1. • “For she had eyes and chose me.”
― William Shakespeare, Othello
• Whenever v see someone we like, our pupils grow larger. It's almost
as if our eyes are trying to see as much of this person as possible. <3
<3
• This is an involuntary and uncontrollable physiological response.
• Thus, you can often tell if a men/woman is attracted to you by
observing his/her pupils, and whether they expand or contract, or
maybe do nothing.
• (Note: contracting would not be good for you... as it likely means he/she not only is not attracted to you, but
actively dislikes you. Sorry about that.)
4. ANATOMY OF PUPIL
An aperture present in the centre of the iris.
Size of the pupil determines the amount of light that enters the eye.
Pupil size controlled by the dilator & sphincter muscles of the iris.
5. SIZE ,SHAPE ,LOCATION
Normally there is one pupil in
each eye.
Rarely, there may be more than
one pupil. This congenital
anomaly is called POLYCORIA
Normally, pupil is placed almost
in the centre (slightly nasal) of
the iris.
Rarely it may be congenitally
eccentric ( CORECTOPIA )
6. • Normal pupil size varies from 2.5-4mm depending upon the illumination.
- Miotic pupils are less than 2mm
- Mydriatic pupils are greater than 7mm.
• The size depends on :
Age : Smaller in infants and elderly
Sleep : Smaller due to parasympathetic dominance
Refraction : Hyperopes have smaller pupils
Colour : Darker iris have smaller pupils.
7. • Diameter of the pupil size should be estimated in light, using either a
normal room light or a hand held transilluminator.
• Should be assessed in darkness using the dimmest possible room light
& then during near stimulation using an accomodative target to achieve
maximum constriction of pupils.
8. • Isocoria : Normally the two pupils are equal in size. A slight (one-tenth of
a millimeter) anisocoria is present in a significant percentage of normal
pupil.
• Anisocoria : Difference in pupillary diameter of 2 eyes of the same
individual by 0.3mm or more
9. The pupils are controlled by two
muscles of ectodermal origin-
sphincter pupillae & dilator
pupillae
The size of pupil is essentially
the result of their opposing forces
When maximally contracted the
diameter may be <1mm, when
maximally dilated it may
be>9mm
15. Retinal Ganglion Layer
Optic Nerve
Optic Chiasma
Optic Tract
Pretectal Nucles in Mid Brain
INTERNUNCIAL FIBRES
GOES TO BOTH EWN
Edinger Westphal Nucleus
Pre-ganglionic Fibres originates
&via 3rd nerve ;piercing IO
Ciliary Ganglion
Post Ganglionic Fibres
Sphincter Pupillae
16. Retinal Ganglion Layer
Optic Nerve
Optic Chiasma
Optic Tract
Pretectal Nucles in Mid Brain
INTERNUNCIAL FIBRES
GOES TO BOTH EWN
Edinger Westphal Nucleus
Pre-ganglionic Fibres originates
&via 3rd nerve ;piercing IO
Ciliary Ganglion
Post Ganglionic Fibres
Sphincter Pupillae
Lesion in Optic Tract =
Marcus Gunn Pupil &
Wernicke’s Hemianopic Pupil
Lesion in Internuncial Fibre =
Argyl Robertson Pupil
Lesion in Ciliary Ganglion =
Adie’s Pupil
Cortical: dilated pupils during
epileptic seizures
Spinal-reticular:states of
arousal,excitement
Sleep,coma:inhibitory
influences decline and pupils
are miotic
INHIBIT
17. The peristriate cortex (area 19) at the upper end of the calcarine fissure may be the origin
It is activated when gaze is changed from a distant to a near target
It comprises accommodation,convergence and miosis
The pathway is more ventrally located than the pretectal afferent limb of the light reflex
The final pathway is the oculomotor nerve,ciliary ganglion and the short posterior ciliary nerves
Ratio of ciliary ganglion cells vs. cells to iris sphincter is approx. 30:1
20. Argyll Robertson Pupil ( ARP )
• Bilateral, miotic pupil with irregular margins and are
asymmetrical.
Response to light and near reflex :
Light reflex is absent & accommodation is retained. The
lesion is at the pretectal area. Commonly seen in tertiary
neurosyphilis especially in Tabes.
