1. The document discusses examination of the pupil, including causes of abnormal pupil size and shape such as anisocoria, polycoria, microcoria, and corectopia.
2. Pupillary light reflex is controlled by a four-order neuronal pathway from the retina to the sphincter pupillae muscle. Disorders can occur at different points along this pathway.
3. Tests of pupillary function including light reflex, near response, cocaine and hydroxyamphetamine, and pilocarpine are used to localize lesions and diagnose conditions like Horner's syndrome and Adie's tonic pupil.
This document provides information on pupillary anatomy, physiology, and examination. It discusses the normal anatomy and functions of the pupil. It describes how to perform a systematic pupillary examination, including testing the light reflex and near reflex. It covers common and uncommon disorders that can be diagnosed based on pupillary examination findings, such as Horner's syndrome and Adie's tonic pupil. The document emphasizes that the pupillary examination can provide useful clues about underlying ocular and neurological conditions.
This document discusses pupil size and reaction as it relates to attraction and interest between individuals. It notes that pupil size increases when looking at someone we find attractive due to an involuntary physiological response. It also states that observing whether a person's pupils expand, contract, or do nothing can provide clues as to whether they are attracted to or actively dislike the observer. The document then provides further information on pupil anatomy and control, as well as abnormal pupil responses and conditions that cause them.
This document provides information on pupillary anatomy, physiology, and examination. It discusses the normal anatomy and functions of the pupil. It describes how to perform a systematic pupillary examination, including testing the light reflex and near reflex. It covers common and uncommon disorders that can be diagnosed based on pupillary examination findings, such as Horner's syndrome and Adie's tonic pupil. The document emphasizes that the pupillary examination can provide useful clues about underlying ocular and neurological conditions.
This document discusses pupil size and reaction as it relates to attraction and interest between individuals. It notes that pupil size increases when looking at someone we find attractive due to an involuntary physiological response. It also states that observing whether a person's pupils expand, contract, or do nothing can provide clues as to whether they are attracted to or actively dislike the observer. The document then provides further information on pupil anatomy and control, as well as abnormal pupil responses and conditions that cause them.
This document discusses pupil size and reaction as it relates to attraction and interest between individuals. It notes that pupil size increases when looking at someone we find attractive due to an involuntary physiological response. It also states that observing whether a person's pupils expand, contract, or do nothing can provide clues as to whether they are attracted to or actively dislike the observer. The document then provides details on pupil anatomy, size, shape, location, and neural pathways controlling pupil size.
Pupils Neuroophthalmology Teaching Slides, Dr M D Mohire, Kolhapur, Maharasht...Mahavir Mohire
1) Pupillary testing serves to detect disorders of the pupillary system and visual pathways. It helps guide diagnosis and treatment of central nervous system diseases.
2) The pupils are innervated by both the sympathetic and parasympathetic nervous systems. Sympathetic innervation causes dilation while parasympathetic innervation causes constriction.
3) Abnormal pupils may indicate disorders ranging from optic nerve lesions to third nerve palsies. Conditions like Horner's syndrome and Adie's pupil present with characteristic pupillary findings that can localize the problem.
PUPILARY ABNORMALITY AND PHARMACOLOGIC TESTS.pptxmuezashebr
This document discusses pupillary abnormalities and tests. It begins with an overview of pupillary anatomy and functions. It describes features of the normal pupil and various abnormalities including anisocoria. It discusses defects in the afferent pathway such as total and relative afferent pathway defects. Efferent pathway defects and causes like Horner's syndrome and Adie's tonic pupil are explained. The document concludes with a discussion of pharmacological tests used to evaluate pupillary abnormalities.
The document discusses the anatomy and physiology of the pupil, including its functions, shape, size, and reflexes. It describes how to examine the pupils through tests of light reflex, near reflex, swinging flashlight test, and reaction to pharmacologic agents. Key abnormalities discussed include anisocoria, afferent pathway defects, tonic pupils, Adie's tonic pupil, and Horner's syndrome. The document emphasizes the importance of a systematic approach to pupil examination and provides tips for optimizing the evaluation of pupillary function and detection of disorders.
The document describes the anatomy and physiology of the pupillary light reflex pathway. It discusses the iris, pupil size and shape, functions of the iris such as light control and depth of focus. It then covers clinical uses such as assessing light input and pharmacological response. The document outlines the afferent and efferent pathways in detail from the retina to the Edinger-Westphal nucleus. It discusses various clinical tests and findings including anisocoria and causes.
The document discusses pupil function and abnormal pupil reactions. It covers:
1. The physiology of pupil constriction and dilation which is controlled by the parasympathetic and sympathetic nervous systems respectively.
