Pupils, for professionals
- if smaller pupil norm, think Adie's in the other side
- If the larger pupil normal, think Horner's on the other side
- review, really excellent, Eye 2013
- miosis..small pupil
- ptosis..droopy lid
- various other changes
- lighter iris if long-standing (heterochromia)
- sweating is reduced on the same side of the face
- after CVP line Eye 16
- Eye 2013
- ptosis, 88%, sometimes lower lid might be elevated (upside down ptosis), enophthalmic appearance
- anisocoria, more pronounced in dark: dilatation lag. Examine in room light, dim light, and as the light changes....the Horner's pupil dilates a lot more slowly as the light is dimmed: the difference is most obvious in the first 5 seconds
- Cocaine (or apraclonidine) separates normals: post cocaine ansiocoria >0.8mm, very likely Horners. 4% cocaine prevents nor-adrenaline uptake...it dilates the normal pupil, but has no effect on a Horner's pupil. Iopidine 0.5% (apraclonidine and here) should dilate the Horner's pupil but not the normal pupil (unless the Horner's is very recent). Best to photograph before and after.
- 1% hydroxyamphetamine (available from Moorfields Pharmacy) or 1% phenylephrine will dilate/mydriais in post-ganglionic Horners due to denervation hypersensitivity (wont dilate others). Cannot use within 24 hours of cocaine test. ?? use phenylephrine first.
- there are different causes depending whether 1st, 2nd or 3rd neurones affected.
- 1st order CVA, demyelination..MRI brain/cervical spine, upper thoracic spine
- 2nd order neoplasm, trauma..?CT angiogram
- 3rd base of skull lesion, internal carotid dissection/aneurysm (e.g. after neck injury playing rugby)
- apraclonidine..example JNO 15
Imaging in Horner's
- an excellent review (adults)
- generally (98%) the diagnosis was known at time of diagnosis of the Horner's. In 83% the diagnosis was made. Problems included previous neck/skull surgery, brainstem CVA, chest or skull base masses or trauma.
- Carotid dissection was identified because the Horner's was PAINFUL (with/without trauma).
- Cavernous sinus masses were related to other %5 or 6th) cranial nerve palsy.
- Cervical spine mass (scapular pain/upper limb sensory problems).
- None targeted imaging (no focal signs etc) was not that helpful.
- One patient had a thyroid Ca.
- Central Horners..MS/CVA/tumour
- pre-ganglionic ...trauma, tumour
- post ganglionic...carotid, trigeminal, cavernous sinus
- HS (Horners syndrome) with localizing signs
- 1st order.Brain/spine MRU
- 2nd/3rd CT angiogram
- HS (Horners syndrome) with NO localising sign
- acute/painful, trauma, malignancy... CT angiogram same day
- HS with no localizing signs and no pain/trauma, malignancy, urgent imaging not needed...?CT angiogram
- no light response; sector palsy with slit lamp
- initially pupil is larger than the normal pupil
- normal near reflex
- 66% reduced accommodation...difficult reading
- pilocarpine 0.1% constricts an Adies pupil, not a normal pupil.
- eventually the pupil becomes smaller
- often called a 'tonic pupil': when trying to read pupil does become smaller, but takes much longer than the normal pupil to dilate, hence the term 'tonic'.
- bilateral 4%/year
- if part of Holme's-Adies ankle jerks reduced, no transillumination (HZO...transilluminates)
- may have bilateral peripheral neuropathy
- part of Parinauds or
- Argylle-Robertson pupil
- absent light reflex, brisk near reflex
- measure pupil in bright light
- in dim light
- check near reflex
- examine iris & pupil on slit lamp...other disease?
- if the light reflex is normal
- <1.0mm difference, perhaps physiological (same all illumination)
- otherwise, and if ptosis present, suspect Horner's (different according to illumination as above)
- if the light reflex is abnormal, suspect Adies
- pupils get smaller with age
- constrict with light and accommodation
Do pupils react briskly?
Smaller pupil is abnormal.
Larger pupil is abnormal
history of trauma, intraocular surgery (with iris damage visible on slit lamp)
|probably physiological||likely traumatic||no|
are either of the following present
|?partial third nerve palsy||
are both the following present?
|likely tonic pupil (Adies)||Possible pharmacological dilation|
|normal||dilates||no change||dilates||no change|
|central or preganglionic||no/minor change||dilates||dilates||no change|
|no change||dilates||no change||dilates|
- many drugs dilate pupil..eg atrovent inhaler. Pilocaprine will constrict such a pupil and exclude 111n palsy
- patient may have (?accidentally) instilled such drops
- none-ophthalmologists should remember that many eye conditions cause unequal
or unresponsive pupils: acute glaucoma. acute uveitis, chronic uveitis, surgery, trauma
- even if there is an afferent defect there is no anisocoria
- use a bight light in a dim rook and shine at fovea
- swing the light from one eye to the other to identify an afferent defect
- only need one working pupil
- caused by optic nerve or severe retinal disease
- animation (APD) .exe file 1 mb