the the pupillarypupillary light reflex light reflex

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AnisocoriaAnisocoria ~ ~ Now What?Now What?

Richard Mangan, OD, FAAORichard Mangan, OD, FAAOEye Center of RichmondEye Center of Richmond

Adjunct Faculty, IU School of Adjunct Faculty, IU School of OptometryOptometry

The The PupillaryPupillary Light Reflex Light Reflex Pathway: Afferent & EfferentPathway: Afferent & Efferent

Review of Anatomy

Iris sphincterIris dilatorIris dilatorParasympathetic pathwaySympathetic pathway

Parasympathetic Pathway

Light stimulates the retina then impulse travels with the ganglion cells through the chiasm into the optic tracts. 80% go p gto the LGN , 20% to the pretectal nuclei.They then hemidecussate and terminate at the EW nucleus

Parasympathetic PathwayFour neuron arc

Retina to the pretectal nucleus in the midbrain (1)Pretectal nucleus to the EW nucleus (2)EW nucleus to the ciliary ganglion (3)Ciliary ganglion to the iris sphincter with short ciliary nerves (4)

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Points of Interest

Within the second order neuron there are 30 near response fibers for every light response fiber. This allows for light g p g- near dissociation.The third order neuron runs with cranial nerve III from the brain stem to the ciliary ganglion. Superficially located prior to the cavernous sinus.

Sympathetic PathwaySympathetic Pathway

Three Neuron ArcThree Neuron Arc

Posterior hypothalamus Posterior hypothalamus to to ciliospinalciliospinal center of center of Budge (C8Budge (C8--T2)T2)CSCB to Sup. Cervical CSCB to Sup. Cervical Ganglion in the neckGanglion in the neckSCG to the dilator SCG to the dilator musclemuscle

Pupil Examination Pupil Examination BasicsBasics

Pupil Examination…Pupil Examination………Be SystematicBe Systematic

What are the BCVA’s? …And are the acuities What are the BCVA’s? …And are the acuities equal either corrected or with pinhole?equal either corrected or with pinhole?Are the patients pupils equal in size in bright Are the patients pupils equal in size in bright and dim illumination?and dim illumination?and dim illumination?and dim illumination?If not, is the anisocoria > in dim or bright If not, is the anisocoria > in dim or bright illumination?illumination?Is the near accommodative reflex present and Is the near accommodative reflex present and equal in both eyes?equal in both eyes?Are the accommodative amps = OU?Are the accommodative amps = OU?

Pupil Examination (Cont.)Pupil Examination (Cont.)

If the pupils are equal in size, is the If the pupils are equal in size, is the direct light reflex equally strong in both direct light reflex equally strong in both eyes?eyes?yyIs the consensual light reflex equally Is the consensual light reflex equally strong in both eyes?strong in both eyes?

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APD VIDEOAPD VIDEO

True or False?True or False?

A Cataract can cause and APD?A Cataract can cause and APD?

FALSE If you are finding an APDFALSE If you are finding an APDFALSE…If you are finding an APD, FALSE…If you are finding an APD, check your illumination source first.check your illumination source first.If you still have a + APD, need to find If you still have a + APD, need to find other cause.other cause.

YES or NO?YES or NO?

Is it possible to have optic nerve Is it possible to have optic nerve disease and NOT have an APD?disease and NOT have an APD?

YES…if the disease is bilateral & EQUAL YES…if the disease is bilateral & EQUAL in BOTH eyes (I.e., toxic optic in BOTH eyes (I.e., toxic optic neuropathy)neuropathy)


Macular Degeneration can cause an Macular Degeneration can cause an APD?APD?

TRUE…If the Macular Degeneration is TRUE…If the Macular Degeneration is unilateral & severe enough (Va +/unilateral & severe enough (Va +/--20/400)20/400)


Visual Acuity does not necessarily Visual Acuity does not necessarily correlate with an RAPD?correlate with an RAPD?

