TYPES OF ABNORMAL PUPIL

1. Pupillary abnormalities
Dr.ANUPAMA MANOHARAN
JUNIOR RESIDENT
DEPT. OF OPHTHALMOLOGY
UDHGAMANDALAM GOVERNMENT MEDICAL COLLEGE
AND HOSPITAL OOTY (TN)

2. EXAMINATION OF PUPIL
● Size
● Shape
● Symmetry
● Pupillary reaction
To light - direct and consensual
To near

3. PUPILLARY ABNORMALITIES
● SIZE
○ MICROCORIA
○ MEGALOCORIA
● SHAPE
○ ANIRIDIA
○ KEY HOLE PUPIL
○ FESTOONED PUPIL
○ PERSISTENT PUPILLARY MEMBRANE
● NUMBER
○ POLYCORIA
● POSITION
○ CORECTOPIA
● SYMMETRY
○ ANISOCORIA
● COLOUR
Structural
Functional

4. MICROCORIA. MEGALOCORIA
● <2mm
● Malformation of dilator pupilae
● >6mm
● Malformation of sphincter pupilae

6. Mydriasis >6mm
Unilateral Bilateral
Physiological Pharmacological TCA,BELLADONA
poisoning,antiparkinsonism drugs
Drugs- sympathomimetic,anticholinergics Myopia
Adies tonic pupil Benign episodic mydriasis
Oculomotor nerve palsy Dorsal midbrain lesion
Uncal herniation
Traumatic sphincter tear
Iris ischaemia in case of glaucoma
Ocular siderosis

7. COLOBOMA OF IRIS
● Key hole pupil
● Due to abnormal closure of
embryonic fissure
● Inferonasal
● Associated with defects in
lens,optic nerve, retina.

8. ANIRIDIA
● Complete or partial absence of Iris
● Congenital- true aniridia
● Trauma
● Post surgical

9. ● Iridodialysis :
○ D-shaped pupil
○ dialysis is seen as a dark
biconvex area near the limbus.
○ asymptomatic if covered by the
upper lid;
○ uniocular diplopia and glare
○ surgical repair of the dehiscence

10. FESTOONED PUPIL
● Seen in cases with posterior synaechie
which is incomplete and when the pupil is
dilated it takes the shape of a festoon
● Iridocyclitis
● 360° synechiae-SECLUSIO PUPILLAE
● fibrovascular membrane over pupil-
OCCLUSIO PUPILLAE

12. PERSISTENT PUPILLARY MEMBRANE

13. PPM Contd…
● 8th month of gestation the Pupillary
membrane degenerates
● If the pupil size is <1mm the patients can
develop sensory deprivation ambylopia
● Excision of Pupillary membrane with
vannas or vitreous scissors in early
weeks of life
● Old patients with thin Pupillary
membrane can undergo NDYAG laser
membrane lysis

14. POLYCORIA
● Multiple pupil
● Associated with irido
corneal endothelial
syndrome, Axenfeld Rieger
syndrome
● Uniocular diplopia

15. CORECTOPIA
● Eccentrically placed pupil
● Displacement of pupil
● Normally 0.5 mm inferonasal
from centre of Iris
● Significant-1mm
● Sector Iris hypoplasia
● Rostral midbrain disease
● Axenfield-Rieger syndrome
● ICE Syndrome
● Associated with lens
subluxation-ectopia lentis et
pupillae

16. ANISOCORIA
● Difference between the size of two pupils
>2mm
● Physiological anisocoria-1mm
● Present in 10 to 20 percent
● Anisocoria equal in dim and bright light
● Pathological anisocoria
○ check pupil size in dim light and bright light

18. LEUCOCORIA
● White reflex in pupil
● Congenital cataract
● Retinoblastoma
● Retinopathy of prematurity
● Persistent hyperplastic primary vitreous
● Toxocora endophthalmitis
● Coats disease
● Persistent fetal vasculature (PFV)
● Ocular toxocariasis
● Familial exudative vitreoretinopathy (FEVR)
● Astrocytic hamartoma
● Vitreous hemorrhage
● Coloboma
● Endogenous endophthalmitis
● Rhegmatogenous retinal detachment

19. HIPPUS
● Constant small amplitude fluctuation of pupil under constant illumination
● Bilateral
● Symmetrical
● Non rhythmic unrest or variation of size usually less than 1mm in amplitude
of variation

20. ABNORMAL PUPILLARY REACTION
● Apparent Pupillary defect
● Relative apparent Pupillary defect
● Horner's syndrome
● Adie’s tonic pupil
● Argyl Robertson pupil
● Tectal (dorsal midbrain) pupil
● Hutchison pupil
● Wernicke's hemianopic pupil
● Benign episodic mydriasis

26. CAUSES OF RAPD
● Optic neuritis
● Anterior ischaemic optic neuropathy
● Compressive optic neuropathy
● Retinal vessel occlusion
● Retinal detachment
● Lesions of optic tract
● Chiasmal compression

28. CILIOSPINAL REFLEX

44. LIGHT NEAR DISSOCIATION

53. lesion of optic
tract

59. III CN PALSY

60. BARTON PUPIL
RULE
● Complete third nerve palsy without pupil
involvement is never due to aneurysm

61. Local causes
● Miosis in trauma - sphincter spasm due to prostaglandin release with iritis
● Mydriasis in trauma- sphincter tear
● Glaucoma- Iris ischaemia- dilated sluggish light reflex
● Ocular siderosis- iron deposition in muscles
● Post Intraocular surgeries - scarring and synechiae - poor Pupillary
reaction
● neovascularisation of iris- fibrovascular membrane