Good Hope Eye Clinic

Pupils, for professionals

David Kinshuck

To start

  • if smaller pupil norm, think Adie's in the other side
  • If the larger pupil normal, think Horner's on the other side

Horner's

  • 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

Examination

  • 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
  • anhidrosis

to test

  • 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

 

Adies

  • 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

 

Midbrain

  • part of Parinauds or
  • Argylle-Robertson pupil
  • absent light reflex, brisk near reflex

 

Anisocoria..physiological

  • 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

 

     

Unequal pupils (Pane/Burden/Miller)

 

Do pupils react briskly?

 
 
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yes
no
 
 
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Smaller pupil is abnormal.
Are the following present?

  • mild ptosis
  • dilation lag of the affected pupil in dark
  • anisocoria increased in dark

Larger pupil is abnormal

history of trauma, intraocular surgery (with iris damage visible on slit lamp)

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yes
no
yes
no
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possible Horner's
(?cocaine/apraclonidine test)

probably physiological likely traumatic no
     

are either of the following present

  1. ptosis on the side of the larger pupil
  2. diplopia or abnormal mobility?
   
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yes
no
   
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    ?partial third nerve palsy

are both the following present?

  1. slow constriction to near?
  2. spiraling of the pupil on slit lamp exam
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      yes no
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      likely tonic pupil (Adies) Possible pharmacological dilation

 

Horner's tests (Pane/Burden/Miller)

 

diagnosis

localization

site cocaine apraclonidine hydroxyamphetamine 1% phenylephrine
normal dilates no change dilates no change
central or preganglionic no/minor change dilates dilates no change

post-ganglionic

no change dilates no change dilates

 

Pharmacologic and eye disease

  • 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

Afferent..pupil response to light

  • 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