Anisocoria +/- Ptosis Flashcards
True or False. When you notice a anisocoria, you cannot have a ptosis?
False. In fact you look for the other as well
What muscles are affected by the Central nervous system?
Iris Dilator and Mueller’s Muscle
What ocular structures are impacted by the parasympathetic system, to lids and pupils?
Levator and iris sphicnter
What is most common etiology of a true emergency?
Acute onset
True or False. All of CN3 is involved in a true emergency.
True.
Signs:
Anisocoria, Ptosis and diplopia when the lid is elevated.
What is usually the description of a headache when someone is entering with anisocoria with ptosis and diplopia?
Worst headache i’ve ever had
What do you look for when someone presents with a severe headache + diplopia?
Anisocoria + Ptosis
If a pt. comes in with acute onset of diplopia, what do you look for?
Anisocoria +ptosis + severe headache
For an acute onset emergency, how many of the three (diplopia, severe headache and anisocoria +ptosis) do you require to be considered an emergency?
2/3 or 3/3
What are the differential diagnosis of an emergency?
- Aneurysm at the Circle of Willis
- Rapid increase in size of intracranial mass
- Rapid rise in intracranial pressure
e. g., ventricular or subarachnoid hemorrhage - Brainstem stroke
- Cavernous sinus thrombosis, hemorrhage
What do you do, once you have concluded there is no emergency?
Continue workup. Look for. 1.Anisocoria without ptosis 2.Anisocoria with ptosis 3. Ptosis alone
What is the true neurological test, which Mcnaughty thought was very powerful?
Pupil test
Evaluate:
- Reaction to light
- Reaction to a near stimulus
- Pupil size
- Pupil location - can change laterally
- Pupil shape - post surgery (cataract surgery - surgeon require good pupil dilation to conduct surgery)
What is the afferent ocuoloparasympathetic pathway impact the most?
Optic nerve
What is the efferent ocuoloparasympathetic pathway impact the most?
Oculomotor nerve
When a signal is retrieve, what side of the pretectal nucleus will the information be relayed, when preforming a pupil test?
Ipsilateral side
Describe the primary pathway of the oculosympathetic pathway?
- Hypothalamus –> travels to the center of budge or stellate ganglion
- Stellate ganglion to Superior cervial ganglion
- Superior cervical ganglionSuperior orbital function (lid - muller and iris - radial)
Post ganglionic or tertiary pathway is based on what specific ganglion?
Superior Cervical Ganglion
A photopic loss indicates what type of lesion?
PNS
What type of lesion would be demonstrated if there is a Mesopic predominance?
SNS lesion
What is the only lesion that has an equal mesopic and photopic dysfunction?
Physologic Anisocoria
What region is affected when pupils are more likely to be equal than unequal?
Central parasympathetic
What is the best test to conduct when observing pupil dysfunction?
Bruckner test
What is the most common type of anisocira without ptosis?
physiological anisocoria
When you want to see a long standing physiological anisocoria, what test are you conducting?
Familial album tomography (FAT) - look at photo albums and observe the presence of the pupil size
Note: You can do a cocaine test - negative
What is the ocular pathology you are looking for in the case of anisocoria without ptosis?
1.Pharmacological block
Atropine which is used for uveitis, she felt that it would help with red eye and used a red cap bottle
- The usual suspects
- Iritis - inflammation will affect its ability to function
- Angle closure - iris muscles can become non-functional
- Posterior synechiae
- Trauma
You see that anisocoria without ptosis is more prominent in bright light, you then present Pilocarpine2 to 4%, you observe no miosis. What does this mean?
Pharmacologic block
Note: Miosis usually occurs when there is normal functional of the iris
What is rule #1 when you see anisocoria?
Don’t assume there is a neurological problem until you have ruled out:
- Physiological
- Ocular pathology
- Something directly affecting the muscles
What areas are within the orbit that are involved in the postganglionic parasympathetic system within the orbit?
Ciliary Ganglion, Iris sphincter and Iris dilator
What are the most common differential diagnosis of anisocoria without ptosis, when related to the postganglioic parasympathetic system?
- Trauma affecting the ciliary ganglion
2. Adie’s pupil
What has to be positive when looking for trauma affecting ciliary ganglion?
Trauma
What is the demographics you are looking for someone who has Adie’s tonic?
20 to 40YO
and
Female > Male
What are the signs you are looking for in Adie’s tonic?