2. How to examine pupils including observing size and shape, light reflex testing, swinging flashlight test, and near reflex testing.
3. Various diseases and conditions that can cause abnormal pupil reactions like Horner's syndrome, third nerve palsy, Adie's tonic pupil, and Argyll Robertson pupils.
4. Drugs that can cause mydriasis or miosis by affecting the parasympathetic or sympathetic pathways.
The pupil is an opening in the iris that controls the amount of light entering the eye. It constricts and dilates under autonomic nervous system influence. The normal pupil diameter ranges from 2.5-4 mm in daylight and 1.3-10 mm in extremes. Unequal pupil sizes is called anisocoria. The pupil constricts in response to light and near vision. Abnormal pupils can be congenital, traumatic, inflammatory, or neurological in origin. Tests like cocaine, hydroxyamphetamine, and pilocarpine help localize lesions causing abnormalities like Horner's syndrome or Adie's tonic pupil.
The pupil is a circular opening located in the center of the iris that controls the amount of light entering the eye. It constricts (miosis) and dilates (mydriasis) under autonomic nervous system influence. The iris contains two sets of muscles - the sphincter pupillae contracts the pupil in response to parasympathetic stimulation while the dilator pupillae dilates it with sympathetic stimulation. Abnormal pupils may be unequal in size (anisocoria), irregularly shaped, or have abnormal reactions to light. Various diseases and drugs can affect the pupils.
The pupil is a hole located in the centre of the iris that allows light to enter the retina. The iris contains muscles that control the size of the pupil in response to light and focusing. Anisocoria is when the pupils are unequal sizes and can be caused by physiological factors, trauma, inflammation, or neurological issues. Examining the pupils' reaction to light and focusing is important for evaluating eye and neurological function.
This document discusses the pupil in health and disease. It begins by describing the normal anatomy and function of the pupil, including its size, location, shape, and role in regulating light entry. It then covers various pupil reflexes and abnormalities such as anisocoria, mydriasis, miosis, light-near dissociation, Argyll Robertson pupils, and disorders of the third cranial nerve and sympathetic pathway. Causes, signs, and diagnostic tests for various pupil abnormalities are provided.
This document discusses various pupil abnormalities and anomalies. It defines the pupil and normal pupil size ranges. It then describes several types of pupil disorders including microcoria (small pupil), megalocoria (large pupil), anisocoria (unequal pupil size), polycoria (multiple pupils), and corectopia (eccentric pupil position). It provides details on specific pupil anomalies such as Argyll Robertson pupil, Adie's tonic pupil, Horner's syndrome, Marcus Gunn pupil, amaurotic pupil, and hippus (irregular pupil oscillations). Differential diagnoses and causes are mentioned for several of the disorders.
The pupil functions to control the amount of light entering the eye and is controlled by the sphincter pupillae and dilator pupillae muscles. The pupil size and reactions are assessed to detect abnormalities. Key pupil reflexes include the light, near, and psychosensory reflexes which involve pathways between the retina, pretectal nuclei, Edinger-Westphal nucleus, and ciliary ganglion. Various conditions can cause abnormal pupil sizes or reactions including Horner's syndrome, Adie's pupil, Argyll Robertson pupils, and others involving the optic tracts or brainstem. Careful assessment of anisocoria can provide clues to underlying causes.
Abnormal pupil reactions - mehedi hasanMehedi Hasan
The document discusses abnormal pupillary reactions and evaluations. It describes the normal anatomy and function of the pupil, as well as how to evaluate size, light reflex, and near response. Various abnormalities are then outlined, including afferent pupillary defect, anisocoria, Adie's pupil, Argyll Robertson pupil, Horner's syndrome, Hutchinson's pupil, third nerve palsy, Wernicke's hemianopic pupil, and rare conditions like tadpole and keyhole pupils.
The pupil is a circular opening located in the center of the iris that controls the amount of light entering the eye to ensure optimal vision. Key characteristics of a normal pupil include being equal in size and round between both eyes. Abnormal pupils can be too small (miosis) or too large (mydriasis) and may be caused by medical conditions, drugs, or neurological disorders. Doctors examine the pupil's size, shape, equality, reaction to light, and accommodation to evaluate for any abnormalities.
The pupil is a circular opening located in the center of the iris that controls the amount of light entering the eye. The size of the pupil is regulated by two sets of muscles - the sphincter pupillae constricts the pupil in response to parasympathetic stimulation while the dilator pupillae dilates the pupil under sympathetic influence. Abnormalities in pupil size, shape, reaction to light and accommodation can provide clues to underlying ocular and neurological diseases. Common causes of an abnormal pupil include trauma, inflammation, drugs and disorders of the autonomic nervous system.
