This document discusses the anatomy and physiology of the pupil and its innervation. It covers topics like: - The muscles that control the pupil (sphincter pupillae and dilator pupillae) and their innervation. - Causes of anisocoria (unequal pupil size) like drugs, trauma, and neurological conditions. - Horner's syndrome which causes ptosis, miosis, and anhidrosis due to interruption of the sympathetic pathway. - Adie's tonic pupil which shows a paradoxical constriction to light and dilation with accommodation due to damage to the parasympathetic pathway. - Third nerve palsy which can cause ptosis, diplo

1. DR.PRIYANKA CHOUDHARY
JR-2 OPHTHALMLOGY DEPT
MODERATOR:-DR.ABHA SHUKLA
ASST. PROFF DEPT OF OPHTHALMOLOGY

2.  Size 3-4mm
 Muscles controlling pupil
Sphincter pupillae
Dilator pupillae

3.  AFFERENT FIBRES- these fibres extend from retina to
pretectal nucleus in midbrain
 RODS AND CONES
GANGLION CELLS
OPTIC NERVE
CHIASMA
PRETECTAL NUCLEUS
INTERNUNCIAL FIBRES
Pretectal nucleus to EWN.

7.  parasympathetic ganglion.
 The oculomotor nerve coming into the ganglion contains
= preganglionic axons from the EWN which form synapses with the
ciliary neurons.
=The postganglionic axons run in the short ciliar nerves and
innervate two muscles:
sphicter pupliae, ciliaris( accommodation) muscles
are involuntary – they are controlled by the ANS.
HAS THREE ROOTS
 parasympathetic root of ciliary ganglion originating from Edinger
westphal nucleus (or motor root)
 a sympathetic root of ciliary ganglion from internal carotid
plexus
 a sensory root of ciliary ganglion
DISEASES
 Adie tonic pupil
 Adie syndrome[ (tonic pupil plus absent deep tendon reflexes).
 Light-near dissociation(no reaction of pupil to light but reaction to
accomodation present)

8.  AFFERENT FIBRES- these fibres extend from retina to
pretectal nucleus in midbrain
 RODS AND CONES
GANGLION CELLS
OPTIC NERVE
CHIASMA
PRETECTAL NUCLEUS
INTERNUNCIAL FIBRES
Pretectal nucleus to EWN.

9.  Consists of parasympathetic fibres which
arise from EWN and travel along 3RDnerve.
 Preganglionic fibres enter the inferior
division of 3RD nerve and via the nerve to IO
and relay in ciliary ganglion.
 Postganglionic fibres travel along short ciliary
nerves and supply sphincter pupillae

10.  Difference between the size of two pupil.
TYPE OF ANISOCORIA
 1.PHYSIOLOGIC ANISOCORIA:-
1. Simple/central/essential
2. Minimal anisocoria [<0.4mm]
3. Both pupils react well to light
4. No dilatation lag
5. Isolated condition

11. 2.MIOSIS OF ONE PUPIL
 Effect of local miotic
drug
 Effect of systemic
morphine
 Iridocyclitis
 Horner’s syndrome
 Head injury
 Effect of strong light
3.MYDRIASIS OF ONE PUPIL
 Effect of topical
sympathomimetic drug
 Effect of topical
parasympatholytic drug
 Sphincter damage
 Internal ophthalmoplegia
 Third nerve paralysis
 Belladona poisoning

12.  Difference in pupil size >2mm is considered
pathological and warrants further evaluation.
 Anisocoria is not caused by optic nerve or
afferent pupil pathway dysfunction.
 Assuming sphincter is structurally normal on slit
lamp examination, anisocoria is a sign of
autonomic dysfunction.
 A pupil with a brisk sustained light reflex is a
normal pupil whether or not it appears larger or
smaller than its fellow
 In case pupil which is constricted or
dilated,check for consensual reflex in the other
pupil.presence of consensual reflex indicates
integrity of afferent system in that eye is normal

15. POSTGANGLIONIC-
postganglionic
fibres in the head
Causes- benign
vascular
headache
syndrome , head
trauma, intraaural
or retro parotid
trauma and
cavernous sinus
lesion
CENTRAL-
hypothalamus to
the ciliospinal
centre of budge
at C8-T2
Causes-
brainstem
vascular
lesions,demyeli
nation and
tumors,syringo
myelia and
spinal cord
lesions at C8-T2
PREGANGLIONIC-
C8-T2 of spinal cord
to the course of
preganglionic fibres
to the superior
cervical ganglion
Causes- pancoast’s
tumor , carotid and
aortic aneurysm,
malignant cervical
lymph nodes ,
congenital (birth
trauma)
Oculosympathetic paresis
3 TYPES

16. CLINICAL FEATURES
1. Ptosis
2. Apparent enopthalmos
3. Miosis
4. Dilatation lag
5. Facial anhydrosis
6. Heterochromia iridis

20.  Tonicity caused by damage to ciliary ganglion or
short ciliary nerves (postganglionic
parasympathetic nerve injury)
Characterised by-
 Sectoral iris sphincter palsy
 Poor reaction to light
 Denervation cholinergic supersensitivity
 Strong and tonic response to near vision i.e light
–near dissociation followed by slow redilation
 Idiopathic tonic pupil-adies pupil
 70% patients are female

21.  Accomodative paresis
 Difficulty refocussing for distance

22.  Neurosurgical emergency
 Complete/partial palsy with or without pupil
involvement
 Complete/partial ptosis which may mask
diplopia
 Clinical presentation depends on location of
dysfunctionalong pathway between 3rd nerve
nucleus in midbrain and its branches of 3rd
nerve
 Diagnosis is critical if pupil is involved