Pupil ppt

The pupil is an opening located in the center of the iris that allows light to enter the retina. • Its function is to control the amount of light entering the eye and it does this via contraction (miosis) and dilation (mydriasis) under the influence of the autonomic nervous system
3. • The iris is a contractile structure, consisting mainly of smooth muscle, surrounding the pupil. Light enters the eye through the pupil, and the iris regulates the amount of light by controlling the size of the pupil.
4. The iris contains two groups of smooth muscles: a circular group called the sphincter pupillae. and a radial group called the dilator pupillae.
5. Parasympathetic pathway • First Order – Retina to Pretectal Nucleus in B/S (at level of Superior colliculus) Second Order – Pretectal nucleus to E/W nucleus (bilateral innervation!) Third Order – E/W nucleus to Ciliary Ganglion Fourth Order – Ciliary Ganglion to Sphincter pupillae (via short ciliary nerves) • • •

1. pupil

2. T h e pup il i s a n o p e n i n g lo ca t e d i n the c e n t e r o f the i r i s t h a t a l l ow s l i gh t t o e n t e r t h e r e tin a . • I ts f u n c ti o n i s t o c o n t r o l the am oun t o f l i gh t e nt e r i n g t h e e y e a n d it d o e s t h i s v ia c o n t r a c ti o n ( m i os i s ) a nd d il a t i o n ( m yd r i a s i s ) u n d e r t h e i nf l u e n c e of t h e a ut on o mic n e r vou s sys t e m

3. T h e i r i s i s a c on t r ac t i le s t r u c t u r e , c ons i s ti ng m a i n l y of s m oo t h m us c l e , su r r oun di n g t h e p up il . L i g ht e n t e rs the e y e t h ro ug h t h e p up il , a n d t h e i r i s r e gu l a t e s t h e a m o un t o f l i gh t b y c o nt r o l l i n g t h e s i z e o f t h e p up i l .

4.  T h e i r i s c o n t a i ns t w o g ro up s o f s m o o t h m u s c le s : a c i r c u l a r g r o up c all e d the s p h i n c t e r pu pilla e . a n d a r a d i a l gr ou p ca l l e d t h e d i l a t o r pu pilla e .

5. P a r a s y m p a t h e tic p a t h w a y • F i r s t O r d e r – Re ti n a t o P r e t e c t a l N u c l e us i n B / S ( a t l e v e l of S up e r ior c olli c ul u s) S e c o nd Or d e r – P r e t e c t a l n u c l e us t o E/W n u c l e u s ( bil a t e r a l i n n e r v a ti o n ! ) T h i r d O r d e r – E /W n u c l e us t o C ili a r y G a n gli on Fo u r t h O r d e r – C ili a r y G a n gli on t o S p hi n c t e r p u p i l l a e ( via s h o r t c ili a r y n e r v e s) • • •

6. S y m p a t h e t ic P a t h w a y • F i r s t Or d e r – P ost e r i o r H yp o th a l a m u s t o C ili os p in a l c e nt r e of B u d g e ( C 8 - T 2) (U n c r os s e d i n B r a i n s t e m ) S e c o nd O r d e r – C ili o sp i n a l c e nt r e of B u d ge t o Su p e r i or C e r vi c a l G a n a g li on T h i r d Or d e r – S up e r i or C e r vi c a l G a n g li on t o di l a t or pu p ill a e m u s c l e . ( C l o s e t o I C A a nd j o i ns V 1 in t r a c r a ni a ll y) • •

7. E x a mi n a ti o n o f Pu p i l

8. Y o u ca n t h e n o b s e r v e the p up il s c l os e l y b y sh i n i n g a b r i gh t li gh t o n t h e p a tie n t 's f a c e fr o m b el o w ( m i n i m i s e t h e sh a do w cas t by t h e nos e b y p la c i n g the l i gh t i n t h e mi d li n e ). If y o u t h i n k t h e r e i s s i z e a sy m metr y , a go od t r i c k i s t o s ta n d b ac k a nd o b s e r v e the r e d r e f l e x of bo t h e y e s s im u lta n e ous l y w it h the op ht h a l m os c op e . A s l i gh t d i ff e r e n c e w i l l t h e n b e c o me m or e a pp a r e n t .