The document discusses the physiology of the pupil. It describes the pupil's location, size, shape and how it varies with age. It discusses the muscles that control pupil dilation and constriction. It explains the light reflex pathway and how light causes both pupils to constrict. It also discusses the near reflex pathway and how focusing on near objects causes pupil constriction and eye convergence. Finally, it outlines various drugs that cause pupil dilation (mydriatics) or constriction (miotics) and their mechanisms of action.
The document discusses amaurotic pupil, which is a pupillary abnormality where the eye has no light perception due to severe retinal or optic nerve disease. Key points:
1. An amaurotic pupil will not react directly to light in the affected eye but will consensually contract when light is shown in the normal eye.
2. Testing involves shining light in each eye to check for direct and consensual reactions. An amaurotic pupil shows no direct reaction but normal consensual reaction.
3. Causes include complete optic nerve atrophy, central retinal artery occlusion, glaucoma, or old retinal detachment resulting in no light perception.
This document discusses the pupil and its abnormalities. It covers:
1. The pupil light reflex involves a four neuron arc from the retina to muscles controlling the pupil.
2. Horner's syndrome causes miosis, ptosis, and anhydrosis due to disruption of the sympathetic pathway.
3. Adie's pupil is characterized by a dilated, poorly reactive pupil due to ciliary ganglion denervation.
This document discusses non-invasive guided goal-directed therapy (GDT) for hemodynamic monitoring and optimization. It describes using a bedside monitor to continuously and non-invasively estimate cardiac output and stroke volume based on pulse wave transit time analysis of ECG and pulse oximetry signals. The method is calibrated using intermittent non-invasive blood pressure readings. Studies show this approach can guide fluid administration and help achieve hemodynamic goals like those used in invasive GDT protocols to improve outcomes. The document provides details on set up, use, and limitations of this non-invasive GDT method for perioperative hemodynamic optimization.
The document provides an overview of opioid-free anesthesia (OFA), including who is currently using it, protocols used to achieve OFA, and outcomes compared to opioid anesthesia. A survey of over 600 anesthesiologists found that OFA is used in 26 countries, with methods including ketamine, lidocaine, clonidine, and dexmedetomidine. Studies in Belgium found OFA resulted in less postoperative nausea, better pain scores, and less morphine use compared to opioid anesthesia in 50 patients. A study of 500 patients found better quality of recovery scores with OFA. A retrospective analysis of over 5000 patients found fewer complications with OFA. The document discusses dosing of adjuncts used for OFA and
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfrightmanforbloodline
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
2. Trung tâm mống mắt(iris) cho phép ánh sáng đi vào võng mạc
hình tròn và kích thước bằng nhau
thay đổi từ 3-5mm liên hệ ánh sáng xung quanh
co đồng tử (miotic pupils) khi nhỏ hơn 3mm
giãn đồng tử (mydriatic pupils) khi lớn hơn 7mm
3. ( nhiều lỗ móng mắt)
(Đồng tử bị dời chổ)
(Đường kính giác mạc lớn,
ít gặp, không tiến triển)
(Đồng tử nhỏ, không dãn)
(Đồng tử không đều)
4. Polycoria is a pathological condition of the eye
characterized by more than one pupillary
opening in the iris. It may be congenital or result
from a disease affecting the iris.
Polycoria is extremely rare, and other conditions
are frequently mistaken for it
Microcoria: A congenitally small
pupil with an inability to dilate
5. Corectopia is the displacement of the eye's
pupil from its normal, central position. It may
be associated with high myopia or ectopia
lentis, among other conditions. Medical or
surgical intervention may be indicated for
the treatment of corectopia in some cases
Megalocornea (MGCN, MGCN1) is an extremely
rare nonprogressive condition in which the cornea
has an enlarged diameter, reaching and
exceeding 13 mm. It is noted in some patients
with Marfan syndrome. It is thought to have two
subforms, one with autosomal inheritance and the
other X-linked (Xq21.3-q22)
6. First Order – Retina to Pretectal Nucleus in B/S
(at level of Superior colliculus)
Second Order – Pretectal nucleus to E/W nucleus
(bilateral innervation!)
Third Order – E/W nucleus to Ciliary Ganglion
Fourth Order – Ciliary Ganglion to Sphincter
pupillae (via short ciliary nerves)
8. Đường giao cảm đồng tử
Tk mũi mi
Vân mồ hôi-vận mạch
Cơ muller
9.
