Pupillary Assessment CH2

Question 1

Any pupil smaller than what size is considered miotic?
a) 1 mm
b) 2 mm
c) 3 mm
d) 4 mm

Answer 1

b) If a pupil is 2 mm or smaller, it is considered miotic.

Question 2

Any pupil larger than what size is considered mydriatic?
a) 3 mm
b) 4 mm
c) 5 mm
d) 6 mm

Answer 2

d) A pupil that is 6 mm or larger is considered mydriatic.

Question 3

Which of the following groups tend to have smaller pupils?
a) children
b) myopes
c) people with light blue eyes
d) older people

Answer 3

d) Children, myopes, and those with light blue eyes tend to have larger pupils. Older people
tend to have smaller pupils.

Question 4

Unequal pupil size is termed:
a) anisocoria
b) anisometropia
c) anisochromia
d) aniseikonia

Answer 4

a) Anisocoria is the term for unequal pupil size. (The other answers are all real terms that you might want to look up if you do not know them.)

Question 5

The pupil evaluation includes:

a) size, shape, and reaction to light
b) iris color, roundness, and reaction to light
c) angle depth, iris diameter, reaction to light
d) reaction to cycloplegia, light, and accommodation

Answer 5

a) Evaluation of pupils includes checking each pupil for its size, shape, and reaction to light
(and sometimes to accommodation). After that is done, one pupil is compared to the other. Are they the same size? Shape? Do they respond to light (or accommodation) to the same degree?

Question 6

An iris coloboma usually causes a pupillary shape defect:
a) at 12 o’clock
b) at 3 o’clock
c) at 6 o’clock
d) at 9 o’clock

Answer 6

c) Iris coloboma is a congenital defect where the iris fails to fuse, usually inferiorly (ie, at
6 o’clock).

Question 7

Constriction of the pupil can be accomplished by any of the following except:

a) shining a bright light into the eye
b) having the patient focus on a near object
c) using miotics
d) dimming the room lights

Answer 7

d) Dimming the room lights would make the pupils enlarge.

Question 8

Dilation of the pupil can be accomplished by any of the following except:

a) shining a bright light into the eye
b) pinching the patient’s neck
c) having the patient focus on a distant object
d) dimming the room lights

Answer 8

a) Shining a bright light into the eye causes the pupil to constrict, not dilate.

Question 9

Direct pupillary response refers to:

a) the reaction of both pupils to light
b) the reaction of one pupil to light
c) the reaction of both pupils to near
d) the reaction of one pupil to near

Answer 9

b) The reaction of a single pupil to light is a direct pupillary response.

Question 10

Testing of the consensual light response in healthy eyes is possible because:

a) each pupil reacts to light independently
b) if one pupil reacts to light, the other reacts with it
c) the pupils react to light in reverse order
d) the pupils react to near stimuli independently

Answer 10

b) The consensual light response compares the response (to light) of one pupil to the
response of the other pupil. This is possible because healthy pupils are innervated to do the same thing at the same time, regardless of which eye has the light shining into it.

Question 11

When checking consensual pupil responses to light, all of the following should be done
except:
a) dim the room lights
b) have the patient look at a distant object
c) shine the light source from the side
d) cover the eye not being tested

Answer 11

d) Consensual light response testing requires that you be able to see both pupils, so covering is not appropriate. Covering either eye during any type of pupil check is unnecessary.

Question 12

To test pupillary response to accommodation:

a) observe the pupils as the patient looks from a distant object to a close-up object
b) observe the pupils as the patient looks from a close-up object to a light source
c) observe the pupils as the patient reads the near card
d) observe the pupils as the patient reads the distant chart

Answer 12

a) To see the pupillary change that occurs in accommodation, have the patient look into the distance (accommodation relaxed), then at something up close (accommodation stimulated), or vice versa.

Question 13

To evaluate a patient for tonic pupil (or Adie’s tonic pupil), one would use which
method?

a) pupillometer
b) slit-lamp evaluation
c) cycloplegia
d) accommodation response test

Answer 13

d) In Adie’s tonic pupil, there is a rapid/normal reaction of pupillary constriction when
looking at a near object, but dilation is markedly slow when the patient shifts to look at a distant object. The pupil is also slow in its reaction to light. A pupillometer is used to measure the pupil’s diameter. (Note: Do not confuse a pupillometer with the instrument that measures pupillary distance, which should properly be called an interpupillometer.)

Question 14

Each pupil constricts to direct light. This indicates:
a) there is no relative afferent pupillary defect (RAPD) present
b) the pupils react equally
c) light is passing through each optic nerve
d) equal reaction to accommodation

Answer 14

c) The direct test evaluates each pupil on its own and is not meant to compare the reaction of one pupil to the other. All you can say at this point is that at least some light is traversing the optic nerve of each eye. In order to find a RAPD, you would need to additionally perform the swinging flashlight test. Testing pupillary reaction to accommodation would involve having the patient look at a near then distant object and back, watching the pupillary response as he or she does this; a light is not used.

