Horners Flashcards
Small pupil due to a muscle problem
Small pupil due to a neuromuscular problem
Ciliary spasm from anterior uveitis
Miotics (pilo) or senile miosis
3 ways to determine if pt has horners
- Definition- ptosis, miosis, anhydrosis.
- Cocaine/apraclonidine testing
- Dilation lag test
How is ptosis in horners different than ptosis in CN III palsy
Varies with the tie of day. May get worse later in the day.
Kearn’s lower lid sign= inverse ptosis. Important
Inverse ptosis
Kearn’s lower lid sign
Horners. What is the response to light and near?
Both are intact. However, aniso will be greater in dim than in bright light.
Why is anhydrosis (no sweating) an important factor in horners?
helpful in localizing the lesion!
Pt with horners
dropped w cocaine
Dropped with apraclonidine
Cocaine- Horners Pupil doesn’t dilate
Apraclonidine- Horners pupil dilates, reversal of aniso
How to perform the dilation lag test
Because the sympathetic nervous system is compromised, the pupil will dilate very slow. 5 seconds into the darkness, it will be a different diameter than 10 seconds in.
A normal pupil would reach max dilation after the lights are turned off.
Horners lesion can be located anywhere from where to where
Posterior hypothalamus to the eye.
Determine location by signs, symptoms, and pharm agents.
5 main locations that cause horners syndrome and names
- Spinal cord
- Congenital
- Phrenic nerve syndrome - Brainstem
- Wallenberg’s/Stroke in brain stem/Lateral Medullary Syndrome
- Anterior medullary syndrome - Neck
- Carotid artery dissection
- Vernets. External sheath of carotid. Scapula problems. - Chest
- Pancoasts - Head
- Cluster headaches
- Otitis
- Cavernous sinus
Congenital horners
other signs: Heterochromia(due to reduced tyrosinase activity- sympathetically innervated and creates melanin. Disruption to sympathetic nervous system = lighter pupil), straighter hair, klumpke’s paralysis
Damage at C7 and 8
Klumpke’s paralysis
Spinal birth injury, involved in congenital horners
Wallenberg’s syndrome/lateral medullary syndrome symptoms
May cause horners
- Stroke in the brainstem at the posterior inferior cerebellar artery.
- Vertigo, vomiting, nystagmus.
- Contralateral deficit of pain and temp.
- Inspi horners and loss of facial pain.
- Saccadic dysmetria. Overshoot on side of horners.
- Ask pt to look up
Anterior medullary syndrome
May cause horners.
-Horners in 1 eye, CN 4 palsy on the other side
Horners lesion locations. Describe loss of sweating
- Lesion pre cervical ganglion
- Post cervical ganglion
- At cervical ganglion
- At brainstem
- At spinal cord
- Loss of ipsi facial sweating
- Loss of ipsi forehead sweat
- Loss of face sweating
- Loss of entire half of body ipsi
- Loss of upper half of body
Think cluster headache if pt reports
Red eye, stuffy nose, headache
Vernets syndrome
Drooped shoulder, winged scapula, cannot say La Yogurt.
Problem involving CN 9-12 + horners
External carotid sheath syndrome
Which is more serious? Lesions in horners at first, second, or third order neurons?
People with 2nd degree are prob very ill
People with 3rd degree are prob more benign- cluster HA, migraines, head trauma.
Central, pre and post ganglions involved in horners
Central- first order
pre- 2nd order
post-3rd order
1st: Spinal cord –> Superior cervical ganglion
2nd: Superior cervical ganglion –>ganglia
3rd: Ganglia–> Muscle
What is the lesion if the horners lesion is central/first order?
Involving brain and spinal cord.
- Brainstem glioma
- Syringomyelia
- Spinal cord tumor
- Wallenberg/Lateral medullary syndrome/stroke
What is the lesion if the horners lesion is post/third order?
Cluster HA otitis media cavernous sinus internal carotid artery nasopharyngeal tumor
Difference between Wallenberg and Fovilles syndrome
Wallenberg- Lesion at Posterior inferior cerebellar artery
Fovilles- Lesion at anterior inferior cerebellar artery
Acquired horners syndrome in adults. Symtpoms and what likely caused it based on age?
35% due to neoplasia
Birth-20 years: Trauma
20-50 years: Neoplasia
50+ years: Malignant neoplasia
If horners lesion is located Neck Spinal root Brainstem Intracranial
What is the likely cause/
Neck or chest- neoplasia/quiet
Spinal root- trauma
Brainstem- Vascular disease
intracranial- headache/painful
Small pupil due to a brain problem and stages
Syphillis
Primary
Secondary
Latent
Tertiary- affects eyes.
Tertiary syphilis- other involvement and symptoms
- Cardiovascular (80%)
- Gummy lesions 10%
- CNS involvement 10%
4 types of clinical neurosyphilis
Meningitis
Meningovascular syphilis
Tabes Dorsalis (Syphilis in the posterior columns)
General paresis (dementia paralytic) (syphilis in the frontal lobe)
*Last 2 associated with AR
Syphilis common locations
Frontal lobe (General paresis) Brainstem (AR Pupil) Posterior dorsal column (Tabes dorsalis)
Tabes Dorsalis
Syphilis damage of the posterior dorsal columns
- Weird gait
- Usually affects men
General paresis
Syphilis damage of the frontal lobe
- Generalized paralysis
- Personality disorder
- Memory disturbances
How can syphilis affect the eye? 4 ways
Granulomatous uveitis
Iritis –> Atrophic iritis/iris atrophy
AR (involvement at brainstem)
Neurologic tonic pupil (Involvement at ciliary ganglion)
6 criteria for AR pupil
- Pupil diameter small. Less than 2.5mm
- No pupil response to direct light, consensual response is absent too.
- Near response intact but brisk
- difficult to dilate in dim light
- Usually bilateral
- Aniso may be present
Syphilis testing
Order VDRL blood test
- Non treponema test looks for indirect evidence.
- If positive, then confirm its syphilis with RPR test. Does not require a microscope to interpret. Agglutination= positive
*Positive test doesn’t mean active. May have had it in the past.