10. Pupil
Constricted (mioisis)
Sympathetic
(pupillodilator)
denervation
Drugs (co đồng tử)
Pilocarpine
Morphine
Dilated (mydriasis)
Parasympathetic
(pupilloconstrictor)
denervation
Lesion of the third CN
Drugs (dãn đồng tử)
Atropine
Cocaine
11. Bn nam 49 tuổi
Nhập viện vì đồng tử không đều 2 bên
Không có than phiền về thị lực và thần kinh
12. Tiền sử
Không có bất thường về mắt trước đó
Tăng huyết áp
Tăng lipid máu
Chấn thương nhẹ vùng cổ trước đó
13. Khám thần kinh
Dấu sinh tồn: BP= 122/64, P=69, T=97.0
Dáng đi và CNTKCC bình thường
Các dây sọ bình thường
Đồng tử không đều nhẹ trong phòng sáng
Phòng tối (Dim light)
• Mắt trái: giãn chậm, giãn trì hoãn ở kich thước 4-5 mm,
giảm kích thước sau 15 giây.
• Mắt phải: không giãn – kích thước 2mm
Cả 2 co với ánh sáng chói
Không ghi nhận dấu thần kinh khu trú khác
(đặc biệt: no ptosis, anhydrosis)
15. Khám hệ thống đồng tử
First step: xác định đồng tử có đáp ứng ánh sáng
Second step: so sánh kích thước đồng tử
Third step: thực hiện “swinging flashlight test”
(when there is an interocular difference of 0.5 mm
or more in pupillary diameter), (khi có sự khác biệt đường
kinh giữa 2 mắt là 0,5mm hay hơn)
16. Fourth step: thăm khám tìm bệnh lý. Sau khi hoàn
thành 3 bước đầu:
1. A relative afferent pupillary defect (RAPD)
( thiếu hụt liên hệ đường hướng tâm)
2. An anisocoria with normal responses to light in
both eyes
(đồng tử không đều, đáp ứng bình thường ánh sáng cả 2 mắt)
3. A monocular or bilateral deficit in light responses
(thiếu sót 1 mắt hay 2 bên với đáp ứng ánh sáng)
17. "swinging flashlight test".
An RAPD is usually due to a defect anterior to the optic
chiasm, but a small RAPD can occur in optic tract lesions.
Type of visual field defect distinguishes prechiasmatic RAPD (monocular
defect) and post chiasmatic optic tract RAPDs (binocular defect).
(Phân biệt trước và sau giao thoa thị giác dựa vào thiếu hụt thị trường)
19. (Co 2 bên vừa phải)
(Nhanh, co nhiều hơn 2 bên)
Sau giao thoa
20. (Không co, dãn 2 bên)
(Nhanh, co nhiều hơn, Liên ứng mắt phải)
Trước giao thoa
21. Co yếu với ánh sáng, còn đáp ứng co với kích thích gần.
(90% sợi đáp ứng co đồng tử phục vụ cho phản xạ gần làm
cho px ánh sáng đồng tử dễ bị tổn thương hơn phản xạ gần)
(Occurs because 90% of the fibers responsible for pupillary constriction
are devoted to the near reflex, making it easier to damage the pupillary
light reflex than the near reflex)
22. 1. Small, irregular,
2. Poorly light-reactive pupils with light-near dissociation.
3. A classic type of pupil with light-near dissociation due to
neurosyphilis, but more common in diabetic neuropathy
and chronic Adie's pupils.
+ Đồng tử nhỏ, không đều, mất px ánh sáng nhưng còn
đáp ứng gần
+ Căn nguyên: giang mai thần kinh, biến chứng tk do đái
tháo đường và đồng tử Adie mãn
23.
24.
