midterm new Flashcards
Categories of Pupil Abnormalities
❖ ABNORMAL PUPIL SIZE
❖ ABNORMAL PUPIL REACTIONS
❖ ABNORMAL PUPIL SIZE
- Adie’s Tonic Pupil
- Horner’s Syndrome
Parasympathetic block
Adie’s Tonic Pupil
Sympathetic block
Horner’s Syndrome
❖ ABNORMAL PUPIL REACTIONS
- Marcus Gunn Pupil
- Parinaud’s Syndrome
- Argyll Robertson Pupil
- Afferent Defect
Marcus Gunn Pupil
- Central Defect
- Lesion is in interneurons
- Affector->Physiological Connectors->Interneuron->PC->Effector
Parinaud’s Syndrome
also a Central Defect othe than parinuad’s syndrome
Argyll Robertson Pupil
Any lesion located from the retina to the pretectal nucleus is considered a _______________
relative afferent pupillary defect
Any lesion located from preganglionic to postganglionic fiber is considered a _________
relative efferent pupillary defect
➔ Also known as Relative Afferent Pupillary Defect (RAPD) / (APD) or pupillary escape
MARCUS GUNN PUPIL
➔ This indicates damage at or anterior to the LGN (afferent pathway) specifically to the retinal ganglion cells to optic chiasm of one eye
MARCUS GUNN PUPIL
➔ It is caused by a damage that is unilateral or asymmetric (never bilateral) as seen in several retinal diseases (severe), optic nerve disease, lesion behind the eye etc.
MARCUS GUNN PUPIL
◆ Lesions behind the eye such as tumors developed at the optic nerve
◆ Retinal diseases such as DR
◆ Glaucoma (especially unilateral)
◆ Tumors such as pituitary adenoma (usually develops at optic chiasm)
MARCUS GUNN PUPIL
➔ Always unilateral
➔ Defects are always on the retina itself or optic nerve all the way to optic chiasm (so, problems are also always in afferent)
MARCUS GUNN PUPIL
➔ Location: anterior to the LGN
MARCUS GUNN PUPIL
diseases that cause marcus gunn (6)
- CRAO
- CRVO
- BRVO
- Optic Atrophy
- Marked Retinal Detachment
- Asymmetric POAG
Loss of vision due to: (5)
will not produce the Marcus Gunn response
- corneal
- lenticular
- vitreous
- refractive
- emotional causes
An _________ is anything that moves through the blood vessels until it reaches a vessel that is too small to let it pass.
When this happens, the blood flow is stopped by the embolus. An embolus is often a small piece of a blood clot that breaks off (thromboembolus).
embolus
An _____ is often a small piece of a blood clot that breaks off (thromboembolus).
embolus
tell me what you see in a fundus
- In the fundus, a small circle can be found which is the optic disc (always located nasally).
- In the optic disc, the optic nerve is also present. Together with the optic nerve, there are blood vessels that can be seen. And from there, you can observe the thickest blood vessels. And usually, the optic nerve can also be seen together with the CRA and the CRV.
The function of the Central retinal artery
supply oxygen, nutrients, etc to the retina.
if there is clotting (thrombus, embolus, etc), it blocks the flow of blood vessels to enter inside the retina.
CRAO
when CRA is blocked because of clotting, the retina will be affected and there will be a lack of _____
oxygen
CRA is the main supply of _______ to the retina. (2)
nutrients
oxygen
Expect a ________ since retina is damaged (no oxygen/nutrients supply)
Marcus Gunn pupil
In the optic disc, there are main blood vessels that branch out small blood vessels.
These branches are blocked
Branch Retinal Vein Occlusion
Very common in end stage glaucoma (naipit na ang ON so hinay2 nangamatay ang ON fibers)
Optic Atrophy
atrophy means
degenerating/dying
Color of optic disc is ____ in retinal damage
Normal is yellow.
PALE
is marcus gunn present when optic nerve is dead?
yes
it is a serious event, which may result in complete blindness.
Retina, especially 1st and 2nd layers, is like a curtain which can be easily separated if there is a problem.
Marked Retinal Detachment
Common retinal detachments can be experienced to patients with severe:
diabetic retinopathy (end stage)
- Normal color of fundus:
red-orange
- When the retina is detached, some portion of the fundus will still appear red-orange, but the portion where retina is removed appears ____.
grayish
is when you shine a light in the fundus, it reflects back, so red-orange and that is the retina (as it receives the light). So when the retina is detached, there is also no red-orange reflex that can be seen, so it would be pale/grayish.
mechanism of an ophthalmoscopy
Other eye has glaucoma, the other has none.
