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Efferent Pupil Testing Flashcards

1
Q

What % of the normal population have a simple, central (see-saw) anisocoria?

A

20%

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2
Q

This type of syndrome is anisocoria with one eye larger in bright light and the other larger in dim light.

A

Tonic Pupil Syndrome

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3
Q

Tonic pupil syndrome is associated with damage where?

A

Ciliary Ganglion

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4
Q

What topical med is used to determine if a tonic pupil is present?

A

Pilocarpine 0.125%

- if tonic, pupil will constrict in 30 mins

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5
Q

If you place 0.125% of pilo in the eye and it does not constrict, what are your 2 differentials?

A
  1. Pharmacologically dilated pupil

2. CN III

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6
Q

If we use pilo 1%, what will happen to an eye with a CN III palsy?

A

Constricts pupil

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7
Q

What is a paradoxical pupil?

A

An anisocoria greater in light AND dim

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8
Q

What are the 3 S’s of Tonic pupil?

A
  1. Sector Paralysis
  2. Stromal Spread
  3. Stromal streaming
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9
Q

What are the 3 general causes of tonic pupil?

A
  1. Local disease
  2. Neuropathic (systemic) - diabetes
  3. . Idiopathic (Adie’s)
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10
Q

When is the only case an unequal add is indicated?

A

Unilateral tonic pupil

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11
Q

Adie’s tonic pupil is due to what?

A

Aberrant regeneration of CB fibers to the iris sphincter

  • pupil constricts when the patient attempts to accommodate
  • idiopathic (dx of exclusion)
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12
Q

An acute onset of CNIII palsy with pupil involvement is an anuerysm where?

A

At the junction of PCOM and ICA

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13
Q

What is the etiology of dorsal midbrain syndrome?

A

Compression of dorsal, rostral midbrain in region of posterior comissure

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14
Q

What is the 1st thing to do when you suspect a patient of having DMS?

A

Neuroimaging = MRI/MRV

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15
Q

In DMS, which pupil would be considered abnormal?

A

The large one

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16
Q

What are the 4 signs of DMS?

A
  1. Tectal Pupils
  2. Convergence Retraction Nystagmus
  3. Upgaze Paresis (dorsal midbrain contains upgaze center)
  4. Eyelid retraction (Collier’s sign)
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17
Q

Uncal herniation due to dudden increased ICP shifting cerebelar contents results in what?

A

Hutchinson Pupil (blown pupil)

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18
Q

What is the oculosympathetic triad for Horner’s?

A
  1. Ptosis
  2. Miosis
  3. Anhydrosis
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19
Q

In horner’s, we’re concerned about the ______ pupil with the ______ aperture.

A

small pupil, small aperture

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20
Q

When is the anisocoria greater in a horner’s patient?

A

Anisocoria greater in dim lighting

- horner’s pupil is small, won’t dilate

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21
Q

What is the gold standard diagnostic drop for Horner’s dx? Will the eye dilate?

A

Cocaine

- no the pupil won’t dilate

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22
Q

A horner’s pupil is a lazy dilator, meaning what?

A

The anisocoria will be greater at 5 seconds than at 12 seconds in darkness

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23
Q

When using apraclonidine to diagnose Horner’s, what is our endpoint?

A

Reversal of anisocoria

  • before = horner’s pupil was smaller
  • after = horner’s pupil is bigger
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24
Q

How long should you wait after instillation of apraclonidine to dx horners?

A
  • wait 30 mins

- if no reversal, wait another 30 mins

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25
Q

Apraclonidine is contraindicated in what type of patients?

A

Patient’s under 2; must use cocaine

26
Q

What’s muscle is affected in Horner’s syndrome?

A

Muscle of Mueller

27
Q

The muscle of mueller can only give how much of a ptosis?

28
Q

The levator opens the eye how many mm?

29
Q

If you soak a patient’s finges in water and check the fingertips for wrinkling, but they don’t. What does this indicate and what is it called?

A
  • indicates poor sympathetic innervation

- called Brachial Plexus

30
Q

If patient presents with a right Horner’s and a right CN IV palso, where does the lesion localize to?

A

Cavernous sinus

31
Q

If a patient presents with a right Horner’s and a left CN IV palsy, where does the lesion localize to?

A

Midbrain (brainstem) issue

32
Q

Foville syndrome is found at the level of the ___ and is an infarct of the ____.