25. Đồng tử không đều, phản xạ ánh sáng còn 2 bên
(Anisocoria with Bilaterally Normal Pupillary Reactions to Light)
Dilation Test
(When the pupils dilate well and with no speed difference
between them, the anisocoria is likely to be
physiologic. Physiologic anisocoria of greater than 1 mm
is very uncommon, so when the diference is greater than
1 mm, use of the cocaine test is necessary)
Không đều sinh lý:
giãn đều 2 bên, không khác biệt tốc độ, ít khi chênh lệch trên 1mm
test cocaine khi >1mm là cần thiết
26. Cocaine and Hydroxyamphetamine Tests
The cocaine test is indicated in three situations:
1. For anisocoria greater than 1 mm and normal pupillary light
reactions
2. For slower dilation of the smaller pupil
3. For ptosis ipsilateral to the smaller pupil (suspected
Horner’s syndrome)
27. Test cocaine 5% & 2.5%
Cocaine retards the reuptake and inactivation of
noradrenalin within the synaptic clef. Thus, it is an indirect
sympathomimetic.(chậm sự tái hấp thu và bất hoạt noradrenalin))
When testing infants and small children, use of a 2.5%
solution of cocaine is recommended
The diameters of both pupils are measured before and 1 h
after instillation of the drops (đo kích thước đồng tử trước và 1 giờ
sau nhỏ thuốc)
(pupils’ diameters with a pocket card , photography))
28. Sympathetic Pathway
First Order – Posterior Hypothalamus to
Ciliospinal centre of Budge (C8-T2)
(Uncrossed in Brainstem)
Second Order – Ciliospinal centre of Budge to
Superior Cervical Ganaglion
Third Order – Superior Cervical Ganglion to
dilator pupillae muscle. (Close to
ICA and joins V1 intracranially)
32. Test 1% hydroxyamphetamine
hay 2.5% tyramine
Stimulating the release of noradrenalin into the synaptic clef
at the terminus of the end neuron of the sympathetic chain
(kích thích phóng thích noradrenalin vào khe si-nap ở nơ-ron tận cùng)
33. Nguyên nhân Horner’s pupil
Central – B/S lesions (tumours, vascular and MS)
Syringomyelia, Lat. Med. Syn., S.C. ca.
Preganglionic – Pancoast tumour, Carotid & Aortic
aneurysms, Neck lesions/trauma.
Postganglionic – Cluster headaches, Nasopharyngeal
tumours, Otitis media, Cavernous
sinus mass and ICA disease.
Miscellaneous – Congenital (brachial plexus injury)
Idiopathic.
34. Mất px ánh sáng một hay 2 bên
(Unilateral or Bilateral Disturbances
of Pupillary Light Reactions)
Test đáp ứng gần (Testing the Near Reaction)
1. when there is a unilateral or bilateral abnormality of the
pupillary light reaction)
2. pupils of children and younger adolescents frequently
do not react until the distance between eye and object of
regard is very short (about 10 cm))
3. In some cases, the near response will be found better
preserved than the reaction to light. The latter state is
called light-near dissociation.(phân ly giữa pxas và đáp ứng gần)
35. Mất px ánh sáng một hay 2 bên
(Unilateral or Bilateral Disturbances
of Pupillary Light Reactions)
Oculomotor Testing
A monocular defect in the light response of the pupil raises
the question of a third nerve paresis, while bilateral defcits
can be associated with vertical gaze palsies, such as in
Parinaud’s syndrome
(mất pxas 1 mắt: dây III, trong khi 2 bên + liệt nhìn dọc: hc Parinaud)
Slit-Lamp Examination
- anatomy of the pupil and iris
- sphincter atrophy or traumatic disruption
- spontaneous movements
36. Test Pilocarpine 1% và 0.1%
Pilocarpine 0,1%
1.when the diagnosis of a tonic pupil is suspected but not
clearly confirmed at the slit lamp
2.the tonic pupil has a characteristic denervation
hypersensitivity to a cholinergic stimulus
Pilocarpine 1%
1. when light, maximal accommodative effort, or weak
pilocarpine will not cause the pupil to constrict
2. If the higher concentration of pilocarpine fails to constrict
the pupil, there is a problem within the iris/pupil itself
3. If an anticholinergic drug (such as atropine or scopolamine)
has produced a pharmacologic dilation, the test with 1%
pilocarpine is the one reliable way of proving a drug-induced
mydriasis
37. Argyll-Robertson
pupil
Small, irreg
Does not react to light
Reacts to
accommodation
Causes
syphilis
diabetes
Miotonic pupil
(Adie’s syndrome)
Dilated
Poor response to light
and convergence.
Constricts with weak
Pilocarpine
Holmes-Adie syndrome
Reduced tendon
reflexes (Knee, ankle)
- Orthostatic hypotension
Tổn thương đường hướng và ly tâm
(Afferent & efferent defects)
38.
39. Horner’s Syndrome
- The pupil is smaller, light reaction remains normal.
- In 90% of cases, a ptosis of the upper lid
(paresis of Müller’s smooth muscle within the
palpebral levator muscle complex).
40. Horner’s Syndrome
- The pupil is smaller, light reaction remains normal.
- In 90% of cases, a ptosis of the upper lid
(paresis of Müller’s smooth muscle within the
palpebral levator muscle complex).