9. P up i l s P u p il i s t h e c ir c u la r a p e r t u r e i n t h e ce n t r e o f i r i s . I t s n o r mal s i z e i s 3 - 4 mm . i t i s g r a y i s h bl ac k i n c o l ou r.

10. P o i n t s t o b e no t e d i n p up i l N u m b e r-n o r m a l l y t h e r e i s o ne p up il . Mo r e t h a n on e pup i l i s ca ll e d p o l y c o ri a . L o c ati on - n or m a l l y alm o s t c e n t r al , s l i gh tl y n a s a l . E cce nt r ic p u p il i s ca lle d c orr ec t op i a . S i z e o f pu pil s

11. N o r m a l pu p il m a y be v a r i a ble s i z e s b ut sh o ul d b e e q u a l r ea c t t o li g h t c e n t r a l r o u n d A b no r m a l u n e q u a l dil a t e d or c on s t r i c t e d n o t r e a c ti ng t o li g ht i r r e gul a r ( e g t ea r d r o p ) n o t c e n t r a l

12. A ss e ss i n g pu p i l l a r y reflexe s T h e r e a r e es s e n t i a ll y t h r e e r e f l e x e s t o s p ec ifi ca l l y te s t f o r :  L i g h t- re fl e x t es t  Sw i ng i n g f l ash li g h t t e s t  N e a r - re f l e x t e s t

13. P u p i l l a r y r e a c t i o ns   • P u p illa ry R e f l e x e s L i gh t r e f l e x - D ir ec t - thr o w l i gh t i n t o t h e e y e , l oo k f o r p u pilla ry c ons t r i c t i o n i n t h e s a me e y e C o ns e n su a l - k ee p a n o b s t r u c ti o n b e t w ee n t h e t w o e y es . T h row li g h t i n o n e e y e , l oo k for c ons t r i c ti on i n ot h e r e y e . •

14.  L i gh t - r e f l e x t e st • W h at it a ssesse s - the i n t e g r i t y of the pu p ill a r y li g ht r e f l e x p a t h w a y. H o w t o p e r f orm it - d im the a m bi e nt li g h t a nd a s k t h e p a ti e n t t o f ix a te a d i s t a nt t a r g e t . S hi n e the r i g ht e ye f r om t h e r i g ht s ide a n d the l e f t f r om t h e l e f t s id e . (M a k e s u r e y ou do n ot s t a nd i n f r o nt of t h e p a ti e nt a s th e i r p u pil s w ill a c c o m moda te t o f o c us o n yo u ) . Re c o r d w h e t h e r th e r e i s a d i r e c t p up i ll a r y r e s p on s e ( t h e p u pil c o nst r i c ts w h e n the l i g ht i s sh o ne o n it ) a n d a c ons e n sua l r e s po n s e ( the f e ll ow p u p i l c on s t r i c t s t o o ) . N or m al t e s t - th e r e sho u l d be a b r i sk , s i m ult a n e o u s, e q u a l r e spo n s e o f b o t h p u pil s i n r e s p on s e t o light sh o ne i n o ne o r the oth e r e y e . • •

15.  S w i n g i ng f l a s h li ght t e st • W h at it a ssesse s - c o m p a r e s d i r e c t a nd c on s e n sua l r e s p on s e s of ea c h e ye ( a s o p p os e d t o se e i n g w h e t h e r th e y a r e t h e r e or n ot ) . H o w t o p e r f orm it - u s e t h e sa m e c on d iti o n s a s f o r the li g h t r e f l e x t es t a n d c h e c k thi s r e f l e x f i r s t . The n, m o v e the b e a m sw i f tl y a nd r h y th m i c a l l y f r om o n e e y e t o the oth e r , m a k i ng s u r e th a t y ou a ll ow t h e sa m e a m o u n t o f li g h t e x p os u r e on e a c h e y e a nd th a t ea c h i s illu m i n a t e d f r om t h e sa m e a n g l e . Y ou s ho u l d note the p u pill a r y c on s t r i c ti on o f b o t h e y e s w h e n the b e a m i s m a i n t ai n e d . H o w e v e r , w h e n it i s sw u n g, l o ok a t w h a t h a p p e ns t o t h e p u pil of t h e e ye y o u a r e c o n c e r n e d a b o u t a nd c o m p a r e t h i s w it h w h a t i s h a p p e n i ng t o the f e ll ow e y e . •

