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Fall 2014 Neuro Ophthalmic Disease > Fall 2014: Lecture 3: Pupil Disorders > Flashcards

Fall 2014: Lecture 3: Pupil Disorders Flashcards

1
Q

Parasympathetic Pathway: Afferent

  1. Nerves that Decussate at the Chiasm: Number of Fibers that cross?
  2. Afferent Fibers Synapse at what Nuclei?
  3. INTERNEURONS from the Pretectal nucleus connect to what?
A
  1. 53 CROSS, and 47 Uncrossed
  2. At the PRETECTAL Nuclei
  3. To the Ipsilateral AND Contralateral EW-Nucleus
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2
Q

Parasympathetic Pathway: Efferent

  1. Describe the Efferent Pathway from the EW-NUCLEI to Pupil Constriction.
A
  1. a. EW-Nuclei –> Midbrain EXIT w/3rd NERVE –> CAVERNOUS SINUS (3rd nerve DIVIDES, and Pupil Fibers travel w/INF. Division of 3rd Nerve) –> CILIARY GANGLION in Orbit –> Travel w/IO Muscle –> Innervates PUPILLARY SPHINCTER and CB –> PUPIL CONSTRICTION due to Ach RELEASE!!!
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3
Q

Parasympathetic Pathway

  1. The FIBERS that Innervate the IRIS SPHINCTER MUSCLE Rung along what?
A
  1. Along the OUTSIDE of the 3rd NERVE
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4
Q

Sympathetic Pathway

  1. First Order Neuron
    a. Begins where in the Brain?
    b. Descends thru what area of the brain?
    c. Synapses where?
  2. Second Order (Preganglionic)
    a. Leaves Spinal Cord and Travels over what?
    b. Ascends with what?
    c. Synapses at what ganglion?
  3. Third Order (Postganglionic)
    a. Ascends along what and into what?
    b. Sympathetic Branches follow what Nerves?
    c. Releases what at what muscle?
    d. The Sympathetic Fibers also travel to what muscles?
A
  1. a. Posterior Hypothalamus
    b. Thru the Brain Stem and Cervical Spinal Cord
    c. At the C8-T2 Spinal Cord (Ciliospinal Center of Budge)
  2. a. Over the APEX of the Lung
    b. with the ICA
    c. at the Superior Cervical Ganglion
  3. a. the ICA into the Cavernous Sinus
    b. CN6, then V1 (Nasociliary Branch), then LONG Ciliary Nerve to the Iris
    c. Norepi at the Iris Dilator Muscle
    d. to Tarsal muscles of the upper and lower eyelids
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5
Q

Sympathetic Pathway

  1. Sudomotor Fibers: What are they?
    a. They go to the face and follow what?
A
  1. Nerves for Sweating

a. follow the ECA and Facial Arteries

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6
Q

Grading an RAPD

  1. 6 Filters rated as what?
  2. Filters are placed over what?
A
  1. 0.3, 0.6, 0.9, 1.2, 1.5 and 1.8 log unit optical density values.
  2. Over the Good Eye during the swinging flashlight test until the pupillary responses are equal.
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7
Q

Grading an RAPD

  1. Subjective System
    a. 1+
    b. 2+
    c. 3+
    d. 4+
A
  1. a. Weak initial pupillary constriction followed by greater redilation
    b. Initial pupillary stall followed by greater redilation
    c. immediate pupillary dilation
    d. No reaction to light (AMAUROTIC PUPIL)
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8
Q

APD Detection

  1. Requires only one “working” Pupil. If a Pt is Pharmalogically dilated in the Left Eye, u can still check for an APD by observing the reaction of the right pupil.

How will the right pupil react during the APD test if

a. No APD
b. + APD OD
c. + APD OS

A
  1. a. Constrict
    b. Dilate
    c. Dilate

???

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9
Q

Bilateral RAPD?

  1. How will pupils react if BOTH Optic Nerves are Damaged Equally?
    a. RAPD Test is relative to what?
    b. The Marcus Gunn Phenomenon REQUIRES what?
A
  1. Both pupils will have SLUGGISH Direct and Consensual Reactions
    a. to the Other Eye
    b. Asymmetry of the AFFERENT LIGHT TRANSMISSION PATHWAYS
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10
Q

Anisocoria

  1. Define
  2. Is it Physiologic or Pathologic?
  3. Most common type of Anisocoria is what?
  4. Pupil size is controlled by what?
  5. Pathologic Anisiocoria is due to what?
  6. Afferent defects DO NOT CAUSE what?
A
  1. Asymmetric Pupil Sizes
  2. Can be Either
  3. is Physiologic
  4. by EFFERENT Parasympathetic and SYMPATHETIC Pathways
  5. due to an EFFERENT Dysfunction
  6. Do not cause ANISOCORIA
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11
Q

About what % of the normal population has physiologic anisocoria?