Asymmetric Primary Open-Angle Glaucoma
type of glaucoma which is asymptomatic or “silent killer”
Open angle
type of glaucoma which is painful, “emergency”
Angle-closure
Glaucoma = increased IOP due to: (2)
A. Increased AH production
B. Blocked drainage / trabecular meshwork
How does the AH flow inside the eye?
The AH originates at the ciliary process
The AH travels to the posterior part of the iris
then passes thru the pupil
all the way to the anterior chamber
The AH will now be drained in the trabecular meshwork.
So if there are problems in the flow, glaucoma occurs.
When there is increased AH production, drainage can’t keep up.
When there is too much AH, it pushes back the vitreous humor until the optic nerve will get stuck
This only happens gradually, not immediately
OPEN ANGLE glaucoma
-Usual sign experienced by px with this type of glaucoma: sudden blackening of vision, then back to normal, black again, then normal..
open angle glaucoma
which part of the eye produces aqueous humor?
ciliary process
division of ciliary body
ciliary process
ciliary body
muscle responsible for accommodation
ciliary muscle
category of glaucoma which is hereditary is nature
primary
category of glaucoma which is acquired
secondary
- Blocked trabecular meshwork
- Most common is due to diabetic retinopathy (especially if px has no drug maintenance, either the eyes or kidneys will be affected)
CLOSE ANGLE GLAUCOMA
Our eyes are sensitive when it comes to changes in the blood
If there is an increase in blood sugar, there will be a __________
Therefore, the retina will not get its nourishment.
decrease in oxygen in the eyes.
WHAT HAPPENS WHEN THERE’S LACK OF OXYGEN IN THE EYES
retina will produce its own blood vessels to have enough supply of blood
different stages of DR: (3)
(1) background,
(2) non-proliferative,
(3) proliferative
Proliferative means
growing
Type of DR where theres new blood vessels are developing in response to low oxygen in the eyes
Proliferative DR
new blood vessels are developing in response to low oxygen in the eyes but these new small blood vessels are very fragile. So they easily rupture. When small blood vessels rupture, it is called ___________.
microaneurysm
what is microaneurysm
when small bv rupture
initial symptom of microaneurysm
blurring of vision
Due to low oxygen of the eyes, the retina produces new blood vessels. To produce these new blood vessels, it also releases ____
therefore, producing small blood vessels, so it proliferates.
vascular endothelial growth factor (VEGF)
So if eyes continue to produce VEGF, from the posterior, it will travel to the anterior. So, as it travels to the anterior, the blood vessels of the iris will also proliferate due to VEGF.
So with an increased VEGF, blood vessels will proliferate until the trabecular meshwork is blocked hence, glaucoma occurs.
This type of angle-closure is specifically called:____
angle-closure neovascularization glaucoma
stimulates the formation of blood vessels
vascular endothelial growth factor
It is the most common type of glaucoma here in the PH
close angle glaucoma
Patient is in pain, an immediate emergency and surgery procedure is needed. But first, to relieve the pain, a mannitol is given to the px.
close angle glaucoma
close angle glaucoma symptoms (3)
dilated pupil
swollen cornea (corneal edema)
pale fundus.
patient has diabetes. Patient neglected it, px got diabetic retinopathy. His DR got worse, it became Proliferative DR, so the blood vessels inside the eyes are growing.
Due to low oxygen because of increased blood sugar, new blood vessels are needed to form in order to supply the retina. However, these new blood vessels are very small and fragile.
Therefore, it easily ruptures (microaneurysm). When the retina forms new blood vessels, it also releases a chemical called VEGF. This will then travel to the anterior chamber where the blood vessels of the iris will also proliferate causing the trabecular meshwork to be blocked. When TM is blocked, AH cannot be drained causing angle-closure neovascularization glaucoma.
Marcus Gunn Pupil – Method of Diagnosis
Method of diagnosis: Swinging Flashlight Test
In an affected eye with Marcus Gunn, the consensual response is greater than the direct response.
A. When light is directed into the right eye → (normal direct and consensual response of that eye) → both eyes are smaller
B. When light is directed into the left eye → (normal direct and consensual response of that eye) → both eyes are smaller
C. Swinging the light back to the other eye causes normal pupil constriction.
Patient with No Pupillary Defect
A. When light is directed into the normal eye → (normal direct and consensual response of that eye) → both eyes are smaller
B. When light is directed into the affected eye → both pupils are larger (slightly dilate)
C. Swinging the light back to the other eyes causes normal pupil constriction.
Patient with Marcus Gunn
if it’s an afferent defect, the pathway is from the ____ (5)
Any problem related to the retina and the optic nerve, it has a Marcus Gunn pupil.
retina, optic nerve, optic chiasm, optic tract before the LGN
➔ A parasympathetic condition that is central and bilateral in nature.
