Pupils

Question 1

Pupils Reactions Procedure -

Answer 1

1) Room lights on
2) Prescription NOT worn
3) Explain “this test checks your pupil reflexes to light”
4) Ask: “Please look at a letter/spotlight on the distance chart”

Question 2

What to Measure and Observe?

Answer 2

 Are the pupils EQUAL IN SIZE?
 Are the pupils ROUND?
 Measure the DIAMETER of the pupil

Question 3

Anisocoria

Answer 3

Defined by a difference of 0.4 mm or more between the sizes of the pupils of the eyes.

Question 4

Use a letter if Unaided Vision ______

Answer 4

Better than 6/18

Question 5

Use spot if Unaided Vision ________

Answer 5

Worse than 6/18

Question 6

Anisocoria is often entirely harmless but ______________

Answer 6

Can be a sign of more serious medical problems like pathology, injury, surgery etc.

Question 7

Size of a Normal Pupil

LIGHT

Answer 7

2-4mm

Question 8

Size of a Normal Pupil

DARK

Answer 8

4-8mm

Question 9

With age, pupils get smaller and the dilator muscles atrophy

Answer 9

Senile Miosis

Question 10

Pupillary Hippus

Answer 10

The physiological spasmodic, rhythmic, dilating and contracting pupillary movements between the sphincter and dilator muscles in response to light.

Question 11

Direct & Consensual Response Procedure -

Answer 11

1) Leave room lights off
2) Remind patient: “Please keep looking at the letter/spotlight.”
3) Shine a light in Right Pupil from inferotemporal side at a distance of 5-10cm using a pen torch

Question 12

Swinging Flashlight Test

Answer 12

Used for the detection of Relative Afferent Pupillary Defects.

Question 13

Swinging Flashlight Test Procedure -

Answer 13

1) Leave room light off
2) Remind patient: “Please keep looking at the letter/spotlight.”
3) Shine a light in R pupil for 2-3seconds from the inferior side at a distance of 5-10cm
4) Quickly shine light in L pupil for 2-3seconds
5) Alternate several times

Question 14

What is RAPD?

Answer 14

Relative Afferent Pupillary Defect =

Detected if one eye dilates (rather than constricts) when the light shone on it.

Question 15

Normal Pupils Acronym

Answer 15

PERRLA

No RAPD

Question 16

Near Response to Light

Answer 16

Only do this if the light reflex is abnormal

Question 17

Near Response to Light Procedure -

Answer 17

1) Leave room light off
2) Remind patient: “Please keep looking at the letter/spotlight.”

3) Ask: “Now look at my finger.”
Hold finger about 25cm in front of the patient.

4) Observe extent of pupillary constriction as patient changes fixation from D to N
5) Ask “Now look back at the letter/spotlight”
6) Observe extent of pupillary dilation as patient changes fixation from N to D.
7) Record ‘Light-Near Dissociation’ if light reflex abnormal while near reflex normal.

Question 18

Near Response to Light Procedure -

Answer 18

1) Leave room light off
2) Remind patient: “Please keep looking at the letter/spotlight.”

3) Ask: “Now look at my finger.”
Hold finger about 25cm in front of the patient.

4) Observe the extent of pupillary constriction as the patient changes fixation from D to N
5) Ask “Now look back at the letter/spotlight”
6) Observe the extent of pupillary dilation as the patient changes fixation from N to D.
7) Record ‘Light-Near Dissociation’ if light reflex abnormal while near reflex normal.

Question 19

Horners Syndrome

Answer 19

A condition characterised by a contracted pupil, drooping upper eyelid, and local inability to sweat on one side of the face, caused by damage to sympathetic nerves on that side of the neck.

Meiosis
Ptosis
Anhidrosis

Question 20

Physiological Anisocoria

Answer 20

About 20% of normal people have a slight difference in pupil size of less than 1 mm.

Question 21

Mechanical Anisocoria

Answer 21

Occasionally previous trauma, eye surgery, or inflammation (uveitis, angle-closure glaucoma) can lead to adhesions between the iris and the lens.

Question 22

What are the key things to assess with Pupils?

Answer 22

1. Anisocoria
2. Horners Syndrome
3. Adie Tonic Pupil
4. Oculomotor Nerve Palsy

Question 23

Adie Tonic Pupil

Answer 23

A pupil with Parasympathetic denervation that constricts poorly to light but reacts better to accommodation - Near response.

Question 24

Oculomotor Nerve Palsy

Answer 24

Ischemia, intracranial aneurysm, demyelinating diseases (e.g., multiple sclerosis), head trauma, and brain tumours are the most common causes of oculomotor nerve palsy in adults. In ischemic lesions of the oculomotor nerve, the pupillary function is usually spared whereas in compressive lesions the pupil is involved.

Question 25

Marcus Gunn pupil

Answer 25

RAPD present

No Anisocoria

Question 26

Dilatation

Answer 26

Defined as a region of dilation, an area of abnormal enlargement, or the surgical enlargement of a region.

Question 27

What is the most common cause of Marcus Gunn pupil?

Answer 27

Optic nerve lesion due to Glaucoma, MS

Question 28

Direct Reflex

Answer 28

The pupillary response to the luminance of light that enters the ipsilateral eye, causing it to constrict - Meiosis.

Question 29

Consensual Reflex

Answer 29

The pupillary response to the luminance of light that enters the contralateral eye, causing it to constrict - Meiosis.

Question 30

Corectopia

Answer 30

Eccentric displacement of the eye’s pupil from its normal, central position

Question 31

Polycoria

Answer 31

More than one pupil

Question 32

Amaurotic Pupil

Answer 32

Pupil in an eye that is blind because of ocular or optic nerve disease; this pupil will not contract to light except when the normal fellow eye is stimulated with light.

Question 33

Parinaud syndrome

Answer 33

A constellation of upward gaze palsy, convergence retraction nystagmus, light-near dissociation, and bilateral lid retraction.

Question 34

Ocular Motility:

Ideal Answer

Answer 34

Full and extensive, with no limitations in any gaze position, and no pain or diplopia reported.