Pupil abnormality Mohammad Pakravan MD

Associate Professor Labbafinejad Medical Center

Pupils

Are a round and equal holes in the middle of iris which adjust light entrance into the eye.

Sphincter by 3th N, dilators by sympathetic3 to 6 mm in normal light.They are larger in children than eldery.Miosis is pupil diameter less than 3 mm.

- cholinergics - morphine- sleeping

Mydriasis when pupil diameter more than 6mm

Dyscoria Abnormalities of pupil shapeCorectopia PolycoriaIridoplegia in response to light and near

effortIris bombe

Anisocoria physiologic less than 0.5mm

- more prevalent in elderlySphincter rupturePS in uveitisAACG3th n palsy

- compressive- microvascular

Horner syndrome

Horner’s syndromeMiosis, ptosis, anhydrosisAny problem in sympathetic pathway

- boroncogenic carsinoma of lung apex (pancost’s tumor)- neck trauma- syrengomyelia - aorta or carotid artery aneurysm- neck spinal tumor- idiopathic congenital (heterochromia iridis)- brain stem vascular abnormality

Pharmacologic tests for anisocoriaCocaine 4- 10% prevent reuptake of

neurepinephrine and induce mydriasis in normal eye but not in Horner’s syndrome.

Hydroxyamphetamine 1% releases neuradrenaline in synapsis and is effective in preganglionic type but not effective in postsynaptic type.

Sympathetic pathwayBrain stem > medulla > C8, T1 , T2 > apex of

lung > aorta > superior cervical sympathetic chain > internal carotid > muller muscles and dilator muscle of pupil

Parasympathetic pathwayPupillomotor nerves > brain stem

sublentiform nucleus > edinger westphal nucleuses> 3th N nasocilliary > ciliary ganglion > sphincter muscles of iris

TAPD (total afferent pupillary defect); amarotic pupil The eye in affected side is totally blind.

RAPD (relative afferent pupillary defect); Marcus Gunn PupilIn retinal or optic nerve diseaseNot seen in cataractIs graded from 0 to 4+

Argyll-Robertson pupil; Tabes dorsalisSmall, irregular, unequal pupilsUsually bilateralResponse to light is small or negative.Remained response to accommodationUsually bilateralPupils dilate poorly

Tonic pupil; Holmes AdieInnervations of Pupillary sphincter and or

ciliary muscles are involved80% unilateralBenign and more prevalent in femalesInvolved pupil is dilated and irregularPoor response to lightRemained response to nearMaybe accompanied by deep tendon reflex

involvement (Adie’s syndrome)Slow accomodation