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Ophthalmology 2023 > Acute visual disturbance 4 - anisocoria > Flashcards

Acute visual disturbance 4 - anisocoria Flashcards

1
Q

anisocoria means

A

unequal pupils
relatively common

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2
Q

how different do the pupils have to be

A

difference in pupil size >1mm

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3
Q

anisocoria may be due to

A

impaired dilation (sympathetic)
or impaired constriction (parasympathetic)

causes range from benign to life threatening

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4
Q

how do you know which is the problem eye

A
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5
Q

what should you do if the anisocoria gets worse under bright light

A

third nerve palsies cause problems with ocular motility, the eye turns down and out and there is ptosis
if this features are not present there may be a different condition called Adie’s tonic pupil

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6
Q

what are you concerned about if the anisocoria gets worse under dim light

A
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7
Q

constriction is

A

parasympathetic

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8
Q

dilatation is

A

sympathetic

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9
Q

sympathetic pathway

A

three order neutron pathway
1. hypothalamus -> ciliospinal centre of budge (C8 - T2)
2. -> lung apex & ICA -> superior cervical ganglion (carotid bifurcation)
3. ICA & cavernous sinus -> nasociliary nerve (CN V) -> dilator muscle, Muller muscle and lower eyelid smooth muscle

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10
Q

parasympathetic pathway

A

four-order neutron pathway
1. retinal ganglion cells -> optic nerve, chiasma, tract -> bilateral pretectal nuclei (dorsal midbrain)
2. -> bilateral EW nuclei
3. -> CN III -> cavernous sinus, superior orbital fissure & ipsilateral cilliary ganglion
4. -> post ganglionic short ciliary nerves -> pupil sphincter and ciliary muscles

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11
Q

HxPC of anisocoria

A

may be asymptomatic
there may be glare (if one pupil is dilated), impaired accomodation
may be chronic or sudden onset
associated symptoms may include headache, ptosis, diplopia, neck pain, focal nuerology, pulsatile tinnitus

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12
Q

POHx (past ocular history)

A

uveitis (can cause abnormal pupil, but this is not likely to be affected by dim or bright light)
ocular or head/neck surgery

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13
Q

medication Hx

A

atropine or pilocarpine eye drops
sublingual atropine, nasal decongestants

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14
Q

what examinations should you do

A
  1. visual Acuity
  2. visual Fields
  3. pupil Reflexes
  4. Opthalmoscopy
  5. Colour vision

AFROC

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15
Q

ptosis and strabismus indicates

A

third nerve palsy

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16
Q

proptosis indicates

A

orbital tumour

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17
Q

if there is anterior chamber cells, and posterior synechiae

A

uveitis

18
Q

if theree is sectoral palsy and vermiform movements

A

adie’s

19
Q

heterochromia may indicate

A

congenital horner’s

20
Q

what are some things you might see on a list lamp

A

structural defects, anterior chamber cells, posterior synechiae
sectoral palsy and vermiform movements
heterochromia

21
Q

anisocoria greater in the dark

A

sympathetic lesion, may be Horner;s syndrome, uveitis, mechanical

22
Q

how do you confirm if it is Horner’ syndrome

A

use apraclonidine
this will cause dilatation in Horner’e due to denervation sensitivity (alpha-1 effect predominates over alpha-2)

23
Q

anisocoria greater in the light

A

parasympathetic defect
may be caused by third nerve palsy, adie’s trauma, pharmacological

24
Q

how do you confirm Adie’s

A

low dose pilocarpine (0.1%) causes constriction in Adie’s pupil from hypersensitivity due to up regulation of cholinergic receptors

25
Q

how to figure out the cause of a anisworia greater in light

A
26
Q

physiological unequal pupil sizes

A

up to 20% of the population have uneven pupil sizes <1mm difference
the inequality will persist in light and dark
may be intermittent, persistent or self resolving

27
Q

oculomotor nerve palsy

A

third nerve palsy
depressed and out turned eye
a third nerve palsy does not always have pupil involvement
pupil involvement indicates that there may be an aneurysm of the posterior communicating artery causing the third nerve palsy

28
Q

why does pupil involvement in a third nerve palsy call for concern

A

a third nerve palsy does not always have pupil involvement
pupil involvement indicates that there may be an aneurysm of the posterior communicating artery causing the third nerve palsy

requires prompt imaging

29
Q

aetiology of oculomotor palsy

A

microvascular, aneurysm, tumour, trauma, infiltrative (e.g. leukaemia)
most cases without pupil involvement are ischameic (hypertension, diabetes etc.)

30
Q

presentation of occulomotor nerve palsy

A

diplopia, ptosis, pain, pupil involvement
eye turned down and out
unable to adduct, infraduct, supraduct

31
Q

DDx for oculomotor nerve palsy

A

myasthenia gravis
thyroid orbitopathy
giant cell arteritis

32
Q

prognosis of oculomotor nerve palsy

A

ischameic cases often resolve within 3 months

33
Q

aetiology Horner’s syndrome

A

central (first order): CVA, demyelination, tumour
preganglionic (second order): apical lung CA, mediastinal aneurysm, neck/thoracic surgery
postganglionic (third order): ICA dissection, cavernous sinus lesions (thrombosis, tumour etc.)

34
Q

presentation of Horner’s syndrome

A

ptosis, mitosis, anhidrosis, ocular redness, asymmetric facial flushing
systemic neurological signs and symptoms

35
Q

DDx of Horner’s syndrome

A

physiological anisocoria, involutional ptosis, CN III palsy, chronic Adie pupil

36
Q

management of Horner’s syndrome

A

clinical diagnosis confirmed with apraclonidine
acute painful Horner’s (ICA dissection) = emergency
other management based on aetiology

37
Q

what do you do for acute painful Horner’s

A

ICA dissection
emergency
CTA/MRA and anticoagulation

38
Q

prognosis of Horner’s syndrome

A

this depends on the aetiology

39
Q

aetiology of Adie’s tonic pupil

A
  • ciliary ganglion damage -> postganglionic parasympathetic denervation -> mydriasis worse in light (sluggish light reflex)
  • idiopathic, post-viral, trauma including surgery, migraine, tumour, VZV, EtOH
40
Q

presentation of Adie tonic pupil

A

mainly unilateral, F>M, approx 30 yo, photophobia, slow dark adaptation, blurriness
light near dissociation
can happen post virl
generally benign

Ophthalmology 2023 (18 decks)

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