The document discusses abnormal pupillary reactions and evaluations. It describes the normal anatomy and function of the pupil, as well as how to evaluate size, light reflex, and near response. Various abnormalities are then outlined, including afferent pupillary defect, anisocoria, Adie's pupil, Argyll Robertson pupil, Horner's syndrome, Hutchinson's pupil, third nerve palsy, Wernicke's hemianopic pupil, and rare conditions like tadpole and keyhole pupils.

1. ABNORMAL PUPILLARY REACTIONS
MEHEDI HASAN
JUNIOR OPTOMETRIST
The largest & oldest multispecialty eye hospital

2. PUPIL
It is a circular aperture at the center of the iris that
allows light to enter the retina. The normal pupil size
in adults varies from 2 to 4 mm in diameter in bright
light to 4 to 8 mm in the dark.

3. FUNCTIONS OF PUPIL
Regulates amount of light entering eye ( Dilation and Constriction)
Reduces spherical , chromatic aberration
Increases depth of focus
Sphincter pupillae
(Constrictor)
Dilator pupillae

4. EVALUATION
 Are the pupils round or irregularly shaped ?
 Are the pupils equal in size ? In light and dark ?
 Do the pupils react to a light stimulus ?
 If not , do they react to a near target ?

5. HOW DO WE RECORD
Parameters Right eye Left eye
Size of pupil in dark
Size of pupil in light
Reaction to light
(direct)
Reaction to light
(indirect)
Reaction to Near
Dilation to dark

6. SIZE
 1. Hand-held pupil gauge (Haab scale)
 2.Hand-held pupil camera
 3.Infra red video Pupilography

7. THE LIGHT REFLEX

8. THE LIGHT REFLEX
Optic nerve

9. THE LIGHT REFLEX
Optic nerve
Optic chiasma

10. THE LIGHT REFLEX
Optic nerve
Optic chiasma
Optical tract

11. THE LIGHT REFLEX
Optic nerve
Optic chiasma
Optical tract
The pretectal nucleus

12. THE LIGHT REFLEX
Optic nerve
Optic chiasma
Optical tract
The pretectal nucleus Edinger-Westphal
nucleus

13. THE LIGHT REFLEX
Optic nerve
Optic chiasma
Optical tract
The pretectal nucleus Edinger-Westphal
nucleus
Oculomotor nerve
( CN III )

14. THE LIGHT REFLEX
Optic nerve
Optic chiasma
Optical tract
The pretectal nucleus Edinger-Westphal
nucleus
Oculomotor nerve
( CN III )
Ciliary ganglion

15. THE LIGHT REFLEX
Optic nerve
Optic chiasma
Optical tract
The pretectal nucleus Edinger-Westphal
nucleus
Oculomotor nerve
( CN III )
Ciliary ganglion
Short ciliary nerves
to both constrictors
of the eye
(Sphincter pupillae
muscle)

16. THE LIGHT REFLEX
If light enters an eye, the pupil of this eye constricts
(direct light reflex), and there is an equal
constriction of the pupil of the other eye
(consensual light reflex).

17. NEAR REFLEX ( ACCOMMODATION REFLEX /
ACCOMMODATION-CONVERGENCE REFLEX )
Near Reflex is basically a triad of : I. Miosis
II. Convergence
III. Accommodation
Afferent impulses remain the same as the light reflex.
The near reflex pathway bypasses the pretectal nuclei and
descends directly to EWN.
From the ciliary ganglion to both : ciliary ganglion for
accommodation & ciliary muscle for sphincter pupillae.

18. NEAR REFLEX
 Important if direct response is weak.
 Moderate room light .
 Use Accommodative target.

19. LIGHT-NEAR DISSOCIATION
NEAR RESPONSE > LIGHT RESPONSE = LIGHT-NEAR DISSOCIATION

20. PUPILLARY DILATION
 Looking for dilation lag.
Normal pupillary dilation involves : Sphincter relaxation + Dilator contraction
 Normal pupils return to their widest size within 12 - 15 seconds ( max occurs within 5 seconds )
 Dilation lag is present when pupil takes 25 seconds to return to maximum size in dark ( starting after 10
- 12 seconds )

