PUPILLARY PATHWAY

 Pupilloconstrictor light reflex pathway (parasympathetic fibers)

 Near reflexes:
o Convergence near reflex pathway
o Accommodation reflex pathway
 Pupillary dilatation pathway (sympathetic fibers)
 Darkness reflex
 Psychosensory reflex
LESIONS OF THE PUPIL

Location of lesion
1. Amaurotic pupil Complete optic nerve/retinal lesion  Total afferent pupillaty defect
 NLP
 Affected eye : RC -/+
Unaffected eye : RC +/-
2. Marcus Gunn pupil Incomplete optic nerve/severe retinal  Relative afferent papillary defect
lesion  Indicates an asymmetry of afferent light transmission
 Tested by swinging flashlight test (grade I-IV)
 Will not be present in:
 Symmetric bilateral lesion of the optic nerve/retinal disease
 Will not occur if:
 Chiasmal lesion
 Post chiasmal lesion
(as in these areas fibers are present from the opposite eye)
 Opacities of the ocular media will not cause a MG pupil if a strong
enough flashlight is used.
3. Wenicke pupil Optic tract lesion  Light reflex is absent when light is thrown from the nasal to the
temporal half of retina of the affected eye.
 Light reflex is absent when light is thrown from the temporal to
nasal half of retina of the unaffected eye.
 Light reflex is present when light is thrown from the temporal to
the nasal half of retina of the affected eye.
 Light reflex is present when light is thrown from the nasal to
temporal half of retina of the unaffected eye.
 + Homonymous hemianopia
4. Argyll Robertson Lesion in the region of tectum  Disturbance of the normal inhibitory pathways from the RAS upon
pupil the parasympathetic Edinger-Westhpal subnucleus  excessive
Lesion involve the internuncial neurons parasympathetic activity  small pupil (miosis)
between pretectal nucleus and Edinger-  Features :
Westphal nucleus  The vision in the affected eye is normal (visual pathway is
not affected)
 Pupil is no reaction to light
 The near reflex is normal
 Pupil is miotic and irregular
 Pupil dilate very poorly with mydriatics.
5. Pseudo-Argyll CN III palsy with pupillary involvement
Robertson pupil
6. Tonic pupil Lesion in ciliary ganglion/short ciliary nerve
7. Adie-tonic pupil Denervation of the postganglionic supply of
the sphincter pupillae and ciliary muscle
8. Hutchinson’s pupil Ipsilateral, expanding
intracranial supratentorial mass (tumor or
subdural hematoma)
 causing downward displacement of the
hippocampal gyrus and uncal herniation
across the tentorial edge with entrapment
of the third nerve.
9. Horner syndrome Lesion of the symphatetic system
3 types:
1. Central/first order neuron
• due to brainstem vascular lesions
or demyelinating lesions.
• + Brainstem signs and sudden
onset of vertigo.
2. Preganglionic/second order neuron:
• Pancoast’s tumor of the lung or
surgery in the neck
3. Postganglionic/third order neuron
• cavernous sinus lesions or head
trauma
• + ipsilateral vascular headache
10. Reader syndrome occasional middle fossa mass  Horner
syndrome + involvement CN.V
Light-Near Dissociation
Etiology:
• Argyll Robertson pupil
• Bilateral complete afferent pupillary defect as in bilateral optic atrophy
• Lesions in the pretectal area
• Reaction to light is absent and to near reflex very slow and tonic
• Accommodative paresis is present
• The affected pupil is larger (midriasis)
• Generally unilateral
• Cholinergic supersensitivity of the denervated muscle (constricted
with 0.125% pilocarpine; N : doesn’t constrict)
• Tonic pupil + absent deep tendon reflexes in the lower extremities
• Occurs in comatose patients
• Unilaterally dilated, poorly reactive pupils.
• CN III palsy
• An internal ophthalmoplegia
• Characteristic features:
1. Ptosis: due to paralysis of the Muller’s muscle
2. Enophthalmos : due to weakness of the inferior tarsal
muscle  elevation of the inferior eyelid.
3. Miosis : due to unopposed action of the sphincter pupillae
following paralysis of the dilator pathway. Pupillary
reactions are normal to light and near.
Dilatation lag : When the lights are turned off the Horner’s
pupil dilates more slowly than the normal pupil because it
lacks the pull of the dilator pupillae.
4. Facial anhydrosis : Reduced sweating on the ipsilateral face
and neck.
Characteristic for preganglionic Horner’s syndrome.
5. Heterochromia iridis : in congenital Horner’s syndrome
• Horner syndrome + pain