Other causes include :
- Diabetes
- Wernicke’s encephalopathy
- Encephalitis,
21. Small pupils < 2 mm
Often irregular
Near response is brisk and normal
Light reflex is absent
Iris atrophy is frequent with iris showing transillumination
defects and poor dilatation with mydriatics
Visual acuity is usually normal
22. TOTAL AFFERENT PATHWAY DEFECT (TAPD) OR AMAUROTIC
PUPIL
RELATIVE AFFERENT PATHWAY DEFECT
(RAPD) OR
MARCUS GUNN PUPIL
Caused by a complete optic nerve or retinal lesion leading to
total blindness on the affected side.
Characterized by the following:-
The involved eye is completely blind (i.e no light perception)
Absence of direct light reflex on the affected side and
absence of consenual light reflex on the normal side.
When the normal eye is stimulated, both pupils react
normally.
In diffuse illumination, both pupils are equal in size.
Near reflex is normal in both eyes.
It is the paradoxical response of a pupil
to light in the presence of a relative
afferent pathway defect (RAPD).
Caused by an incomplete optic nerve
lesion or a severe retinal disease.
It is best tested by ‘swinging flashlight
test’
24. Causes Of RAPD
Unilateral optic neuropathies ,if a condition is bilaterally symmetrical, there will not be an
RAPD.
Optic neuritis - Even very mild optic neuritis with a minimal loss of vision can lead to a very
strong RAPD.
Ischemic optic neuropathies - These include arteritic (Giant Cell Arteritis) and non-arteritic
causes.
Glaucoma
Traumatic optic neuropathy
Optic nerve tumor - This is a rare cause, and includes primary tumors of the optic nerve
(glioma, meningioma) or tumors compressing the optic nerve (sphenoid wing meningioma,
pituitary lesions, etc.
Orbital disease - This could include compressive damage to the optic nerve from thyroid
related orbitopathy.
Radiation optic nerve damage
.
25. Methods To Grade RAPD
1. Swinging Light Reflex
2. Kestenbaum’s number – pupil gauge/ neutral density filter.
3. Infrared videography
4. Computerized pupillometry.
26. GRADING OF RAPD
Grades Acc. To Swinging Light Reflex
• Grade 1: A weak initial pupillary
constriction followed by greater
redilation
• Grade 2: An initial pupillary stall
followed by greater redilation
• Grade 3: An immediate pupillary
dilation
• Grade 4: immediate pupillary
dilatation with pupillary
constriction.
• Grade 5: immediate pupillary
constriction with no dilatation.
Grade Acc. To Neutral Filter
Density Filter
• Neutral density filters come in
densities of 0.3, 0.6, 0.9 and 1.2 log
units, and
• higher densities can be obtained by
combining filter.
• Densityof the RAPD is the density of
the filter required to neutralize it.
• Grade I, 0.3 to 0.6 log;
• Grade II, 0.45 to 1.2 log;
• GradeIII, 0.75 to 1.5 log;
• Grade IV, 1.5 to 2.7 log;
• Grade V, too dense to measure.
27.
28.
29. CONDITION WHICH WILL NOT CAUSE RAPD
• Refractive Error (even if extreme)
except Amblyopia
• Media Opacity (a bright enough light
will indicate NO RAPD)
– Cataract (even if completely opaque)
– Corneal scar
– Hyphema
– Vitreous hemorrhage
• Strabismus
• Conditions with an Efferent Pupillary
Defect
– Third Cranial Nerve Palsy
– Adie's Pupil
– Horner's Syndrome
• Conditions which are typically
bilaterally symmetrical will not show
an RAPD:
– Bilateral retinitis pigmentosa
– Bilateral nutritional or metabolic optic
neuropathies
• Mild retinal problems, including:
– Mild background diabetic retinopathy
– Central serous choroidopathy
– Non-ischemic vein occlusions
– Mild macular degeneration
31. Efferent Pupillary Defect
(Fixed Dilated Pupil)
I Midbrain
damage
1.Dorsal midbrain (
the EW nucleus & its
light reflex input)
2.Ventral midbrain
(fascicular portion of
third nerve )
II. Damage to the IIIrd nerve
(from interpeduncular fossa to
ciliary ganglion)
1.Basal aneurysms
2.Supratentorial
space occupying
masses
3.Basal
granulomatous
meningitis
4.Ischemic
oculomotor palsy
5.Parasellar tumor
III. Damage to the
ciliary ganglion or
short ciliary nerves
1.Local Tonic Pupil
-viral ciliary
ganglionitis
-choroidal trauma
-blunt trauma to the
globe
2.ADIE’S SYNDROME
Damage to IRIS
1.Degenerative or
inflammatory
diseases of the iris
2.Posterior synechiae
3.Acute rise of IOP
(hypoxia of sphincter)
4. Traumatic
iridoplegia
**Horner Syndrome**
32. Hutchinson’s Pupil
• Hutchinson's pupil is a clinical sign in which the pupil on the side of
an intracranial mass lesion is dilated and unreactive to light, due to
compression of the oculomotor nerve on that side. The sign is named
after Sir Jonathan Hutchinson.