16. N or m a l t e s t - t h e pup i l s hou l d c o ns t r i c t o r s t a y t h e sa me s i ze . If i t d i l a t e s w h e n li g ht i s s hon e o n i t , t h e n thi s m ea n s t h at t h e li g ht r e f l e x i s w e a k e r th a n t h e c o ns e n s u a l r e fl e x ( p ro du ce d b y w i t hd r a w i ng l i gh t fr o m t h e un a f f ec te d e y e ), s ugg es ti n g o p tic n e r v e p a t ho l ogy . T h i s a b n o r m a l r e sp o ns e i s k now n a s a r e lati v e a f f e r e n t p u p il l a ry d e f e c t ( R A P D ) a n d i s a v e ry im po r t a n t s i g n. No te t h a t t h i s i s a c o m p a r a t i v e t es t: yo u ca nn ot h a v e a b i l a t e r al R AP D.

17. P u p i l l a ry r e a ct i on s  N e a r r e f l e x - pup i l c on tr ac t s w h i l e l oo k ing a t n e a r ob je c t . I t h a s 2 p a r t s – c o nv e r g e n c e r e f l e x i. e . c o nt r ac t i o n o f p u pil o n c o n v e r g e n ce a cc o m m od a t i o n r e f l e x i . e . c on t r ac t i o n on a c c o m m od a t i o n

18.  N e a r - r e f l e x t e s t • W hat it ass es s e s - t h i s a ssesse s the m i o s i s c o m p o n e nt of n e a r f ix a ti o n . ( The o th e r t w o c o m p o n e nt s a r e a cc o mm o d a ti o n : i n c r e a se d l e n s thi c k n e s s a nd c u r v a t u r e , a nd c o n v e r g e n c e o f t h e e y e s ) . H o w t o p er f orm it - i n a no r m a ll y lit r o o m , i n s t r u c t the p a t i e nt t o l o o k a t a d i s t a nt t a r g e t . B r i n g a n o bj e c t ( t o y, p a t i e nt ' s t h u m b) i n t o th e i r n e a r po i nt ( a bo u t a n a r m ' s l e n gt h a w a y) a nd o bs er v e t h e pu p ill a r y r e f l e x w h e n t h e i r f i x a ti o n sh i f t s t o the n e a r t a r g e t . N o r mal t es t - th e r e sho u l d be a b r i s k c on s t r i c ti o n . A n e a r- li g h t d i s soc i a ti o n d e scr i b e s the s itu a ti on w h e r e the p a t i e nt h a s a s i g ni f i c a ntl y b e tt e r p u pill a r y n e a r r e f l e x t h a n li g ht r e f l e x. • •

19. Abn o r m a l pu p i l s

20.  A n i s o c o r i a • T h is r e f e r s t o u n e q u a l pu p il s . T h i s i s ph y s iol o gi c a l i n a b o u t 2 0% o f p e o p l e . H o w e v e r , i f thi s i s a n e w c o m pl a int , the s t e ps t o t h e u n d e r l y i n g di a g n osi s lie i n d e t e r m in ing w hi c h o f t h e p u pil s i s a b no r m a l a nd t h e n l o o k f or a s s o c i a t e d s i g ns. The f i r s t s te p i s t o c o m p a r e the p u p i l s i n li g ht a n d dim c o n d iti on s : I f t h e r e i s a p o o r r ea c ti on t o li g ht i n o n e e ye a nd the a n i soc o r ia i s m o r e e vi d e n t i n a w e ll lit r o o m , th e n the a f f ec t e d p up i l i s a b n o r m a ll y l a r g e . I f t h e r e i s a g o o d r e a c ti on t o li g ht i n bo th e y e s b u t a p o or d i l a ti o n i n the d a r k ( i. e . the a ni s o c o r ia i s e n h a n c e d ) , th e n t h e a f f e c t e d pu p il i s a b n o r m a ll y s m a ll . • •

