Pupil brainteaser

Disorders of the afferent and efferent (parasympathetic)

pupillary pathways will follow. Please determine, if there is
a afferent or efferent defect or both. If possible, make a
diagnosis. Speculate about aetiology and suggest further
tests. Move back and forth in the presentation.
If a pupil does not react at all, you will need the near
response.
 Terms

Direct lightreaction means the reaction

of the illuminated eye.
Indirect or consensual reaction is what
the fellow eye does.

direct consensual
 N. III.
N. opticus

EWN

PT Midbrain

You will need this anatomical schedule. Located within the

midbrain: Pretectum, Edinger Westphal Nuclei
direct consensual
consensual direct

This is a normal finding: Pupils have

same size (= are isocoric) react
bilateral equally on light.
Your turn:

Task 1
What happened?
Go back and describe what you
saw (direct/consensual). Interprete
the findings.
Solution follows on next slides.
Direct light reaction absent,
consensual is missing too, if the
patient‘s right eye (left on the slide) is
illuminated.
Direct light reaction present, PT
consensual works too, if the patient‘s EWK
left eye (right on the slide) is
illuminated.
Interpretation: The right eye is blind, N. III.
amaurotic pupil, maximal form of an
afferent defect N. opticus
Task 2
A
BC
DEF
GHIKL
What happened?
Go back and describe what you
saw (direct/consensual, near
effort). Interprete the findings.
Solution follows on next slides.
Direct light reaction absent, but
consensual present, if the patient‘s
right eye is illuminated.
This proves, that the right is not blind
inspite of missing light reaction.
Anisocoria becomes obvious.
The right pupil does neither react if
the left eye is illuminated. The light
reaction of the left eye proves that the
left eye is seeing.
Innervation of the right pupil sphincter
muscle must be impaired, an efferent
defect.
 A
BC
DEF
GHIKL

PT

EWK

As the light reaction doesn‘t work we

try the near response. This works. We
are dealing with a light-near
N. III.
dissociation. The would be a typical
finding in a tonic pupil. N. opticus
Task 3
A
BC
DEF
GHIKL
What happened?
Go back and describe what you
saw (direct/consensual, near
effort). Interprete the findings.
Solution follows on next slides.
direct and consensual lightreaction
cannot be elicited via the right eye
Directe und consensual Lichtreaktion
can neither be eleicited via left eye.
This patient might be blind or have
had his pupils dilated. We need the
near response.
 A
BC
DEF
GHIKL

PT

Now the pupils react, again light- EWK

near dissociation, this time bilateral,

either bilateral tonic pupil (rarely so
symmetric) or dorsal midbrain N. III.
syndrome (Parinaud) or bilateral
blind (unlikely, because he fixates N. opticus
the near target well)
Task 4
A
BC
DEF
GHIKL
What happened?
Go back and describe what you
saw (direct/consensual, near
effort). Interprete the findings.
Solution follows on next slides.
Direct light reaction cannot be elicited
via the right eye, but consensual
reaction present. This shows that the
right eye is not blind.
Nothing happens when the left eye is
illuminated. This shows that the left
eye is blind, becuuse its pupil has just
demonstrated that it is able to react.
Hence amaurotic pupil on the lest
side and efferent problem on the right
side. We need the near response
additionally.
 A
BC
DEF
GHIKL

PT

Even near resposne doesn‘t work, EWK

right pupil completely immobile, and

left eye blind. This may be due to a
parasellar tumour. N. III.

N. opticus
Task 5
A
BC
DEF
GHIKL
What happened?
Go back and describe what you
saw (direct/consensual, near
effort). Interprete the findings.
Solution follows on next slides.
Directe light reaction cannot be
elicited via right eye, neither the
consensual reaction of the lest eye.
Light reaction of the right eye can
neither be elicited consensually, but
direct reaction on the left side works.
So it is clear that the left eye is both
blind and has a efferent defect
additionally.
 A
BC
DEF
GHIKL

PT

Near reaction of the right eye works. EWK

The right eye could be a blind eye

with a tonic pupil.
N. III.

N. opticus
 I hope you liked it. Please
construct more tasks out of the
elements you may pick from the
slides and send them to me.
The animations were produced with Powerpoint on a Macintosh with OS 9 (this
indicates that this is not new). Newer Powerpoint versions on Windows and OSX
offer better animations („change size“), which were not available at the time when I
did this. So feel free to use current possibilities.

© Helmut Wilhelm
helmut.wilhelm@med.uni-tuebingen.de