The document discusses various abnormalities of the pupil, including anisocoria, Marcus-Gunn pupil, and congenital conditions such as aniridia and iris coloboma. It outlines the features, differential diagnoses, and management strategies for several conditions affecting pupillary reflexes and structure. The document also highlights the impact of neurological disorders on pupil function, detailing conditions like Horner's syndrome and Adie's tonic pupil.

1. ABNORMALITIES OF
PUPIL
Kh.Md.Imrul Morshed
B.Optom( 6th Batch )
Institute of Community Ophthalmology,
Chittagong

2. Pupil
 It is a circular aperture at the centre of the iris
that allows light to enter the retina.
 The size of pupil normally varies between 2 to
4 mm .

3. Abnormal pupils
 Anisocoria:
 Anisocoria means unequal pupils.
 If there is a poor reaction to light in one eye and
the anisocoria is more evident in a well lit room,
then the affected pupil is abnormally large.
 If there is a good reaction to light in both eyes
but a poor dilation in the dark then the affected
pupil is abnormally small.

4. The abnormally large pupil
 Features - there is poor constriction in a
well lit room.
 Differential diagnosis –
 traumatic iris damage
 third cranial nerve palsy
 pharmacological dilation (i.e. dilating
drops)
 Adie's pupil
 iris rubeosis.

5. The abnormally small pupil
 Features - there is poor dilation in a dim
room.
 Differential diagnosis –
 physiologically small pupil
 pilocarpine drops
 uvietis with synaechiae
 Horner's syndrome.

6. Dilated pupil of right eye

7. Anomalies of pupillary
reflexes
 Marcus-gunn pupil:
 It is also known as Related afferent pupillary
defect (RAPD) or pupillary escape
phenomenon.
 It occurs in defect of visual pathway anterior to
the chaisma.
 It consists of –
1. A diminished amplitude to pupillary reaction
2. Pupillary dilation with continuous light
stimulation.

8. Marcus-gunn pupil

9.  Detection : The test for its detection is called
swinging flash light test . Normally, if a
illuminated pen light is alternately directed to
each eye the pupils constrict and do not vary
as the light alternate between the eyes.
 In afferent pupillary defect both pupils dilate
when the light is moved from the unaffected
eye to the affected eye. But they constrict
when the light is directed to the normal eye.

10. Examination of RAPD

11. Causes of Marcus-Gunn pupil
 Optic neuritis
 Ischemic optical disease
 Optic nerve damage
(Trauma,Radiation,Tumor)
 Retinal detachment
 Severe macular degeneration

12. Diseases affecting the
pupils
 Congenital Abnormalities:
 Aniridia:
 The term Aniridia implies an absence of Iris.
 In the majority of cases a small stump of iris
tissue exists at the iris root.

13. Aniridia with a small stump of
iris tissue at the iris root.

14. Etiology of Aniridia
 Aniridia is an congenital anomaly that
develops at approximately twelfth week of
gestation .
 Two-thirds of the cases are inherited in the
autosomal dominant fashion. The remaining
one-third of the cases appear as a result of
spontaneous mutation .

15. Ocular Signs and Symptoms
 Photophobia
 Corneal opacification
 Congenital polar cataracts
 Lens dislocations
 Progressive Glaucoma

16. Management
 Colored contact lens.
 Early goniotomy can be performed to prevent
blockage to trabecular meshwork.
 Filtering surgery.
 Cyclocryotherapy

17. Iris Coloboma
 This is an uncommon
congenital condition
characterized by a
unilateral or bilateral
partial iris defect.
 It is a condition where
normal tissues of iris is
missing from birth.
 It creates “Key-hole” or
“Cats-eye” appearance
to the iris.
Iris Coloboma With a
Key-hole appearance

18. Etiology of Iris coloboma
 The eye develops quickly during the first three
months of growth of a fetus. A gap , known as
the choroidal fissure, appears at the bottom of
the stalks that eventually form the eye.This
fissure generally closes by the seventh week
of gestation. If it doesnot close , a coloboma or
space forms.