A
  1. 20%
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12
Q

Physiologic Anisocoria

  1. Both pupils will have what?
  2. The Degree of Anisocoria is approximately what in light and dark?
  3. The degree of Anisocoria can do what from day to day?
  4. Anisocoria may even do what?
A
  1. a Normal, brisk reaction to light
  2. Equal
  3. can vary
  4. may even switch sides.
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13
Q

Pathologic Anisocoria

  1. Pupil Too SMALL!! (What 3 things?)
    a. Aniso is greater in the light/dark?
  2. Pupil too BIG (4 things)
    a. Aniso greater in light/dark?
A
  1. Pharmacologic; Horner Syndrome; Uveitis
    a. Dark
  2. 3rd Nerve Palsy; Tonic Pupil; Trauma; Pharmacologic
    a. LIGHT!
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14
Q

Pharmacologic CONSTRICTION!

  1. Pilocarpine
    a. Tx for what Dz that is not frequently used anymore?
  2. Pesticides containing what?
    a. What do they do?
  3. What other drug?
A
  1. a. Glaucoma
  2. Organophosphates
    a. Potent Nerve agent. INHIBITS ACHE
  3. Opiates
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15
Q

Pupil Constriction 2: Horner Syndrome

  1. Damage to what Nervous System?
  2. What happens due to this damage?
  3. Ocular Signs? (6)
  4. Ptosis seen in Pts w/Horner Syndrome is due to Dysfunction of which Eyelid Muscle?
A
  1. Sympathetic NS
  2. Decreased NE release at the IRIS DILATOR
  3. a. Ptosis: (UPPER and LOWER LID)
    b. MIOSIS (IPSILATERAL of LESION)
    c. ANHIDROSIS
    d. Pupils tend to have normal Light reaction
    e. Aniso GREATER in DARK!
    f. DILATION LAG (Slow dilation of affected pupil in the dark)
  4. Superior Tarsal Muscle
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16
Q

Causes of Horner Syndrome

  1. Central (1st order): Head or Neck (4)
  2. Preganglionic (2nd order): Neck or Chest) (3)
    a. MAIN ONE?
  3. Postganglionic (3rd Order) (4)
    a. MAIN one?
A
  1. a. Brainstem Stroke/Tumor
    b. Spinal Cord Lesion
    c. Cervical Spondylosis
  2. a. ICA Dissection!
    b. Apical Lung Tumor (Pancoast Tumor)
    c. Latrogenic (from Neck or chest Sx)
  3. a. ICA Dissection!
    b. Cavernous Sinus Lesion
    c. Latrogenic (from Neck Sx)
    d. Cluster HAs!
17
Q

ICA Dissection

  1. What is a Carotid Artery Dissection?
A
  1. SEPARATION of the Layers of the Artery WALL!
18
Q

Pancoast Tumor

  1. Tumor at what part of the Lung?
  2. Associated with what?
A
  1. Apex of the Lung

2. Arm pain on the SIDE of the LESION!

19
Q

Congenital Horner Syndrome

  1. CONGENITAL or VERY LONG STANDING?
  2. The AFFECTED EYE is usually Lighter/Darker in color?
  3. What part of the IRIS REQUIRES SYMPATHETIC INPUT during Development?
  4. Congenital Causes (4)?
A
  1. HETEROCHROMIA!
  2. LIGHTER
  3. Iris Melanocytes
  4. Birth Trauma, Iatrogenic, Neuroblastoma, Vascular Anomalies
20
Q

Pharmacologic Testing

  1. Diagnostic (2)
  2. Localization (2)
A
  1. a. Cocaine
    b. Apraclonidine
  2. a. Hydroxyamphetamine
    b. Phenylephrine
21
Q

