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Pupil Abnormalities Pupil Abnormalities PupilAbnormalities PupilAbnormalities

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Pathwayofthepupillarylightreflex Pathwayofthepupillarylightreflex
consistsof: consistsof:
Retinalreceptorcells et a ecepto ce s
Bipolarcells
Ganglioncells
Afferent
visual
pathway
Opticnerveandtract
Pretectalnucleus inthemidbrain
pathway
EdingerWestphal nucleus
Twoneuronepathwayviathe
O l
Eff t
Oculomotornerve
Sphincterpupillae (constrictormuscleofiris)
Efferent
visual
pathway
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Anatomy of the pupil reflexes Anatomy of the pupil reflexes Anatomyofthepupilreflexes Anatomyofthepupilreflexes
Thesizeofthepupilsdependsonthebalance
ofparasympatheticand sympathetic activity p y p y p y
supplyingtheiris(efferentvisualpathway):
parasympathetic activityconstricts thepupil
sympatheticactivitydilates thepupil
.
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Thelightreflex Thelightreflex
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Thelightreflex Thelightreflex
(Light reflex) (Lightreflex)
The
parasympathetic
pathway
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Illustration sourced from Clinical Ophthalmology: A Systematic Approach
5
th
edition by Jack J. Kanski
Sympathetic pathway Sympathetic pathway y y y y
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Sympathetic pathway Sympathetic pathway
C2 level, angle of jaw
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Illustration sourced from Clinical Ophthalmology: A Systematic
Approach
5
th
edition by Jack J. Kanski
NormalLightreflex NormalLightreflex
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Illustration sourced from Clinical Ophthalmology: A Systematic Approach
5
th
edition by Jack J. Kanski
Examination of pupils Examination of pupils Examinationofpupils Examinationofpupils
before dilating beforedilating
size,symmetry
shape
near reflex nearreflex
lightreflex
Relativeafferentpupildefect(RAPD)
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Anisocoria Anisocoria Anisocoria Anisocoria
Differenceinpupilsizebetweenthe p p
eyes maybephysiologicalor
pathological pathological
Physiologicalanisocoria
normalvariationinpupilsize
uncommon uncommon
usuallylessthan1mm
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Factorsaffectingpupilsize Factorsaffectingpupilsize g p p g p p
Topicalmedications: p
Mydriatics /miotics/otheragents
Trauma: Trauma:
traumaticmydriasis/sphincterrupture/surgical
trauma / posterior synechiae trauma/posteriorsynechiae
Diseaseprocesses:
uveitis / acute angle closure glaucoma uveitis/acuteangleclosureglaucoma
Systemicmedications:
N i ( hi hidi ) i i Narcotics(morphine,pethidine)causemiosis
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Conditions with Pathological Pupil Size Conditions with Pathological Pupil Size ConditionswithPathologicalPupilSize ConditionswithPathologicalPupilSize
Abnormally small pupil Abnormallysmallpupil:
Hornerssyndrome
Argyll Robertson pupil ArgyllRobertsonpupil
Narcotics
Abnormallylargepupil:
Adies tonic pupil Adie stonicpupil
Pupilinvolved3rdnervepalsy
Bilateraldilatedpupils coma p p
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HornersSyndrome HornersSyndrome
Oculosympatheticparesis.interruptionofthe
sympathetic supply along the three neuron pathway sympatheticsupplyalongthethreeneuronpathway
Miosis
Ptosis
Apparent enophthalmos Apparentenophthalmos
Cutaneousanhydrosis
Other features iris hypopigmentation in congenital Otherfeatures irishypopigmentation incongenital
cases
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Horners Syndrome Horners Syndrome Horner sSyndrome Horner sSyndrome
Diagnosisconfirmedbytopicalcocainetest g y p
Abnormal pupil fails to dilate whilst the normal pupil Abnormalpupilfailstodilatewhilstthenormalpupil
willdilate(lossofnoradrenalineatnervejunction)
Otherassociatedclinicalsignsandsymptoms.
