Dont Miss Pupil Anisocoria

Devi Azri Wahyuni

Ophthalmology Department
Mohammad Hoesin Hospital Palembang /
Sriwijaya University
2016

Introduction
The pupil is a hole located in the center of the
iris of the eye allows light to enter the retina
The iris is a thin strip of smooth muscle which
regulates the amount of light entering the eye
by controlling the size of the pupil

 Pupillary function is an important

objective clinical sign in patients with
visual loss and neurologic disease.
In some patients, an abnormal pupillary
response may be the only objective sign
of organic visual dysfunction. in others, it
may herald the presence of a life threatening
cerebral aneurysm or tumor.

PUPILS FUNCTION

1. Control of retinal ilumination

2. Reduction in optical aberrations
3. Depth of focus

CONTROL OF PUPILS

Constricts
- Sphincter pupillae a circular group of smooth
muscle
- Parasympathetic fibres in the oculomotor nerve
through the ciliary ganglion via short ciliary nerve
Dilates
- Dilator pupillae a radial muscle group
- Sympatheric nerve from hypothalamus via the
carotid artery entering the globe through short ciliary
nerves

PUPILS
INNERVATION
Afferent Pupillary Pathway
- pupillary fibers follows the optic tract and
separate from the optic tract just anterior to the
lateral geniculate body.
- They then enter the midbrain, where they synapse
to pretectal nucleus.
- leave pretectal nucleus & distributes
approximately equally to both EndingerWestphal
nuclei

 Efferent Pupillary Pathway

- The efferent pupillary light pathway begins at the
Endinger-Westphal (E-W) nuclei.
- The efferent pupillary pathway divided :
Parasymphatetic pathway
Sympathetic pathway :
1. Central (first-order) neuron.
2. Preganglionic (second-order) neuron.
3. Postganglionic (third-order) neuron

PUPILS SIZE
Pupil diameter

- Dark adaptation 4,5 7,0 mm

- Bright adaptation 2,5 6 mm.
Miosis < 3 mm
Midriasis > 6 mm

Isocoria and Anisocoria

Isocoria equality in the diameters of 2
pupils
Anisocoria inequality in the diameters
of 2 pupils

Anisocoria (pupillary
inequality)

Can be due to serious pathology

and a systematic approach is
required to elucidate the diagnosis

Anisocoria
Worse in
light

Abnormality in the
iris sphincter
( constriction
failure )

Worse in
dark

Abnormality in
the Iris dilator
(dilatation
failure)

No difference in
light and dark

Physiological

Causes of
Anisocoria
Worse in
Bright Light

Large
Abnormal
PupilConstriction
Failure

Parasympatheti
c
Causes
pathway
3rd cranial nerve palsy
- Microvascular injury subarachnoid or
cavernous sinus.
- microvascular infarct : include
aneurysmal compression,
tumor, inflammation.
Adies tonic pupil

Causes of
Anisocoria

Worse in Dim
Light

Causes

Small Pupil Abnormal

Dilatation
Failure
Sympathetic
pathway

Physiologic :
- Commonest (20% of population)
- Pupillary function normal
- Degree of anisocoria remains the same in light
and dark
Horners pupil
Argyll Robertson Pupil

Approach History of the present illness

1. First try and determine if the patient is aware of

the anisocoria, and when the patient first
became aware of the anisocoria old
photographs may be very useful in helping
make this distinction
2 Inquire about any previous eye/head injury ,
eye surgery, previous eye disease which
may have produced pupillary inequality

3. Determine whether the patient has any eye pain or

discomfort or any visual changes.
4. Inquire about headache or face pain or neck pain
. Headache + a dilated unresponsive pupil => ?
aneurysm compressing the third cranial nerve
. Face or anterior neck pain + a miotic pupil => ?
Horners syndrome secondary to carotid artery
dissection

5. Inquire carefully about possible eye contact or po

ingestion of drugs/toxins
6. Inquire about abnormal neurological symtoms
Focal weakness or sensory deficits
Dysarthria or dysphagia or diploplia
Ataxia or vertigo
Face paresthesia or hyperalgesia

Approach
Examination
1. Examine the patients pupils under normal
room light conditions

Shine a bright light in each eye and determine

whether both pupils respond to light (direct
and consensually)