TRUE…a person with endTRUE…a person with end--stage stage glaucoma can have an APD with good glaucoma can have an APD with good central acuity.central acuity.

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Identifying & Recording: Identifying & Recording: Exam Clinical PearlsExam Clinical Pearls

Ø PERRLAØ PERRLABIO > BIO > Transilluminator > Transilluminator > PenlightPenlightNeutral Density Neutral Density FiltersFiltersFat ScanFat Scan

Physiological AnisocoriaPhysiological Anisocoria

Physiological Physiological AnisocoriaAnisocoria Physiologic AnisocoriaPhysiologic Anisocoria

AnisocoriaAnisocoria of < 1mm (to 2mm)of < 1mm (to 2mm)20% of the US Population has Simple or 20% of the US Population has Simple or PhysiologicalPhysiological AnisocoriaAnisocoriaPhysiological Physiological AnisocoriaAnisocoria..The degree of The degree of anisocoriaanisocoria can vary from can vary from day to day and even switch sides.day to day and even switch sides.Unequal Unequal supranuclearsupranuclear inhibition in EW inhibition in EW nucleus. Fairly consistent across light nucleus. Fairly consistent across light levelslevels

Which is the Abnormal Pupil?Which is the Abnormal Pupil?

The pupil that reacts sluggishly to lightThe pupil that reacts sluggishly to light

If Aniso > in Bright => Larger PupilIf Aniso > in Bright => Larger PupilIf Aniso > in Bright => Larger PupilIf Aniso > in Bright => Larger PupilParasympathetic DenervationParasympathetic Denervation

If Aniso > in Dim => Smaller PupilIf Aniso > in Dim => Smaller PupilAbnormal Sympathetic InnervationAbnormal Sympathetic Innervation

DDX of AnisocoriaDDX of Anisocoria

PhysiologicalPhysiologicalAdiesAdies TonicTonicThird N. PalsyThird N. Palsy

PharmacologicalPharmacologicalAngleAngle--ClosureClosureTraumaTraumayy

Horner’sHorner’sIritisIritisArgyllArgyll--Robertson Robertson

Congenital Congenital Malformation / Malformation / ColobomaColobomaBEPM (Benign BEPM (Benign Episodic Episodic PupillaryPupillaryMydriasisMydriasis

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Anisocoria: Case HistoryAnisocoria: Case History Anisocoria: Case HistoryAnisocoria: Case History

Temporal Aspects?Temporal Aspects?Eye Pain?Eye Pain?Decreased VA?Decreased VA?

Diplopia?Diplopia?Hx of Trauma?Hx of Trauma?Drops or Ung’s?Drops or Ung’s?

Arm, Chest, Head, Arm, Chest, Head, or Neck Pain?or Neck Pain?Nuchal Rigidity?Nuchal Rigidity?Hx of Stroke, Hx of Stroke, Cancer, or SurgeryCancer, or Surgery

Current Medications Current Medications (including OTC’s)?(including OTC’s)?STD’s, Shingles, MS, STD’s, Shingles, MS, Thyroid Disease, Thyroid Disease, Diabetes?Diabetes?Alcohol Usage?Alcohol Usage?

Anisocoria: Exam TechniquesAnisocoria: Exam Techniques Anisocoria: Exam TechniquesAnisocoria: Exam Techniques

VA’sVA’sExternalExternal

PtosisPtosis

Pupillary Pupillary Assessment:Assessment:

Iris ColorIris Color

AnyhdrosisAnyhdrosis

EOM’sEOM’sColor VA, Red Color VA, Red DesaturationDesaturationSLE & TonometrySLE & Tonometry

Pupil Size(s) & ShapePupil Size(s) & ShapeReactivityReactivityDilation LagDilation LagNear ResponseNear ResponseVermiform ChangesVermiform Changes

VF Testing & DFEVF Testing & DFE

Anisocoria: Need to RuleAnisocoria: Need to Rule--out!out!

