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Review on PupilsA Neuro-Optometric Viewpoint
Deepayan Kar et.al*
1stAugust, 2014
*1Supriyo Chatterjee DOS;2Debasis Dutta DO MS
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Financial DisclosuresNONEAcademic purposes only
Deepayan Kar 2014
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics
Intrinsic Muscles: Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria
Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture
False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil More Clinical Condition
Conclusion
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics
Intrinsic Muscles: Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria
Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture
False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil More Clinical Condition
Conclusion
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Pupil: Basic facts
Function of the pupil:Modifies amount of light entering the eye; increases
sensitivity of the eye
Increases depth of focus
Minimizes chromatic and spherical aberrations
Newborns and the elderly are miotic, withthe elderly having 1/3rd size of that of a 20
year old Pupils are mioticduring sleep, with blinking,
and with forced closure
larger pupil response foveal stimulation
Accomodation Convergence Pupillary
constriction
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics
Intrinsic Muscles: Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria
Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture
False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil More Clinical Condition
Conclusion
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Pupillary Innervation: Pharmacokin
imitate the effects of the parasympathetic nervous system (constrict)
Parasympathomimetics
imitate the effects of the active sympathetic nervous system (dilate)
Sympathomimetics
inhibit the action of the parasympathetic nervous system (dilate)
Parasympatholytics
inhibit the action of the sympathetic nervous system (constrict)
Sympatholytics
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics
Intrinsic Muscles: Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria
Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture
False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Condition
Conclusion
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Intrinsic Muscles:Innervation
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Intrinsic Muscles:Innervation Ty
Types of
Innervation
Parasympathetic
Sphincterpupillae
Ciliary m.
Sympathetic
Dilator pupillae
IntrinsicMuscles
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics Intrinsic Muscles:
Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria
Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture
False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Condition
Conclusion
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Light Reflex Pathway: Parasympath
Afferent
Pathway
ganglion cell layer, through the optic nerve
chiasm:nasal fibers of each retina cross optic tract
pretectal nucleus
posterior commissure and terminate in the Edinger-Westphal nu
Efferent
Pathway
begins at the Edinger-Westphal nucleus oculomotor branch (CN III)
enters the orbitthrough the superior orbital fissure
ciliary ganglion
Sphincter pupillae (via short ciliary nerves)
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Light Reflex Pathway: Parasympath
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Light Reflex Pathway: In Action
Optic Nerve (II)
Optic Chiasm
Optic Tract
Pretectal Nucleus
Edinger-CNIII Nu
Ciliary G
SphinctSphincterp. (OS)
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics Intrinsic Muscles:
Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria
Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture
False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Condition
Conclusion
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Pupillo-Dilator Pathway: Sympath
Significance: Horners syndrome (results from a lesion within the sympathetic pathway)
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics Intrinsic Muscles:
Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria
Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Condition
Conclusion
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Near Reflex: Triad Response
Accommodation
Miosis
convergence
Initiated by the
to fixate a neaAfferent pathwa
to light reflex p
Efferent pathwpass to the occipital through the prestriatpremotor area of thefibres pass througradiata and internal coculomotor nucleus
Clinical significance Argyll-Robertson Pup
dissociation)
Parinaudssyndrome
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Near Reflex: Light-Near Dissociat
oabsence of a miotic reaction to light (both direct and co
with the preservation of a miotic reaction to near stim(accommodation-convergence)
Causes: syphilis (Argyll-Robertson), Adiespupil, Parinaudssyndrome, RAPD, physiolog
retinal disease, aberrant regeneration of CN 3, diabetes, myotonic dystrophy,alcoholism, herpes zoster ophthalmicus (HZO)
DDx: Abnormal Light and Near Response: Pharmacologic, trauma, CN 3 palsy
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics Intrinsic Muscles:
Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Condition
Conclusion
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Anisocoria
asymmetric in size of pupils
Physiologic anisocoria commonand normal variant in up to 20% of the population variation should be no more than 1mm both eyes should react to light normally
Can be dangerous! if a manifestation of Horner's syndrome (e.g. carotid dissection) or from d
the third nerve (e.g. aneurysmal expansion)
Consider further workup such as imaging if anisocoria is suspected to be frpathologic process
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics Intrinsic Muscles:
Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Condition
Conclusion
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Pupillary Reaction: Types
PupillaryLight Reflexes
Direct Consensual
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics Intrinsic Muscles:
Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Condition
Conclusion
Relative Afferent Pupillary Defe
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Relative Afferent Pupillary Defe(RAPD): Marcus-Gunn Pupil
Occurs in:
large retinal lesion asymmetric optic nerve disease
chiasm lesion
optic tract lesion (contralateral RAPD)
Swinging Flashlight Test
RAPD: Clinical
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RAPD: ClinicalPicture
large relative afferent pupildefect of the right eye OD
Normal direct+consensualreflex OU in unaffected eye
No direct/ consensual reflexOU in effected eye
Deepayan Kar 2014
h d
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Whydoes RAPD occur?
RAPD Negative OS RAPD Positi
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Yanoff, Myron, Jay S. Duker, andJames J. Augsburger. "The Pupils:Randy H. Kardon." Ophthalmology.
