examination of pupil by pushkar dhir

• “For she had eyes and chose me.” ― William Shakespeare, Othello

• Whenever v see someone we like, our pupils grow larger. It's almost as if our eyes are trying to see as much of this person as possible. <3 <3

• This is an involuntary and uncontrollable physiological response.

• Thus, you can often tell if a men/woman is attracted to you by observing his/her pupils, and whether they expand or contract, or maybe do nothing.

• (Note: contracting would not be good for you... as it likely means he/she not only is not attracted to you, but actively dislikes you. Sorry about that.)

So R They Interested in you or me???????

EXAMINATION OF PUPIL

Presenter:-Dr. Pushkar Moderator:-Dr. Varshini

ANATOMY OF PUPIL An aperture present in the centre of the iris. Size of the pupil determines the amount of light that enters the eye. Pupil size controlled by the dilator & sphincter muscles of the iris.

SIZE ,SHAPE ,LOCATION

Normally there is one pupil in each eye.

Rarely, there may be more than one pupil. This congenital anomaly is called POLYCORIA

Normally, pupil is placed almost in the centre (slightly nasal) of the iris.

Rarely it may be congenitally eccentric ( CORECTOPIA )

• Normal pupil size varies from 2.5-4mm depending upon the illumination.

- Miotic pupils are less than 2mm

- Mydriatic pupils are greater than 7mm.

• The size depends on : Age : Smaller in infants and elderly Sleep : Smaller due to parasympathetic dominance Refraction : Hyperopes have smaller pupils Colour : Darker iris have smaller pupils.

• Diameter of the pupil size should be estimated in light, using either a normal room light or a hand held transilluminator.

• Should be assessed in darkness using the dimmest possible room light & then during near stimulation using an accomodative target to achieve maximum constriction of pupils.

• Isocoria : Normally the two pupils are equal in size. A slight (one-tenth of a millimeter) anisocoria is present in a significant percentage of normal pupil.

• Anisocoria : Difference in pupillary diameter of 2 eyes of the same individual by 0.3mm or more

The pupils are controlled by two muscles of ectodermal origin- sphincter pupillae & dilator pupillae

The size of pupil is essentially the result of their opposing forces

When maximally contracted the diameter may be <1mm, when maximally dilated it may be>9mm

NEURAL PATHWAYS

NEUROLOGICAL

AFFERENT PATHWAY

1.For Light Reflex2.For Near Reflex

3.For Accomodation Reflex

EFFERENT PATHWAY

1.For Constriction 2.For Dilatation

VISUAL PATHWAY

VISUAL PATHWAY

VISUAL PATHWAY

Retinal Ganglion Layer

Optic Nerve

Optic Chiasma

Optic Tract

Pretectal Nucles in Mid Brain

INTERNUNCIAL FIBRES GOES TO BOTH EWN

Edinger Westphal Nucleus

Pre-ganglionic Fibres originates &via 3rd nerve ;piercing IO

Ciliary Ganglion

Post Ganglionic Fibres

Sphincter Pupillae

LIGHT REFLEX

Retinal Ganglion Layer

Optic Nerve

Optic Chiasma

Optic Tract

Pretectal Nucles in Mid Brain

INTERNUNCIAL FIBRES GOES TO BOTH EWN

Edinger Westphal Nucleus

Pre-ganglionic Fibres originates &via 3rd nerve ;piercing IO

Ciliary Ganglion

Post Ganglionic Fibres

Sphincter Pupillae

Lesion in Optic Tract = Marcus Gunn Pupil & Wernicke’s Hemianopic Pupil

Lesion in Internuncial Fibre = Argyl Robertson Pupil

Lesion in Ciliary Ganglion = Adie’s Pupil

Cortical: dilated pupils during epileptic seizures

Spinal-reticular:states of arousal,excitement

Sleep,coma:inhibitory influences decline and pupils are miotic

INHIBIT

The peristriate cortex (area 19) at the upper end of the calcarine fissure may be the origin It is activated when gaze is changed from a distant to a near target

It comprises accommodation,convergence and miosisThe pathway is more ventrally located than the pretectal afferent limb of the light reflex

The final pathway is the oculomotor nerve,ciliary ganglion and the short posterior ciliary nervesRatio of ciliary ganglion cells vs. cells to iris sphincter is approx. 30:1

ABNORMAL PUPILLARY REFLEXES

Argyll Robertson Pupil ( ARP )

• Bilateral, miotic pupil with irregular margins and are asymmetrical.

Response to light and near reflex : Light reflex is absent & accommodation is retained. The

lesion is at the pretectal area. Commonly seen in tertiary neurosyphilis especially in Tabes.

