4/20/16 Pupils Maple Grove Fridley Maplewood - … · Maple Grove Fridley Maplewood ... flashlight test 3) AnisocoriaALWAYS present 4) Accommodation can be affected ... (VDRL) §

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PupilsMore Than What Meets the Eye

Jordan Keith, OD, FAAOMinneapolis, MN

Maple Grove Fridley Maplewood

Greg Kraupa, OD

Jordan Keith , ODAshley Herde, OD

Tina McCarty, ODSteve Nauman, OD Mitch Albers, OD Brad Richter, OD

Objectives

§ Review anatomy

§ Normal pupils

§ Abnormal pupils

Fig 14-10

Light response

CN II = AFFERENT

CN III = EFFERENT

Parasympathetic pathway

1) Miosis

2) Accommodation

R L

Fig 14-9

Near response

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Sympathetic pathway1) Mydriasis

2) Muller’s muscle

Fig 14-15

Normal

Normal Normal

Fig 14-10

Light responseCN II = AFFERENT

CN III = EFFERENT

R L

Anisocoria?

Afferent Disruption

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Afferent Disruption Afferent Disruption

Fig 14-10

Light responseCN II = AFFERENT Disruption

1) Weaker direct response

2) (+) APD indicates unilateral or asymmetric retinal and/or prechiasmaloptic nerve disease

3) Anisocoria NEVER present

4) If disease equal and symmetric there will NOT be a (+) APD

R L Grading a (+) APD

APD Grade I: a weak init ial constrict ion and greater redilatat ion

Grade II: init ial stall and greater redilatat ion

Grade III: immediate pupillary dilatat ion

Grade IV: immediate pupillary dilatat ion following prolonged illumination of the good eye for 6 seconds

Grade V: immediate pupillary dilatat ion with no secondary constrict ion

Bell RA, et al. Arch Ophthalmol. 1993 Jul;111(7):938-42

Fig 14-10

Light responseCN II = AFFERENT

CN III = EFFERENT

R L

Anisocoria?

Efferent Disruption

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Efferent Disruption Efferent Disruption

Fig 14-10

Light responseCN III = EFFERENT

Disruption

1) Poor direct response

2) Affected side stays dilated on swinging flashlight test

3) Anisocoria ALWAYS present

4) Accommodation can be affected

R L Clinical Presentations

Presentation

No Anisocoria

(+) APDAfferent disruption

Anisocoria

Pupil dilated (bigger difference in light)

Pupil miotic (bigger difference in night)

No Anisocoria(+) APD

Afferent disruption

Glaucoma

NAION/AAION

RD

Optic neuritis

Optic nerve compressive disease

Dense vitreous heme

Note: corneal scars , cataracts , amblyopia and maculopathy (unless severe)

do not cause an APD with a bright light source

Anisocoria

Pupil dilated (bigger difference in l ight)

Adie’s tonic pupil

Pupil involving CN III palsy

Pharmacologic

Trauma/mechanical

Pupil miotic (bigger difference in dark)

Horner’s syndrome

Uveitis

Argyll Robertson

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35 year-old female / blurry vision OD 35 year-old female / blurry vision OD

35 year-old female / blurry vision OD

Fig 14-10

R L

1) Acute dilated pupil (that constricts over time)

2) Female predominance (2.6:1)

3) Commonly young (20-40)

4) Typically unilateral (80%)

5) Minimal (if any) response to l ight

6) Vermiform movement with segmental paralysis

7) Poor accommodation

8) Damage to cil iary ganglion with unknown etiology

Adie’s Tonic Pupil


Video courtesy of Kyle Cheatham, OD, FAAO

Instillation of 0.10% pilocarpine

OD Before OD After

Photos courtesy of Kyle Cheatham, OD, FAAO

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§ Sphincter muscle has cholinergic hypersensitivity

§ Low concentrations of pilocarpine will cause constriction of an Adie’s tonic pupil and have minimal to no affect on a normal pupil

Bourgon P, et al. Am J Ophthalmol. 1978 Mar;85(3):373-7

Irises of healthy 20-40 year-olds exposed to four concentrations of pilocarpine

• Pupillary constriction0.25%

• Pupillary constriction0.125%

• No pupillary constriction0.0625%

• No pupillary constriction0.0313%

Leavitt JA, et al. Am J Ophthalmol. 2002 Mar;133(3):333-6


Assessment§ Dilute one part 1% pilocarpine with 7 parts saline to achieve 0.125%§ Instill one drop into both eyes

§ Maximum effect 30-60 minutes

Treatment and Management§ Dilute 0.125% pilocarpine bid-qid to decrease glare

§ Bifocals or readers to help with accommodative deficiency

§ Usually resolves within months

Fig 14-10


R L

Presentation?

CN III Anatomy

IR

MR

IOSR

Levator

Pupil

Pupi

l

Pupil

Pupil

PCA

CN III palsy

CN III Palsy

Diabetes associated (10%)

75% pupil sparing

25% relative pupil sparing

Aneurysmal compression (10%)

75% fully-dilated non-reactive pupil involving

Dhume KU, et al. Indian J Ophthalmol. 2013 Jan-Feb;61(1):13-7Jacobson DM, et al. . Arch Ophthalmol. 1998;116:723–7Keane JR, et al. Can J Neurol Sci. 2010 Sep;37(5):662-70

Kissel JT, et al. Ann Neurol. 1983;13:149–54Keane JR. Ann Neurol. 1983;14:696–7

70% pain

95% pain

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Other Causes of CN III Palsy With Pupil Involvement

§ Giant cell arteritis

§ Pituitary apoplexy

§ Demyelinating disease (e.g. MS)