Larger Pupil is ABNLarger Pupil is ABNAdie’s Tonic PupilAdie’s Tonic PupilCompressive III N.Compressive III N.

Smaller is ABNSmaller is ABNHorner’s SyndromeHorner’s SyndromeArgyllArgyll--RobertsonRobertson

PharmacologicalPharmacological PharmacologicalPharmacological

Pharmacological Pharmacological AnisocoriaAnisocoria

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PharmacologyTopical drugs ( Visine )Systemic drugs. Heroin , morphine , codeine lead to miosis. Dramamine , cocaine , levodopa , and antihistamines lead to mydriasis. Belladona and jimsonjimsonAngel’s Trumpet (Datura)Preparation H!!!!!!! (2.5% phenyl)Scopolomine motion sickness patchesFlea / tick control products1% pilocarpine test. Will constrict a compressive or tonic pupil but not a pharmacological one

PharmacologyPharmacologyFlea and tick sprays / Flea and tick sprays / collars / powderscollars / powders

Permethrin: found in Permethrin: found in some sprays. Has some sprays. Has sympathetic effects sympathetic effects (dilation, normal near (dilation, normal near i i )i i )

Some cause mydriasis, Some cause mydriasis, some cause miosis!some cause miosis!

vision)vision)Anticholinesterase Anticholinesterase products found in products found in collars, powders, and collars, powders, and foggers: heightened foggers: heightened parasympathetic effect parasympathetic effect (miosis, accom. spasm)(miosis, accom. spasm)

Adie’s Tonic PupilAdie’s Tonic Pupil Adie’s Tonic PupilAdie’s Tonic Pupil

StatsStatsFemales 3:1Females 3:1Age: 20Age: 20--4040

Key FindingsKey FindingsDilated pupil with Dilated pupil with poor to absent direct poor to absent direct response.response.

80% Unilateral 80% Unilateral InitiallyInitiallyBecomes bilateral at Becomes bilateral at rate of 1rate of 1--4% / year4% / yearEtiologyEtiology

Idiopathic vs. ViralIdiopathic vs. Viral

ppTonic near responsesTonic near responsesReduced Reduced AccomAccomAmpsAmpsLook for segmental Look for segmental palsy of Iris palsy of Iris sphincter musclesphincter muscle

Adie’s Tonic PupilAdie’s Tonic PupilNormal Room Normal Room IlluminationIllumination

Poor Direct ResponsePoor Direct ResponseFair to Good Fair to Good ConcensualConcensual

(+) Near Response (+) Near Response After Prolonged EffortAfter Prolonged Effort

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Segmental Palsy VideoSegmental Palsy Video

Adie’s Tonic Pupil: Adie’s Tonic Pupil: Additional TestingAdditional Testing

Dilute (0.125%) Dilute (0.125%) PilocarpinePilocarpineDenervationDenervation SupersensitivitySupersensitivityParasympathetic defect occursParasympathetic defect occurs AFTERAFTER thetheParasympathetic defect occurs Parasympathetic defect occurs AFTERAFTER the the fibers leave the fibers leave the CiliaryCiliary Ganglion.Ganglion.Exaggerated Exaggerated pupillarypupillary constriction in the constriction in the Tonic pupil with little to no constriction of Tonic pupil with little to no constriction of normal pupil.normal pupil.