Question 15

Testing that reveals normal-appearing pupils that react appropriately is documented
by the acronym:
a) PERRLA
b) RAPD
c) CSM
d) PEAR

Answer 15

a) PERRLA stands for “pupils equally round and reactive to light and accommodation.”

Question 15

The most common cause of a false-positive pupillary defect is:
a) glaucoma
b) papilledema
c) RAPD
d) weak flashlight batteries

Answer 15

d) You probably will not see this question on the test, but it does make an important point.
Any time you detect a pupillary defect, double-check with another penlight.

Question 16

Each of the following could cause abnormal pupil shape except:
a) surgery
b) trauma
c) birth defect
d) Marcus Gunn

Answer 16

d) The Marcus Gunn pupillary defect affects the pupil’s reaction, not its shape. An example
of a congenitally abnormal pupil shape is the coloboma.

Question 17

Each of the following disorders can cause a change in pupil size except:
a) iritis
b) angle-closure glaucoma attack
c) drug reactions
d) open-angle glaucoma

Answer 17

d) Open-angle glaucoma has no effect on pupil size. Some medications for glaucoma do
(the miotics), but that was not the way the question was worded. Iritis causes a smaller
pupil, angle-closure causes a larger pupil, and drug reactions can go either way.

Question 18

Argyll Robertson pupils are often:

a) unreactive to direct or consensual light
b) unreactive to accommodation
c) reactive to light
d) sluggishly reactive to accommodation

Answer 18

a) The hallmark of Argyll Robertson pupils is their lack of response to direct or consensual light.

Question 19

You discover that your patient has an Argyll Robertson pupil. This pupillary defect is
associated with:

a) acquired immune deficiency syndrome (AIDS)
b) syphilis
c) gonorrhea
d) rubella

Answer 19

b) The Argyll Robertson pupil is a sign of syphilis.

Question 20

Which of the following is associated with ptosis, miosis, and lack of perspiration
(anhydrosis) on the affected side?

a) Adie’s tonic pupil
b) Horner’s syndrome
c) Argyll Robertson pupil
d) Marcus Gunn pupil

Answer 20

b) Horner’s syndrome is identified by the triad of ptosis, miosis, and anhydrosis on the
affected side.

Question 21

Horner’s syndrome is caused by:

a) nerve damage
b) keratoconjunctivitis
c) syphilis
d) Herpes zoster

Answer 21

a) Horner’s syndrome is caused by nerve damage that specifically affects eyelid position, pupil size, and facial perspiration to varying degrees.

Question 22

Adie’s tonic pupil (or tonic pupil) is caused by:

a) systemic rubella
b) sympathetic ophthalmia
c) gonorrhea
d) nerve damage

Answer 22

d) Damage to the short posterior ciliary nerves is the cause of Adie’s tonic pupil.

Question 23

You might first suspect that the patient has a tonic pupil when:

a) the response to direct light is slow
b) the pupil enlarges in direct light
c) that eye also has a ptotic lid
d) the patient is photophobic

Answer 23

a) A tonic pupil will have a slow reaction to direct light. A pupil that enlarges in direct light
most likely has a Marcus Gunn, or RAPD defect. Horner’s syndrome exhibits ptosis on that same side.

Question 24

A relative afferent pupillary defect (RAPD) is identified by using the:

a) cross cover test
b) pupillometer
c) swinging flashlight test
d) direct flashlight test

Answer 24

c) The swinging flashlight test is used to test the consensual light response, comparing the
light reaction of one pupil to the other. This is how an RAPD is identified.

Question 25

The presence of a RAPD:

a) demonstrates a totally blind eye
b) indicates a problem in the optic nerve
c) indicates a defect in the facial nerve
d) indicates a problem in the cerebral cortex

Answer 25

b) The Marcus Gunn pupil can be identified by shining the light in one eye, then the other,
also known as the swinging flashlight test. An eye with a Marcus Gunn pupil usually has
poorer vision than the normal eye, but is not necessarily blind. It generally indicates a
problem with the optic nerve.

Question 26

An eye with a RAPD usually has:

a) redness and pain
b) subnormal visual acuity
c) delayed extraocular muscle responses
d) irregular astigmatism

Answer 26

b) RAPD indicates optic nerve damage, so visual acuity is usually compromised to some
degree.

Question 27

Another name for a RAPD is:
a) Argyll Robertson pupils
b) Adie’s syndrome
c) Marcus Gunn pupil
d) tonic pupil

Answer 27

c) Another name you may hear for RAPD is Marcus Gunn pupil.

Question 28

You are performing a swinging flashlight test. The right pupil does not react at all when you shine the light in it. When you swing over to the left eye, the left pupil constricts rapidly. When you swing back to the right eye, there is again no reaction. This indicates:

a) a normal reaction
b) RAPD OD by reverse
c) RAPD OS by reverse
d) a tonic pupil

Answer 28

b) Usually, a RAPD is identified when the unaffected eye constricts rapidly and the affected eye dilates when you swing back to it. But one can still identify an RAPD in a fixed pupil by the reaction of the other (reverse), reactive eye, as in this scenario.