IOS/PC - Case Study: Horner's Syndrome - Week 5 Flashcards
Consider the following clinical case: The patient ( 50 year old male) came in complaining of a bit of redness in the right eye and a "droopy" right eye lid that was worsening over the last 8 weeks. There was no history of trauma and there was nothing contributory from his earlier ocular and medical histories. Smoker: 2-3 packs of cigarettes a day for 35 years. Refraction revealed hyperopia with astigmatism. Best-corrected visual acuity was 6/7 in RE and 6/6 in LE. External examination showed an anisocoria (2 mm RE, 3 mm LE) that was much worse in dim light (2.5 mm RE, 5.5 mm LE). There was no afferent pupillary defect. The interpalpebral fissure of the right eye measured less than that of the left (7 mm RE, 11 mm LE). Extraocular muscles, color vision and cover testing were normal. The slit lamp exam was normal in both eyes. IOPs were 14mm Hg O.U. The dilated fundus examination revealed cup-to-disc ratios of .45/.45 OD, 50/.50 O.S. Further history : Patient complained of right shoulder pain, radiating into the ulnar distribution of the right arm.
Which is the abnormal eye?
Which innervation pathway to the affected eye is impaired and why?
What can be done to confirm this?
One eye could be abnormally dilated or the other abnormally constricted but here the ptosis (droopy lid) helps identify which side is impaired.
A miotic pupil suggests a failure of sympathetic innervation to the dilator muscles.
One way to check for this is to check for sympathetic activity by applying cocaine eye drops. As these block norepinephrine reuptake, the normally innervated eye should dilate but the abnormal one won’t.
Consider the following clinical case: The patient ( 50 year old male) came in complaining of a bit of redness in the right eye and a "droopy" right eye lid that was worsening over the last 8 weeks. There was no history of trauma and there was nothing contributory from his earlier ocular and medical histories. Smoker: 2-3 packs of cigarettes a day for 35 years. Refraction revealed hyperopia with astigmatism. Best-corrected visual acuity was 6/7 in RE and 6/6 in LE. External examination showed an anisocoria (2 mm RE, 3 mm LE) that was much worse in dim light (2.5 mm RE, 5.5 mm LE). There was no afferent pupillary defect. The interpalpebral fissure of the right eye measured less than that of the left (7 mm RE, 11 mm LE). Extraocular muscles, color vision and cover testing were normal. The slit lamp exam was normal in both eyes. IOPs were 14mm Hg O.U. The dilated fundus examination revealed cup-to-disc ratios of .45/.45 OD, 50/.50 O.S. Further history : Patient complained of right shoulder pain, radiating into the ulnar distribution of the right arm.
How can you assess if a third order neuron is affected, or whether it is more central?
Apply hydroxyamphetamine eye drops. This forces release of neurotransmitter from the axon terminal. But this won’t happen it is a third order neuron defect.
Consider the following clinical case: The patient ( 50 year old male) came in complaining of a bit of redness in the right eye and a "droopy" right eye lid that was worsening over the last 8 weeks. There was no history of trauma and there was nothing contributory from his earlier ocular and medical histories. Smoker: 2-3 packs of cigarettes a day for 35 years. Refraction revealed hyperopia with astigmatism. Best-corrected visual acuity was 6/7 in RE and 6/6 in LE. External examination showed an anisocoria (2 mm RE, 3 mm LE) that was much worse in dim light (2.5 mm RE, 5.5 mm LE). There was no afferent pupillary defect. The interpalpebral fissure of the right eye measured less than that of the left (7 mm RE, 11 mm LE). Extraocular muscles, color vision and cover testing were normal. The slit lamp exam was normal in both eyes. IOPs were 14mm Hg O.U. The dilated fundus examination revealed cup-to-disc ratios of .45/.45 OD, 50/.50 O.S. Further history : Patient complained of right shoulder pain, radiating into the ulnar distribution of the right arm.
Suppose that eye drop testing suggests sympathetic innervation impairment, and that the third order neurons are intact. What do these results indicate, and what can be done to localise the pathology?
Considering the patient’s medical history, suggest the most likely pathology.
