This document discusses anisocoria, or unequal pupil size, and provides guidance on differentiating between sympathetic and parasympathetic causes based on pupil response tests. For sympathetic causes, it recommends testing for dilation lag in the dark, response to cocaine and hydroxyamphetamine. For parasympathetic causes, it suggests checking the iris, light reaction, near reaction, response to low-dose and high-dose pilocarpine to determine if the cause is tonic pupil, third nerve palsy or an atropinic pupil. Differentiating the cause is important as it could indicate conditions like Horner's syndrome or damage to the iris.

1. ANISOCORIA
Abdelmonem M. Hamed,
MD
Professor of Ophthalmology Benha College of
Medicine
Fellow of Baylor College, USA

2. LightAnisocoria
Is it in dark or light
Dark
Sympathetic
lesion…weak dilator Ms
1.Dlation lag in dark:
• yes…Horner
• No….Simple anisocoria
2. Cocaine test
• smaller pupil dilate
poorly…Horner
• both pupils dilate
equally…simple Anisocoria
3.Hydroxyamphetamin
test to DD post ganglionic
Horner
Parasympathetic
lesion…weak sphincter Ms
1. Is the iris normal?
Yes…..go to #2
No…iris damage …(transillumation)
2. Does sphincter reacts to light?
Yes…..go to #3
No…it might be atropine,
3. Does pupil react to near > light?
Yes…tonic pupil (light near dissociation)
No…may be atropine
4. Is it sensitive to pilocarpine 0.125%?
Yes…..tonic pupil
No……may be atropine
5. Does it constrict with pilocarpine 1%?
Yes….3rd nerve palsy
No….Atropinic pupil