This document discusses pupillary examination and various aspects of pupillary reflexes. It begins by describing the pathway of the pupillary light reflex from the retina through the brain. It then discusses the efferent pathway from the Edinger-Westphal nucleus to the iris sphincter muscle. The document also covers the near reflex pathway and differences between the light and near reflexes. It provides tips for examining pupillary reflexes, potential causes of anisocoria, and tests such as color vision testing and confrontation visual field testing.

1. Dr/ Reyad Abo Yossif (MRCOphth)
Ophthalmology specialist
Shebin Elkom ophthalmology hospital

2. Workup .3
Examination

3. PUPILLARY EXAMINATON

4. -Light reflex (Direct & Consensual)
-Near reflex
PUPILLARY REFLEXES

6. PATHWAY OF PUPILLARY LIGHT REFLEX

7. The afferent pathway starts at the retinal ganglion
cell layer and then travel through the optic nerve, optic
chiasm, and optic tract, join the brachium of the
superior colliculus, and travel to the pretectal area of
the midbrain, which sends fibers bilaterally to the
efferent Edinger-Westphal nuclei of the oculomotor
complex
THE PUPILLARY LIGHT REFLEX HAS
TRADITIONALLY BEEN DIVIDED INTO TWO
SEPARATE PATHWAYS :

8. The efferent pathway : From the E-W nucleus,
efferent pupillary parasympathetic preganglionic
fibers travel on the oculomotor nerve to synapse in
the ciliary ganglion, which sends parasympathetic
postganglionic axons in the short ciliary nerve to
innervate the iris sphincter smooth muscle via M3
muscarinic receptors.

9. The accommodation reflex to near vision includes :
Miosis, Convergence and Accomodation.
Since this reflex entails image analysis, optic paths to the
cortex must be involved.
The cortico-collicular path, and connections between
the superior colliculus and the Edinger-Westphal nucleus
complete the central route.
The efferent path is the same as that of the light reflex for
innervation of the sphincter pupillae and ciliaris oculi;
convergence requires coordinated action of all the extra-
ocular muscles, some contracting, others relaxing.
NEAR REFLEX

10. Light reflex Near reflex

11. Pupil Examination
 Observe ( Check lids for ptosis, iris colour for heterochromia)
 Ask patient to look at a distant target (to avoid near reflex)
 Measure pupil diameter in ambient bright light
 Measure pupil diameter in ambient dim light ( discover
Anisocoria)
 Check direct and consensual pupillary response for each side
 Check for RAPD
 Ask patient to look at a near target ( Check near response )

13. Lesions of optic nerve produce an unresponsive pupillary light
reflex on both sides ( absolute afferent pupillary defect / Amourotic
pupil) from light shined in the affcted eye with optic atrophy.
With light shined in the unaffected eye, both pupils constrict.
ABSOLUTE AFFERENT PUPILLARY DEFECT

14. Pupil testing should be performed prior to instillation of
dilation drops.
A relative afferent pupillary defect (RAPD or APD)
indicates unilateral or asymmetric disease of the retina or
optic nerve.
It is estimated that at least 25% of RNFL loss is required
to induce an APD.
RELATIVE AFFERENT PUPILLARY DEFECT
(MARCUS GUNN PUPIL )

15. It is named after Scottish ophthalmologist Robert Marcus
Gunn.
A positive RAPD means there are differences between the
two eyes in the afferent pathway due to retinal or optic nerve
disease.
If the light used is sufficiently bright, even a dense cataract
or corneal scar will not give a RAPD as long as the retina
and optic nerve are healthy.
Indeed, the test can be used to assess the health of the retina
and optic nerve behind a dense cataract, for example.
RELATIVE AFFERENT PUPILLARY DEFECT
(MARCUS GUNN PUPIL )

16. In glaucoma, if other tests of visual function (e.g. visual
fields) are not possible, detecting a RAPD can be very
useful as it indicates that there is more optic nerve damage
in one eye than in the other, even if the visual acuity in
both eyes is equal.
NOTE:
If the glaucomatous damage is equal in the two eyes, there
will be no RAPD, however severe the damage is.
The swinging flashlight test can detect an APD, but in the
case of bilateral symmetric optic neuropathy, an APD may
be absent.
RELATIVE AFFERENT PUPILLARY DEFECT
(MARCUS GUNN PUPIL )

17. Clinical grading of an APD is explained below. This grading system is
comparable to the neutral density filter grading system, in which neutral
density filters in increasing amounts are placed in front of the non-APD eye
until an equal pupillary response is achieved

