Pupil

1. Pupil

2. •Thepupilisanroundedopeninglocatedin
thecenteroftheiristhatallowslightto
entertheretina.
•Itsfunctionistocontroltheamountoflight
enteringtheeyeanditdoesthisvia
contraction(miosis)anddilation
(mydriasis)undertheinfluenceofthe
autonomicnervoussystem

5. Range of pupil diameters
Day light: 2.5 -4.0 mm
Extremes:1.3 -10 mm
Anisocoria -unequal diameters.
The Pupil -Characteristics

6. Light:
Direct: light in OD right pupil constricts
Indirect(consensual): light in OD left pupil constricts
Near response: pupils constrict for near vision (due to
accommodation and convergence)
Sensory/emotional
Drugs with autonomic actions:
Miotics:activate sphincter (PS) or block dilator (S)
Mydriatics: activate dilator (S) or block sphincter (PS)
Pupil Responses

8. Abnormal pupil
•Congenitaldefects(e.g.coloboma,aniridiaand
polycoria,corectopia,congenitalhornerssyndrom)
•Trauma:mydriasisorsphincterruptureDshapedpupil
inirridodyalisisandsurgicaltrauma.
•Inflammatory:iridocyclitismiosis,Irregularnarrow
pupil,Festoonedpupil(effectofmydriaticsinpresence
ofposteriorsynechiae).
•Angleclosureglaucoma:Afixedverticallyovalmid-
dilatedpupilinassociationwithseverepain,aredeye,a
cloudycorneaandsystemicmalaisesuggestsacutewhich
warrantsimmediatereferral.

9. Systemic: Diabetis narcotics(morphine, pethidine)
cause miosis.
mydriatics and miotics.
Abnormalreflex

10. Congenitalabnormalities
Aniridia-thisisabilateralconditionarisingfromtheabnormal
neuroectodermaldevelopmentsecondarytogeneticmutation.Itis
associatedwithglaucomaandanumberofserious,systemic
abnormalities.
abnormalities of the Shape:

11. Coloboma:

12. (corectopia,ectopiapupillae)Ectopic(Misplaced)Pupils:
Isolatedectopicpupilsmaybeinheritantthepupilsmaybe
displacedinanydirectionthepupilsisfrequentlyassociatedwith
ectopialentis,congenitalglaucoma,microcornea,ocularcoloboma,
andhighmyopia.Ectopicpupilsalsooccurinsomepatientswith
albinismandsomepatientswithAxenfieldRiegeranomaly.
acquiredcorectopiamayoccurinpatientswithseveremidbrain
damag,ICEsyndrome,posteriorpolymorphouscornealdystrophy.

13. PolycoriaandPseudopolycoria:
Intruepolycoria,theextrapupilorpupilsareequipped
withasphinctermusclethatcontractsonexposuretolight.Thisisan
extremelyrarecongenitalcondition.Thispseudopolycoriaispassive
constriction,distortion,orevenocclusionoftheaccessorypupil
whenthetruepupilisdilated(Morecommonly,pseudopolycoria
occursasanacquireddisorderfromdirectiristraumaincluding
surgery,photocoagulation,ischemia,orglaucomaoraspartofa
degenerativeprocesssuchastheICEsyndrome

14. Irregular pupil in a case of iridocyclitis

15. Angle closure glaucoma

16. Constricted
Sluggishly reactive due to
Glycogen infiltration of spincter
Autonomic denervation
Arteriosclerosis of radial iris vessels
Pupil in diabetes

17. Acquired structural abnormalities
Pseudoexfoliationsyndrome:

18. Abnormal reflex
Unilaterallight-neardissociation-afferentconductiondefect,
Adiepupil,herpeszosterophthalmicus,aberrantregenerationof
thethirdcranialnerve.
Bilateral-neurosyphilis,diabetes,myotonicdystrophy,Parinaud
dorsalmidbrainsyndrome.

19. Light reflex:
Absolutafferent pupillarydefect.
RAPD ( relative afferent pupillarydefect)
•RAPDseen in optic nerve & retinal
diseases with extensive retinal damage

20. EfferentPupillaryDefect
DDx
A
B
C
D
D

21. EfferentPupillaryDefect
DDx
Adie’spupil
Botulism
CN III lesion
Direct trauma
Drugs

22. •Adie’spupil( later)
•Botulism
–Botulinumtoxinbindsirreversiblyto
presynapticneuron.
–Peripheral& cranialnerve Producesan
exotoxininhibitingAChrelease

23. Occular signs
Ptosis
Extraoccular palsies
Markedly fixed & dilated pupils
Occular symptoms of botulism
Diplopia
Blurred vision
Photophobia

24. CN III lesion
Vascular lesion
Aneurysm
Neoplasm
Trauma
Inflammatory
Infiltrative lesion
Cavernous sinus lesion

25. Direct trauma
Damage to the nerve endings
Damage to the iris sphincter
muscle

26. Drugs
Anticholinergics
Atropine, scopolamine,
hyoscyamine
Ipratropium bromide (nebulizer)

27. Todifferantiate:
Inafferent(sensory)lesions,thepupilsare
equalinsize.Anisocoria(inequalityof
pupillarysize)impliesdiseaseoftheefferent
(motor)nerve,irisormusclesofthepupil.