41. Khuyến cáo
Khi test thuốc tiền hạch (preganglionic pharmacologic
testing) dương tính:
BS Thần kinh đánh giá các triệu chứng
Khi test thuốc hậu hạch (postganglionic pharmacologic
testing) dương tính:
Nếu vấn đề đơn độc và không cấp, hỏi bệnh sử: cluster
headaches hay migraine
42. Khi có tổn thương dây sọ, xảy ra cấp: MRI, CT
Xảy ra bẩm sinh hay trẻ em: loại trừ neuroblastoma
43. Hội chứng giãn đồng tử(Tonic Pupil Syndrome)
1. usually monocular loss parasympathetic innervation of
the eye. The site of damage is at the ciliary ganglion or in
the short posterior ciliary nerves.
(tổn thương phó giao cảm một bên, từ hạch mi hay dây tk ngắn mi sau)
2. idiopathic (has no identifable cause). It is frequently
associated with a loss of deep tendon refexes
(Adie-Holmes’ syndrome), or less commonly with
sudomotor disturbances (Ross syndrome) or with vascular
disease.
(vô căn, hay kết hợp mất px gối, ít gặp rối loạn tiết mồ hôi hay bệnh
mạch máu)
44. 3. Acutely, the tonic pupil is enlarged, but shrinks gradually
over a period of a year or more. It can become so small
that the diagnosis is not suspected until the slit-lamp
examination, where the typical segmental sphincter
movements can be seen.
(cấp tính, giãn đồng tử, co lại từ từ thời gian trên 1 năm hay hơn,
thăm khám slit-lamp segmental sphinter movement)
4. The near response is demonstrable in all but the most
acute cases
(đáp ứng gần trong hầu hết ca cấp tính)
45. Nguyên nhân
Most commonly, the affected patients are women between
30 and 40 years of age
In a few cases, the cause can be established, or at least
confidently suspected:
- after orbital trauma,(sau chấn thương hốc mắt)
- extensive panretinal photocoagulation (quang đông),
- outbreaks of varicella zoster, (siêu vi)
- orbital ischemia with active giant cell arteritis, (viêm đm đại
bào)
- and only rarely associated with a malignancy and a
suspected paraneoplastic syndrome.(cận ung thư)
46. testing of the erythrocyte sedimentation rate(VS)
or of C-reactive protein(CRP) levels, since giant
cell arteritis can present in this way
47. Behavior of the pupil in pupillotonia. The light reaction is
nearly gone (above), while the near reaction is easily
detectable, though slow to respond (below)
48. Liên hệ đồng tử trong liệt dây III
1. damage to the third cranial nerve at locations
between the oculomotor nucleus and the ciliary
ganglion.(tổn thương từ nhân dây III và hạch mi)
2. pupillary mydriasis caused by internal
ophthalmoplegia as part of a third nerve palsy
indicates a high probability of a compressive
mechanism, such as by a tumor or an aneurysm
(giãn đồng tử trong liệt dây III: chèn ép, u hay
phình mạch….)
49. The parasympathetic fibers lie on the exterior surface of
the nerve exposing them to damage when the oculomotor
nerve is compromised by an external mass effect
50. Tổn thương vùng lưng não giữa- hc Parinaud
(Lesions of the Dorsal Midbrain: Parinaud’s Syndrome)
1. deficit in the light reactions of the pupil
2. retained accommodative miosis, and loss of connection to
the Edinger-Westphal nucleus and the final common
pathway of third nerve function
3. the clinical presentation of this syndrome includes loss of
upward saccadic movements, and convergence retraction
nystagmus.
mất pxas
phân ly đáp ứng ánh sáng-gần
mất saccade nhìn lên
convergence retraction nystagmus
51. Tổn thương mống mắt (Iris)
1. identifed at the slit lamp, can find even subtle tears in
the iris sphincter
2. An attack of angle closure glaucoma typically causes a
mid-dilated pupil that is unresponsive to a light stimulus
3. pharmacologic pupil can be confirmed by instillation of
1% pilocarpine, which will have no effect on the size of
the pupil.
52.
53. Argyll-Robertson Pupils
1. bilateral miosis, no responses to light stimuli
2. preserved near response
3. little or no response to mydriatics
4. tertiary neurosyphilis.
Cần chẩn đoán phân biệt: long-standing cases of tonic
pupillary syndrome (segmental pupil sphincter activity).
54. Giãn đồng tử từng cơn (Intermittent Mydriasis)
appears as an abrupt enlargement of the pupil, lasting 5 to
60 min, and it is unassociated with signs of visual loss.
Intermittent mydriasis: sympathetic or parasympathetic ?