21.  T h e ab n o r m a ll y l a r g e pup il F e a t u re s - t h e r e i s p o o r c ons tri c ti on i n a w e ll l it r oo m . D i ff ere n t i a l di agn o s i s - t r a u m a tic iri s d a m a g e , t h i rd c r a ni a l n e r ve p a l s y, ph a r m ac o l og i c al dil a t i o n ( i . e . d ilati n g d r ops ), Ad ie 's pup i l , i r i s ru b e os i s .

22.  T h e ab n o r m a ll y s m a ll p u p il F e a t u re s - t h e r e i s p o o r dil a t i o n i n a dim r oo m . D i ff ere n t i a l di agn o s i s - phy s i o l o gi ca ll y s m a ll p up il , pil o c a r p i n e dr ops , uv i e t i s w it h s yn ae c h i ae , Ho r n e r's sy n d r o m e .

23. N o t e : D i l a t e d p up i l o f L e f t e y e

24. P up i l • C o n s t r i c t e d (m ioi s i s ) S ymp athetic (pupi l lodilat o r ) d e n e r v a t i on D rugs P il o c a r p ine Mor ph i n e • D i l a t e d (m y dri a s i s) Para s ymp athetic (pup i lloc on s t r ict o r ) d e n e r v ati on L e s i on of t he t h i rd CN D rugs • A t r op i n e C o ca i n e

25. S h a p e o f pu p i l • • • S h a p e no r m a ll y c i r c u la r Ir r e gu l a r n a rrow p up i l - i ri do c y c l i ti s F es t oo n e d p up i l - i r r e g ul a r pup i l a ft e r p a t c h y d i l a t a t i o n ( e ff e c t o f m yd r i a tic s i n pr e s e n ce o f p os t e r i o r sy n ec h i a e )

26.  T h e ab n o r m a ll y s h ap e d pup i l F e a t u r e s - a pup il sh o u l d b e r ou n d . D e v i a t i o n f r o m t h i s s u gg e s t s a bno r m a l i ti e s . D iff e r e n t ial d i ag n os i s - c ong e n it a l d e f ec t s ( e . g. c o l o bo ma ), i r i s i nf l a m m a t i o n o r t r a u m a , A r gy ll R ob e rt so n pup i l s . A fi x e d ov a l p u p il i n as so c iati o n w i t h s e v e r e p a i n , a r e d e y e , a c l oud y c o r n e a a n d s y s t e mic m a lai s e sug g e s t s a c u te a ng l e c l os ur e g l a u c o ma w hi c h w a r r a n t s i mme d i a te r e f e rr al .

27. Irregu l a r pupil i n a ca s e of i rido c yc l it i s

28.  T h e abn o r m a l l y re a c t i ng pup il L i ght re f l e x t e s t - a b no r m a liti e s a r i s e a s a r esu lt of s e v e r e o ptic n e r ve d a m a g e ( e .g. t r a n se c ti o n) - t h e p a ti e n t w ill be bli n d i n th a t e y e , n e it h e r pu p il r e a c t s w h e n t h e a ff e c t e d s ide i s s timul a t e d b ut bot h p upi ls r e a c t n o r m a ll y w h e n the f e ll o w e y e i s s ti m u l a t e d. S w i n g i ng f l a s h li ght t e s t - w h e n t h e pu p il e x h ibit s a n R A P D , it i s d e s c r ib e d a s a Mar c us G u nn p up i l . I t su g g es t s o p t ic n e r v e di s e a s e , c e nt r a l r e ti n a l a r t e r y o r v e i n o c c l u s i o n s , e xt e nsi v e r e tin a l l e s i on . A m i l d R A PD m a y a l s o o cc ur i n a m b l yo p i a , w it h v i t . h g , R D or a d v a n c e d m a c u l a r d e g e n e r a ti o n .