21. ABNORMALITIES
Pupillary
disorders
Afferent
pupillary
defects
Anisocoria
Abnormal
shape

22. AFFERENT PUPILLARY DEFECT

23. RELATIVE AFFERENT PUPILLARY DEFECT (RAPD, MARCUS GUNN
PUPIL)

24. RELATIVE AFFERENT PUPILLARY DEFECT (RAPD, MARCUS GUNN
PUPIL)

26. GRADING OF RAPD

27. PARADOXICAL PUPILLARY PHENOMENA
The pupil starts constricting in dark at first ,then
starts dilating.
Causes :
 CSNB
 Congenital achromatopsia
 Optic nerve hypoplasia
 leber's congenital amaurosis
 Albinism
 RP

28. ANISOCORIA
Anisocoria is a condition characterized by an unequal size of the pupils.

29. ANISOCORIA
Anisocoria is a condition characterized by an unequal size of the pupils.
Physiological (Anisocoria of around 1 mm is present in around 20% of the normal population)

30. ANISOCORIA
Anisocoria is a condition characterized by an unequal size of the pupils.
Physiological (Anisocoria of around 1 mm is present in around 20% of the normal population)
Pathological

31. ANISOCORIA
Anisocoria is a condition characterized by an unequal size of the pupils.
Physiological (Anisocoria of around 1 mm is present in around 20% of the normal population)
Pathological
Size
Reactions
Pharmacological tests

33. ADIE'S (TONIC) PUPIL
The tonic pupil, sometimes called Adie tonic pupil or simply the Adie pupil, is the term used to denote a
pupil with parasympathetic denervation that constricts poorly to light but reacts better to accommodation
(near response), such that the initially larger Adie pupil becomes smaller than its normal fellow and remains
tonically constricted, redilating very slowly when exposed to dark.
Caused by the damage to the postganglionic parasympathetic fibres i.e, at level of ciliary ganglion or short
ciliary nerves

34. Right Adie pupil. (A) Large right pupil; (B) absent or sluggish direct light reflex; (C) consensual light reflex is simil
A B C

35. ARGYLL ROBERTSON PUPIL
Small ( >2mm ), irregular pupils (almost always bilateral)
No reaction to light,normal near response (light near
dissociation),
often iris atrophy and iris transillumination defects, and poor
dilation with drops

36. The entire syndrome includes :
„ Absence of light reaction,
„ Presence of accommodation reaction,
„ Pupils are miotic, irregular
„ Atrophic depigmented patches on iris.
„ Pupils fail to dilate with mydriatic, but
constrict further with eserine.
„ Presence of good vision in both eyes.

37. HORNER'S SYNDROME
Light illumination
Dark illumination

38. HORNER'S SYNDROME
A B
Horner syndrome. (A) Right Horner syndrome; (B) heterochromia iridis associated with a left
congenital Horner syndrome in a child

39. HUTCHINSON'S PUPIL
A pupil that is dilated and completely inactive to all stimuli. It is associated with lesions of the central
nervous system, as may occur in head injury.
Stage 1 : the parasympathetic fibers on the side of injury are irritated, leading to constriction of pupil on that
side.
stage 2 : the parasympathetic fibers on the side of injury are paralysed, leading to dilatation of pupil. The
fibers on the opposite oculomotor nerve are irritated, leading to constriction on opposite side.
stage 3 : the parasympathetic fibers on both sides are paralysed - leading to bilateral pupillary dilatation.

40. THIRD NERVE PALSY
 Pupillary dysfunction associated with ptosis
and limitation of extraocular mobility
 pupil mid-dilated Maximum anisocoria
occurs in bright light
 0.125% pilocarpine no constriction but
constrict with 1%

41. WERNICKE’S HEMIANOPIC PUPIL
 Wernicke's Hemianopic pupil occurs as a result of a lesion in the optic tract .
 Light reflex is absent on temporal half of the retina of affected side and nasal half on the opposite side.
 Light reflex is present on nasal half of affected side and temporal half of opposite side.

42. TADPOLE PUPIL
Tadpole pupil is a rare phenomenon in
which segmental spasm of the iris dilator
muscle results in a tadpole-shaped pupil

43. TADPOLE PUPIL

44. KEYHOLE PUPIL
A pupil with an coloboma at the pupillary margin.

45. HOME MESSAGE

46. EVERY ENDING
IS REALLY JUST A
NEW BEGINING