Wills neuro

Question 1

Anisocoria - constricted pupil DDx

Answer 1

V
I: -Iritis/posterior synechiae
- long-standing Adie pupil (initially dilated –> but constricts over time. Hypersensitive to pilocarpine 0.125%)
T
A
M: -unilateral use of miotic (e.g. pilocarpine)
I: -Argyll Robertson (syphilitic) - usually b/L but may see mild anisocoria
N: -Horner syndrome

-l

Question 2

Anisocoria - dilated pupil

Answer 2

V
I: Adie (tonic*) pupil - minimally reactive to light and slowly/tonically to convergence. Hypersensitive to pilocarpine 0.125%.
T: trauma (iris sphincter muscle damage - look for torn pupil margin or iris TID)
A
M: u/L exposure to mydriatic
I
N: CN3 palsy

*Diagnostic features of tonic pupils include sluggish, segmental pupillary responses to light and better response to near effort followed by slow redilation. A tonic pupil is caused by postganglionic parasympathetic pupillomotor damage.

Question 3

Anisocoria history questions

Answer 3

when first noted? 
associated Si/Sx?
ocular trauma?
eye medications?
syphilis?
old photographs?

Question 4

Anisocoria work-up

Answer 4

anisocoria greater in light (abnml pupil = larger pupil) vs. anisocoria greater in dark (abnml pupil = smaller pupil)

RAPD?

Pupillary near response (abnml in Adie, Argyll-Roberson, and dorsal mid-brain syndrome)

Look for ptosis, ocular motility, examine pupillary margin

Question 5

Anisocoria greater in the dark - dilation occurs with 10% cocaine

Answer 5

Physiologic ansiocoria (+dilation lag of smaller pupil ABSENT)

Question 6

Anisocoria greater in the dark - dilation DOES NOT occur with 10% cocaine

Answer 6

Horner syndrome (+dilation lag of smaller pupil PRESENT)

Question 7

1% hydroxyamphetamine RESULTS in dilation

Answer 7

Pre-ganglionic or CENTRAL Horner’s

mnemonic: think - where does amphetamine work - in the brain… think pre/central Horner’s

Question 8

1% hydroxyamphetamine does NOT result in dilation

Answer 8

POST-ganglionic Horner’s

Question 9

NO constriction with 0.125% pilocarpine

Answer 9

need to then try pilocarpine 1% to distinguish between CN3 palsy and pharmacologic pupil dilation

Question 10

CONSTRICTION occurs with 0.125% pilocarpine

Answer 10

Adie’s pupil: sector iris palsy, tonic near constriction

(with the pilocarpine, the Adie pupil will usually have constricted SIGNIFICANTLY more than the fellow pupil at 10-15 min)

Question 11

CONSTRICTION occurs 1% pilocarpine

Answer 11

CN3 palsy (anisocoria greater in the light)

Question 12

CONSTRICTION does NOT occur with 1% pilocarpine

Answer 12

pharmacologic pupil dilation (b/c the normal pupil will constrict a lot more than the dilated pupil)

Question 13

Apraclonidine and Horner’s

Answer 13

The diagnosis of Horner syndrome is supported when there is REVERSAL of the anisocoria. This is the result the alpha-2 agonist effect of apraclonidine on the NORMAL pupil and the dominant alpha-1 effect from adrenergic receptor SUPER-SENSITIVITY in the Horner pupil, which takes 2 to 5 days to develop. The ptosis is also reversed with apraclonidine and this effect is seen within 5 minutes of administering the apraclonidine drops, owing to the rapid penetration through the conjunctiva to gain access to Mueller’s muscle.