DiminshedDiminshed Deep Tendon Reflexes = Deep Tendon Reflexes = HolmesHolmes--AdiesAdies SyndromeSyndrome

Adie’s tonic pupil (OD)Adie’s tonic pupil (OD)

Tonic Pupil with & w/o Tonic Pupil with & w/o PiloPilo 0.12% 0.12%

Image from http://www.atlasophthalmology.com/atlas/photo.jsf?node=5831&locale=en

AdiesAdies Clinical PearlsClinical PearlsWith a higher concentration of 1% With a higher concentration of 1% pilocarpinepilocarpine, even third, even third--nerve nerve palsy related pupil will constrict. palsy related pupil will constrict. PharmPharm dilation likely will not.dilation likely will not.Most cases of the tonic pupil are idiopathic or caused by Most cases of the tonic pupil are idiopathic or caused by trauma. trauma. An acute tonic pupil in patients over 60 years of age warrants An acute tonic pupil in patients over 60 years of age warrants an erythrocyte sedimentation rate to rule out giant cell an erythrocyte sedimentation rate to rule out giant cell arteritisarteritis..Syphilis needs to be worked up if a patient is male, and has Syphilis needs to be worked up if a patient is male, and has bilateral tonic pupils.bilateral tonic pupils.The tonic pupil is distinguished from other causes of lightThe tonic pupil is distinguished from other causes of light--near near dissociation by the presents of TONIC near response.dissociation by the presents of TONIC near response.Pharmacological testing, 0.125% Pharmacological testing, 0.125% pilocarpinepilocarpine or 2.5% or 2.5% methacholinemethacholine causes causes denervationdenervation supersensitivitysupersensitivity..

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Isolated Third N. Palsy w/ Isolated Third N. Palsy w/ Pupil InvolvmentPupil Involvment

Isolated Third N. Palsy w/ Isolated Third N. Palsy w/ Pupil InvolvementPupil Involvement

Sudden Onset Unilateral Sudden Onset Unilateral PtosisPtosis with Eye with Eye or Head Painor Head PainAcuity is Typically Unaffected unlessAcuity is Typically Unaffected unlessAcuity is Typically Unaffected unless Acuity is Typically Unaffected unless damage is in Superior Orbital Fissuredamage is in Superior Orbital FissureEye is in nonEye is in non--comitantcomitant exotropicexotropic & & hypotropichypotropic position (“down & out”)position (“down & out”)

Isolated Third N. PalsyIsolated Third N. Palsy 33rdrd N w/ Pupil Involvement OSN w/ Pupil Involvement OS

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Posterior Communicating Artery Aneurysm Posterior Communicating Artery Aneurysm (Most (Most Common)Common)Tumor or TraumaTumor or TraumaHZOHZOHZOHZOLeukemiaLeukemiaUncalUncal HerniationHerniation SyndromeSyndrome

Space Occupying LesionSpace Occupying LesionSubdural HematomaSubdural Hematoma

Pituitary ApoplexyPituitary ApoplexyIschemic Vascular Disease (Rare)Ischemic Vascular Disease (Rare)

Pupil sparing / Pupil involving

Rule of thumb : Pupil sparing third nerve palsies tend to be ischemic while those involving the pupil tend to be due toinvolving the pupil tend to be due to aneurysms or tumorsNot a firm rulePupil sparing may become pupil involving so follow very closely

Pupil involving vs. pupil Pupil involving vs. pupil sparingsparing

Pupil involving vs. pupil Pupil involving vs. pupil sparingsparing

Third Nerve Management

Immediate Gad enhanced MRI / MRA if any question of aneurysmalinvolvement. Patient may complain of a y psevere headache and will often have other neurological signsIf patient is diabetic or hypertensive and the pupil is not involved they can be followed closely without imaging studies

Third Nerve Management

Patient education and reassurance a mustDiplopia relief with patchingDiplopia relief with patchingMost ischemic palsies resolve over several months

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ManagementManagementHospital Neurosurgical Consult ASAPHospital Neurosurgical Consult ASAPCT/MRI/MRACT/MRI/MRACT/MRI/MRACT/MRI/MRALumbar PunctureLumbar PunctureCerebral AngiographyCerebral Angiography

Horner’s SyndromeHorner’s Syndrome

Anatomy of the Sympathetic Anatomy of the Sympathetic Pathway to the EyePathway to the Eye

Horner’s Syndrome: Horner’s Syndrome: Clinical FeaturesClinical Features

A.A. Moderate Moderate PtosisPtosis (2(2--3mm) due to paralysis 3mm) due to paralysis of Muller’s muscleof Muller’s muscle

B.B. ““Upside Down PtosisUpside Down Ptosis” ” -- Mild elevation of the Mild elevation of the lower lid due to paralysis of the smooth lower lid due to paralysis of the smooth muscle attached to the inferior tarsal plate.muscle attached to the inferior tarsal plate.