19. Signs and Symptoms
 Missing iris tissue
 Reduced vision
 Key-hole or cat-eye shaped pupil
 photophobia

20. Management
 Usually there is no cure for coloboma.
 Colored contact lens
 Surgery

21. leukocoria
 Refers to a white pupillary reflex from the retina of
the eye.
Leukocoria in the left eye

22. Etiology of Leukocoria
 Many conditions cause leukocoria that are-
 Congenital cataract
 Retinal detachment
 Retinoblastoma
 Endophthalmitis
 Retinopathy of prematurity

23. Signs and Symptoms
 Vision problems.
 Eye pain.
 Redness of the white part of the eye.
 Bleeding in the front part of the eye.
 Bulging of the eye.
 A pupil that doesn’t constrict when exposure to
the bright light.
 A different color in each iris.

24. Management
 Leukocoria is managed by treating any other
underlying conditions ( Retinal detachment ,
cataract e.t.c ) which are responsible for the
appearance of the white pupil.

25. Acquired Structural
Abnormalities
 Pseudoexfoliation Syndrome:
 This is a condition characterized by deposition of
a grey-white fibro granular extracellular matrix
material deposited on the anterior lens.
 It is seen on the slit-lamp examination , as a fine
grey dusting around the pupil .
 Pupil shape and function are not affected
 It is clinically significant due to its association with
glaucoma and its potential to make cataract
surgery more tricky.

26. Pseudoexfoliation Syndrome

27. Signs and Symptoms
 White flaky materials on pupillary border of the
iris.
Management
 IOP lowering medications as first line therapy.
 Argon Laser Trabeculoplasty (ALT)
 Selective Laser Trabeculoplasty (SLT)

28. Sphincter Tear
 Iris tear can occur as a
result of blunt or
penetrating trauma and
can also occur during
intraocular surgery.
 Tears may be
associated with
Glaucoma and visual
problems. Tear in the spincter
muscle

29. Neurological Abnormalities
 Horner’s Syndrome:
 It is a syndrome that consists of miosis, partial
ptosis and endophthalmitis.
 Sometimes associated with unilateral absence of
sweating of the face of the affected side
(Anhydrosis).
 In congenital form there may be associated
heterochromia of iris .

30. Horner’s Syndrome

31. Etiology
 Horner’s syndrome can be caused by any
interruption in a set of nerve fibers that start in
the part of brain called hypothalamus and
travel to the face and eyes .
 Injury to the carotid artery of the brain.
 Injury to the nerves at the base of the neck
called the brachial plexus.
 Migraine
 Tumor in the top of the lung.

32. Management
 If cosmetically unaccepted , ptosis may be
corrected surgically.

33. Adie’s Tonic Pupil
 It is a neurological disorder characterized by a
tonically dilated pupil that reacts slowly to light
but shows a more definite response to
accommodation.
 Cause:
 Caused by Postganglionic parasympathetic
pupillomotor damage.

34. Adie’s Tonic Pupil in the left
eye

35. Signs and Symptoms
 Abnormally dilated pupil which doesn’t
constrict in response to light .
 Hyperopia due to accommodation paresis .
 Photophobia
 Blurry vision
 Facial pain
 Headache

36. Management
 There is no effective treatment.
 Weak miotics may be helpful
 Near correction may be given to the affected
eye.

37. Argyll-Robertson’s Pupil
 It is a bilateral abnormality characterized by
failure of the pupils to constrict with light , but
retention of constriction present with
accommodation.

38. Argyll Robertson pupil

39. Causes
 Neuro-syphilis- here all signs are present.
 Non-syphilitic causes :
 Diabetes
 Multiple sclerosis
 Hemorrhage and tumors involving the pretectal
region .

40. Management
 Syphilis is the major cause of Argyll Robertson
pupil. Administration of penicillin intravenously
is the method to treat almost all stages of
syphilis.