28. Adie’s Tonic Pupil
Dilated pupil; poor light response; better near response
Due to ciliary ganglion disease or short ciliaryinitially
paralyzes sphincter pupillae and may paralyze ciliary muscle,
causing failure of accommodation
Gradually accommodation returns (more fibers from ciliary
ganglion innervate near than light response)
Pupil sphincter response returns more slowly, and remains
sluggish to light and more responsive to near (accommodation)
Usually unilateral
Response tonically to dilute pilocarpine due to denervation
hypersensitivity

29. Dynamic Anisocoria -Adie’s Tonic Pupil (OD)
Adie’s Pupil -room light Poor direct response

30. Dynamic Anisocoria -Adie’s Tonic Pupil (OD)
Poor consensual responseBetter near response

31. Dynamic Anisocoria -Adie’s Tonic Pupil (OS)
Immediately after
prolonged near
fixation
dilation lag (OS)
Eventually left
pupil fully
redilates
Hypersensitive
response to
pilocarpine
(parasympathomimetic)

32. Parinaud syndrome
•Bilateral mid-dilated pupils that react
poorly to light but constrict normally with
convergence (i.e., not tonic). Associated
with eyelid retraction, supranuclear upgaze
paralysis, and convergence retraction
nystagmus. An MRI should be performed to
rule out pinealoma and other midbrain
pathology.

33. Argyll Robertson pupil
•Causes
•neurosyphilis, DM, encephalitis, MS and
alcholism.
•ch:
•Asmall irregular pupil , anisocoria, light-
near dissociation: light reflex absent &near
is normal, poor dilatation in dark and
mydriatics

34. Raeder’s Syndrome
•Unilateral headache (cluster) or facial pain
in distribution of trigemial nerve
•Ptosis
•Miosis
•Conjunctival hyperemia

35. Horner’s Syndrome (Oculosympathetic
Paresis)

36. Congenital Horner’s Syndrome

37. Pharmacologic Evaluation

38. Cocaine test
•Produces pupillary dilation by preventing
reuptake of norepinephrine
•Cocaine 10% (2 drops, 5 minutes apart)
•In order to act it require functioning
oculosympathatic pathway.
•Dilate normal pupil only

39. Mechanism of action

41. Apraclonidine test
•α
2agonist with significant α
1effect
•Apraclonidine produces significant dilation
of the affected pupil, but the normal pupil
will fail to respond

43. Hydroxyamphetamine Localizing
Test
•Dilates the pupil only in presence of endogenous
norepinephrine.
•2 drops of 1% hydroxyamphetamine 2 days
after cocaine test.

44. •Indirect-acting receptor agonist
–Forces norepinephrine from sympathetic nerve
terminal
•localization of Horner’s syndrome lesion
–Mydriasis central or preganglionic
–No mydriasis postganglionic

45. Requires postganglionic be intact

46. Adrinaline 1:1000 test In both eye:
•In preganglionic lesion→ both pupil not
dilate because adrinaline is destroyed by
amine oxidase
•In postganglionic lesion → Horner`s pupil
will dilate because amine oxidase is absent.

47. Dilatation Lag Test
Demonstrates impaired sympathetic response of the
affected pupil with flash photography.series of 3
photographs were taken.
•The first was in room light with added light in one
eye from a penlight.
•The second photograph was taken in darkness, 4
to 5 seconds after the lights were turned off.
•the third, in darkness 10 to 12 seconds after the
lights were extinguished.
Horner’s pupil will lag behind in dilation, especially
at 4-5 seconds

48. Dilatation Lag Test

49. Pourfourde Petit Syndrome
This syndrome is the clinical opposite of
Horner syndrome. It represents
oculosympatheticoveractivity
unilateral mydriasis, lid retraction, apparent
exophthalmos, and conjunctivalblanching
Seen after trauma, brachial plexus
anesthetic block or other injury, and
parotidectomy

50. Hutchinson’s pupil
•Useful in assessment of head injuries
•Stage1 : Ipsilateral pupil (on the side of
head injury shows contraction due to
irritation, Contralateral (normal) pupil –
normal
•Stage2 : Ipsilateral pupil shows dilatation
due to paralysis , contralateral pupil
constricts (irritation spreads to normal side)

51. Stage3 : Both pupils dilate. Stage of
bilateral paralysis. To assess pupil
repeatedly is important, therefore
mydriatics should be avoided in case of
head injuries

52. Conclusions

53. abnormally constricted pupil
–Unilateral use of a miotic.
–Iritis: Eye pain, redness, and anterior chamber
cells and flare.
–Horner syndrome:miosis ptosis anophthalmos.
–Argyll Robertson pupil:acc reflex preserved.
–Long-standing Adie pupil: The pupil is initially
dilated, but over time may constrict.
Hypersensitive to pilocarpine 0.125%.
–Pontine hge.

54. Abnormally dilated pupil
–Iris sphincter muscle damage from trauma:
Torn pupillary margin or iris transillumination
defects seen on slit-lamp examination.
–Adie (tonic) pupil.
–Third nerve palsy.
–Unilateral exposure to a mydriatic.
–Coma.

56. Thank you