Anisocoria

Question 1

T/F: If you see anisocoria or ptosis, always look for the other one.

Answer 1

T

Question 2

True emergencies:

Answer 2

1. Onset
2. All of CN3 including pupil (pt has anisocoria, ptosis, and diplopia)
3. Distressed/neurological signs
4. Worst HA

Question 3

Pt presents w anisocoria and ptosis, look for:

Answer 3

Severe HA + diplopia

Question 4

Pt presents w severe HA, look for:

Answer 4

Anisocoria + ptosis + diplopia

Question 5

Pt presents w acute onset diplopia, look for:

Answer 5

Anisocoria + ptosis + severe HA

Question 6

Emergency DDx:

Answer 6

• Aneurysm (Circle of Willis)
• Rapid increase in intracranial mass
• Rapid increase in intracranial pressure
• Brainstem stroke
• Cavernous sinus thrombosis, hemorrhage

Question 7

Anisocoria wo ptosis: physiological -

Answer 7

1. Equal asymmetry in dim and bright
2. Usually small size differ
3. Long-standing - order FAT scan
4. Neg cocaine test

Question 8

Anisocoria wo ptosis: pathological -

Answer 8

1. Pharmacological block
2. Iritis
3. Angle closure
4. Post synechiae
5. Trauma

Question 9

Anisocoria wo ptosis: location of pathology -

Answer 9

Eye ball

Question 10

Anisocoria wo ptosis: ___ parasympathetic

DDx:

Answer 10

Postganglionic

1. Trauma affecting CG
2. Adie’s pupil

Question 11

Unusual etiologies of anisocoria wo ptosis:

Answer 11

• Pain mediated

- Episodic unilateral mydriasis

Question 12

Pain-mediated anisocoria:

Answer 12

• Miotic pupil and in pain
• Mediated CNV
• May be accompanied by pseudoptosis

Question 13

Episodic unilateral mydriasis (aka seesaw):

Answer 13

• Comes and goes

- Not associated w any underlying pathology

Question 14

Episodic unilateral mydriasis (aka seesaw) mgmt:

Answer 14

• Reassure and monitor

Question 15

Ptosis + mydriasis =

Ptosis + miosis =

Answer 15

CN3

Sympathetic

Question 16

Aniso > dim =

Aniso > bright =

Answer 16

Sympathetic

Parasympathetic

Question 17

Parasym: preganglionic = CN3

Answer 17

• Tumor
• Aneurysm
• Hutchinson’s pupil
• Cavernous sinus thrombosis
• Diabetes
• Migraine

Question 18

Hutchinson’s pupil: complete, ___ oculomotor nerve palsy, involving the ___.

Answer 18

Unilateral; pupil

Question 19

Hutchinson’s pupil: ___ and unresponsive to light and near

Answer 19

Mydriatic

Question 20

Hutchinson’s pupil: pt is ___ and may be in coma.

Answer 20

Unwell

Question 21

Hutchinson’s pupil: associated w any cause of rapid increase in ___

Answer 21

Intracranial pressure (hemorrhage)

Question 22

Argyll robertson pupil: ___, unilateral or bilateral

Answer 22

Miotic

Question 23

Argyll robertson pupil: near response > ___

Answer 23

Light response

Question 24

Argyll robertson pupil: eye must have ___

Answer 24

Vision

Question 25

Argyll robertson pupil: difficult to ___

Answer 25

Dilate

Question 26

Argyll robertson pupil: think ___

Answer 26

Tertiary neuro-syphilis

Question 27

Adie’s tonic pupil: demographics?

Tonic -

Answer 27

20-40 yo F

Slow, not unresponsive

Question 28

Adie’s tonic pupil: ___ > light response

Answer 28

Near response

Question 29

Adie’s tonic pupil: ___ contraction, ___ pupillary border, stromal streaming

Answer 29

Sector; vermiform

Question 30

Adie’s tonic pupil: unilateral or bilateral?

Answer 30

Unilateral

Question 31

Adie’s tonic pupil: positive ___ supersensitivity

Answer 31

Dennervation

Question 32

Adie’s tonic pupil: mgmt?

Answer 32

• Monitor any changes 4-6 wks

- Reassure pt

Question 33

Tectal pupils: ___ and usually bilateral

Answer 33

Mydriatic (Adie’s is unilateral)

Question 34

T/F: Tectal pupils and Adie’s are mydriatic

Answer 34

T

Question 35

Tectal pupils: ___ > light response

Answer 35

Near response

Question 36

Tectal pupils: think ___

Answer 36

Dorsal midbrain syndrome (pinealoma)

Question 37

Light near dissociation syndromes:

Answer 37

1. Adie’s tonic pupil (sluggish)
2. Tectal pupils (mydriatic)
3. Argyll-robertson pupils (miotic)
4. Diabetes, aberrant regeneration of CN3, myotonic dystrophy