C.C. Apparent Enophthalmos due to A & B aboveApparent Enophthalmos due to A & B aboveD.D. + Dilation Lag (classic finding)+ Dilation Lag (classic finding)E.E. Decreased IOP on affected sideDecreased IOP on affected side

Dilation LagDilation LagHorner’s Syndrome: Horner’s Syndrome: Clinical FeaturesClinical Features

F.F. MiosisMiosis, more noticeable in dim illumination. , more noticeable in dim illumination. Note: Pupil rxns to light and near are Note: Pupil rxns to light and near are normal.normal.

G.G. AnhydrosisAnhydrosis on Ipsilateral side of face if on Ipsilateral side of face if lesion is below the Superior Cervical lesion is below the Superior Cervical Ganglion => Not a 3Ganglion => Not a 3rdrd order neuron.order neuron.

H.H. Increase in Amplitude of Accommodation Increase in Amplitude of Accommodation due to unopposed action of the due to unopposed action of the parasympathetic.parasympathetic.

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Horner’s pupil (OS)Horner’s pupil (OS) Horner’s

Miosis with normal reaction to lightPtosis and upside down ptosis ( loss of muscle tone ))Heterochromia if congenital and anhydrosis if the lesion is below the SC ganglion but before the carotid bifurcationHypotony Can occasionally get partial involvement with ptosis only (no miosis)

Horner’s Syndrome: Horner’s Syndrome: Clinical Features…Clinical Features…LastlyLastly

Horner’s: Horner’s: Localization of LesionLocalization of Lesion

4% Cocaine4% Cocaine+ Test => Anisocoria will increase+ Test => Anisocoria will increase

Hydroxyamphetamine (Paradrine 1%)Hydroxyamphetamine (Paradrine 1%)Hydroxyamphetamine (Paradrine 1%)Hydroxyamphetamine (Paradrine 1%)Preganglionic lesion => YES dilationPreganglionic lesion => YES dilationPostganglionic lesion => No dilationPostganglionic lesion => No dilation

If suspect preIf suspect pre--ganglionic lesion => ganglionic lesion => Chest CT or XChest CT or X--ray.ray.

Horner’sTesting ; 4% cocaine will dilate a normal pupil by blocking the re-uptake of epinephrine but will not dilate the Horner’s pupil. Shelf life of only six months if preserved and cost of $90More practical: 1% Iopidine will dilate a Horner’s pupil after 30-45 minutes but will not dilate a normal pupil. 0.5% works also1% hydroxyamphetamine will dilate a first or second order Horner’s but not a third by releasing NE from postganglionic synapses. Must wait one hour to check and need 72 hour washout if cocaine was usedPtosis only patients will get lid elevation with Naphazoline. Little pupillary mydriasis.

Most Common Causes of Most Common Causes of Horner’s SyndromeHorner’s Syndrome

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Horner’s Causes

First order : Neoplasms , Wallenberg’s syndrome , trauma , vertebral - basilar insufficiencySecond order : Pancoast or thyroid tumor , neck trauma or surgeryThird order : Cluster headaches , cavernous sinus lesion , dissecting carotid aneurysmTesting: MRI , MRA , and chest X-ray

Wallenberg’s syndromeWallenberg’s syndrome

Stroke of vertebral Stroke of vertebral or posterior inferior or posterior inferior cerebellar artery in cerebellar artery in th b i tth b i t

Difficulty swallowingDifficulty swallowingHoarsenessHoarsenessDizzinessDizziness

the brainstemthe brainstemNauseaNauseaGait disturbanceGait disturbanceNystagmusNystagmusUncontrollable Uncontrollable hiccupshiccups

Raeder’s syndromeRaeder’s syndromeHorner’s with pain in Horner’s with pain in the distribution area the distribution area of V1. Caused by a of V1. Caused by a neoplasm neoplasm compressing the compressing the trigeminal nerve. trigeminal nerve. Differential for cluster Differential for cluster headaches. headaches.

