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3P: Neuro > Pupillary Disorders > Flashcards

Pupillary Disorders Flashcards

1
Q

What is the round part of the iris that is located just around the pupil

A

Collarette

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2
Q

What layer of the iris contains the muscle that is involved with miosis

A

Iris stroma

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3
Q

What layer of the iris contains the muscle that is involved with dilation

A

Anterior iris epithelium

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4
Q

What does persistent pupillary membrane look like

A

Strands of iris going across the pupil

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5
Q

What is aniridia

A

Lack of iris

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6
Q

Keyhole pupil

A

Iris coloboma

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7
Q

Congenital causes of abnormally shaped pupils

A

Aniridia Ectopic lentis et papillae Iris coloboma Anterior chamber cleavage anomalies Ectopic pupils Persistent pupillary membranes

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8
Q

Acquired cubes of abnormally shaped pupils

A

Iritis Truama (accidental or surgical) Iris atrophy (DM, Herpetic disease) Neurological

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9
Q

Aniridia

A

Congenital -hypoplastic iris creates a large pupillary opening -associated ocular findings often include cataracts, glaucoma, and impaired vision due to macular or optic nerve hypoplasia

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10
Q

Ectopia lentis et papillae

A

Congenital -rare AR condition -bialteral displacement of the pupil, usually inferotemporally -lens dislocation in the opposite direction -associated ocular anomalies include severe axial myopia, RD, enlarged corneal diameter, cataract, and abnormal iris transillumination -affected patients have microspherophakia, miosis, and poor pupillary dilation with mydriasis

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11
Q

Ectopic pupils

A

Congenital -may be inherited as an isolated ocular finding -an idiopathic tractional ectopic pupil, in which a fibrous structure tethers the pupillary margin to the peripheral cornea and causes a misplaced pupil

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12
Q

Iris coloboma

A

Congenital -a notch inferiroly or infranasally in the iris -this anomaly may be accompanied by chorioretinal or optic nerve coloboma -coloboma may occur in isolation in healthy individuals or in patients with chromosomal duplication or deletions -seen in complex congential disorders such as CHARGE syndrome

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13
Q

Anterior chamber cleave anomalies

A

Congenital -peters (centeral corneal defects) -Rieger syndrome (peripheral defects) -associated with misshapen pupils accompanied by abnormal adhesions between the cornea and iris

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14
Q

Persistent pupillary membrane

A

Congential -spoke like opacities across the pupil -these derive from persistence of the tunica vasculoa lentis

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15
Q

Normal or abnormal? OD: 4mm bright light; 6mm dim light OS: 5.5mm bright light; 7.5mm dim light Both pupils response briskly to light

A

Normal

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16
Q

Normal or abnormal? OD: 4mm bright light; 6mm dim light OS:6.5mm bright light; 6.5mm dim light OS dilated when swinging flashlight from OD to OS

A

Abnormal

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17
Q

Normal or abnormal OD: 4mm bright; 6mm dim OS: 4mm bright, 6mm dim Both pupils respond briskly to light

A

Normal

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18
Q

Isolated lesions of the lateral geniculate nucleus DO NOT affect pupillary size or light reactivity, T/F

A

True

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19
Q

The efferent pupillary light pathway has which of the following nerve involved? -long ciliary nerve -CN IV -Short ciliary nerve -CN VI

A

Short ciliary nerve

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20
Q

Afferent pupillary light pathway

A

-pupillary fibers travel with visual fibers as far as the posterior option tract, with the nasal fibers crossing the chasm -the pupillary fibers exit in the posterior third of the optic tract and travel within the brachium of the superior colliculus to pretectal nucleus and synapse -the fibers then travel to the two EW nuclei. The fibers that cross to the opposite EW nucleus travel in the posterior commissure

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21
Q

Efferent pupillary light pathway

A

-the pregnaglionic fibers leave the EW nucleu (midbrain) with the motor fibers of the CN III and follow the inferior deivision of that nerve into the orbit -the parasympathetic fibers leave the inferior division and enter the ciliary ganglion as the parasympathetic root and synapse at the CG -the postganglionic fibers travel with short ciliary nerves to the anterior segment of the eye to innervate the sphincter (constriction)

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22
Q

Disruption in the afferent pathway of light stimulation

A

RAPD Pretectal pupils Argyll Robertson pupil

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23
Q

RAPD

A

-disruption in the afferent pathway of light stimulation Causes are large RD, CRAO, CRVO, optics nerve ischemia, optic neuritis, optic compression, asymmetric glaucoma, optic tract lesion (contralateral RAPD) -amaurotic (deafferented) pupil. Associated with vision loss.

