B”H
Joseph N. Trachtman, O.D., Ph.D. F.C.O.V.D.-A
ABSTRACT
BACKGROUND
Approximately 20% of the popula-
tion has anisocoria. Therefore, how
do we make a differential diagnosis
between a normal physiological
state and a pathological condition?
A frequenct cause of anisocoria is a
miotic pupil of Horner’s syndrome,
first described by Horner in 1869.
Three case histories of anisocoria
are presented to illustrate various
etiologies.
CASE SUMMARY
Patient 1: A 25-year-old male pre-
sented a miotic pupil O.D., with par-
tial ptosis O.S. Previous examina-
tions by eye care professionals
attributed the ptosis to contact lens
wear, while not addressing the
miotic pupil. Instillation of 1:1,000
phenylephrine O.U. revealed pupil
dilation O.D., with no effect O.S.
Upon further questioning of the
patient and his mother, it was
learned that the patient had upper
lid surgery O.S. following a child-
hood trauma.
It is suspected that the surgery
weakened the levator palpebrae su-
perioris muscle, which is innervated
by the sympathetic nervous system.
Accordingly, when the patient is
tired the ptosis is more prominent.
Email: tracht@accommotrac.com
ANISOCORIA & HORNER'S SYNDROME
SUMMARY & DISCUSSION
CASE SUMMARY (continued)
The patient was offered accommo-
dative training, which in some
cases can restore the pupil
function as noted in the following
history.
Patient 2: A 56-year-old male’s chief
complaint was a history of exotrop-
ia. Examination revealed a 25 p.d.
intermittent alternating exotropia
at near, and a miotic pupil O.D. In-
stillation of 1:1,000 phenylephrine
O.U. revealed no pupil dilation O.D.
or O.S.
Upon further inquiries it was
learned that the patient had an ad-
verse relationship with his father,
who sat to his right at the dinner
table.
Freud’s report of the vision anoma-
lies of Anna O led to an awareness
of the relationship between vision
and psychological processes.
Vision training to relax accommo-
dation using the Accommotrac®
Vision Trainer resulted in equal
pupil sizes O.U.
Patient 3: A 39-year-old male had
the complaints of unstable focusing
and cognitive impairment following
a series of rear-end automobile ac-
cidents. Upon examination he was
noted to have a miotic pupil, and
partial ptosis O.D.
Vision Improvement Center of Seattle, PS
PATIENT TRAINING RESULTS
PRE
Patient 1
August 25, 2016
Patient 2
June 20, 2016
Patient 3
March 3, 2017
CASE SUMMARY (continued)
Instillation of 1:1,000 pheny-
lephrine O.U. revealed pupil
dilation O.D., and no effect O.S.
MRI testing found mild disc
protrusion and stenosis at C3-4,
and trauma to the right insula.
DISCUSSION
Three patients with anisocoria
had three different etiologies,
with two testing positive for
Horner’s syndrome, with the
specific neurological impair-
ment being discovered for one
of them.
1020 NE 63rd Street #101
POST
August 25, 2016
September 29, 2016
March 3, 2017
DISCUSSION (continued)
For the second patient a psycho-
genic etiology is proposed.
As is known, there are three
retinohypo-thalamic tracts, and
the hypothalamus is one of
the components of the limbic
system. The sympathetic
nervous system fibers inner-
vating the pupil arise from
the hypothalamus.
It can be, therefore, logical to
assume that an interference in
this pathway may be an
eitiology of Horner’s syndrome.
Seattle, WA
www.accommotrac.com
SUGGESTED READING
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