• Dilated pupils which occur in cerebral injury or haemorrhage,cerebral
abcees and oedema.
• Herniation of temporal lobe into the tentorial hiatus.
• 3 stages:-
Intial stage of miosis due to irritation of I/L 3rd nerve.
Dilation of I/L pupil which still react to light & convergence though the
patient is drowsy.
True H.P is dilated with loss of all the reflexes.
• +/- Paresis of EOM supplied by 3rd CN.
33. ADIE’s Pupil
It is usually unilateral (in 80%)
Affects healthy young women >> men.
It may be assoc. with absent knee jerk.
The affected pupil is large and irregular
(anisocoria)
The light reflex is absent or slow.
Near reflex is slow and tonic.
Accommodative paresis.
There may be assoc. mild regional impairment of
corneal sensations
Retinal Ganglion Layer
Optic Nerve
Optic Chiasma
Optic Tract
Pretectal Nucles in Mid
Brain
INTERNUNCIAL
FIBRES GOES TO
BOTH EWN
Edwinger Wespar Nucleus
Pre-ganglionic Fibres
originates &via 3rd nerve
;piercing IO
Ciliary Ganglion
Post Ganglionic Fibres
Sphincter Pupillae
Lesion in
Cilliary
Ganglion =
Adie’s Pupil
34. ADIE’s Pupil
Pharmacological testing helps in the diagnosis of Adie’s tonic pupil.
In 80-90% of patients with Adie’s tonic pupil, 0.125% pilocarpine or 2.5% methacholine
causes denervation supersensitivity.
The concentration is too weak to cause constriction of the normal pupil.
35. Method to do Pilocarpine test.
• 0.125% pilocarpine (prepared by diluting one part 1%
pilocarpine with 7 parts balanced salt solution)
– Patient is fixating at a distance to prevent near accommodative
reflex. Measure the pupil size of each eye.
– Instill a drop of 0.125 pilocarpine ophthalmic solution in each eye, and
recheck the pupils in 10-15 minutes.
– A positive test result – The tonic pupil constricts significantly more than
the contralateral pupil
36. HORNER’S SYNDROME
( OCULOSYMPATHETIC PARESIS )
CENTRAL
LESION : hypothalamus
to C8-T2
CAUSES :
brainstem & spinal
cord/
vascular/demyelinatin
g/tumors/syringomyel
ia
PREGANGLIONIC
LESION : C8-T2 to
superior cervical
ganglion
CAUSES: pancoast
tumour/carotid
and aortic
aneurysm &
dissection/neck
lesions-
glands,trauma &
post surgical
POSTGANGLIONIC
LESION :superior
cervical ganglion to ICA
to cavernous sinus to V1
CAUSES :ICA
dissection,
cavernous sinus
mass,
nasopharyngeal
tumor, otitis
media, cluster
headache
37. Cause of Lesion:-
Brainstem & spinal
cord/vascular/demyeli
nating/tumors/syringo
myelia
LESION : C8-T2 to superior cervical ganglion
pancoast tumour/carotid and aortic aneurysm &
dissection/neck lesions- glands,trauma & post surgical
LESION :superior cervical
ganglion to ICA to
cavernous sinus to VI
ICA dissection, cavernous
sinus mass, nasopharyngeal
tumor, otitis media, cluster
headache
38. 1. Ptosis:- Superior Tarsel
muscle component of
LPS supplied by
occulomotor muscle.
2. Dilator Pupillae
3. Orbitalis:- Helps in
protusion of eye ball
4. Sweat Glands on face
5. Sympathetic Supply of
muscle of Blood
vessels.( cause of
flushing)
6. Newborn iris is always
blue.
Sympathetic fibres help
deposit melanin in 2
years after birth