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24
Q

Pretectal pupils

A

-disruption in the afferent pathway if light stimulation –lesions affecting the dorsal midbrain, causing the parinaud syndrome -associated upgaze paresis, head tilt -usually both pupils are involved because the lesion usually takes out both pretectal nuclei, although size and light reactivity may be asymmetric -RAPD is usually contralateral to the lesion -light near dissociation

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25
Accommodation-convergence reaction pathways
Afferent - LGN-striate cortex-FEF-pretectal nucleus Efferent -same as light reflex
26
Efferent accommodative convergence reaction
-parasympathetic -preganglionic fibers leave the EW nucleus with the motor fibers of the CN III and follow the inferior division of that nerve into the orbit -parasympathetic fibers leave the inferior division and enter the CG as the parasympathetic root and synapse at the CG -the postganglionic fibers travel to the anteiror segment of the eye to innervate the sphincter (constriction) and ciliary muscles ( accommodation)
27
Argyll Robertson pupil
-bilateral in most causes -interrupt fibers from the pretectal nucleus to the parasympathetic nucleus -shows poor direct and Norma consensual response but does constrict with the near repsosne (light near dissociation) -because the fibers that carry inhibitory feedback to the parasympathetic nucleus also pass through this region, miosis is evident in darkness, with the affected pupil smaller than would be seen in the normal individual -diabetic neuropathy, alcoholic neuropathy, or neurosyphillis
28
Disruption of the efferent pathway of light stimulation (parasympathetic)
Ocular motility impairment (CN III palsy) Tonic pupil (Adies tonic pupil) Pharmacologically dilated pupils NMJ blockade
29
Oculomotor motility impairment (CNIII palsy)
Disruption int he efferent pathway of light stimulation (parasympathetic) -para fibers are superficial to CN III as the nerve emerges from the midbrain -the para fibers are especially vulnerable to compression -CN III involvement that includes the pupil is highly suspicious of a compressive intracranial lesion (aneurysm) -emergent CT and CT angiography to MRI scan and MRI angiography can be obtained. Do not dilate this patient, send to ER right away
30
Third nerve palsy that includes pupil involves
Highly suspicious of a compressive intracranial lesion. Emergent CT or MRI needs done Do not dilate Send to ER
31
Tonic pupil will contrast by administration of which eye drop
1% pilocarpine
32
Tonic pupil
-disruption in the efferent pathway of light stimulation (parasympathetic) -damage to the CG or short ciliary nerve -characterized by poor pupillary light response and loss of accommodation -decreased corneal sensitivity often occurs
33
Adies tonic pupil
-unknown cause -typically 20-40yo women -the tonic pupil eventually becomes smaller and does not dilate well in the dark -significant clinical miosis if apply a dilute concentration of pilocarpine because the sphincter muscle is supersensitive
34
Does Adies tonic pupil respond to near objects
No
35
Tonic pupil managment
Rule out neurosyphilis and GCA
36
Pharmacologically dilated pupils
Scopolamine patch Visine 1% pilocarpine drops will fail because there is not damage on the pathway
37
NMJ blockade
Patients with botulism can develop bilaterally dilated pupils
38
Other ocular causes of unreactive pupils
Ocular trauma Angle closure glaucoma Iritis Congential mydriasis
39
Normal or abnormal? OD: 4mm bright; 6mm dim OS: 5.5mm bright; 7.5mm dim Both pupils responds briskly to light and no dilation lag (within 5s) in dim illumination
Normal
40
Normal or abnormal? OD: 4mm bright; 6mm dim OS: 5mm bright; 6.5mm dim Both pupils responds briskly to light and OS shows dilation lag (10-20s) in dim illumination
