Clinic: Pupils summarised Flashcards

1
Q

Afferent innervation of pupils (5)

A

Retina –> ON –> OC –> OT (bilaterally) –> pretectal nuclei (bilateral)

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2
Q

Efferent innervation of pupils (4)

A

EW nucleus –> 3rd nerve –> Cil ganglion –> Short cil nerves

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3
Q

Sympathetic innervation of dilator pathway (5)

A

Hypothalamus –> ciliospinal centre (@T1) –> superior cervical ganglion –> dilator pupillae + eyelid smooth muscle

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4
Q

Parasympathetic innervation of sphincter pathway (4)

A

EW nucleus –> 3rd nerve –> cil ganglion –> short cil nerve –> iris sphincter

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5
Q

Diagnostic criteria for Horner’s syndrome (8)

A

Anisocoria (in dim) with dilation lag
Plus any of: ptosis, facial anhydrosis, mildly reduced IOP (1-2) on affected side, conj flush, increased accommodation, iris heterachromia (if congenital/long standing)

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6
Q

How can we localise the pathology of horner’s syndrome?

A
  1. Apraclonidine: reversal of anisocoria indicates horner’s syndrome (alternatively, no dilation with cocaine will also reveal horner’s syndrome)
  2. Phenyl Ephrine 1%:
    dilation = post-ganglionic horners (3rd order neuron)
    no dilation = pre-ganglionic or central horners

http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742010001100020

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7
Q

List 3 causes for 1st order neuron horner’s

A

stroke
tumour
neck trauma

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8
Q

List 4 causes for 2nd order neuron horner’s

A

lung cancer (pancoast tumour)
Surgery in chest cavity
neck trauma
thyroid mass

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9
Q

List 4 causes for 3rd order neuron horner’s

A

damage to carotid artery
damage to jugular vein
tumours
infection

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10
Q

List 2 causes for congenital horner’s

A

brachial plexus trauma

forceps delivery at birth

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11
Q

Describe the light/near response for a parasympathetic mid brain lesion

A

Light: no response
Near: yes response (constriction)

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12
Q

List 2 midbrain lesions resulting in parasympathetic deficits

A
Parinauds syndrome (large pupil)
Argyll Robertson pupil (small pupil)
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13
Q

Describe the clinical features of parinauds syndrome (2)

A

Large pupil

Nystagmus on attempted up gaze

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14
Q

List one potential cause of parinauds syndrome

A

pineal tumour

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15
Q

Describe the clinical features of Argyll Robertson Pupil (3)

A

Both pupils irregular and miotic (ironically, since its a parasymp problem)
total absence of light reaction (both pupils)
Brisk near response

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16
Q

List 2 potential causes of Argyll Robertson pupil

A

Neurosyphilis (main one to suspect)

Diabetic neuropathy

17
Q

Describe the light/near response for a parasympathetic peripheral brain lesion

A

Light: no
Near: no

18
Q

List 4 potential causes of a peripheral brain lesion

A

Iris trauma (will also have increased IOP)
CN3 palsy
Drug usage
Viral (Adies, HSV)

NB: Adies is most common cause

19
Q

List 2 clinical features of Adies tonic pupil (3)

A

Mydriasis (in bright)
Cholinergic supersensitivity (0.125% or 1% pilocarpine can identify)
Sector iris palsy

20
Q

List 4 potential causes of CN3 palsy

A

head injury
infection
migraine
brain tumour

21
Q

Why should you check ocular motility in a pupil patient?

A

Check for CN3 palsy.

22
Q

Describe the clinical features of complete CN3 palsy (3)

A

Complete ptosis
Eyes down + out
Pupil may be fixed + dilated or may be normal

23
Q

Describe the clinical features of partial CN3 palsy (3)

A

STRAB - ExoT (weak MR) or HyperT (weak IR) or HypoT (weak SR and/or IIO)
Ptosis
Enlarged pupil - poor light and near response (due to weak sphincter)

24
Q

How do you manage a CN3 palsy? (3)

A

Immediate referral: urgent MRI + MRA or CT

Extreme emergency if pain + stiffness + headache (possible aneurysm rupture)

25
Q

List 6 potential causes for RAPD

A
Large RD
CRAO/CRVO
On ischemia
Asymmetric Glaucoma
Optic Neuritis
Optic Nerve compression
26
Q

How do you grade RAPD?

A
No RAPD: pupils constrict and show equal physiological escape
1+: escape apparent @ 3 sec only
2+: escape apparent @ 2 sec
3+: escape apparent @ 1 sec
4+: immediate dilation (no constriction)
27
Q

How can you differentially diagnose CN3 palsy from pharmacological pupil dilation?

A

Pilocarpine 1% test. If constriction occurs, it’s CN3 palsy.