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BMB Test 2 > B7-033 CBCL Pupillary Abnormalities > Flashcards

B7-033 CBCL Pupillary Abnormalities Flashcards

1
Q

parasympathetic pupillary light reflex: when you shine a light in one eye, […] constricts

A

both eyes

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2
Q

problems with the parasympathetic pupillary light reflex typically indicate an issue in the […]

A

midbrain

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3
Q

why does the parasympathetic pupillary light reflex illicit an equal response from both eyes?

A

it is a “double crossed” system

parasympathetic fibers cross at the posterior commissure of the midbrain at the Edinger-westphal nucleus and the pretectal nucleus

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4
Q

pupil constrictors are […] neurons with […] receptors

A

cholinergic
muscarinic

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5
Q

how would cholinergic agonists affect pupils?

A

constrict

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6
Q

how would cholinergic antagonists affect pupils?

A

dilate

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7
Q

unilateral dysfunction of the pupillary constrictors is called

A

internal ophthalmoplegia

(caused by anything that affects CN III)

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8
Q

causes of internal ophthalmoplegia

A

herniation
midbrain lesion (stroke, would see long tract involvement)
aneurysm in the posterior communicating (would see involvement of other eye muscles)
ciliary ganglion degeneration
thermal injury to short ciliary nerves
pharmacologic blockade (anticholinergic in eye)

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9
Q

aggressive photocoagulation for diabetic retinopathy can cause

A

thermal injury to short ciliary nerves

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10
Q

uncal herniation can compress CN […]

A

III

(cause of internal ophthalmoplegia- will have decreased consciousness)

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11
Q

extreme sensitivity to dilute pilocarpine can indicate a lesion at […]

A

short ciliary nerves (or postganglionic)

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12
Q

pupil doesn’t constrict in response to 1% pilocarpine

A

pharmacologic blockade

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13
Q

what emotions cause sympathetic pupillary dilation?

A

fear
anger
pain
arousal

(also contracts smooth tarsal muscles of eyelids to open eye more)

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14
Q

first order neuron of the sympathetic chain involved in Horner’s syndrome

A

hypothalamus to spinal cord

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15
Q

second order neuron of the sympathetic chain involved in Horner’s syndrome synapses at

A

superior cervical ganglion

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16
Q

third order neuron of the sympathetic chain involved in Horner’s syndrome projects to [4]

A

sweat glands of forehead
smooth muscle of eyelid
pupillary dilator
sweat glands of face

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17
Q

most of the sudomotor fibers of the face follow the […]

A

external carotid artery

(if a patient presents with Horner’s syndrome but is sweating normally, the lesion must be distal to the bifurcation of the carotid-must be along internal carotid, opthalmic artery, or eye)

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18
Q

pupillary dilators are […] neurons with […] receptors

A

noradrenergic
alpha 1

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19
Q

some causes of Horner’s syndrome

A

brainstem strokes (lateral medulla)
multiple sclerosis
syringomyelia
pancoast tumor
thyroid carcinoma
carotid artery aneurysm

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20
Q

anhidrosis is usually absent if the […] neuron of the sympathetic pathway was affected

A

3rd order

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21
Q

blocks the reuptake of norepinephrine

A

cocaine

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22
Q

use of […] drops can confirm the presence of Horner’s syndrome

A

cocaine

anisocoria worsens

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23
Q

anisocoria worsens with hydroxy amphetamine in both eyes

A

post-ganglionic lesion (sympathetic, 3rd order)

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24
Q

anisocoria lessens with hydroxy amphetamine in both eyes

A

preganglionic

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25
Q

anisocoria worse in bright light indicates an issue with

A

CN III

(parasympathetic issue)

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26
Q

anisocoria worse in dark room indicates an issue with

A

sympathetics

(Horner’s syndrome)

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27
Q

dilation lag in going from light room to dark

A

sympathetic issue (horner’s)

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28
Q

shining light in the unaffected eye results in greater constriction than when light is shined in the affected eye

A

afferent pupillary defect

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29
Q

same relative anisocoria is present in all lighting conditions
no dilation lag

A

benign essential anisocoria

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30
Q

if anisocoria is worse in the light its a […] issue

A

parasympathetic

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31
Q

if anisocoria is worse in the dark its a […] issue

A

sympathetic

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32
Q

if anisocoria is the same in the light and dark its a […] issue

A

physiologic

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33
Q

muscle that serves as the pupillary dilator

A

radial muscle

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34
Q

muscle that serves as the pupillary constrictor

A

circular muscles in iris

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35
Q

circular muscle that rounds the lens

A

ciliary muscle

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36
Q

secretes the aqueous humor

A

secretory epithelium

(raises IOP)