18. RAPD Examination

19. Anisocoria is a condition characterized by unequal pupil sizes.
It is relatively common, and causes vary from benign physiologic
anisocoria to potentially life-threatening emergencies.
Thus, thorough clinical evaluation is important for the appropriate
diagnosis and management of the underlying cause.
Generally, anisocoria is caused by impaired dilation (a sympathetic
response) or impaired constriction (a parasympathetic response) of
pupils.
An injury or lesion in either pathway may result in changes in pupil
size.
ANISOCORIA

20. -Physiologic (also known as simple or essential) anisocoria is the
most common cause of unequal pupil sizes, affecting up to 20% of
the population .
-It is a benign condition with a difference in pupil size of less than
or equal to 1 mm .
-The exact cause is unknown, but it is thought to be due to transient
asymmetric supranuclear inhibition of the Edinger-Westphal
nucleus that controls the pupillary sphincter .
-Light and near responses are intact, and
-the degree of anisocoria is typically equal in light and dark.
-Physiologic anisocoria may be intermittent, persistent, or even self-
resolving.
PHYSIOLOGIC ANISOCORIA

21. Anisocoria

23. -External eye structures should be examined for associated ocular
manifestations.
-Ptosis and gaze deviation may suggest an oculomotor nerve palsy,
whereas proptosis may indicate and underlying space-occupying
lesion within the orbit.
EXAMINATION TIPS

24. -Pupillary exam is done in dim light with the patient’s eyes fixed on
a distant object to eliminate the near reaction. Pupils should be
compared for size in light and in dark (normal size difference is less
than 0.4 mm), shape, position, symmetry, and reactivity.
-The pupils should be evaluated for direct and consensual responses
that are normally equal in speed and magnitude.
-Accommodation to near stimuli should also be examined as light-
near dissociation.
-Impaired light reaction in the setting of a normal near reaction may
suggest Adie’s tonic pupil or Argyll Robertson pupil of syphilis.
EXAMINATION TIPS

25. The slit-lamp examination can provide additional
information for associated or coexisting ocular conditions.
Congenital, traumatic and surgical causes of anisocoria
will often be associated with other structural defects. The
anterior chamber can be examined for signs of iritis or
uveitis.
Abnormal gonioscopy and tonometry findings may
suggest angle closure glaucoma. The clinical picture of
Adie’s tonic pupil under slit-lamp examination shows iris
sector palsy and vermiform iris movement .
EXAMINATION TIPS

26. A detailed neurologic exam is important to localize
lesions, look for accompanying signs of cranial
nerve involvement, and assess for focal neurologic
deficits in the sensory, motor, and deep tendon
reflex pathways.
EXAMINATION TIPS

27. - Miosis
- Mild Ptosis
- Anhydrosis
Horner syndrome

28. Special examinations
 Color vision test
 Motility tests , Cover-uncover tests , prism tests
 Confrontation test
 Cranial nerves examination
 Gonioscopy

29. Dr Shinobu Ishihara introduced in 1917 the
most well known color blindness test. Each of
his tests consists of a set of colored dotted
plates, each of them showing either a number
or a path.
Color vision testing can be beneficial when optic
nerve disease is suspected because the degree
of dyschromatopsia may be greater than the
degree of visual acuity loss.
ISHIHARA COLOR VISION TEST

30. PSEUDOISOCHROMATIC COLOR PLATES OFTEN
MISS MILD CASES OF ACQUIRED
DYSCHROMATOPSIA, BUT THEY ARE
COMMONLY USED AS A GROSS TEST OF COLOR
VISION
A RED-CAPPED BOTTLE CAN BE PRESENTED TO
EACH EYE SEPARATELY FOR OBSERVATION OF
SATURATION DIFFERENCES, SUCH AS A FADED
OR WASHED-OUT RED.
Ishihara Color vision test

31. To distinguish acquired from congenital abnormalities, arrangement
tests should be used.
The Farnsworth Panel D-15 test, along with the more sensitive
Lanthony desaturated 15-hue test, entails the patient arranging 15
colored discs in order of hue and intensity under standard lighting
conditions.
The lengthier, more detailed Farnsworth-Munsell 100-hue test
requires arranging 85 discs compared to its shorter version of 21
chips.

32. Red color desaturation may occur in cases of
optic neuropathy. A red-capped bottle can be
presented to each eye separately for observation
of saturation differences, such as a faded or
washed-out red.
ISHIHARA COLOR VISION TEST

45. Confrontation visual field testing involves having the
patient looking directly at your eye or nose and testing
each quadrant in the patient's visual field by having
them count the number of fingers that you are showing.
This is a test of one eye at a time.
It is useful for the examiner to close one eye so that one
can determine if the patient is seeing appropriately in
their visual field
CONFRONTATION TEST

47. Confrontation test
result recording