Abnormal
41
Normal or abnormal? OD: 4mm bright; 6mm dim OS; 4mm bright; 6mm dim Both pupils respond briskly to light and no dilation lag (within 5s) in dim illumination
Normal
42
Which of the following nerves is involved during pupillary dilation? -long ciliary nerve -CN IV -short ciliary nerve -CN VI
Long ciliary nerve
43
Superior levator innervation
CN III
44
Superior oblique innervation
CN 4
45
Orbicularis oculi innervation
CN 7
46
Mullers muscle innervation
Sympathetic
47
Sympathetic pathway of the pupillary dilation
Hypothalamus (1st order) Spinal cord (T-1 thru T-3) (2nd order) Synapse in superior cervical ganglion (3rd order) Carotid plexus around the ICA Through cavernous sinus Follow nasociliary nerve and then travels with the long ciliary nerves to innervate the iris dilator (dialtion) and the ciliary muscle (inhibitory)
48
Painful horners syndrome should be treated as an emergent situation, T/F
True
49
Horners syndrome
-ptosis (mild), miosis, and facial anhidrosis -pupil dialtion lag with a dim light -pupil reacts normally to light and near stimuli
50
Central Horner syndrome (injury to the first order neuron)
lateral medullary stroke (Wallenberg syndrome). -ipsilateral to the lesion -nystagmus Mesencephalic and pontine lesions -horners plus CN4palsy
51
Preganglionic Horner syndrome (second order)
Pancoast tumor -ipsilateral Brachial plexus injury
52
Postganglionic horners syndrome (injury of third order neuron)
Carotid dissection -ipsilateral headache or pain, ocular or cerebral ischemia Cavernous sinus lesion -can affect CN 3,4, V1, V2
53
What drug can be used to detect pregnaglionic sympathetic pathway
1% hydroxyamphetamine
54
What does cocaine do for horners
Tells us whether or not they have it -pupil will dilate if they have it
55
1% hydroxyamphetamine and preganglionic
Dilates
56
Congential causes of horners in child
Neuroblastoma Birth truama Usually differnt colored eyes if congential
57
Pupillary disorders in other neurological conditions
Coma Optiate intoxiation=pinpoint
58
Migraines and pupils
Dilated pupil and ipsilateral headache
59
Seizures and pupils
Bialteral mydriasis
60
Gillian barre syndrome and pupils
Can affect pupils, especially miller fisher variant
61
Westphal-Piltz reflex
Pupillary constriction in darkness is a normal occurrence when indiviudsuals close their eyes to go to sleep
62
Paradoxic pupillary constriction in the dark
Abnormal -pupillary miosis followed by redialtion when the lights are turned off may suggest a retinal dystrophy such as in congential stationary night blindness or congential acrhomatopsia
63
Tournays pupillary phenomenon
-lateral gaze -10% normal population -pupil of the abducting eye is larger, and either that pupil has dilated or the pupil of the addicting eye has constricted
64
Aculosympathetic spasm
-irritation of the oculosympatheti pathway may result in unilateral pupillary mydriasis, occasionally accompanied by ipsilateral facial flushing, lid retraction, and hyperhidrosis
65
Idiopathic altering anisocoria
Alternating dilating pupils;
66
Tadpole shaped pupils
-exhibit episodic mydriasis with segmental pupillary distortion but intact constriction to light -attributed them to abnormally segmental spasm of the iris dilator muscle
67
With indicated lesion, you may detect what results?
68
With indicated lesion, what response might you expect?
69
With the indicated lesion, what repsosne would you expect?
70
What is the repsosne you would expect
71
What side of the midbrain is going to be affected?
72
What is the expected response?
73
Predicted response?
74
This patient also has facial anhydrosis. What structure is most likely affected?
Cavernous sinus -sympathetic, CN VI, ICA

3P: Neuro (11 decks)

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