Anisocoria and Ptosis_Dr. McNaughton

Question 1

What are you looking for when testing pupil?

Answer 1

reaction to light
reaction to a near stimulus
pupil size
pupil location
pupil shape

Question 2

What kind of anisocoria if the pupil size difference is the same both under bright and dim conditions?

Answer 2

physiologic anisocoria

Question 3

How is the cocaine test work?

Answer 3

It blocks reuptake of norepinephrine

Question 4

What are the ocular pathology that causes anisocoria without ptosis?

Answer 4

These are not neural problems but eye problems

-It can be due to pharmacological block, iritis, angle closure, posterior synechia or trauma.

Question 5

What are the cause of post-ganglionic parasympathetic problems?

Answer 5

1. Trauma affecting ciliary ganglion

2. Adie’s pupil

Question 6

What is Adie’s pupil?

Answer 6

1. Pupil is responsive but slow
2. 20-40 female > male
3. Near response > light response
4. Sector contraction, vermiform pupillary border, stromal streaming
5. Usually unilateral
6. Positive dennervation supersensitivity (test with Pilocarpine (miosis))

Question 7

What are some unusual etiologies of anisocoria without ptosis?

Answer 7

1. Pain-mediated (CN 5)

2. Episodic unilateral mydriasis

Question 8

Parasympathetic system control the muller’s muscles or levator muscles?

Answer 8

Levator muscle. Sympathetic system controls the muller’s muslces.

Question 9

Where do you suspect the lesion if you see ptosis with mydriasis?

Answer 9

CN 3 in parasympathetic system

Question 10

Where do you suspect the lesion if you see ptosis with miosis in the same eye?

Answer 10

in the sympathetic system

Question 11

Lesion in the pre-ganglionic CN3 can be cause by?

Answer 11

1. Tumor
2. Aneurysm
3. Hutchinson’s (ER) pupil (uncal or hippocampal herniation)
4. Cavernous sinus thrombosis
5. Diabetes (15%)
6. Migraine

Question 12

Pre-ganglionic pathology of the parasympathetic can be both what?

Answer 12

nuclear or facicular

Question 13

If the pre-ganglionic pathology of the parasympathetic is both nuclear and fascicular then it’s what?

Answer 13

Stroke

Question 14

What are the different diagnosis of a central lesion (pretectum to EW) of the parasympathetic system?

Answer 14

1. Dorsal midbrain syndrom (pineal gland tumor)
2. Argyll-Robertson pupils due to tertiary neurosyphilis
3. stroke
4. tumor

Question 15

What is the test you can use to distinguish between a physiological anisocoria from a mild Horner’s Syndrome?

Answer 15

Cocaine test.
Dilation = physiological anisocoria
Absent = suspect pre- or post- ganglionic lesion
partial = suspect central lesion (partial nerve functioning and some NE release)

Question 16

Is Phenylephrine and Hydroxyamphetamine direct or indirect acting?

Answer 16

direct acting

Question 17

How does phenylephrine work in diagnosing where is the lesion in Horner’s Syndrome?

Answer 17

It stimulates post-synaptic terminal receptors on the dilator muscle
Slight dilation = suspect central or pre-ganglionic lesion
Dramatic dilation = suspect post-ganglionic lesion in the CN 3

Question 18

How does Hydroxyamphetamine work to locate where the lesion is in Horner’s Syndrome?

Answer 18

It stimulates release of NE from axon terminal, pre-synaptic terminals near the dilator muscle.
Dilation = suspect central or pre-ganglionic lesion
Absent = suspect post-ganglionic lesion

Question 19

If the pt has anhydrosis, where do you suspect the lesion to be?

Answer 19

pre-ganglionic sympathetic system

Question 20

What would you suspect if your pt has post-ganglionic Horner’s that’s not associated with other neurological signs/symptoms but associated with nasal stuffiness, rhinitis, and tearing?

Answer 20

Raeder’s (facial pain syndrome) and monitor/refer to neurology

Question 21

What would you suspect if your pt has post-ganglionic Horner’s that’s associated with other neurological signs/symptoms especially CN 3,4, 5, or 6?

Answer 21

Cavernous sinus (worst case = internal carotid dissection)

Question 22

Is Pre-ganglionic Horner’s associated with neurological signs/symptoms?

Answer 22

No but it’s associated with problems involved organs (1. neck - neoplasm, goiter, grave’s; 2. thorax - pancoast (apical lung) tumor, Skier’s Horner’s)

Question 23

What are the signs that your pt might be having pancoast tumor?

Answer 23

coughing and pre-ganglionic Horner’s

Question 24

Wallenberg syndrome occurs with lesion in which part of the sympathetic system in Horner’s?

Answer 24

Central

Question 25

What are the symptoms of Wallenberg syndrome?

Answer 25

“D”s

Diplopia, Dizziness, Dysarthria (speech), Dysphonia (voice), Dysphagia (swallowing) and Diplegia (bilateral paralysis)

Question 26

What are the emergency differential diagnoses?

Answer 26

1. Aneurysm at the Circle of Willis
2. Rapid increase in size of intracranial mass
3. Rapid rise in intracranial pressure (ex ventricular or subarachnoid hemorrhage)
4. Brainstem stroke
5. Cavernous sinus thrombosis, hemorrhage