ARGYLL ROBERTSON PUPIL
➔ Characteristics of argyl robertson pupil
◆ Dilates poorly in the darkness
◆ Responds poorly or does NOT respond to light
◆ Normal near response (Light-near Dissociation)
➔ It is caused by any interruption in the pattern of CN2 to CN3 or Any interruption of both afferent pathway and the central inhibitory fibers VENTRAL to the aqueduct
ARGYLL ROBERTSON PUPIL
Common causes of argyll robertson pupil (3)
◆ Neurosyphilis (caused by treponema pallidum affect the CNS → Tabes dorsalis) – uses affects Edinger-Westphal nuclei
◆ Long term Diabetes
◆ Alcoholism
- Normal in near
- Abnormal in direct and indirect light reflex
- Lesion is commonly found in the EW. The PN is normal and intact.
argyl robertson pupil
Typically, the pupil constricts to light and dilates to dim light.
The Argyll Robertson pupil occurs when a disease interferes with the light reflex pathway, thereby inhibiting the pupil’s natural response to bright light.
Specifically, Argyll Robertson pupils don’t constrict in response to light but do constrict to focus on a nearby object.
The presence of Argyll Roberton (AR) pupils is typically a highly specific sign of tertiary syphilis
however, they can be caused by other underlying conditions, such as diabetes and multiple sclerosis.
<3
Also known as Whore’s Pupil
ARP
Reasons why Argyll pupil is called as Whore: (2)
Multiple sex partner → syphilis (STD)
It accommodates
Tertiary syphilis is the most common cause of the Argyll Roberston pupil. Caused by a bacteria called Treponema pallidum, syphilis is typically transmitted sexually, but the infection can also occur transplacentally, from an infected pregnant individual to their fetus.
Over time, untreated syphilis can become tertiary syphilis, a late-stage infection marked by damage to the Edinger-Westphal nucleus, the part of the pupillary light reflex pathway in the brain that signals the pupil to constrict in response to bright light.
<3
The bacteria, treponema pallidum, comes from the reproductive system then it will travel to the CNS to the brain to the spinal cord, causing _______.
syphilis
BACTERIA CAUSING SYPHILIS
treponema pallidum
Slowly progressive degeneration of the spinal cord that occurs in the tertiary (third) phase of a syphilis a decade or more after originally contracting the infection
Tabes Dorsalis / syphilitic myelopathy
■ Syphilis has 4 types:
a. Primary
b. Secondary
c. Latent
d. Tertiary
■ When syphilis is left untreated for many years, it will manifest into ______
neurosyphilis
■ Syphilis is a sexually transmitted infection that is spread through direct sexual contact with ____. Can be treated.
syphilis sore
■ Tabes Dorsalis and Neurosyphilis will manifest in the ____
tertiary syphilis
○ This form of neurosyphilis is also rare. It can start to affect the spinal cord 20 years or more after the initial syphilis infection.
○ It is characterized by a triad of clinical symptoms namely gait, unsteadiness, lightning pains, and urinary incontinence.
● Tabes Dorsalis / syphilitic myelopathy
○ This form of neurosyphilis is also rare. It can start to affect the spinal cord 20 years or more after the initial syphilis infection.
● Tabes Dorsalis / syphilitic myelopathy
tabes dorsalis is characterized by a triad of clinical symptoms
gait unsteadiness
lightning pains
urinary incontinence.
Is a chronic disorder of carbohydrate metabolism due to relative or absolute insulin deficiency
Long-term Diabetes
Is a disease of the pancreas
Long-term Diabetes
When a person has diabetes, the _____either cannot produce enough insulin, uses the insulin incorrectly, or both
pancreas
organ secreting insulin
pancreas
There are 2 types of Diabetes:
A. Type 1 – hereditary
B. Type 2 – acquired
Insulin works together with glucose (sugar) in the bloodstream to help it enter the body’s cells to be burned for _____.
If the insulin isn’t functioning properly, glucose cannot _____the cells.
This causes glucose levels in the blood to rise, creating a condition of high blood sugar or diabetes, and leaving the cells without fuel
energy
enter
The normal flow of blood sugar in the body:
Along the bloodstream, there are _____ (3).
nutrients
oxygen
glucose (sugar)
The normal flow of blood sugar in the body:
Along the bloodstream, there are nutrients and oxygen, and also sugar (glucose). Glucose is responsible for cell metabolism for energy. Glucose needs to go to cells but before they enter into the cell, glucose will partner together with insulin (insulin comes from pancreas specifically in the islets of langerhans).
