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9/11/2019
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•Andrew G. Lee, MD• Chair Ophthalmology, Houston Methodist Hospital, Professor of Ophthalmology, Neurology, & Neurosurgery, Weill Cornell Medical College; Clinical Professor, UTMB Galveston; UT MD Anderson Cancer Center; Adjunct Professor, Baylor COM, U. Iowa & U. Buffalo, SUNY
Pupils of the pupil You are a critical part of the ophthalmic team (…whether your doctor tells you so or not)
I have no relevant financial disclosures to the contents of this talk
• Financial interest (stock)• Credential Protection
You are the hero of your own life story….
• Better yet you are a SUPERHERO
• You have a super power
• You get to help your eye doctors be real medical doctors by finding intracranial or systemic diseases
• Do you want to see your super power at work
Your awesome super power: helping your doctor help patients beat death• You can help your doctor decide which patient has bad disease just from looking at their pupils!
• Your super power: Recognizing dangerous neuro‐op pupils
• Recognizing the grim reaper/death & keeping him at bay
• Do you want to try it out?
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Your superpower Overview
• When to worry, when to watch?
• Worry: Pain, Acute, Ptosis, Diplopia, Bilateral, Trauma, Child
• Watch: Asymptomatic, chronic, isolated, longstanding (FAT scan before CAT scan)
Pupil of the pupil
Relative afferent pupillary defect (RAPD)RAPD can occur anywhere along pupil pathway on afferent side
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Relative afferent pupillary defect (RAPD)
• Objective sign of optic neuropathy if unilateral visual loss
• Not seen in media (cataract) or refractive error
• Rare in amblyopia (less than 0.3 Log Unit RAPD is rare)
• Size does NOT matter in neuro‐ophthalmic signs (baby RAPD is a sign of a defect in pupillary afferent pathway just like giant RAPD)
Size does not matter…in neuro‐op
Unexplained RAPD (even a baby RAPD) = Worry
“PERRLA” ≠ NORMAL
Apraclonidine test (inferior image) confirmed suspected diagnosis of Horner syndrome.González Martín‐Moro et al. Horner Syndrome, a New Complication. J Oral Maxillofac Surg 2009.
LIGHT
DARK
AFTER APRACLONIDINE
BEFORE APRACLONIDINE
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Although size does NOT matter in neuro‐ophthalmic signs being smart about it does….
Worry!
Acute painful anisocoria after car accident
Life threatening diagnosis?
Beware carotid dissection Sent for levator dehiscence OS
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Date of download: 4/14/2013Copyright © 2012 American Medical
Association. All rights reserved.
From: Ocular Effects of Apraclonidine in Horner Syndrome
Arch Ophthalmol. 2000;118(7):951-954. doi:10-1001/pubs.Ophthalmol.-ISSN-0003-9950-118-7-ecs90240
A. Baseline
B. Cocaine
C. Apraclonidine.
Worry or watch?
Arq. Neuro‐Psiquiatr.vol.66 no.4 São Paulo Dec. 2008
Small pupilsIrregularPoor lightTiny to lightPinpoint near
Light OD
Light OS
Light nearDissociation OU
Worry or watch?
Anisocoria in a child
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Worry or watch?
Chapter 15The Pupils and AccommodationThomas L. Slamovits, Joel S. Glaser and Joyce N. Mbekeani
Old photos confirm long standing anisocoriafrom birth
Toddler photo
Infant photo
FAT scan before the CAT scan(Family album tomography)
Blurry vision, tonic near reaction OD
Poor light reaction OD
Pilocarpine 1/10% constricts OD
Sphincter tears vs. Sector paresis (Adies pupil)
Chapter 15The Pupils and AccommodationThomas L. Slamovits, Joel S. Glaser and Joyce N. Mbekeani
Acute and chronic Adiespupil (6 months)
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Blurry vision, tonic near reaction OD
Poor light reaction OD
Pilocarpine 1% constricts OD
Worry or watch?
24 y.o. nurse in ICU with new dilated and fixed pupil OS
Pilocarpine 1% OU
Bella donna alkaloids AtroposDeadly Nightshade (Atropa bella donna)
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Pilocarpine 1/10% and pilocarpine 1% do not constrict pupil OD
http://mmcneuro.wordpress.com/2013/02/
Worry or watch?
What’s wrong with this picture?
• 60 y/o diabetic man
• New onset ptosis right
• Right adduction, elevation, & depression deficit
• 45 exotropia (XT)
• Diagnosis: “Ischemic third nerve palsy”
• Plan: “Return 6 weeks”
Acute pupil involved third n. palsyLife threatening diagnosis?
Worry or watch? I tell our technicians….
• If the patient’s complaint is diplopia or ptosis or….
• If you have to lift a ptotic lid to put in the dilating drops then….
• STOP, come get the doctor before dilating
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Rule of the pupil
• A pupil involved third nerve palsy
• Aneurysm of posterior communicating artery until proven otherwise
There is no “I” in “TEAM” and….
•There is no “A” in “MRI”
Summary of Pupils of the Pupil
• When to worry, when to watch
• Worry: Pain, Acute, Ptosis, Diplopia, Bilateral, Trauma, Child
• Watch: Asymptomatic, chronic, isolated, longstanding (FAT scan before CAT scan)
Your superpower
Ms. Flaherty is a Certified Ophthalmic Medical Technologist at Stone Oak Ophthalmology in San Antonio, Texas.
Ophthalmic Professional, Volume: , Issue: August 2012, page(s):
The hero in you
• Ms. Flaherty saw a “red eye” patient
• Headache
• Ptosis
• Smaller pupil
• Diagnosis of Horner syndrome
• MRI head/neck: carotid artery dissection & pseudoaneurysm
• Patient wanted to go his family reunion but Ms. Flaherty convinced him to go to hospital where neurosurgery treated dissection
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Three months laterNote from the neurosurgeon to Ms. Flaherty
• "Your patient's dissection has resolved.“
• There is a small pseudoaneurysm, but this should not pose any significant stroke risk to him.
• I will follow up with him in three months with an MRA.
• I again related to him how lucky he was to have you evaluate him initially and to very promptly identify his problem."
Ms. Flaherty comments
• It is this episode in my long career in ophthalmology that I am most proud of being a JCAHPO Certified Ophthalmic Medical Technologist.
• I can say that this was the first and only time in my career I have ever seen a Horner's Syndrome and I was happy I could identify it. It helped save a life.
• Our patient will be attending many future family reunions and, as for me, I will never forget having had a small hand in making that possible.
Why are we here?....
Thanks for your attention Thank you…
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