Other causes include : - Diabetes - Wernicke’s encephalopathy- Encephalitis,

Small pupils < 2 mm

Often irregular

Near response is brisk and normal

Light reflex is absent

Iris atrophy is frequent with iris showing transillumination defects and poor dilatation with mydriatics

Visual acuity is usually normal

TOTAL AFFERENT PATHWAY DEFECT (TAPD) OR AMAUROTIC PUPIL

RELATIVE AFFERENT PATHWAY DEFECT (RAPD) OR

MARCUS GUNN PUPIL

Caused by a complete optic nerve or retinal lesion leading to total blindness on the affected side.

Characterized by the following:-The involved eye is completely blind (i.e no light perception)

Absence of direct light reflex on the affected side and absence of consenual light reflex on the normal side.

When the normal eye is stimulated, both pupils react normally.

In diffuse illumination, both pupils are equal in size.

Near reflex is normal in both eyes.

It is the paradoxical response of a pupil to light in the presence of a relative afferent pathway defect (RAPD).

Caused by an incomplete optic nerve lesion or a severe retinal disease.

It is best tested by ‘swinging flashlight test’

Animation

Causes Of RAPD Unilateral optic neuropathies ,if a condition is bilaterally symmetrical, there will not be an

RAPD.

Optic neuritis - Even very mild optic neuritis with a minimal loss of vision can lead to a very strong RAPD.

Ischemic optic neuropathies - These include arteritic (Giant Cell Arteritis) and non-arteritic causes.

Glaucoma

Traumatic optic neuropathy Optic nerve tumor - This is a rare cause, and includes primary tumors of the optic nerve

(glioma, meningioma) or tumors compressing the optic nerve (sphenoid wing meningioma, pituitary lesions, etc.

Orbital disease - This could include compressive damage to the optic nerve from thyroid related orbitopathy.

Radiation optic nerve damage

.

Methods To Grade RAPD

1. Swinging Light Reflex

2. Kestenbaum’s number – pupil gauge/ neutral density filter.

3. Infrared videography

4. Computerized pupillometry.

GRADING OF RAPD

Grades Acc. To Swinging Light Reflex

• Grade 1:  A weak initial pupillary constriction followed by greater redilation

• Grade 2:  An initial pupillary stall followed by greater redilation 

• Grade 3:  An immediate pupillary dilation

• Grade 4:  immediate pupillary dilatation with pupillary constriction.

• Grade 5: immediate pupillary constriction with no dilatation.

Grade Acc. To Neutral Filter Density Filter

• Neutral density filters come in densities of 0.3, 0.6, 0.9 and 1.2 log units, and

• higher densities can be obtained by combining filter.

• Densityof the RAPD is the density of the filter required to neutralize it.

• Grade I, 0.3 to 0.6 log;• Grade II, 0.45 to 1.2 log; • GradeIII, 0.75 to 1.5 log; • Grade IV, 1.5 to 2.7 log; • Grade V, too dense to measure.

CONDITION WHICH WILL NOT CAUSE RAPD

• Refractive Error (even if extreme) except Amblyopia

• Media Opacity (a bright enough light will indicate NO RAPD) – Cataract (even if completely opaque)– Corneal scar– Hyphema– Vitreous hemorrhage

• Strabismus

• Conditions with an Efferent Pupillary Defect – Third Cranial Nerve Palsy– Adie's Pupil– Horner's Syndrome

• Conditions which are typically bilaterally symmetrical will not show an RAPD: – Bilateral retinitis pigmentosa– Bilateral nutritional or metabolic

optic neuropathies

• Mild retinal problems, including: – Mild background diabetic

retinopathy– Central serous choroidopathy– Non-ischemic vein occlusions– Mild macular degeneration

EFFERANT PUPILLARY

DEFECTS

Efferent Pupillary Defect (Fixed Dilated Pupil)

I Midbrain damage

II. Damage to the IIIrd nerve

(from interpeduncular fossa to ciliary

ganglion)

1.Basal aneurysms2.Supratentorial space

occupying masses3.Basal granulomatous

meningitis4.Ischemic oculomotor palsy

5.Parasellar tumor

III. Damage to the ciliary

ganglion or short ciliary

nerves

1.Local Tonic Pupil-viral ciliary

ganglionitis -

choroidal trauma-blunt

trauma to the globe

2.ADIE’S SYNDRO

ME

Damage to IRIS

1.Degenerative or inflammatory diseases of the iris

2.Posterior synechiae

3.Acute rise of IOP (hypoxia of sphincter)

4. Traumatic iridoplegia

**Horner Syndrome**

Hutchinson’s Pupil• Hutchinson's pupil is a clinical sign in which the pupil

on the side of an intracranial mass lesion is dilated and unreactive to light, due to compression of the oculomotor nerve on that side. The sign is named after Sir Jonathan Hutchinson.

• Dilated pupils which occur in cerebral injury or haemorrhage,cerebral abcees and oedema.

• Herniation of temporal lobe into the tentorial hiatus.• 3 stages:- Intial stage of miosis due to irritation of I/L 3rd nerve. Dilation of I/L pupil which still react to light & convergence though the patient is

drowsy. True H.P is dilated with loss of all the reflexes.