Diagnostic Pharmacologic Testing

  1. Cocaine
    a. %?
    b. Normal?
    c. Horner Syndrome?
    d. Mechanism?
  2. Apraclonidine
    a. %?
    b. Normal?
    c. Horner Syndrome?
    d. Mechanism?
A
  1. a. 4-10%
    b. Dilation
    c. Reduced/No Dilation
    d. Cocaine Blocks REUPTAKE of NE, resulting in DILATION of a NORMAL PUPIL!! In Horners, a Lack of NE in the Synaptic Cleft will fail to dilate.
  2. a. 0.5-1%
    b. No Dilation
    c. Dilate
    d. Sympathetic DENERVATION causes HYPERSENSITIVITY of ALPHA RECEPTORS on the PUPILLARY DILATOR MUSCLE!!!
22
Q

Pharm Testing: Localization

  1. Hydroxyamphetamine
    a. %?
    b. Normal?
    c. Preganglionic or CENTRAL?
    d. Postganglionic?
    e. Mechanism?
  2. Phenylephrine
    a. %?
    b. Normal?
    c. Preganglionic or Central?
    d. Postganglionic?
    e. Mechanism?
A
  1. a. 1%
    b. Dilation
    c. Dilation
    d. No Dilation
    e. this drug increases release of NE from the Postganglionic NERVE ENDINGS.
  2. a. 1%
    b. Slight Dilation
    c. Slight Dilation
    d. BIG DILATION
    e. Denervation SUPERSENSITIVITY (Can take up to 10 DAYS!)
23
Q

Management

  1. Face or Neck Pain SUGGESTS what is going on?
  2. Central or Preganglionic? (4)
  3. Postganglionic (2)?
A
  1. IC Dissection! (EMERGENCY!)
  2. a. MRI of head and neck
    b. MRA
    c. Chest X-Ray or CT Scan
    d. Spine Scan
  3. a. MRI
    b. MRA
24
Q

Pharmacologic DILATION

  1. Anticholinergic Agents (3)
  2. Sympathomimetic/Alpha-Agonist (2)
  3. Plants (3)
  4. Scopolamine Patch (used for what?)
  5. Inhalants used for what?
A
  1. a. ACT: Atropine, Cyclopentolate, Tropicamide
  2. a. Phenylephrine, Tetrahydrozoline
  3. a. Angel’s Trumpet
    b. Belladonna
    c. Jimson Weed
  4. Motion Sickness
  5. for Asthma
25
Q

Traumatic Pupil

  1. Damage to what part of the Iris?
  2. What types of Previous Sx?
  3. Pupil Usually dilates how?
  4. Is any reaction present?
A
  1. to the IRIS SPHINCTER
  2. Cataract or Corneal Sx
  3. Dilates Irregularly
  4. Some reaction usually present.
26
Q

Adie Tonic Pupil (1)

  1. Etiology?
  2. % UNILATERAL?
  3. FEMALES:MALES Ratio?
  4. Age?
  5. How does the pupil present?
  6. Accommodation affected?
  7. EOM Motility?
  8. Associated with LOSS of DEEP TENDON REFLEXES (called what?)
A
  1. Unknown (Maybe Viral or AI)
  2. 80%; Rarely becomes bilateral
  3. 5:1
  4. 20-40 y/o
  5. Dilated pupil w/POOR to Absent Light Reaction; SLOW CONSTRICTION to NEAR w/SLOW REDILATION
  6. May have DECREASED ACCOMMODATION
  7. Normal
  8. ADIE SYNDROME
27
Q

Tonic Pupil

  1. Tonic Pupil: Define
  2. Most Tonic Pupils are WHAT?
  3. TONIC PUPIL can also be caused by what 4 things? (IIIT)
A
  1. Iris Sphincter and Ciliary Muscle Dysfunction from DAMAGE to CILIARY GANGLION or Postganglionic Short Ciliary Nerves
  2. IDIOPATHIC (Adie Tonic Pupil)
  3. a. Inflammation
    b. Infection
    c. Ischemia
    d. Tumor
28
Q

Adie Tonic Pupil

  1. Segmental Contraction of the Iris
    a. What results in Areas of SEGMENTAL CONTRACTION ADJACENT to Sector Paralysis?

b. When Normal Portions Contract, what do they do?
c. They refer to this Contraction as WHAT?