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37
Q

aqueous humor drains into the

A

canal of Schlemm

(lowers IOP)

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38
Q

the ciliary muscle and sphincter are under […] control

A

muscarinic

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39
Q

the pupillary dilator is under […] control

A

a-1 adrenergic

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40
Q

the ciliary epithelium is under […] control

A

beta adrenergic

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41
Q

[parasympathetic/sympathetic]
miosis

A

parasympathetic

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42
Q

[parasympathetic/sympathetic]
accomodation

A

parasympathetic

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43
Q

[parasympathetic/sympathetic]
outflow of aqueous humor

A

parasympathetic

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44
Q

[parasympathetic/sympathetic]
lacrimation

A

parasympathetic

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45
Q

parasympathetic effects can be mimicked by […] agonist

A

muscarinic

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46
Q

in the accomodated state, the ciliary muscle […] and the zonular fibers […]

A

contract
relax

(rounds the lens)

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47
Q

in the unaccomodated state, the ciliary muscle […] and the zonular fibers […]

A

relax
contract

(flattens the lens)

48
Q

[…] promotes aqueous humor drainage

A

accomodation

49
Q

[parasympathetic/sympathetic]
mydriasis

A

sympathetic

50
Q

sympathetic effects can be mimicked by […]

A

cocaine

51
Q

stimulation of the ciliary epithelium via […] receptor activity promotes aqueous humor

A

beta

52
Q

in what type of glaucoma does drainage occur normally?

A

open angle

(IOP can be increased or normal)

53
Q

in what type of glaucoma does the iris and cornea impinge, occluding drainage?

A

closed angle

(IOP is increased)

54
Q

pharmacologic treatment for closed angle glaucoma

A

muscarinic agonists that open the trabecular network

carbachol (direct)
physostigmine (indirect)

55
Q

surgery to treat closed angle glaucoma

A

iridectomy

56
Q

pharmacologic treatment for open angle glaucoma

A

beta antagonists

timolol (topical application, long half life)

57
Q

internal ophthamoplegia causes weakness of the […] muscles

A

pupillary constrictors

58
Q

constriction of the pupil due to a dilute cholinomimetic drug (pilocarpine) indicates a […] lesion

A

postganglionic

59
Q

most of the structures involved in parasympathetic innervation of the eye are contained in the […]

A

midbrain

60
Q

an afferent pupillary defect indicates a lesion in the

A

optic nerve

61
Q

symptoms of Horner’s syndrome

A

miosis
ptosis
anhidrosis

62
Q

sympathetic innervation to the face controls [3]

A

pupillary dilation
eyelid elevation
anhidrosis

63
Q

[…] ciliary nerves constrict the eye

A

short

64
Q

the majority of sudomotor fibers traveling to the sweat glands of the face follow the […] carotid

A

external

65
Q

[…] nucleus sends fibers to the Edinger-Westphal nucleus

A

pretectal

66
Q

fibers from the right pretectal nucleus will go to […] Edinger-Westphal nucleus

A

both

(left and right EWN receive information from both sides)

67
Q

if one pupil is larger than the other or reacts differently, it is called

A

anisocoria

68
Q

[…] ciliary nerves dilate the eyes

A

long

69
Q

in ambient light, will a patient with an occulomotor nerve lesion have anisocoria?

A

yes

affected pupil will appear dilated

70
Q

will a patient with an occulomotor nerve lesion have a direct or consensual response to light shone directly in the eye?

A

no response to either

71
Q

in ambient light, will a patient with a Horner’s syndrome have anisocoria?

A

yes

affected eye will be constricted

72
Q

will a patient with a Horner’s syndrome have a direct or consensual response to light shone directly in the eye?

A

yes, both (affected eye may constrict more than unaffected eye)

(will be a dilation lag going from light to dark)

73
Q

in ambient light, will an afferent pupillary defect have anisocoria?

A

no

74
Q

will a patient with an afferent pupillary defect have a direct or consensual response to light shone directly in the eye?

A

they will have a consensual response
they will NOT have a direct response

(swinging flashlight test is useful)

75
Q

the same relative anisocoria is present is all lighting conditions
no dilation lag

A

benign essential anisocoria

76
Q

common cause of afferent pupillary defect

A

optic neuritis (multiple sclerosis)

77
Q

ocular procedures are sometimes complicated by damage to the [2]

A

iris sphincter
short ciliary nerves

78
Q

short ciliary nerve injury will have what response to low dose pilocarpine?

A

preserved constriction

(Adie’s tonic pupil- denervation hypersensitivity causes upregulation of postsynaptic ACh receptors)

79
Q

pupillary sphincter muscle injury will have what response to pilocarpine?