Near response > Light response
Unilateral
- Iris will be streaming or waving
- Sectoral contraction
- Positive dennervation supersensitivity - If the postganglionic pathway was damaged, there is nothing coming from the synapse. The post-sympathetic receptors in the muscle will become ultra-sensitive by upregulation.
When you want to test adie’s, what are drug and what response are you looking for?
Pilocarpine 0.125% and if miosis is present, then Adies
Note: This is testing for the supersensitivity dennervation
What is the management of Adie’s tonic?
Monitor for any changes at 4 to 6 weeks
What are the signs of pain mediated anisocoria?
- Miotic pupil, eye in pain
- Mediated by CN-V
- May be accompanied by pseudoptosis
What is the key regarding pain mediated anisocoria?
Find the ocular problem and manage
What is the name of an anisocoria that comes and goes, which may even switch eyes?
See saw anisocoria (episodic unilateral mydriasis)
Mcnaughty said he asked about a Ocular pharm question, which was:
Your pt comes in with a ptosis in the left eye and large pupil in the right eye. What could this be?
Pt doesn’t have a ptosis but is taking a drug that is causing the sympathetic system inducing the muellers muscles to contract.
If you notice a ptosis in the side that is involved and mydriasis, where is the involvement occuring?
CN3
What impact occurs when there is lesion in the sympathetic system?
Ptosis + Miosis
What is the best was of distinguishing between sympathetic and parasympathetic impact on the pupil?
Dim vs. Bright
Aniso > dim = sympathetic
Aniso > bright = parasympathetic
If you have a true preganglionic involving CN3, what symptom will you see that accompanies this type of aniso?
Diplopia
What are the associated factors that may cause a CN3 dysfunction, which causes ptosis and aniso with diplopia?
- Tumor
- Aneurysm- check for High BP
- Hutchinson’s (“ER”) pupil*
- Cavernous sinus thrombosis*
- Diabetes (15%) - presents like a diabetic - longstanding
- Migraine - vascular tone and fluctation is vascular tone
What is Hutchinsons Pupil?
Hippocampal Herniation
- Complete, unilateral oculomotor nerve palsy, involving the pupil
- Pupil is mydriatic and unresponsive to light and to near
- Patient is clearly unwell, may be in coma
- Associated with any cause of rapid increase in intracranial pressure
e. g. hemorrhage
What is spared when there is lesion from the pretectum to EW?
Most of CN3 (no aniso and no diplopia)
Note: You will see neurosyphilis - think of argyll-robertson pupils
Parinaud’s syndrome (Dorsal Midbrain syndrome) will show what sign/symptoms?
1.Lid retraction
2.Gaze palsy for up-gaze
3.Pulsating retraction of the globe on attempted up-gaze
4.Tectal pupils
IT IS POSSIBLE TO HAVE COMPONENTS WITHOUT ALL 4
Exam question:
How do you find the difference between Adies from Argyll’s?
THINK: DORSAL MIDBRAIN MASS (E.G. PINEALOMA)
Slide 57
Pain in the arm, near the center of budge, is a good indication of what oculosympathetic paresis?
Horner’s Syndrome
Test with: Cocaine - if there is no dilation = Horner’s
Exam question:
You suspect horner’s and you see a robust dilation, what does this mean when conducting a cocaine test?
Physiologic Anisocoria
Partial = suspect central lesion - on hit a partial amount of neurons
Why would cocaine cause a absent pupil response, which is suspect of pre or post ganglionic lesion?
Cocaine works indirectly on norepi, if the cleft has been damaged, there will be no norepi, which means that the cocaine is ineffective
Anhydroisis is linked to what lesion?
Post ganglionic
What drug will show slight dilation when testing aniso in low lighting conditions?
Phenylephrine 1% - indirectly
Which means a pre or central lesion but if you see a an Excessive dilation, than you will see a post ganglionic
Exam question: A pt presents with nasal stuffiness, rhinitis and tearing what is this conditiion?
Raeder’s - facial pain syndrome
slide 66
Exam question:
Which ones have in common in central or not?
CN 3, 4, 5 and 6. What type of presentation will alert you in all four or combination of these nerves?
Central 5, 6,7 8,
Cavernous sinus
Worst case = internal carotid dissection which produces post ganglionic horner’s
Compare = slide 67 and 75
Focus on the following slides for the final examination.
12, 13, 42, 47 and 49