29.  N e a r - r e f l e x t es t - t h e r e a r e s e v e r a l c a us e s o f l i gh t- n ea r d i s so c iati o n w hi c h ca n b e g r o u p e d a c c o r d i n g t o wh et h e r t h e p ro b l e m i s u n il a te r a l or b i l a te r a l: U n ilat e ra l l i gh t - n e a r d i ss o c i a t i o n - a f f e r e nt c o ndu c t i o n d e f ec t , A d ie pup i l , h e r p e s z os t e r o ph t h alm i c u s , a b e rr a nt r e g e n e r a ti o n of the t h i rd c r a ni a l n e r v e . B il a t e ra l - n e u r osyp hili s , d i a b et e s , m yo t o nic d ys t ro phy , P a r i n a ud d o r s al mi db r a i n s ynd r o m e , e n ce ph aliti s , c h ro n ic a l c o ho l i s m .

30. D i s ea s e s a f f e c t i ng th e p u p i l s

31.  C o n g e n i t a l a bn o r m a li t i e s • A n i r i d i a - th is i s a b il a t e r a l c o n d it i o n a r i s i n g f r om the a b n o r m a l n e u r o ec tod e r m a l d e v e l o p m e nt s e c o nd a r y t o g e n et ic m ut a ti on. I t i s a ss o c i a t e d w it h gl a u c o m a a nd a numbe r of s e r i o u s , s y s t e mic a b n o r m a liti e s. C ol o bom a : thi s i s a n u n c o m m on, c o ng e n it a l c o n d i ti o n c h a r a c t e r i s e d b y a u n il a t e r a l or b il a t e r a l p a r ti a l i r i s d e f ect . Le u c o c o r i a r e f e r s t o a w hite p upil a nd m a y be d ue to a n u m b e r o f c o nd i ti on s . C o n g e nit a l cata r a c t s a r e g e n e r a ll y e as il y i d e n ti f i e d b u t a ll p a t i e nt s m u s t be a s s e s s e d f or t h e p o ss i b ilit y of r e ti n o b l a s t o m a . O t h e r c o n d i ti o ns c a u s i ng a w h i t e pu p il i n cl u de p e r s i s t e n t f e t a l v a sc ul a t u r e s y n d r om e , Coat ' s di se a s e a n d R O P. • •

32. A c q uire d s truc t ural a b n o r m ali t ie s • P s eud o e xfo l iati on s y ndr o m e - thi s i s a c ond i ti on c h ara c t eri s e d by d e po s i t i on of a gre y - w h ite fi b r ogr a nul a r ext r a cellu l a r m atr ix m ater i a l d e po s ite d on the anteri or le n s . I t i s s e e n, on s lit - la m p e x a minati on, a s a f ine gre y du s ti ng a round the pupi l. P upil s h a pe a nd fun cti o n a r e not affecte d - i t i s cl i nic a l l y s ignificant due t o it s a s s o ciati on w it h gla u c oma a nd it s pot ential to m ak e C A T A R CT s urg e ry m o re tric ky. Sp h incte r te ar - i r i s t e a r c a n o cc ur a s a re s u l t of blunt o r p e n e t rati ng t r a uma an d ca n al s o o c c ur duri ng i n t ra o cula r s u rge ry. T ea rs m a y be a s s o ciate d w it h gla u c oma a n d , if la r ge , vi s u al probl e m s . A ll tea r s , ho w e v e r s m al l, n e e d ophth a lmol o g ic a l a s s e s s men t. S y nechiae - thi s r efe rs t o a dh e s i o n s b et w ee n the le ns a nd the i r i s ( po s te r i or s yn ech i a e ) or the i r i s a nd t h e p e r iph e r al c orn e a (per i ph e r al anteri or s yn echiae ). T h e s e ad h e s i ons w i ll give r i s e t o a n a bnorm al ly s h a p e d pupil; t r e a t m ent d e p en ds on the und erlyi ng ca u s e . U v eit i c p o s ter ior s yn e c h i a e are b r o k e n w i th m yd r iatic s w h erea s g l a u com at o u s anteri or s y n e chia e m a y be m a n a g e d w i th mioti c s . • •