Suggests the lesion is pre-ganglionic.
Given he is a heavy smoker for 35 years, and complains of right shoulder pain radiating to the ulnar, the pathway of the second order neuron becomes especially important.
An MRI scan will indicate a Pancoast’s tumour of the lung at the apex, and this presses on the axons of the second order neuron.
This is Horner’s syndrome.
Consider the following clinical case: The patient ( 50 year old male) came in complaining of a bit of redness in the right eye and a "droopy" right eye lid that was worsening over the last 8 weeks. There was no history of trauma and there was nothing contributory from his earlier ocular and medical histories. Smoker: 2-3 packs of cigarettes a day for 35 years. Refraction revealed hyperopia with astigmatism. Best-corrected visual acuity was 6/7 in RE and 6/6 in LE. External examination showed an anisocoria (2 mm RE, 3 mm LE) that was much worse in dim light (2.5 mm RE, 5.5 mm LE). There was no afferent pupillary defect. The interpalpebral fissure of the right eye measured less than that of the left (7 mm RE, 11 mm LE). Extraocular muscles, color vision and cover testing were normal. The slit lamp exam was normal in both eyes. IOPs were 14mm Hg O.U. The dilated fundus examination revealed cup-to-disc ratios of .45/.45 OD, 50/.50 O.S. Further history : Patient complained of right shoulder pain, radiating into the ulnar distribution of the right arm.
Suppose that eye drop testing suggests a lesion od the third order neuron. What is significant about this, and why is this form of Horners syndrome urgent?
The pathway of the third order neuron lies on the carotid artery plexus.
Aneurysms here can compress the nerve, and impact function.
If this artery ruptures, instant death can occur, and referral for neurological assessment is urgent.
Consider the following clinical case: The patient ( 50 year old male) came in complaining of a bit of redness in the right eye and a "droopy" right eye lid that was worsening over the last 8 weeks. There was no history of trauma and there was nothing contributory from his earlier ocular and medical histories. Smoker: 2-3 packs of cigarettes a day for 35 years. Refraction revealed hyperopia with astigmatism. Best-corrected visual acuity was 6/7 in RE and 6/6 in LE. External examination showed an anisocoria (2 mm RE, 3 mm LE) that was much worse in dim light (2.5 mm RE, 5.5 mm LE). There was no afferent pupillary defect. The interpalpebral fissure of the right eye measured less than that of the left (7 mm RE, 11 mm LE). Extraocular muscles, color vision and cover testing were normal. The slit lamp exam was normal in both eyes. IOPs were 14mm Hg O.U. The dilated fundus examination revealed cup-to-disc ratios of .45/.45 OD, 50/.50 O.S. Further history : Patient complained of right shoulder pain, radiating into the ulnar distribution of the right arm.
Consider the ptosis. What order neuron runs to the eyelids, and what pathway innervate it? Which nerve is responsible? What is significant about certain nerves leaving the superior cervical ganglion, where do they go, and how would a lesion of the third order neuron be seen clinically?
The third order neuron runs to the eyelids.
The third cranial nerve and sympathetic pathway innervate the eyelid.
A nerve leaves the superior cervical ganglion to the sudomotor and vasoconstrictor fibres of the face, regulating sweating.
A lesion of the third order neuron will mean the side of the face with the lesion will not sweat, even in hot conditions.
Describe congenital Horner’s syndrome, and two secondary conditions associated with it.
Sympathetic innervation is involved in pigment distribution in early life. Horner’s syndrome will lead to a hypopigmented iris.
The hypopigmented eye will have ptosis and anisocoria, the smaller pupil.
Describe adies tonic pupil. What population is it often seen in, what could cause it, and what is it due to?
A patient presents with one large and one small pupil, with no other pathologies.
The anisocoria is most obvious in bright light.
Typically seen in young women, sometimes after a viral illness, and begins monocularly.
Due to damage to the ciliary ganglion or short ciliary nerves to the sphincter.
Does an eye affected with adies tonic pupil respond to light? What about near vision?
Unresponsive to light, but reactive to near vision. This response is sluggish.