( headache / apical lung pathology/ long tract (headache/apicallungpathology/longtract
neurologysigns)willdetermineappropriate
investigations investigations
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Right Horners syndrome Right Horners syndrome RightHorner ssyndrome RightHorner ssyndrome
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Argyll Robertson Pupil Argyll Robertson Pupil ArgyllRobertsonPupil ArgyllRobertsonPupil
Specificsignofneurosyphilis
Small and irregular pupils Smallandirregularpupils
Usuallybilateralbut
t i asymmetric
Donotrespondtolightbut p g
nearresponsenormal(light
near dissociation) neardissociation)
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AdiesPupil AdiesPupil
Postganglionicparasympatheticdenervation:
Causes:idiopathic,viral,diabetes,trauma p , , ,
Glare/accommodativedifficulties
M d i i Mydriasis
Light neardissociation.slowconstrictionon
prolongedneareffortandslowredilationtodistance p g
Usuallyyoungfemales 90%unilateralinitially,but
oftenbecomesbilateral
Pupil becomes tonic with time even miotic Pupilbecomestonicwithtime.evenmiotic
Ifdecreasedtendonreflexespresent HolmesAdie
syndrome
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J K1
AdiesPupil AdiesPupil pp
f d b d h Diagnosisconfirmedbydenervationhypersensitivity
toweakcholinergic(pilocarpine0.1%)abnormalpupil
ll h l l l ff d willconstrictwhilstnormalpupilremainsunaffected
Aberrantreinnervation ofpupillarysphinctermuscle
contractionsofpartofthepupilmargin(vermiform p p p g (
movement)
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Bilateral recent Adies pupils Bilateral recent Adies pupils BilateralrecentAdie spupils BilateralrecentAdie spupils
Semi-dilated, irregular; iris affected segmentally
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Semi dilated, irregular; iris affected segmentally
AnatomyoftheCNIII AnatomyoftheCNIII
Oculomotor nucleus
Pons
Clivus
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Illustration sourced from Clinical Ophthalmology: A Systematic Approach
5
th
edition by Jack J. Kanski
Applied Applied
Bl d l i l f
Applied Applied
anatomyof anatomyof
Bloodvesselsonpiamatersupplysurface
ofthenerveincludingpupillary
fibres (damagedby
compressivelesions)
theCNIII theCNIII
Vasanervorumsupplypart
ofnervebutnotpupillary p p y
fibres.Pupilsparinginmedical(noncompressive)
lesionse.g.diabetes
Illustration sourced from Clinical Ophthalmology: A Systematic Approach
5
th
edition by Jack J. Kanski
Causes of CN III palsy Causes of CN III palsy CausesofCNIIIpalsy CausesofCNIIIpalsy
Microvascular infarction Microvascularinfarction
Occlusionvasa nervorum
Risks:diabetes,hypertension,atherosclerosis,
Compressive lesion Compressivelesion
Aneurysm(usuallypostcommunicatingartery)
T Tumour
Trauma
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N III l N III l NIIIpalsy NIIIpalsy
Ptosis mydriasis andcycloplegia Ptosis, mydriasis and cycloplegia
Eye down and out
Normal abduction
Limited depression
Limited adduction Limited elevation
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Partial right CN III palsy PartialrightCNIIIpalsy
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Left CN III palsy Left CN III palsy LeftCNIIIpalsy LeftCNIIIpalsy
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Whatdoyoulookforifthereis Whatdoyoulookforifthereis yy
anisocoria? anisocoria?
Makesurepatienthasnothadanyeyedrops
instilled instilled
Checkforprescription,overthecounter
vasoconstrictors or herbal medications vasoconstrictorsor herbal medications
Anyhistoryofeyesurgery(iatrogenic)
Checkforothersignssuchasptosis,orocular
motilityproblems
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RRelative elative AAfferent fferent PPupil upil DDefect efect ((RAPD RAPD)) RRelative elative AAfferent fferent PPupil upil DDefect efect ((RAPD RAPD))
Th f RAPD i th b f ThepresenceofRAPDintheabsenceofgross
oculardiseaseindicatesaneurologicallesionof
the anterior is al path a (afferent s stem) theanteriorvisualpathway(afferentsystem)
Detectedusingtheswingingflashlighttest
Abnormalpupilrespondstoconsensuallight
but not direct light butnotdirectlight
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Causes of RAPD Causes of RAPD CausesofRAPD CausesofRAPD
Optic nerve disorders (optic nerve compression optic Opticnervedisorders(opticnervecompression,optic
neuritis)
Chiasma compression Chiasma compression
Retinaldetachment
Large unilateral macular lesion Largeunilateralmacularlesion
Unilateralglaucoma
RAPDnotproducedbycornealopacity,cataract,
vitreous haemorrhage refractive error amblyopia vitreoushaemorrhage,refractiveerror,amblyopia.
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RRelative elative
AAff t ff t AAfferent fferent
PPupil upil PPupil upil
DDefect efect
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Illustration sourced from Clinical Ophthalmology: A Systematic Approach
5
th
edition by Jack J. Kanski
RRelative elative AAfferent fferent PPupil upil DDefect efect RRelative elative AAfferent fferent PPupil upil DDefect efect
RAPDvideo
Availableforviewing
b i onwebsite
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Mydriatics Mydriatics Mydriatics Mydriatics
Cholinergic antagonists ( ti h li i ) Cholinergicantagonists(anticholinergics)
Atropine
Cyclopentolate (Cyclogyl)
Tropicamide (Mydriacyl) p ( y y )
Systemic effects: Atropine: Hot as a hare, mad as a hatter, red as a beet Systemiceffects:Atropine: Hotasahare,madasahatter,redasabeet
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Mydriatics Mydriatics continued continued Mydriatics Mydriatics continued continued
Adrenergic agents Adrenergicagents
adrenergicagonist phenylephrine 2.5%and10%
Systemiceffects:Hypertension,stroke,myocardialinfarct

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receptorsmediatesmoothmusclecontraction
Cocaineblocksreuptakeofnoradrenalinintopresynaptic vesicles,thus
accumulating and causing dilatation in an intact neuron accumulatingandcausingdilatationinanintactneuron
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Miotics Miotics Miotics Miotics
Cholinergic (direct): Pilocarpine Cholinergic(direct):Pilocarpine
Anticholinesterases (indirectcholinergic):
physostigmine,neostigmine
Postganglionic parasympathetic nerves respond to muscarine.
Somatic motor and preganglionic autonomic nerves respond to nicotine
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The End The End The End The End
All material contained in this presentation is copyright of
The University of Auckland, Department of Ophthalmology
and should not be reproduced without written permission and should not be reproduced without written permission
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