Then determine whether the anisocoria

is greater in bright light or in the dark

using a low intensity beam

tangentially across the front of the face
with just enough illumination to be able
to see the pupils when evaluating the
pupillary response in the dark

2. Evaluate the patients accomodative pupillary

response to near vision

Patient looks at the end of his nose, or examiners

finger is brought in from below the level of the nose) to
determine whether the patient has near-light
dissociation

3. Check for visual acuity.

4. Check for any limitation of extra-ocular
eye movements (or subtle diploplia in
certain directions of gaze) pathology
of the extraocular nerves (3rd, 4th
and/or 6th cranial nerves)
5. Examine the anterior chamber, iris,
pupillary responses with a slit lamp

6. Check for ptosis and reverse ptosis of the

lower eyelid Check for strength of the
the levator palbebrae muscle (normal
eyelid elevation = 12mm)
7. Check for any neurological dysfunction
cranial nerve dysfunction, focal sensorimotor
deficits, dysarthria, Cerebellar dysfunction
8.

Check for Neck bruits (carotid artery

dissection =>
Horners syndrome)
Neck masses (pressing on the sympathetic

Case Study

1. Horners Pupil

Oculosympathetic paresis
interruption of the sympathetic
supply along the three neuron
patway.
Miosis
Ptosis
Apparent enophalmos
Cutaneous anhydrosis
Other feature iris hypopigmentation
on congenital cases

Horners Syndrome

Male 34 yo, from Internal

Medicine Department with
complaints of anisocoria and
ptosis (droopy eyelid)
Ptosis in the
right eye

Anisocoria

28

In bright light

In dim light

29

Anhidrosis on the right side

30

Rontgen Thorax

31

CT Scan Thorax
Kesan

32

33

2. Oculomotor nerve
palsy

Pupillary involvement in third nerve palsy is

almost always accompanied by ptosis and
limited ocular motility.
Pupillary dysfunction is an important factor in
evaluating an acute third nerve palsy. When
the pupil is involved, an aneurysm at the
junction of the internal carotid and posterior
communicating arteries must be excluded.
If the pupil is spared and all other functions of
the third nerve are completely paretic, an

Pupil Involving 3rd Nerve Palsy

Aneurysm at
junction of
posterior
communicating
artery and
internal carotid
artery

Partial pupil
involvement in
25-47% of
patients with
posterior
communicating

Case 1
A 55-year-old woman presented to the
Emergency Department with complaints of
headache, droopy eyelid and double vision, her
symptoms worsened and she began to develop
diplopia.
On exam, right-sided ptosis, a dilated pupil
with a sluggish light response, and a downward
and lateral deviation of the right eye.
The remainder of neurologic exam was within
normal limits.

 Damage or compression of the oculomotor

nerve by an aneurysm an also cause anisocoria,
typically
associated
with
ptosis
and
ophthalmoparesis

Case 2
A forty-seven-year-old female patient with
sudden ptosis, dilated pupil and diplopia
without pain, three days prior. She had no
trauma or systemic disease history.
Approximately 30 prism diopters exotropia was
seen in the primary position. Anterior and
posterior segment examination was normal in
both eyes.
Posterior communicating artery aneurysm
was seen in enhanced MRI and MRI
angiography

Posterior communicating artery

aneurysm

Traumatic Pupil
Contusion Injury of the eye may
cause :

Miosis

may be due to
sphincter spasm
seen with iritis

Mydriasis
May be due to contusion
injury (or actual rupture)
of
the
iris
sphincter
muscle :
a. Irregular pupil
b.Poorly responsive to 2%

Ocular Trauma

Trauma Examination
Visual acuity
Pupil testing
Eye movement
Visual field
Palpasi eyelid and orbital margins

Pupil large
degreasing reactiont to
light and near, irreguler pupil ( spinter
damage)

Thank

Anisocoria greater in bright

light
Segmental iris
palsy

Iris anatomy
normal
YE
S

Supersensitive to 0,1
% pilocarpine
NO

YES

Adie tonic
pupil
YES

NO

Suspect
pharmacologic
mydriasis

Traumatic
iridoplegia, iris
ischemia, siderosis

Constricts with
1,0 % pilocarpine

Iris damage

NO

Third-nerve
palsy

Pharmacologic
al mydriasis

Symptoms of a
ruptured aneurysm

Sudden onset of
a severe
headache
Nausea and
vomiting
Stiff neck
Transient loss of
vision or
consciousness

