Problem Pupils
Author: Hamza Shah, OD, MS
Chart from “Will Eye Manual”
| Pupil Condition | Description |
|---|---|
| Horner’s Syndrome | Characterized by a triad of ptosis, miosis, and anhidrosis on one side of the face. Results from disruption of sympathetic nerve pathways, often due to tumors, trauma, or neurological disorders. |
| Adie’s Pupil | Presents as a dilated pupil that reacts slowly to light and accommodates better. Typically unilateral, it is associated with damage to the ciliary ganglion and is commonly benign, affecting younger women. |
| Cranial Nerve III (CN3) Palsy | Oculomotor nerve palsy (CN III) innervates four of the extraocular rectus muscles (excluding the lateral rectus), as well as the sphincter pupillary muscles, ciliary muscle, and levator muscle. Common findings in affected patients include a downward and outward position of the eye, ptosis, a dilated pupil, and loss of accommodation. In rare cases, the eye may present with an isolated dilated pupil. Ischemic CN III palsies can be pupil-sparing. It is recommended that these patients undergo MRI or MRA of the brain and orbits to rule out specific pathologies. |
| Argyll Robertson Pupil | Characterized by small, irregular pupils that constrict during accommodation but do not react to light. Often associated with syphilis and other CNS diseases, indicating a disruption in the pupillary light reflex pathway. |
| Pharmacologically Dilated Pupil | Pharmacological anisocoria can occur when a mydriatic agent interacts with the eye, affecting either the dilator or sphincter muscle. Agents that can cause pupil dilation include dilation drops, scopolamine patches, glycopyrrolate antiperspirants, nasal vasoconstrictors, and herbal substances. In contrast, prostaglandins, opioids, and certain insecticides can lead to pupillary constriction. |
| Traumatic Pupil | Abnormalities result from trauma to the eye, including irregular shape, size differences, or impaired response. These changes may indicate underlying structural damage requiring further evaluation. |
75-year-old patient above presented for acute onset of binocular double vision. She also had a dilated pupil and noticeable proptosis on the right side.
Reference:
Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. (Year). In Harris, A. (Ed.) Philadelphia: Wolters Kluwer..
EyeWiki. (n.d.). Anisocoria. EyeWiki. Retrieved August 27, 2024, from https://eyewiki.org/Anisocoria