33. N e u r o l og i c a l a b n o r m a li t i e s

34. H o r n e r ’s synd r o m e - t h i s s ynd r o me i s c h a r a ct e r i se d b y m i os i s w i t h a pu pil t h a t i s s l o w t o d i l a t e , a mil d ( 1 - 2 m m ) p t o s i s , i ps ilat e r a l a n h yd ro s i s a n d a p p a r e n t e n oph t h a l m os ( a ff e ct e d e y e a p p ea rs t o b e s unk e n) a s a r e su lt o f a c o m b i n a t i o n o f t h e pt os i s a nd a s l i gh t e l e v a ti on o f t h e i n f e r i o r e y e li d . T h e i r i d e s ma y be o f d i ff e r e n t c o l o u rs i f the l e s i on i s c ong e nit a l o r l on g- s t a nd i ng . D e p e nd i n g o n t h e l o ca ti on of t h e l e s i o n, so me or all o f t h e s e f e at u r e s w i ll b e pr e s e nt .

35. H o r n e r’ s • O c ul o symp a t h e tic p a r es i s Pt o s i s : mi ld (1-2m m ) M i o s i s Ip s ilateral a nhi d r o s i s D oe s not dilate w it h cocaine 4%

36. C a us e s o f H o r n e r ’ s pup i l • Ce n t r a l – B/ S l es i o n s ( tum ou r s , v a s c u l a r a n d M S) • P r e g a n g lion i c – P a n c o a s t tum ou r , C a r oti d & A o r tic a n e u r ys m s , N e c k l es i o ns/t r a u m a . P ost g a n gli o nic – C l u s t e r h e a d a c h e s , N a s o p h a r y n g e a l tumou r s , O titi s m e di a , Ca v e r n o us s i n us m a s s a n d I C A d i se a se . Mi sc e l la n e o us – C on g e nit a l ( b r a c hi a l p l e xus in ju r y ) I d iop a thi c . • •

37. C on f i r m a t i o n o f Ho r n e r's s y nd r o me i s w i t h i ns til l a ti on o f a d r o p of 4 % c o c ai n e :  i n p hys i o l og i c al a n i s o c o r i a , t h i s r e su lt s i n dil a t i o n wh e r ea s it do es n ' t wh e r e t h e r e i s a H o r n e r's syn dr o me .

38. F ur t h e r lo ca l i s a ti o n of the p r ob l e m i s ca r ri e d o u t w it h 1 % h yd ro xy a m ph e t a mi n e ( P a r e d r i n e ). I ns t i ll a t i o n i s don e > 4 8 ho urs a f t e r t h e c o ca ine t e s t a s c o c ai n e a ff e c t s t h e P a r e d r i n e . Pu pill a ry dil a t i o n sugg e s t s a c e n t r al o r p r e g a n g li o n ic H o r n e r's syn dr o me w h e r e a s i f dil a t i o n do e s n o t o cc u r , t h e l e s i o n i s li k e l y t o b e p os t g a ng li o n i c .