§ Midbrain infarction

§ Oculomotor nerve schwannoma/meningioma

§ Brain metastasis

§ Trauma

§ Ophthalmoplegic migraine

An isolated dilated pupil without ocular dysmotility or ptosis rarely

(never) represents a third nerve palsy

Pupil Involving CN III Palsy

Assessment§ Pupil has been found to be supersensitive to pilocarpine

§ 1% pilocarpine causes pupil constrict ion

§ Immediate neuroimaging to test for mass/aneurysm§ In pupil involving CN III palsies § Age < 50 without history of DM or HTN

§ Progressing part ial CN III palsies § CN III palsy > 3 months in duration without improvement

§ Addit ional CN involvement or neurological abnormalit ies

Jacobson DM, et al. J Neuro-ophthalmol. 1998 Sep;18(3):171-5

Pupil Involving CN III Palsy

Assessment

§ Neuroimaging may not be required in pupil-sparing CN III palsies age > 50 with known vasculopathic risk factors § Associated with the rare risk of missing an aneurysm sparing

the pupils

§ Observe daily for 14 days from onset for delayed pupil involvement then every 4-6 weeks

Anisocoria

Pupil dilated (bigger difference in l ight)

Adie’s tonic pupil


Pharmacologic

Trauma/mechanical

Pupil miotic (bigger difference in dark)

Horner’s syndrome

Uveitis

Argyll Robertson

Horner’s Syndrome(oculosympathetic

paresis)

Presentation?

Fig 14-15

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Horner’s Syndrome Horner’s Syndrome

Horner’s Syndrome(oculosympathetic paresis)

Presentation§ Ptosis typically 1-2 mm

§ Miosis

§ Dilation lag

§ Anihidrosis


Congenital-Traumatic delivery at birth-Look at old photos and for lighter iris on affected side


paresis)

First/second order-Stroke

-Cervical spine disease

-Tumor

-Neck/chest surgery or trauma

Fig 14-15


paresis)

Third order-Carotid artery dissection

-Cavernous sinus disease

-Cluster headaches

-Herpes Zoster

-Otitis media

Fig 14-15

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Assessment§ 4-10% cocaine/hydroxyamphetamine

§ Gold standard

§ 0.5% apraclonidine (Iopidine)§ Proposed substitute

§ Causes reversal of anisocoria

Koc F, et al. Br J Ophthalmol. Nov 2005; 89(11): 1442-44Brown SM, Aouchiche R, Freedman KA. Arch Ophthalmol 2003;121:1201–3

Bacal DA, et al. Arch Ophthalmol 2004;122:276–9Morales J, et al. Arch Ophthalmol 2000;118:951–4

Kawasaki A, et al. Klin Monbl Augenheilkd. May 2008;225(5):520-2


Treatment and Managment

§ Old cases more likely benign § Monitor if signs point to congenital

§ New onset cases require more extensive diagnostic workup § CT scan of chest to evaluate lung apex

§ MRI/MRA head and neck § Carotid doppler if carotid artery dissect ion is suspected (neck pain)

§ 0.5% apraclonodine tid in affected eye can be used to raise ptosis

Argyll-Robertson Pupil

Presentation§ Bilateral (80-90%) asymmetric miotic pupils

§ Light-near dissociation

Argyll-Robertson Pupil

Argyll-Robertson Pupil Argyll-Robertson Pupil

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Argyll-Robertson PupilLight response Near response Argyll-Robertson Pupil

Causes§ Neurosyphilis

§ Diabetes

§ Alcoholism

Argyll-Robertson PupilAssessment

§ Look for interstitial keratitis, chorioretinitis, papillitis, and uveitis

§ FTA-ABS or MHA-TP

§ Rapid plasma reagin (RPR) or venereal disease research laboratories (VDRL)

§ Has been suggested that patients with bilateral tonic pupils should be screened for syphilis

Thompson HS, Kardon RH. J Neuroophthalmol 2006 Jun;26(2):134-8

Physiologic (simple) Anisocoria

Unequal pupil size in the absence of disease

20% of population

0.4 mm or more clinically significant

A variable phenomenon

Loewenfeld IE. Trans Am Acad Op hthalm ol Oto -lary ngo l. 1 9 7 7 ;8 3 :8 3 2

Lam BL, Corb ett J, Thom p son HS. Am J Op hthalm ol. 1 9 8 7 Ju l 1 5 ;1 0 4 (1 ):6 9 -7 3Lam BL, Thom p son HS, Walls RC. Op hthalm ology . 1 9 9 6 May ; 1 0 3 (5 ):7 9 0 -3

Physiologic (simple) Anisocoria Physiologic (simple) Anisocoria

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Physiologic (simple) Anisocoria Physiologic (simple) Anisocoria

Assessment § Measure pupil size in normal and dim room

illumination

§ If difference in size is consistent between the two eyes and both are reactive, diagnosis is confirmed

§ Example: OD 6mm - 4mm. OS 5mm - 3mm.

Pupillary athetosis (hippus)

§ Spasmodic, rhythmical dilation and constriction of the pupil, independent of illumination, convergence, or psychic stimuli

§ In general it is benign and most noticeable in younger patients when examining pupils with light

§ A retrospective study of 117 hospitalized patients with hippus found an increased 30-day mortality when compared to controls and adjusted for other factors (odds ratio=4.1, p<0.001)

Denny JC, et al. Am J Med 2008 Mar;121(3):239-45

Objectives

§ Review anatomy

§ Normal pupils

§ Abnormal pupils

Contact [email protected]

Documents

4/20/16 Pupils Maple Grove Fridley Maplewood - … · Maple Grove Fridley Maplewood ... flashlight test 3) AnisocoriaALWAYS present 4) Accommodation can be affected ... (VDRL) §