ABNORMAL REACTIONS OF PUPIL Lamyaa Anwar AlGhafli 211523025
Aug 07, 2015
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