Once cells receive glucose, they can work functionally because it now has energy.
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insulin comes from pancreas specifically in the
islets of langerhans
The problem here is that the pancreas does not produce enough insulin.
Therefore, only a small portion of glucose can enter the cells. The remaining portion remains in the bloodstream and will not be metabolized anymore, causing hyperglycemia.
TYPE 1 DIABETES
The problem here is that the person eats too much food. So when they eat too much, the fats will get stuck in the receptors of the cells.
So, the insulin is normal and the glucose is now ready to partner with insulin, but both cannot enter in the cells because there is blockage of fats.
Diet should consider low food intake and exercise more to burn the fats (cholesterol).
TYPE 2 DIABETES
Since glucose cannot pass and enter in the cell, the body ____.
So what the patient does is he eats more and more food to get energy. So when a patient eats more, its manifestation is called as ____.
weakens
polyphagia
type 2 diabetes:
So when you eat more, blood sugar also increases (________) but still glucose cannot be utilized due to absence of insulin.
So what the body does is to _______for the blood sugar to be flushed out. This is called ___
hyperglycemia
urinate
polyuria
type 2 diabetes:
So when you eat more, blood sugar also increases (________) but still glucose cannot be utilized due to absence of insulin.
So what the body does is to _______for the blood sugar to be flushed out. This is called ___
hyperglycemia
urinate
polyuria
So when a patient experiences excessive urination (______), he also experiences dehydration. So what the patient does is to always drink water
polyuria
Disorders with afferent pathway defect (3)
amaurotic pupil/ AAPD/TAPD
marcus gunn pupil/ RAPD
werncke’s heminopic pupil
Disorders that has an efferent pathway defect (3)
argyll robertson pupil (ARP)
tonic pupil/adie’s pupil
mydriasis
A_______ is a blood clot that forms in a vein.
thrombus
the medical term for always drinking water (excessive thirst).
polydipsia
abnormal pupil size refers to:
anisocoria
it is the difference with pupil size between the eyes
anisocoria
types of anisocoria
-physiological anisocoria
-pathological anisocoria
type of anisocoria due to normal difference in balance or parasympathetic and sympathetic drive to the pupils
physiological anisocoria
hallmarks of physiological anisocoria (2)
- lessens when measure in bright light
- brisk and normal measures in accommodative targets
a type of anisocoria due to the denervation of the sympathetic and parasympathetic block
pathological anisocoria
a type of abnormal pupil reaction where the defect is afferent
marcus gunn pupil
a type of abnormal pupil reaction where the defect is afferent
marcus gunn pupil
a type of abnormal pupil reaction where the defect is central (2)
parinaud’s syndrome
argyll robertson pupil
sympathetic vs parasympathetic NS
type of metabolism
sympa- catabolic
para- anabolic
sympathetic vs parasympathetic NS
nickname
sympa- fight or flight system
para- rest and repair system
other name based on locations
sympathetic vs parasympathetic NS
other name based on locations
sympa- adrenergic/ thoracolumbar
para- cholinergic/ craniosacral
sympathetic vs parasympathetic NS
location of control
sympa- thoracic and upper lumbar segments of the spinal cord (T1-L2)
para- brainstem and sacral spinal cord
sympathetic vs parasympathetic NS
ocular structures
sympa- T1-T3
para- midbrain and pons paroli
sympathetic vs. parasympathetic NS
outflow
sympa- spinal cord (T1-L2)
para- cranial nerves (CN 3,7,9,10)
the sympa and para outflows are controlled by what?
hypothalamus
this integrates the anatomic and neuroendocrine system to preserve body homeostasis
hypothalamus
hypothalamus receives signals from all parts of the nervous system, afferent input from the viscera and information concerning the _____ in the blood, this input is integrated whitin the hypothalamus and transmitted to the lower centers in the ____ and spinal cord
hormone levels
brainstem
hypothalamus receives signals from all parts of the nervous system, afferent input from the viscera and information concerning the _____ in the blood, this input is integrated whitin the hypothalamus and transmitted to the lower centers in the ____ and spinal cord
hormone levels
brainstem
oculat structures innervated by sympa NS vs. Para NS
sympa:
dillator pupillae
ciliary muscle (inhibitory effect)
mueller’s muscle
lacrimal glands (hyposecretion)
choroidal and conjuctival bv (constricted)
para:
shincter pupillae
ciliary muscle (excitatory effect)
lacrimal glands
choroidal and conjunctival bv (dilated)
percentage of fibers (sphincter pupillae)
3%
percentage of fibers (ciliary muscle)
97%
stimulation of ciliary muscles lead to what?
accommodation
stimulation of sphincter pupillae leads to?
miosis
cranial nerve right after nucleus
CN7
ventral root is between?
