Evaluation of Pupils and it’s

Neuro ophthalmic importance

Dr.Mahesh kumar
Dept. Of Neuro-Ophthalmology
Aravind Eye hospital
MADURAI
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Pupillary abnormalities Evaluation
 History
• Trauma
• Surgery
• Occupation
• Drug history
• Past herpetic infection
• Migraine

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Examination

 S/L examination

 Cornea

 Anterior chamber

 Trans illumination of iris

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Testing pupillary reaction to light
 Dim room
 Fixate on a distant target
 Shine the light from below and
illuminate both the pupils uniformly
 Size and the shape of the pupils

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 Pupillary
pathway

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Case 1
 25 year old woman comes with the
complaints of defective vision in her
right eye of 10 days duration. Her
visual acuity in both eyes were 6/6.
Right pupil had a relative afferent
pupillary defect. Colour vision in the
right was 5/10 and in the left eye was
10/10 Ishihara. Fundi were NORMAL
both eyes.
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VIDEO RAPD

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 1. RAPD – Assymetric damage to the
visual pathway
 RAPD on one side does not mean the
other side is normal
 No RAPD if the damage is symmetric.
 Only One working pupil enough

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Small RAPD
• Amblyopia
• Monoocular occlusion
• Anisocoria
• Complete blood – hyphema, Vitreous
haem.
• Large Macular lesion
• CATARACT-
• NO RAPD
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 Quantification of Afferent Pupillary
defect

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Case 2
 60 year old man comes with the
complaints of drooping of the left upper
lid 10 days duration.
 VA OD-6/24
 OS- 6/36
 Cataract

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3rd nerve lesion

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EFFERENT PUPILLARY DEFECT

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 Third nerve lesion
• Right Dilated fixed pupil
RIGHT EYE LEFT EYE

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 Third nerve lesion
• Right Dilated fixed pupil
RIGHT EYE LEFT EYE

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Posterior communicating artery aneurysm

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Case 3 - 30 yr /Male

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HUTCHINSON’S PUPIL

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Case 4 25 yr / female
 Blurring of vision and photophobia
right eye 10 days duration
 VA- Right- 6/9 +0.50 6/6
• Left - 6/6
 Pupil Right eye – unreactive to light
and slow to convergence
• Left eye- D+ C +

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0.125% pilo carpine
 1 ml of 2% pilocarpine + 14 ml of
artificial tear solution
 30 mins

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Adie’s tonic pupil
 Postganglionic parasympathetic
 No ptosis , Ophthalmoplegia
 Mydriatic pupil
 Segmental iris contraction
 Slow tonic redilatation
 Light near dissociation

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Parinaud’s Dorsal midbrain
syndrome
 Vertical gaze palsy ( Up>down)
 Lidretraction ( Collier’s sign)
 Convergence retraction nystamus

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Light near dissociation
 Argyll Robertson pupil
• Miotic pupils
• Typically bilateral
• Rostral midbrain damage
 Syphilis , DM, MS

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Dilated pupil
 Anisocoria more in bright light
• 3rd nerve palsy
• Adie’s Pupil
 Light near dissociation
• Adie’s Pupil
• Argyll Robertson Pupil
• Parinaud’s Dorsal midbrain syndrome

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Sympathetic Palsy

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 Chest Xray
 Pharmacologic tests
• 10% cocaine
• 1% hydroxy amphetamine

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Sympathetic pathway

Sympathetic pathway

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Sympathetic pathway

Sympathetic pathway

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Sympathetic pathway

Sympathetic pathway

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Sympathetic pathway

Sympathetic pathway

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Sympathetic pathway

Sympathetic pathway

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Sympathetic palsy
 Miosis
 Ptosis
 Anhydrosis
 Anisocoria worse in dark
 Dilatation lag

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 Preganglionic
• Wallenberg ( PICA infarct)
• Pancoast tumour ( lung apex)
 Postganglionic
• Cluster headache
• Idiopathic
 Either pre or postganglionic
• ICA dissection
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 Anisocoria

Normal light Abnormal light reaction

reaction
( More in darkness) ( More in Bright light)
Adie’s
Physiologic Third nerve palsy
Horner’s Pharmacologic
Sphincter damage
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COMA
 Normal pupils
 METABOLIC CAUSE

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Normal lighting

Dim illumination

Bright illumination

Accommodation

Response to
pilocarpine
0.125% •Ptosis
•Vermiform •Eyes Partial
•Absent deviated ptosis
Other clinical Laterally.
tendon
features reflexes •Pain
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