• +/- Paresis of EOM supplied by 3rd CN.

ADIE’s Pupil It is usually unilateral (in 80%)

Affects healthy young women >> men.

It may be assoc. with absent knee jerk. The affected pupil is large and irregular

(anisocoria)

The light reflex is absent or slow.

Near reflex is slow and tonic.

Accommodative paresis.

There may be assoc. mild regional impairment of corneal sensations

Retinal Ganglion Layer

Optic Nerve

Optic Chiasma

Optic Tract

Pretectal Nucles in Mid Brain

INTERNUNCIAL FIBRES GOES TO BOTH EWN

Edwinger Wespar Nucleus

Pre-ganglionic Fibres originates &via 3rd nerve ;piercing IO

Ciliary Ganglion

Post Ganglionic Fibres

Sphincter Pupillae

Lesion in Cilliary Ganglion = Adie’s Pupil

ADIE’s Pupil

Pharmacological testing helps in the diagnosis of Adie’s tonic pupil.

In 80-90% of patients with Adie’s tonic pupil, 0.125% pilocarpine or 2.5% methacholine causes denervation supersensitivity. The concentration is too weak to cause constriction of the normal pupil.

Method to do Pilocarpine test.

• 0.125% pilocarpine (prepared by diluting one part 1% pilocarpine with 7 parts balanced salt solution)– Patient is fixating at a distance to prevent near accommodative reflex. 

Measure the pupil size of each eye.– Instill a drop of 0.125 pilocarpine ophthalmic solution in each eye, and

recheck the pupils in 10-15 minutes. – A positive test result – The tonic pupil constricts significantly more than

the contralateral pupil

HORNER’S SYNDROME( OCULOSYMPATHETIC PARESIS )

CENTRAL

LESION : hypothalamus to C8-T2

CAUSES : brainstem & spinal

cord/ vascular/demyelinating/tumors/syringomye

lia

PREGANGLIONIC

LESION : C8-T2 to superior cervical

ganglion

CAUSES: pancoast tumour/carotid and aortic aneurysm &

dissection/neck lesions- glands,trauma

& post surgical

POSTGANGLIONIC

LESION :superior cervical ganglion to

ICA to cavernous sinus to V1

CAUSES :ICA dissection, cavernous

sinus mass, nasopharyngeal

tumor, otitis media, cluster headache

Cause of Lesion:-Brainstem & spinal cord/vascular/demyelinating/tumors/syringomyelia

LESION : C8-T2 to superior cervical ganglionpancoast tumour/carotid and aortic aneurysm & dissection/neck lesions- glands,trauma & post surgical

LESION :superior cervical ganglion to ICA to cavernous sinus to VIICA dissection, cavernous sinus mass, nasopharyngeal tumor, otitis media, cluster headache

1. Ptosis:- Superior Tarsel muscle component of LPS supplied by occulomotor muscle.

2. Dilator Pupillae

3. Orbitalis:- Helps in protusion of eye ball

4. Sweat Glands on face

5. Sympathetic Supply of muscle of Blood vessels.( cause of flushing)

6. Newborn iris is always blue.

Sympathetic fibres help deposit melanin in 2 years after birth

How To Reach Diagnosis

References

• http://www.cehjournal.org/article/how-to-test-for-a-relative-afferent-pupillary-defect-rapd/

• http://www.turner-white.com/pdf/hp_jan99_pupil.pdf• http

://content.lib.utah.edu:81/cgi-bin/showfile.exe?CISOROOT=/ehsl-nam&CISOPTR=3881&filename=3829.pdf

• http://www.richmondeye.com/clinical-content-the-relative-afferent-pupillary-defect/

• http://www.nature.com/eye/journal/v9/n5/full/eye1995151a.html

• http://www.turner-white.com/pdf/hp_jan99_pupil.pdf

• For feedback & brickbats plz mail at• ykush@yahoo.co.in./drdhir2014@gmail.com

EVALUATION OF A PATIENT WITH ANISOCORIA

Retinal Ganglion Layer

Optic Nerve

Optic Chiasma

Optic Tract

Pretectal Nucles in Mid Brain

INTERNUNCIAL FIBRES GOES TO BOTH EWN

Edwinger Wespar Nucleus

Pre-ganglionic Fibres originates &via 3rd nerve ;piercing IO

Ciliary Ganglion

Post Ganglionic Fibres

Sphincter Pupillae

Dorsal &Lateral Geniculate Body

Optic Radiation / Geniculo – calcrine

tract

Visual Cortex

Dorsal -Lateral Geniculate Body in Thalamus

Optic Radiation/Geniculo calcrine tract

Visual Cortex (Stria & Parastriae Cortex)

Pontine centre of Both Sides

Edinger Westpal nucleus

To Accesory Ciliary Ganglion