Đồng tử xuất hiện giãn đột ngột, kéo dài từ 5-60
phút, không có mất thị lực
55. The probability of an aneurysm being the cause is very low, as
long as the mydriasis is not associated with signs of oculomotor
paralysis
56. Tadpole-Shaped Pupil
1. hypersympathetic activity affects only a portion of the
pupillary dilators.
2. the result is an irregular oval shape
3. If the ophthalmic examination is normal between
episodes, it is not necessary to do any additional
workup
Cường giao cảm,
ảnh hưởng 1 phần
cơ giãn đồng tử
57. Paradoxical Pupils(đồng tử nghịch lý)
1. response to a light (constriction in the dark) has been
associated with heredofamilial retinal dystrophies.
58. Co đồng tử bẩm sinh và giãn đồng tử dai dẳng
(Congenital Miosis and Persistent Mydriasis)
1. two anomalies of pupillary size are of clinical
importance, one is congenital miosis, and the other is a
persistent mydriasis
2. develops during the second or third decade of age
59. Đồng tử dao động(Oscillations of the Pupil)
1. illumination has continuous oscillatory movement
2. pupillary unrest
3. physiologic phenomenon.
4. In the past, and still used in current publications, this has
been called hippus (from the Greek word for “horse”)
Còn dùng từ hippus (tiếng Hy lạp: ngựa)
Chiếu sáng vào đồng tử dao động liên tục, không nghỉ
Hiện tượng sinh lý
60. Đồng tử dao động(Oscillations of the Pupil)
Light-Induced Pupillary Oscillations
- At low levels of light, the light-induced oscillations are most
apparent
- Large amplitude oscillations can be seen in life-threatening
circumstances, such as in Cheyne-Stokes breathing
- Anxious patients are sometimes bothered by oscillations of
the pupil (bn lo âu đôi khi khó chịu do đồng tử dao động)
61. Bn nam 45 tuổi, khám bệnh vì có một đồng tử nhỏ hơn( đặc
biệt trong tối chênh lệch nhiều hơn), bn sụp mi nhẹ bên trái.
BN khai bệnh xảy ra 2 ngày trước đó sau khi bn thấy đau
nhiều vùng cổ
Chẩn đoán nghĩ nhiều nhất? Bóc tách đm cảnh(carotid
dissection )
62. If the asymmetry is worse in dim light, the small pupil is
abnormal (failure to dilate).
if the asymmetry is worse in bright light, the large pupil
is abnormal (failure to constrict) .
64. A Horner's pupil dilates slowly and incompletely after
several seconds in dim light ("dilation lag").
Ptosis of the upper lid is usually mild because sympathetic
pathways only contribute to lid elevation via Muller's muscle
(CN III and levator palpebrae do the rest).
Sometimes small "upward" ptosis of the lower lid occurs
(there is a sympathetically innervated muscle in both upper and lower lids).
65. Physiologic ("simple") anisocoria:
Approximately 20% of normal people have a small
anisocoria ( < 1 mm), and it often fluctuates.
Differentiated from Horner's by dilation to cocaine 4%,
and by lack of ptosis or anhidrosis.
66.
67. 1. Is there oculosympatbetic palsy (a Homer's pupil)?
68. 2. Is the lesion preganglionic (1st or 2nd order neurons)
or postganglionic (3rd order neurons)?
69. 3. If the lesion is postganglionic, is it proximal or
distal to the internal carotid artery?
Sợi vận mồ hôi đến mặt thông qua động mạch cảnh
ngoài. Không tiết mồ hôi mặt đề nghị tổn thương gốc.
Hc Horner nơ-ron thứ 3 chủ yếu là bóc tách đm cảnh
70. Bn nữ 32 tuổi than phiền đồng tử giãn bên phải, bn ghi nhân
sau khi soi gương. BN không có triệu chứng gì khác. Khám
không có sụp mi, vận động mắt bình thường, đồng tử mất
đáp ứng với ánh sáng bên(p). Các test tại chổ tiếp theo?
Chẩn đoán nếu đồng tử co lai khi nhìn hội tụ.
72. Abnormally large pupils typically have abnormal light reflexes.
Third nerve palsy:
• Isolated mydriasis without ptosis or extraocular muscle
weakness is rarely .
• CN III palsy complete: Prominent ptosis (levator
weakness), eye "down and out" (weak-ness of superior
rectus, inferior oblique, medial rectus). Consider:
+ Aneurysm (posterior communicating artery is classic).
+ Pituitary apoplexy.
+ Giant cell arteritis.
+ Meningeal syndromes (e.g., tuberculosis, sarcoid, carcinomatous, and
lymphomatous).
73. Pupil-sparing: Ptosis and CN III weakness,
• Classically due to diabetic infarction.