ArgyllArgyll--Robertson PupilRobertson Pupil

Argyll - RobertsonBilateral, asymmetrically miotic pupils which are irregularPoor dilation with poor response to light but brisk near responseHallmark of tertiary neurosyphilis.

ArgyllArgyll--Robertson Pupil: Robertson Pupil: Clinical FeaturesClinical Features

Pupils are small and frequently irregularPupils are small and frequently irregularKey Finding: LND PupilKey Finding: LND PupilKey Finding: LND PupilKey Finding: LND PupilBilateral Asymmetric Pupil InvolvementBilateral Asymmetric Pupil InvolvementVA’s are typically NORMALVA’s are typically NORMALPoor dilation with Poor dilation with MydriaticsMydriatics

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ArgyllArgyll--Robertson pupilRobertson pupil AR PupilsAR Pupils

ArgyllArgyll--Robertson Pupil: Robertson Pupil: WorkWork--upup

As this is a Hallmark Sign for As this is a Hallmark Sign for Neurosyphilis, need to rule this out, as Neurosyphilis, need to rule this out, as well as HIV:well as HIV:

FTAFTA--Abs, VDRLAbs, VDRLNeurological workNeurological work--upupConsider MRI, Lumbar PunctureConsider MRI, Lumbar Puncture

Anisocoria Case ReportAnisocoria Case Report

55 yr. Old caucasian female55 yr. Old caucasian femaleCC: droopy eyelid OD for 1 month, no CC: droopy eyelid OD for 1 month, no other complaints or symptomsother complaints or symptomsother complaints or symptoms.other complaints or symptoms.Patient & Family Ocular & Medical Hx Patient & Family Ocular & Medical Hx ––NegativeNegativeMedications: Evista, Calcium Sup.Medications: Evista, Calcium Sup.


Clinical Findings:Clinical Findings:BVA: 20/20 OD, OSBVA: 20/20 OD, OSPupils:Pupils:Pupils:Pupils:

((--) APD) APDSize (light): 2.5mm OD, 3.0mm OSSize (light): 2.5mm OD, 3.0mm OSSize (dim): 3.0mm OD, 6.5mm OSSize (dim): 3.0mm OD, 6.5mm OS((--) LND) LND

EOM’s / CT: NormalEOM’s / CT: Normal

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Clinical Findings Continued:Clinical Findings Continued:Lid EvalLid Eval

UL 2mm on cornea OD; IPF 5mmUL 2mm on cornea OD; IPF 5mmUL 2mm on cornea OD; IPF 5mmUL 2mm on cornea OD; IPF 5mmUL 1mm above cornea OS; IPF 8mmUL 1mm above cornea OS; IPF 8mmLL elevation ODLL elevation OD

Iris Color EqualIris Color Equal


Clinical FindingsClinical FindingsTA: TA: 10/1210/12SLE:SLE: NormalNormalSLE:SLE: NormalNormalDFE:DFE: C/D: 0.2 OD, 0.2 OS (good color)C/D: 0.2 OD, 0.2 OS (good color)Macula & Retina: Normal OUMacula & Retina: Normal OU

Q1: Which of the following tests is least Q1: Which of the following tests is least appropriate to confirm the diagnosis?appropriate to confirm the diagnosis?

