Horner's, addies, Argyll Robertson

Question 1

Signs and Symptoms of Horner’s syndrome

Answer 1

Ptosis, anhydrosis, can be asymptomatic.
Anisoconia greater in dim light
The abnormal small pupil dilated less than the normal
lighter iris colour, loss of sweating, can occur
Light and near reactions can still be intact.

Question 2

Horners: First order (central) neuron

Answer 2

The first order (central) neuron descends caudally from the hypothalamus to the first synapse in the cervical spinal cord (C8-T2 level). The descending sympathetic tract is in close proximity to other tracts and nuclei in the brainstem.

Question 3

Horners: Second order (preganglionic) neuron

Answer 3

The second order (preganglionic) neuron destined for the head and neck exits the spinal cord and travels in the cervical sympathetic chain through the brachial plexus, over the pulmonary apex and synapses in the superior cervical ganglion. The superior cervical ganglion is located near the angle of the mandible and bifurcation of the common carotid artery.

Question 4

Horners: Third order (postganglionic) neuron

Answer 4

The third order (postganglionic) neuron for the orbit enters the cranium within the adventitia of the internal carotid artery into the cavernous sinus. Here the oculosympathetic fibers exit the internal carotid artery in close proximity to the trigeminal ganglion and the sixth cranial nerve and join the 1st division of the trigeminal nerve to enter the orbit.

. The fibers (long ciliary nerve) innervate the dilator muscles of the iris and the smooth muscle (Müller’s muscle) in the upper and lower eyelid (inferior retractors).

· The vasomotor and sudomotor fibers to the face exit the superior cervical ganglion and ascend in the external carotid artery.

· Pupillary constriction is produced by parasympathetic (cholinergic) fibers that travel with the third cranial (oculomotor) nerve.

Question 5

DDx’s to consider with pupil defect

Answer 5

● Physiological anisocoria

● Argyll Robertson pupil

● Adie’s pupil

● Third nerve palsy (isolated)

● Retrobulbar tumour

Stroke 
MS or optic nueritis 
pancoast tumor 
cluster headache
migraine
VZV

In children consider:
neuroblastoma
lymphoma
metastasis

Question 6

Horners: which is the affected pupil?

Answer 6

The smaller pupil

Question 7

Which pharmalogical agent is used to test fo horners?

Answer 7

0.125% phenylephrine: a normal pupil would not dilate, horners will due to sensitivity.

Question 8

Horners: Agent to distinguish between 1 and 2nd v 3rd neuron? (don’t use in Aus)

Answer 8

hydroxyamphetamine: if dilation 1 or 2nd

Question 9

Horners management?

Answer 9

Management

· REFER to the ophthalmologist to treat the underlying cause behind the condition

· Surgical management of ptosis

NB: If first or second order, urgent referral

Question 10

Addies tonic: Signs and symptoms:

Answer 10

● Dilated or mid dilated pupil unreactive to light

● Constrict to near objects but sluggish redilation

● Loss of deep tendon reflexes (involuntary muscle contractions due to sudden stimulus)

● Often asymptomatic

● Long term, the affected pupil will become smaller and “tonic”

Question 11

Addies tonic: Signs and symptoms:

Answer 11

● Dilated or mid dilated pupil unreactive to light

● Constrict to near objects but sluggish redilation

● Loss of deep tendon reflexes (involuntary muscle contractions due to sudden stimulus)

● Often asymptomatic

● Long term, the affected pupil will become smaller and “tonic”

Ussually presents unlilaterally but can later occur in the other eye

Question 12

Will pupils constrict at near?

Answer 12

YES

Question 13

Will pupils constrict at near?

Answer 13

YES, slow tonic constrictions

Question 14

Management of Addies tonic pupil?

Answer 14

· Refer to GP for systemic work up

· The ciliary ganglion is damaged, then collateral branches grow to the ciliary ganglion and sphincter

• The ciliary muscle fibres now innervate the sphincter
• Normally self-resolving condition but you could get blood samples

Question 15

Argyll Robertson pupil signs and symptoms:

Answer 15

Small pupil

· Slow/no pupil response to light but ok near response

Question 16

Argyll Robertson pupil signs and symptoms:

Answer 16

Small pupils
bilateral condition
dilate poorly to darkness

· Slow/no pupil response to light but ok near response

Question 17

Horners Pathophysiology

Answer 17

Horner’s syndrome results from a lesion to the sympathetic pathways that supply the head and neck, including the oculosympathetic fibers.

Question 18

Horners epidemiology

Answer 18

In a population based study of Horner’s syndrome in the pediatric age group, the incidence of Horner’s syndrome was estimated to be 1.42 per 100 000 patients younger than 19 years, with a birth prevalence of 1 in 6250 for those with a congenital onset

Question 19

Management of Argyll Robertson pupil

Answer 19

· Refer to GP for systemic health check and to determine underlying caus

Question 20

Management of Argyll Robertson pupil

Answer 20

· Refer to GP for systemic health check and to determine underlying cause

also has an association with syphilis