Anisocoria

Question 1

Main things to worry about when someone has a dilated pupil

Answer 1

Dilated pupil + CN 3 palsy
-if pupil is involved, aneurysm, get to ER

If ONLY dilated pupil

• put diluted pilo in the eye
• constricts=Adies
• doesnt constrict=pharmacological (scopolamine, plants)

Question 2

Side effects of topamax

Answer 2

Bialteral angle closure

Myopic shift

Question 3

If aniso is > in light

Answer 3

CN III
Adies
Pharm

Question 4

If aniso is > in light

Answer 4

Syphillis
Horners
Uveitis

Question 5

What is the correct definition of sensitivity

Answer 5

The probability of a test giving a positive result in patients with the disease

Question 6

Adies tonic pupil

Answer 6

Acute dilated pupil due to an idiopathic lesion in the CG or the ciliary nerves, causing decreased innervation to the iris sphincter muscle

Question 7

Who gets Adies

Answer 7

Most common in young (20-40) females. Typically unilateral but becomes bilateral at a rate of 4% per year

Question 8

Short posterior ciliary nerves and Adies

Answer 8

Innervates the ciliary muscle and also arise from the ciliary ganglion, thus patients with Adies may also have decreased accommodation, resulting in a complaint of blur at near

Question 9

Adies signs

Answer 9

Patients will present with minimal to no constriction of the affected pupil in response to light, but with a slow constrict in response to a near object. Anisocoria will be greatest under bright illumination due to poor innervation to the iris sphincter muscle (unable to constrict)

The iris will have a vermiform movement when looked at under slit lamp.
-decreased cell in CG but there are still SOME

Question 10

Argyle Robertson pupil

Answer 10

Miotic pupil due to a lesion in the tectotegmental tract, which carries information from both pretectal nuclei to their respective ipsilateral and contralateral EW nuclei.

ARP

• accommodative response present
• FEF still working

Question 11

What is Argyll Robertson pupil associated

Answer 11

Neurosyphilis
DM
Alcoholism

Question 12

Signs of argyll Robertson pupils

Answer 12

Light-near dissociation (the pupil does not react or constricts poorly to light, but constricts normally in response to convergence and accommodation). Pupil constriction in response to near objects is controlled by the FEF, which is not affected here

Anisocoria will be greatest in the dark

Question 13

Horners syndrome

Answer 13

Miotic pupil due to a lesion in the sympathetic nervous system pathway. Aniso will be greater in dark.

Classic triad of mild ptosis (poor innervation to mullers), miosis (due to poor innervation of the iris dilator), and anyhdrosis (due to lack of innervation to sweat glands)

Some less common findings: heterochromia, LL reverse ptosis, conj hyperemia, increased amplitude of accommodation

Question 14

Pre-ganglionic central lesion for horners

Answer 14

From the hypothalamus to the ciliospinal center of Budge.
Causes
-CVA
-demyelinating disease
-tumor

Question 15

Pre-ganglionic lesion in horners

Answer 15

From the ciliospinal center of Budge to the superior cervical ganglion 
Causes
-thyroid mass
-neck trauma
-Hx of thyroid or neck surgery

Question 16

Post-ganglionic lesion for horners

Answer 16

From the superior cervical ganglion to the iris dilator
Causes
-head trauma
-cavernous sinus syndrome
-carotid dissection (pain and Hx of trauma)
-cavernous sinus fistula
-ICA aneurysm

Question 17

Pancoast tumor and horners

Answer 17

The most common pre ganglionic lesion

Question 18

Superior CN 3

Answer 18

Innervates levator and the SR

Question 19

Inferior CN3 innervation

Answer 19

IR, MR, IO

Parasympathetic fibers also travel along this division

Question 20

Complete CN3 palsy

Answer 20

Occurs when both divisions are impaired resulting in a lack of innervation to all 4 EOMs and the levator muscle; the eye will be directed down and out, with a significant ipsilateral ptosis. An incomplete CN 3 palsy is anything less than a complete 3 palsy

Question 21

Why might someone with a complete CN palsy not complain of diplopia

Answer 21

Because of the huge ptosis

Question 22

Most common causes of CN3 palsy

Answer 22

Microvascular infarcts, trauma, and aneurysms

Question 23

Pupillary fibers and CN3

Answer 23

Pupillary fibers travel on the outside of CN3; thus a pupil involving CN 3 palsy is much more likely to be caused by a compressive lesion rather than a microvascular infarct. Any pupil involving CN 2 palsy warrants immediate imaging with an MRI/MRA to r/o a compressive tumor or aneurysm (most commonly involving the PCA)

Because the pupil can rarely become involved after the initial presentation, patients with pupil sparing CN3 palsys should be monitored closely for 1 week to ensure the pupil does not become involved

Question 24

Topamax and its side effects

Answer 24

Indicated for the treatment of seizures, and is also RXed off label for the treatment of migraines and weight loss. It may result in superciliary fusion, causing an anterior shift in iris-lens diaphragm and subsequent angle closure (commonly within the first month or after an increase in the dosage). It will be bilateral

May also cause a myopic shift in refractive error

Question 25

Treatment of angle closure from topamax

Answer 25

Dilate.

The ONLY time you ever dilate an angle closure patient

Question 26

Systemic association with Adies

Answer 26

Diminished deep tendon reflexes

Question 27

Cocaine and/or apraclonidine for horners

Answer 27

Normal pupil-dilate

Horners pupil-no dilation

Question 28

Hydroxy in a horners pupil

Answer 28

Already confirmed with cocaine that it is horners, this tells us where it is

Pre-ganglionic=dilation (1st and 2nd order)
Post-ganglionic=no dilation (3rd order)

Question 29

Treatment for Adies

Answer 29

There really isnt any

Just give them an add to help with blur at near

Question 30

Specificity

Answer 30

The probability of a test giving a negative result when the patient does not have the disease

Question 31

Positive predictive value

Answer 31

The probability that a patient has a disease when the test it positive

Question 32

Negative predictive value

Answer 32

The probability that a patient does not have a disease when the test is negative