Risk factors
for
aneurysm rupture
include:
- Smoking,
- High blood pressure,
- Alcohol
- Genetic
factors
(family inherited)
- Atherosclerosis(hard
ening
of
the
arteries)
- Oral contraceptives

MRA Sensitivity for Detecting

Aneurysms

CTA Sensitivity for Detecting

Aneurysms

 Angiogram is an invasive
procedure, where a catheter is
inserted into an artery and
passed through the blood
vessels to the brain.
Magnetic resonance imagi
ng
(MRI) scan is a noninvasive
test, which uses a magnetic
field. An MRA (Magnetic
Resonance Angiogram) is the
same non-invasive study.

Horner
Syndrome
1,0 %
hydroxyampheta
mine

Both pupil dilate

First or secondorder neuron

horner syndrome

Small pupil
unchanged

Third-order
neuron Horner
Syndrome

Anisocoria same in
dim and in bright
light
YES
Physiologic
anisocoria

Anisocoria greater in
dim light
Dilator muscle
working right
No or unsure

Cocaine
Both eyes dilate

Anisocoria
> 1.0 mm

Horner
Syndrome

rFunctional or
mechanical
restriction to
dilatation

Synechiae, uveitis,
miotic drops, old
Adie pupils

Mechanical /
pharmacologic
miosis

Horners
syndrome

CN3 palsy

Right horners
syndrome : miosis with
approximately 2mm

Right horners
syndrome : the right
pupil failed to dilate
while the left eye
dilated to 7 mm with
10% cocain.

Physical Examination
horner
Measurement of pupillary diameter in dim
and bright light and the reactivity of the pupils
to light and accommodation
Examination for dilation lag of the pupil
immediately after the room lights are dimmed
Examination of the upper lids for ptosis
Examination of the lower lids for upside-down
ptosis (eg, the position of the lower lid with
respect to the inferior limbus)

Observation of extraocular movements

Biomicroscopic
examination
of
the
pupillary margin and iris structure and
color
Confrontational visual field testing and
testing of facial sensation
Observation
for
the
presence
of
nystagmus,
facial
swelling,
lymphadenopathy, or vesicular eruptions

Treatment
Treat the underlying disorder if
possible.
Ptosis surgery may be performed as
needed.

Sinister Pupils
Associated with
motor nerve
palsies

Oculomotor
nerve
palsy
(diplopia/ptosis)

pupil is LARGE
Horners Syndrome
(ptosis)
Pupil is SMALL
Marcus Gunn Pupil

Associated with
visual loss

Compresive optic
neuropathy

Argyll Robertson
Pupil
Tertiary syphilis involving the central nervous

system.
small pupils (<2mm), often irregular.
Do not react to light, but the near response and
subsequent redilation are normal and brisk.
Are seen in widespread autonomic neuropathies
such as bilateral tonic pupils (chronic), diabetes,
chronis alcoholism, as well as in encephalitis,
following panretinal photocoagulation

Argyll Robertson
Pupil
Small, irregular pupils that do not react to light,
but do to near.
Dilate poorly in the dark and in response to
mydriatic agents,
including cocaine and paredine.
May be unilateral and thus imitate the miosis of
Horners
syndrome (more marked anisocoria in the dark and
after
cocaine or paredrine.
Approximately 20 % of patients with neurosyphilis
will
demonstrate the above pupillary phenomena.
Another 50% of patients with neurosyphilis will
demonstrate

Beyond the pupils

Is there lid ptosis on one side?
Are the eye movements full?

Clues to the
cause of the
Horners
syndrome are
based on the
location of the
lesion

Another approach is to only use

the algorithms if the patient does
not have opthalmologic anisocoria
due to structural damage of the
eye
Algorithm number 1
For patients with a normal light
reaction and whose anisocoria is
greatest in the dark => the smaller
pupil in the dark is the abnormal pupil
(dilation problem with the smaller
pupil)

Algorithm number 2
For patients with an abnormal
light reaction and whose
anisocoria is greatest in bright
light conditions => the larger
pupil is the abnormal pupil
(constriction problem with the
larger pupil)

Findings
Tonic pupil
3rd nerve
palsy
Mydriatic
eyedrops
Parinaud
syndrome
Argyll
Robertson
pupil
Sympathomim
etic drugs

Light reaction Near reaction 1% pilocarpine

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