C1 and T2
what comes after vidian nerve?
maxillary nerve
CN3 leads to ____ division
superior
T1-T2 is the ciliospinal ____ of the bridge
center
hypothalamus is the _____ neuron
first/central neuron
addies tonic is a _______ block
parasympathetic block
it is the build up of protein amyloid
amyloidosis
5 conditions that can cause adie’s tonic pupil
autonomic neuropathies
amyloidosis
herpes zoster
orbital injury
extensive panretinal coagulation or cryotherapy
the lesion in adies tonic is located at the
ciliary ganglion
it is the denervation of PG nerve supply of the short ciliary nerve to sphincter and ciliary muscle
adie’s tonic pupil
what are the signs and symptoms of adie’s tonic pupil? (8)
- mydriasis and cycloplegia
- internal ophthalmoplegia
- light-near dissociation
- slow constriction and reduction after light or near stimulus
- oval pupil
- sudden BOV
- photophobia
- reduction in knee jerk reflex
this type of disorder is common in young women (3rd to 5th decades)
it is unilateral and the affected eye us dilated
adie’s tonic pupil
this is a disorder which reacts poorly to light
has a poor direct and consensual reponse
adie’s tonic pupil
reacts strongly but slowly and tonic to near targets
redilates very slowly when patient refixates at distance
adie’s tonic pupil
method of diagnosis in adie’s tonic pupil
raective with 0.125% pilocarpine (hyperactive since a normal eye reacts to 0.5%)
treatment of adie’s tonic pupil
-directed towards the symptom
-accommodation problem (bifocals)
-photophobia (diluted pilocarpine or cosmetic contact lenses)
it is a sympathetic block where the lesion is at the superior cervical sympathetic ganglion or its pupillary fibers via nasociliary nerve, through long ciliary nerve which innervates
horner’s syndrome
horner’s syndrome is a sympathetic block where the lesion is at the _________ or its ______ via ______, through ______ which innervates:
mueller’s muscle
dilator pupillae
sweat glands of neck and face
superior cervical sympathetic ganglion
pupillary fibers
nasociliary nerve
long ciliary nerve
in horner’s syndrome, the long ciliary nerve which innervates: (3)
mueller’s muscle
dilator pupillae
sweat glands of neck and face
common cause of horner’s syndrome
lung cancer
types of sympathetic block in horner’s syndrome:
preganglionic (neoplasm at brain)
central (stroke)
post ganglionic (vascular origin)
signs and symptoms of horner’s syndrome (4)
-mueller’s muscle at eyelid (lid retraction, sympathetic injury, partial blapharoptosis)
-dilator pupillae (mydriasis, sympathetic injury, miosis)
-sweatglands of neck and face (sweating, sympathetic injury, facial anhidrosis) + iris heterochromia (congenital)
-pupils react normally to light and near
method of diagnosis in horner’s syndrome
- dark dilation test -> (2)
2.1 normal dilation
2.1.1 physiologic or benign anisocoria
2.2 delayed or incomplete dilation
2.2.1 cocain test
2.2.1.1 normal
2.2.1.2 pathologic
2.2.1.2.1 hydrosyamphetamine test
2.2.1.2.1.2 horner’s syndrome 1st/2nd neuron lesion
2.2.1.2.1.2.2 horner’s syndrome 3rd neuron lesion
it is a type of drug which is indirect acting from erythroxylon coca
cocaine
from erythroxylon coca, also has local anesthetic properly with ISA
cocaine
this drug’s mechanism of action is it blocks reuptake of NE at post ganglionic nerve
cocaine
the ocular effects of cocaine: (3)
vasodilation
local anesthesia
mydriasis
this drug’s mechanism of action is enhance the release of norepinephrine at post synaptic postganglionic neuron (3rd neuron)
1% hydroxyamphetmine
this drug’s use if for mydriasis (central and preganglionic lesions)
in postganglionic lesions, they don’t dilate using this drug
1% hydroxyamphetmine
pinching neck should ______ pupil
dilate
cranial nerve for opening eye
CN3 oculomotor
cranial nerve for closing eye
CN 7 facial
ipsilateral
same side
direct light reflex
contralateral
opposite side
indirect
pupil have abnormal shape
dyscoria