A

no response

80
Q

in physiologic anisocoria, both pupils have […] to light

A

retained reaction (constriction)

81
Q

what medication can be given to discern between physiological anisocoria and Horner’s syndrome?

A

cocaine

82
Q

how would a patient with physiological anisocoria react to cocaine?

contrast with Horner’s syndrome

A

physiological anisocoria: bilateral pupillary dilation

Horners: minimal dilation effect (less NE released)

83
Q

prevents the reuptake of NE

A

cocaine

84
Q

uncal herniation can compress the […] nerve

A

oculomotor

(interruption of parasympathetic fibers)

85
Q

parasympthetic fibers of the occulomotor nerve are located where?

A

periphery (damaged first)

86
Q

large, non-reactive pupil that responds quickly to a weak parasympathetic agent

A

Adie’s Tonic pupil

87
Q

in a patient with Horner’s syndrome, dilation with hydroxy amphetamine hydrobromide indicates a lesion where?

A

1st or 2nd order (preganglionic)

(pupil would not dilate with a post ganglionic lesion)

88
Q

what effect does iprotropium have on the pupil?

A

inhibits parasympathetic output –> mydriasis

(commonly found in nebulizing treatments)

89
Q

post-operative non-reactive pupil that does not recover with instillation of pilocarpine indicates injury to

A

pupillary sphincter muscle (preganglionic)

90
Q

post-operative non-reactive pupil that does recover with instillation of pilocarpine indicates injury to

A

short ciliary nerve

91
Q

bilateral small pupils that do not react to light but do constrict with near vision

A

Argyll-Robertson pupils

(Light-Near dissociation, heavily associated with neurosyphilis)

92
Q

Light-Near dissociation caused by neurosyphilis

A

Argyll Robertson pupil

93
Q

afferent pupillary defect, with pupil constricting if the opposite eye has light shone into it is called

A

Marcus Gunn pupil

94
Q

a pharmacologically dilated pupil [would/would not] easily constrict to a dilute parasympathetic agent

A

would not

95
Q

unilateral pupillary defect that has a robust response to a low dose parasympathetic agent

A

Adie’s tonic pupil

(indicates post ganglionic parasympathetic damage)

96
Q

cause of the afferent defect in Marcus Gunn pupil

A

unilateral optic neuropathy (commonly optic neuritis or tumors of the optic nerve sheath)

97
Q

a normal pupil will […] when cocaine is instilled

A

dilate

98
Q

a pupil affected by a lesion in the third order neuron of the sympathetic chain will […] when cocaine is instilled

A

no response

99
Q

a pupil with physiologic anisocoria will […] when cocaine is instilled

A

dilate

100
Q

hallmark of physiologic anisocoria

A

pupil size difference remains the same in the light or the dark

101
Q

anisocoria is clearly worse in the light

A

parasympathetic problem

102
Q

anisocoria is clearly worse in the dark

A

sympathetic problem

103
Q

most likely structure to be affected by a syrinx causing Horner’s syndrome

A

intermediolateral cell column

104
Q

the afferent visual fibers serving the pupillary light reflex cross in the […] of the midbrain

A

posterior commissure

(allows for consensual response)

105
Q

a pineal gland tumor can cause what symptoms?

A

bilateral unreactive pupils with decreased vertical gaze

106
Q

bilateral, unreactive pupils with decreased vertical gaze indicates […] syndrome

A

dorsal midbrain

(aka Parinaud syndrome, caused by compression of PCA, often by pineal gland tumor)

107
Q

dilation of both pupils following hydroxyampehtamine drops indicates a lesion where?

A

1st or 2nd order neuron (there is NE to release)

preganglionic

108
Q

absence of dilation of both pupils following hydroxyampehtamine drops indicates a lesion where?

A

3rd order neuron (no NE to release)

postganglionic

109
Q

aggressive laser therapy for diabetic retinopathy may cause thermal damage to […]

A

short ciliary nerves

postganglionic

110
Q

how does denervation hypersensitivity of the short ciliary nerves react to pilocarpine?

A

after axons degenerate, the smooth muscles become super sensitive to ACh and its agonists, so would cause constriction at a very dilute dose

111
Q

one or both pupils do not constrict normally

A

internal ophthalmoplegia

112
Q

muscle that adducts the eye

A

medial rectus

113
Q

innervates the superior oblique

A

trochlear

114
Q

innervates the lateral rectus

A

abducens

115
Q
A

why is neuro just word salad?!?! 😩

116
Q

[internal/external] In Horner’s syndrome, sudomotor fibers follow the […] carotid artery

A

external

sweating can be preserved with Horner syndrome if lesion is past bifurcation of the common carotid
“sweat outside”

117
Q

[internal/external] In Horner’s syndrome, pupil dilator fibers follow the […] carotid artery

A

internal

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