1.1. 44--10% Cocaine test10% Cocaine test2.2. .125% Pilocarpine test.125% Pilocarpine test33 Paradrine 1% testParadrine 1% test3.3. Paradrine 1% testParadrine 1% test4.4. All of the aboveAll of the above5.5. None of the aboveNone of the above

Q1: Which of the following tests is least Q1: Which of the following tests is least appropriate to confirm the diagnosis?appropriate to confirm the diagnosis?

1.1. 44--10% Cocaine test10% Cocaine test2.2. .125% Pilocarpine test.125% Pilocarpine test33 Paradrine 1% testParadrine 1% test3.3. Paradrine 1% testParadrine 1% test4.4. All of the aboveAll of the above5.5. None of the aboveNone of the above

Q2: Which of the following is Q2: Which of the following is the most likely diagnosis?the most likely diagnosis?

1.1. Congenital Horner’s SyndromeCongenital Horner’s Syndrome2.2. Acquired Horner’s SyndromeAcquired Horner’s Syndrome33 Adie’s Tonic PupilAdie’s Tonic Pupil3.3. Adie s Tonic PupilAdie s Tonic Pupil4.4. CN III PalsyCN III Palsy5.5. ArgyllArgyll--Robertson PupilRobertson Pupil

Q2: Which of the following is Q2: Which of the following is the most likely diagnosis?the most likely diagnosis?

1.1. Congenital Horner’s SyndromeCongenital Horner’s Syndrome2.2. Acquired Horner’s SyndromeAcquired Horner’s Syndrome33 Adie’s Tonic PupilAdie’s Tonic Pupil3.3. Adie s Tonic PupilAdie s Tonic Pupil4.4. CN III PalsyCN III Palsy5.5. ArgyllArgyll--Robertson PupilRobertson Pupil

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Q3: Which of the following is NOT considered Q3: Which of the following is NOT considered appropriate management for this condition?appropriate management for this condition?

1.1. Chest XChest X--RayRay2.2. Brain ImagingBrain Imaging33 Referral to a NeurospecialistReferral to a Neurospecialist3.3. Referral to a NeurospecialistReferral to a Neurospecialist4.4. All of the above are appropriateAll of the above are appropriate5.5. None of the above are appropriateNone of the above are appropriate

Q3: Which of the following is NOT considered Q3: Which of the following is NOT considered appropriate management for this condition?appropriate management for this condition?

1.1. Chest XChest X--RayRay2.2. Brain ImagingBrain Imaging33 Referral to a NeurospecialistReferral to a Neurospecialist3.3. Referral to a NeurospecialistReferral to a Neurospecialist4.4. All of the above are appropriateAll of the above are appropriate5.5. None of the above are appropriateNone of the above are appropriate

Q4: Which of the following indicates the Q4: Which of the following indicates the congenital / infantile form of this condition?congenital / infantile form of this condition?

1.1. Mild Ptosis with excellent levator Mild Ptosis with excellent levator functionfunction

22 Miotic Anisocoria most apparent inMiotic Anisocoria most apparent in2.2. Miotic Anisocoria, most apparent in Miotic Anisocoria, most apparent in darknessdarkness

3.3. Lower Lid ElevationLower Lid Elevation4.4. Ipsilateral AnhydrosisIpsilateral Anhydrosis5.5. HeterochromiaHeterochromia

Q4: Which of the following indicates the Q4: Which of the following indicates the congenital / infantile form of this condition?congenital / infantile form of this condition?

1.1. Mild Ptosis with excellent levator Mild Ptosis with excellent levator functionfunction

22 Miotic Anisocoria most apparent inMiotic Anisocoria most apparent in2.2. Miotic Anisocoria, most apparent in Miotic Anisocoria, most apparent in darknessdarkness

3.3. Lower Lid ElevationLower Lid Elevation4.4. Ipsilateral AnhydrosisIpsilateral Anhydrosis5.5. HeterochromiaHeterochromia

Thank You!Thank You!

the the pupillarypupillary light reflex light reflex

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