulus

Adies Tonic Pupil: Diagnosis


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Adie s Tonic Pupil: Diagnosis

dilute pilocarpine (0.125%) ormecholyl 2.5%

will constrict the tonic pupilbut not normal pupil

false-positive test can occur in CN

3 palsy

Associations: Holmes-Adie syndrome described with

Adie's pupil and absent deep tendonreflexes, orthostatic hypotension

Unequal contraction from the 11 o'clock to 1

puckering of the iris st NS= junction of the no AS= atonic sphincter

Discussion Outline


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Discussion Outline

Basic facts


Innervation Types









Argyll-Robertson Pupi




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Argyll Robertson Pupil

bilateral small, irregular pupils

light-near dissociation absence of a miotic reaction to light (both direct and consensual)

with the preservation of a miotic reaction to near stimulus (accommodation-con

hallmark of tertiary neurosyphillis

Pupils will NOT constrict to light but they WILL constrict with accommodatio

Discussion Outline


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Discussion Outline

Basic facts


Innervation Types










More Clinical Conditio Conclusion

More Clinical Conditions


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More Clinical Conditions

Hutchinsons Pupil unilateral dilated, poorly reactive pupil in comatose patient

due to ipsilateral supratentorial mass causing displacement of hippoc(uncal herniation) entrapping CN 3

pupillomotor fibers travel in peripheral portion of nerve, suscearly damage from compression

ParinaudsSyndrome pupils become mid-dilated

light near dissociation of the pupils (DDx: ARP)

Discussion Outline


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Discussion Outline

Basic facts


Innervation Types











Conclusion


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Conclusion

Compare pupil size: if abnormal, look at the effect of chillumination

Look for an irregularity in the shape of the pupil

Assess the direct and consensual reaction to light

Look for a relative afferent pupillary defect RAPD

Conclusion


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Conclusion

Assess the near reaction/ reflex

Examine the patient for any associated features (abnormeye movements, asymmetry of lid position)

Consider pharmacological testing


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Thank YouDEE

deepa

review on pupils - neurological approach - by deepayan kar

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