3rd ed. Vol. 1. Edinburgh: MosbyElsevier, 2009
Lowenstein O Loewenfeld IE In: Davs
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Lowenstein O, Loewenfeld IE. In: DavsThe eye, vol 3. New York: Academic Pre
Dark-adapted normal suflashes,b, of increasing into the right eye to produ
pupillary constriction. Ladecreases with intensity were recorded simultaneinfrared pupillography d
pupil tracing (solid line) tracing (broken line) mov
Reactions of the pupil to different intensities. At ththere was a short pupil lithe pupil dilated (escapestimulus. At the brighter contractions were larger sustained, also exhibiting(hippus).
P ill hi d t ti RA
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Pupillographic demonstration: RA
F l RAPD C
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False RAPD: Causes
amblyopia previously patched eye
tilted light source directed off the macula
What about Efferent Pupillary Defects (EPD)? CN III nerve palsy
internal ophthalmoplegia
Di i O tli
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics
Intrinsic Muscles: Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture False RAPD: Causes
Pupillary Defects: Clini
Horners Syndrome:
Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Condition Conclusion
P ill D f t Cli i l C diti
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Pupillary Defects: Clinical Conditi
Horners syndrome
Adies Tonic Pupil
Argyll-Robertson pupils
Disc ssion O tline
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics
Intrinsic Muscles: Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome:
Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Condition Conclusion
Horners Syndrome: Classic Tria
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Horner s Syndrome: Classic Tria
Loss of sympatheticinnervation causing the
clinical triad of:
Ptosis
(drooping eyelid)
Miosis
(pupillary constriction)
An
(decre(ipsilateral blepharoptosis)
Horner's Syndrome: Causes
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Horner s Syndrome: Causes
carotid artery dissection
pancoast tumors, nasopharyngial tumors
lymphoproliferative disorders
brachial plexus injury cavernous sinus thrombosis
fibromuscular dysplasia
Denervation
(sympathetic
CAD
Horners Syndrome:
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o e s Sy d o e:Features
Miosis Ptosis Anhydrosis
Site of lesion can be life threatening!
CAA: enlargement of the lumen of the carotid
artery demonstrated in the carotid angiogramDeepayan Kar 2014
Horners Syndrome:
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yFeatures
Miosis Ptosis Anhydrosis
Use pharmacologic testing!
MRI: bright signal in the wall of the
carotid artery resulting from blood
Carotid
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ArterialDissection
Discussion Outline
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics Intrinsic Muscles:
Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria
Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Condition Conclusion
Adies Tonic Pupil
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Adie s Tonic Pupil
Dilated, tonic pupil due to postganglionic parasympathetic pupillomotor da
90% women (2040 years of age)
80% unilateral
benign condition
Pathology: loss of ganglion cells in ciliary ganglion
degenerated axons in short ciliary nerves (affects sphincter mu
Denervation (parasympath
Adies Tonic Pupil: Findings
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Adie s Tonic Pupil: Findings
Initially, pupil is dilated, poorlyreactive and sluggish
Later becomes miotic; segmentalcontraction of pupil (vermiform
movements)
Light-near dissociation with slow(tonic) redilation after near stimulus
Adies Tonic Pupil: Diagnosis
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Adie s Tonic Pupil: Diagnosis
dilute pilocarpine (0.125%) ormecholyl 2.5%
will constrict the tonic pupilbut not normal pupil
false-positive test can occur in CN
3 palsy
Associations: Holmes-Adie syndrome described with
Adie's pupil and absent deep tendonreflexes, orthostatic hypotension
Unequal contraction from the 11 o'clock to 1
puckering of the iris st NS= junction of the no AS= atonic sphincter
Discussion Outline
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics Intrinsic Muscles:
Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupi
More Clinical Condition Conclusion
Argyll-Robertson Pupil
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Argyll Robertson Pupil
bilateral small, irregular pupils
light-near dissociation absence of a miotic reaction to light (both direct and consensual)
with the preservation of a miotic reaction to near stimulus (accommodation-con
hallmark of tertiary neurosyphillis
Pupils will NOT constrict to light but they WILL constrict with accommodatio
Discussion Outline
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics Intrinsic Muscles:
Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Conditio Conclusion
More Clinical Conditions
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More Clinical Conditions
Hutchinsons Pupil unilateral dilated, poorly reactive pupil in comatose patient
due to ipsilateral supratentorial mass causing displacement of hippoc(uncal herniation) entrapping CN 3
pupillomotor fibers travel in peripheral portion of nerve, suscearly damage from compression
ParinaudsSyndrome pupils become mid-dilated
light near dissociation of the pupils (DDx: ARP)
Discussion Outline
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Discussion Outline
Basic facts
Pupillary Innervation: Pharmacokinetics Intrinsic Muscles:
Innervation Types
Light Reflex Pathway: Parasympathetic
Pupillo-Dilator Pathway: Sympathetic
Near Reflex: Triad Response
Anisocoria Pupillary Reaction: Types
Relative Afferent Pupillary Defect (RAPD) Marcus-Gunn Pupil Pupillographic demonstration Why does RAPD occur? Clinical Picture False RAPD: Causes
Pupillary Defects: Clinica
Horners Syndrome: Classic Triad Causes Features
Adies Tonic Pupil: Findings Diagnosis
Argyll-Robertson Pupil
More Clinical Condition Conclusion
Conclusion
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Conclusion
Compare pupil size: if abnormal, look at the effect of chillumination
Look for an irregularity in the shape of the pupil
Assess the direct and consensual reaction to light
Look for a relative afferent pupillary defect RAPD
Conclusion
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Conclusion
Assess the near reaction/ reflex
Examine the patient for any associated features (abnormeye movements, asymmetry of lid position)
Consider pharmacological testing
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Thank YouDEE
deepa