A
  1. a. Partial Preservation of the Pupil’s Parasympathetic Innervation
    b. They Pull and Twist Paralyzed Segments towards them.
    c. VERMIFORM “Worm-Like” MOVEMENTS
29
Q

Testing Adie’s Pupil

  1. Adie Pupils are SUPERSENSITIVE to what AGENTS?
    a. They CONSTRICT with what?
    b. A Normal pupil will Constrict/Not Constrict with this Drop?
A
  1. CHOLINERGIC AGENTS
    a. DILUTE 0.1% Pilocarpine
    b. NOT CONSTRICT!
30
Q

Management

  1. If Presentation is NOT Typical, what should be done?
  2. Life Threatening?
  3. Accommodative Dysfunction?
  4. Photophobia?
  5. Cosmesis?
A
  1. Systemic w/u
  2. No. (Over time, Adie’s Pupil Gets Smaller…can take months to years)
  3. Reading Glasses
  4. Sunglasses, 0.1% Pilocarpine
  5. Colored Contacts!
31
Q

CN 3 PALSY

  1. What 3 Signs are there?
A
  1. a. Mydriasis
    b. Ptosis
    c. Abnormal EOMs
32
Q

Pupil Involved 3rd Nerve Palsy

  1. WHAT is GOING ON?
    a. 3 CAUSES. Which is an EMERGENCY?!
A
  1. COMPRESSION of the NERVE!
    a. ANEURYSM: EMERGENCE: an Expanding aneurysm can RUPTURE and Kill the Pt w/in HOURS! (usually at junction of IC or Posterior Communicating Artery)
    b. Tumors
    c. Uncal Herniation due to Increased Intracranial Pressure
33
Q

Third Nerve Palsy

  1. a Partial 3rd Nerve Palsy can PRESENT HOW?

a. MR?
b. IR?
c. SR and/or IO?
d. Levator?
e. How common is a PUPIL only 3rd nerve PALSY?

A
  1. w/ANY COMBO of Muscle involvement (innervated by CN 3) to ANY DEGREE (mild to severe!)
    a. Exotropia
    b. Hypertropia
    c. Hypotropia
    d. Ptosis
    e. It’s VERY RARE!!
34
Q

Third Nerve Palsy: Management

  1. What should be done?
A
  1. URGENT MRI w/CONTRAST PLUS MRA or CTA!!!

* A Pupil involved 3rd Nerve Palsy is an ANEURYSM until PROVEN OTHERWISE!!

35
Q

Pupil Reaction to Accommodation

  1. Light-Near Dissociation refers to pupils that react how to LIGHT STIMULATION, and How when viewing a Near Target?
  2. Number of Parasympathetic Fibers going to the Ciliary Body compared to those going to the Iris Sphincter Muscle?
    a. U can have a Pupil with what kind of Reaction to light, with what kind of Near Reaction?
    b. THERE Is NO CONDITION with with what?
A
  1. React POORLY to Light Stimulation; Constrict more BRISKLY when viewing a near target.
  2. 30:1
    a. w/a Sluggish Reaction to LIGHT and a PRESERVED NEAR REACTION!
    b. No condition w/a Brisk Pupil Reaction to light and a Decreased Near Reaction!
36
Q

Causes of Light-Near Dissociation (5)

A
  1. Argyll Robertson Pupil
  2. Adie’s Tonic Pupil
  3. Aberrent Regeneration of the CN 3
  4. Dorsal Midbrain Syndrome (Parinaud Syndrome)
  5. Severe Loss of Vision (Retina or Optic Nerves)
37
Q

Near Reflex Pathway

  1. Follows what pathway?
    a. However, what does it BYPASS?

b. Damage to what areas of the brain will explain some forms of Pupillary Light-near dissociation?

A
  1. Parasympathetic Pathway

a. the PRETECTAL NUCLEI in the Dorsal Midbrain and Descends DIRECTLY to the EW-N

38
Q

Parinaud Syndrome

  1. AKA?
  2. Pupils: What do they look like?
  3. What kind of Paresis (what gaze)?
    a. What kind of Nystagmus?
    c. What happens to the Eyelids?
  4. Cause?
A
  1. Dorsal Midbrain Syndrome
  2. Mid-Dilated w/Light-Near Dissociation due to INTACT Supranuclear Influences
  3. Upgaze Paresis
    a. Convergence Retraction Nystagmus
    b. Eyelid Retraction
  4. Pineal Gland Tumor
39
Q

Argyll Robertson Pupils

  1. Bilateral Miotic Pupils of what size?
  2. Light Reaction?
  3. Testing?
A
  1. <2 mm
  2. None, but they have a NORMAL NEAR RESPONSE
  3. Rapid Plasma Reagin Test (RPR); Venereal Disease Research Lab Test (VDRL)

and FTA-ABS

Fall 2014 Neuro Ophthalmic Disease (14 decks)

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