Pupils

Question 1

What is abnormal anisocoria?

Answer 1

pupil size difference of more than 0.5 mm (look for lid involvement)

Question 2

What is an amaurotic pupil?

Answer 2

Blind pupil; no DIRECT light reflex

Question 3

What is Hutchinson’s pupil?

Answer 3

unilateral, fixed, dilated pupil

Question 4

When does anhydrosis occur in Horner’s Syndrome?

Answer 4

when lesion is before carotid bifurcation and superior cervical ganglion

Question 5

What is Horner’s syndrome and list three symptoms/effects?

Answer 5

a defect along the sympathetic pathway; ptosis, miosis, and anhydrosis

Question 6

Where do the first order neurons of the sympathetic pathway extend (to and fro)?

Answer 6

posterior hypothalamus to C8-T2

Question 7

What are 3 possible causes for first order neuron Horner’s Syndrome?

Answer 7

cerebrovascular accident (stroke), neck trauma, multiple sclerosis

Question 8

What are 5 possible causes for second order neuron Horner’s Syndrome?

Answer 8

Pancoast’s tumor, Tuberculosis, Metastatic breast cancer, trauma, thyroid neoplasm/surgery

Question 9

Where do the Second order neurons extend from and to

Answer 9

leave spinal cord, over apex of lungs, synapse in superior cervical ganglion

Question 10

Third order neurons are post-ganglionic and travel on the internal carotid until the break into what two separate divisions/pathways

Answer 10

nasociliary nerve -> long ciliary nerves -> pupil dilator,

opthalmic artery -> eyelid muscles (levator palpebrae superioris)

Question 11

What can affect the nasociliary pathway of the 3rd order neurons

Answer 11

internal carotid dissection and aneurysm, and a nasopharyngeal carcinoma

Question 12

What can affect the opthalmic artery pathway of the 3rd order neurons

Answer 12

Migraines

Question 13

Is Horner’s Syndrome in children benign or malignant when it is congenital

Answer 13

benign (brachial plexus injury during birth) but need to rule out a neuroblastoma in sympathetic chain of chest/neck (acquired Horner’s may also be due to a neuroblastoma)

Question 14

When is light-near dissociation diagnostically valuable

Answer 14

if the direct light reflex is absent or abnormal

Question 15

What is the light-near dissociation phenomenon

Answer 15

when response to accommodation is stronger than light response (accommodation fibers out number pupil fibers 30:1)

Question 16

In patients with anisocoria when is a dilated pupil more noticeable and when is a miotic pupil more noticeable

Answer 16

dilated in illumination (sphincter muscle not working well)

miotic in the dark (dilator muscle not working well)

Question 17

List 4 disorders of the para-sympathetic system

Answer 17

trauma, adie’s tonic pupil, third nerve palsy, hutchinson’s pupil

Question 18

What is Adie’s Tonic Pupil

Answer 18

unilaterally dilated pupil with poor reaction to light and slow tonic re-dilation

Question 19

What is Adie’s tonic pupil due to

Answer 19

a denervated ciliary ganglion (sectoral palsy of the iris sphincter)

Question 20

At what rate does the Adie’s tonic pupil become bilateral

Answer 20

(most cases - 80% unilateral), becomes bilateral at 4% per year

Question 21

What symptoms/issues are present with Argyll-Robertson pupils

Answer 21

both pupils are constricted, dilate poorly, respond poorly to dilating agents

Question 22

When is Argyll-Robertson’s commonly seen

Answer 22

in patients with syphilis, diabetes, chronic alcoholism, multiple sclerosis, and sarcoidosis

Question 23

When do you check for accommodative response

Answer 23

only if direct light response is abnormal or absent

Question 24

When is an afferent pathway defect detected (APD)

Answer 24

during “swinging flashlight test”

Question 25

Can an eye with normal visual fields and 20/20 acuity have an APD

Answer 25

YES