A
  • level of the pons (Pontine glioma can cause this)

- infarct of Anterior Inferior Cerebellar Artery (AICA)

33
Q

Wallenberg syndrome is found at the level of the _____ and is an infarct of the _______.

A
  • level of lateral medulla

- infarct of vertebral artery/posterior inferior cerebellar artery (PICA)

34
Q

Phrenic Nerve syndrome is found at the level of the _____. What is the triad?

A
  • level of spinal cord

- hoarseness, hiccups, Horner’s

35
Q

Phrenic nerve syndrome is usually found in whom with what dx?

A
  • usually found in females with metastatic breast cancer
36
Q

What is the triad of an apical lung tumor (Pancoast’s tumor)?

A
  1. Ptosis
  2. Arm Pain
  3. Miosis
37
Q

A painful horner’s is consider what until proven otherwise?

A

Carotid Artery Dissection

38
Q

Why is a carotid artery dissectin a medical emergency? How is it managed?

A
  • lack of blood flow to the brain due to a small lumen = stroke
  • immediate MRI/MRA of neck, CTA
39
Q

Vernet’s syndrome is a tumor where? What are the findings?

A
  • Tumor at the base of the skull

- droopy shoulder, tongue deviates to one side, hoarse voice

40
Q

What are the associated symptoms of Tonic pupil?

A
  • Decreased deep tendon reflexes

- Diminished corneal sensitivity

41
Q

What drug is used to determine pre from post ganglionic Horner’s?

A
  • 1% Paredrine (Hydroxyamphetamine)
42
Q

In a (-) test, Paredrine will dilate the pupils in what instances?

A
  • 1st or 2nd order (pre-gang)

- Acute 3rd order

43
Q

In a (+) test, Paredrine will not dilate the pupils in what instances?

A
  • non-acute 3rd order (post gang)
44
Q

If you drop a patient with Paredrine and it dilates, what does this mean?

A
  • Negative Test

- Preganglionic or Acute 3rd order

45
Q

If you drop a patient with Paredrine and it doesn’t dilate, what does this mean?

A
  • Positive Test

- Postganglionic, Non-acute 3rd order

46
Q

Adults: For 1st and 2nd order Horner’s lesions, what should be imaged?

A

Mid-thorax to level of mandible

47
Q

Adults: For 3rd order horner’s lesions, what’s the management?

A

Possibly no workup

- usually benign

48
Q

Horner’s is found in 17.5% of neuroblastoma cases. What’s the average age of dx for this disease?

A

2 years old

- don’t use aproclonidine to dx; must use cocaine

49
Q

What specific urine test are needed for a neuroblastoma workup? Why?

A
  • VMA = Vanyllymandelic Acid
  • HVA = Homovanillic acid
    (both of these are produced by the tumor)
50
Q

For a 1st order Horner’s, what 2 things are we concerned about. What do we check?

A
  1. Vascular or Trauma

2. Check brainstem

51
Q

For a 2nd order Horner’s, what are we concerned about and what do we check?

A
  1. Neoplasia

2. Apex of the lung (pancoast)

52
Q

For a 3rd order Horner’s, what are we concerned about?

A
  • nothing, usually idiopathic

- benign

53
Q

What is the causative agent in neuro-syphilis?

A

Treponema Pallidum

54
Q

Argyll-robertson is caused by a syphilitic lesion of what?

A
  • lesion of peri-aqueductal gray region in the midbrain

- most common lesion in neurosyphilis

55
Q

What are the blood tests for syphilis?

A 
RPR = current active infection
FTA-ABS = pt had syphilis before, not active
56
Q

How do we distinguish syphilis from neurosyphilis?

A

VDRL = Lumbar puncture

57
Q

What is the tx for neurosyphilis?

58
Q

What are the 5 causes of LND?

A
  1. Tonic pupil
  2. AG neurosyphilis
  3. Amaurotic Pupil
  4. CN III aberrant degen.
  5. DMS (tectal pupil)
59
Q

What are the 3 causes of a small pupil?

A
  1. AG/Neurosyphilis
  2. Horner’s syndrome
  3. Miotics
60
Q

What are the causes of a large pupil?

A
  1. Tonic Pupil
  2. Mydriatics
  3. CN III palsy
  4. DMS/Tectal pupils
  5. Uncal herniation (Hutchinson’s pupil)

Neuro-Malloy (16 decks)

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