39. ) A d i e ' s) t o nic pup il t h i s d e s c r i b e s a un i l a t e r a l ( 80 % o f c a s e s ) m y d r iatic pup i l i n ot h e r w i s e h e a lt h y p a t i e n t s ( t yp i ca l l y you ng a d u lt s , e sp e c i a ll y w o me n ). O v e r m o n t h s t o y ea r s , t h e p up il d imi n i s h e s i n s i ze t o e v e n t u a ll y b e c o me mi o t i c . T h e r e i s a s lu gg i s h , s e c t o r al or n o r e a c ti on t o l i gh t b ut a n o rmal n e a r r e f l e x . R e d ilati o n a f t e r t h e n ear - r es pon s e is s l o w . S lit-lam p e x amin a ti o n m a y r e v ea l s l o w , v e r m if o r m c o nt r ac t i on s o f t h e iri s b u t u ltim a t e l y

40. t h e di a gn o s i s i s c on fi r m e d by t h e pup i l 's h yp e r s e ns i t i v it y t o w e a k miotic d r op s ( e . g . 0 .0 5- . 125 % p i l o ca r p i n e ) w h ic h c a us e s t h e a b no r m a l pup il t o c on t r a ct v i go r ous l y a nd t h e n o r m a l p u p il m i n i mall y . O c ca s i on a l l y , it i s a s s o c i a t e d w i t h d i m i n i sh e d d ee p t e n d o n r e f l e x e s ( Ho lm e s - A d ie sy n d r o m e ) ± a u t on o mic n e r v e dys f un c t i o n .

41. T h e e x a ct c a us e i s no t kn o w n bu t it o f t e n o cc u rs a ft e r a v i r a l il l n e s s ( e . g . h e r p e s z o s t e r o ph t h alm i c us a n d d e n e r v a t i o n of t h e p os t g a ng li o n ic sup pl y t o t h e sph in c t e r pu pill a e i s d e s c r i b e d . T h i s t e n ds t o be a b e n i g n c o nd i t i o n a n d t h e p ati e n t i s s im p l y o b s e r v e d. H ow e v e r, i n f a n t s < 1 y ea r o l d sh o u l d b e r e f e rr e d t o a p ae d i a t r ic n e u r o l og i s t t o r u le ou t f am il i a l dys t o n i a s ( R i l e y D a y s ynd r o m e (

42. A r gy ll R ob e r t so n pu p il - t h e s e a r e c a u se d b y n e u r os y ph il i s . A l t h o ug h usu all y as y mpt o m a t i c , th e y h a v e c h a r ac te r i s t ic f e a t u r e s o n e x a m i n a ti o n . T h e s e i n cl ud e a bil a t e r a l ( usu a l l y a s y mm e t r i ca l ) s m a l l , i rr e g ul a r pup i l s s how i n g a li gh t - n ea r di sso ci a ti o n . T h e y a r e d i f fi c u lt t o d i l a t e . Ma n a g e me n t i s r e l a te d t o t h e und e rl y i n g di s ea s e .

43. • A r g yll - R ob e r t son p u pil S m all , i rre g D o e s not r e act t o l ight R eact s to a c c omm o d a t i on C a u s e s s y p h i li s d i a b e t e s • Mi o tonic p u p il ( A d i e ’ s sy n d r o m e ) – – D il a t e d P oo r r e s pon s e t o l i g ht a n d c onv e r g e n ce . • C on s t r i c ts w it h w ea k Pilocarp i n e H ol m e s -Adie s y nd r o me • – R e du c e d t e ndo n r e f l e x e s ( K n e e , a nk l e ) - O r t ho s t a ti c hyp ot e n s i on c o m p a r i so n

44. D r u g s af f e c t i ng th e pup i l s

45.  T op i c a l d ru g s D i l a t i n g - s y m p a t ho m e m t i c e . g . p h e ny l e ph r i n e , a dr e n a l i n e d i p e r a v ine a n d a ntim us ca r i n i c s e . g . c y c l op e n t o l a t e , t r op i c amide , a t r o pi n e . C ons t r i c t i n g - m us ca ri n ic a g o n i s t s e . g . pil o ca r p i n e .

46.  Sys t e m ic d r ug s D i l a t i n g - s y m p a t ho mi m e t i c s e . g . a dr e n a l i n e a nd a n tim us c a r i n ic s e .g . a t r o pi n e . T h i n k a l s o of tri c y c l ic a n t i d e p r e ss a n t s , a m p h e tam i n e s . C ons t r i c t i n g - o p i a t e s e . g m o r ph i n e a nd or g a no p hosp h a t e ..