• Spares the peripherally located pupillary fibers
74. Adie's tonic pupil:
• Isolated, large, sluggish ("tonic") pupil.
• Light-near dissociation.
• Probably viral/postviral autoimmune damage to ciliary
ganglion (parasympathetic) neurons.
• Constricts to dilute (0.1 %) pilocarpine- which doesn't
constrict normal pupils -because of postsynaptic receptor
hypersensitivity .
• A longstanding Adie's pupil can become small and
irregular ("Argyll Robertson appearance")
Adie's syndrome:
Adie's pupil plus absent/reduced deep tendon reflexes.
75. Pharmacologic pupil (atropinic mydriasis):
Large, sluggish pupil due to scopolamine, albuterol,
atropine, plants such as belladonna…Does not constrict to
undiluted pilocarpine (I%) due to pharmacologic blockade.
Traumatic pupil:
Blunt eye trauma(chấn thương mắt cùn) can disrupt the
pupillary musculature or the parasympathetic fibers leading
to a dilated pupil. This can also be seen following similar
injuries from intraocular surgery
76. Distinguishing ptosis of Horner's syndrome from third
nerve palsy (phân biệt sụp mi trong hc Horner so liệt
dây III)
1. CN III: Weakness of levator: severe ptosis, upper lid
only. CN III never causes isolated ptosis.
2. Horner's: Weakness of Muller's muscle: mild upper
and sometimes small "upward" lower lid ptosis with a
small pupil.
77. Mechanical ptosis:
Due to dehiscence of levator aponeurosis. Associated
with age, long-standing contact lens wear. Asymmetric lid
creases are seen.(do nứt ra gân màng cơ nâng mi)
Lagophthalmos:
Incomplete eye closure during gentle eyelid closure, as
when sleeping. Can occur in Bell's palsy. Requires treatment
with corneal lubrication. (chứng mi mắt không khép kín, như
khi ngủ, liệt Bell)
Blepharospasm:
Brief bilateral involuntary eye closure. Can be triggered/
worsened by bright light. Seen in some dystonias and other
movement disorders. Can be helped with botulinum toxin
78. Eyelid apraxia (thất điều mi mắt):
Most associated with blepharospasm, seen in other conditions
(Parkinson's, progressive supranuclear palsy). Difficulty opening the
eyelids, which appear only gently closed. Patients elevate eyebrows and
forehead in an attempt to open the eyes.
Lid lag(chậm trễ mi mắt):
While pursuing a visual target moving slowly from superior to inferior, the lid
will lag slightly behind its normal position (in normal patients the lid is
always at the limbus (đường biên) ready to protect the cornea). Associated
with thyroid eye disease
Lid twitch(giật mi mắt):
"Cogan's lid twitch" can be seen in myasthenia gravis. After looking
downward, when gaze returns to midposition the lid "jumps" higher before
settling into position. (Resting the levator allows brief return of nonnal
function in a myasthenic.)
79. Upgaze paralysis(liệt nhìn lên):
occurs with lesions of the posterior commisure or pretectal
area and is part of Parinaud's dorsal midbrain syndrome
(upgaze palsy),
+ Lid retraction,
+ Light-near dissociation,
+ Convergence-retraction nystagmus.
Downgaze paralysis(liệt nhìn xuống):
occurs with bilateral lesions in the rostral interstitial
nucleus of the MLF
80. Căn nguyên:
1. Vascular supply: Posterior thalamosubthalamic
paramedian branch of the PCA.
(nhánh sau cận đường giữa đồi hạ đồi)
2. Can occur in association with thalamic infarcts.
3. Up-and downgaze palsies seen in Whipple's disease,
progressive supranuclear palsy, diffuse upper brain
stem disorders.
81. Skew deviation (lệch nghiêng):
Vertical deviation of the eyes not caused by infranuclear
lesions (e.g., CN III or IV palsy).
Caused by lesions in the cerebellum, brain stem, and
vestibulo-ocular pathways.
Most common in lateral medullary syndromes in
which vestibular pathways are affected.
82. Ocular tilt reaction (OTR) (phản ứng nghiêng
nhãn cầu):
Normally when tilting the head, both eyes counter-roll in the
opposite direction (contralateral eye falls, ipsilateral eye
rises). (Bình thường khi nghiêng đầu, cả 2 mắt quay(lăn)cyclotorsion
ngược lại hướng đối bên, mắt đối bện rơi xuống, cùng bên nâng lên)
The OTR (abnormal) is a triad of spontaneous
(1) skew deviation,
(2) cyclotorsion of both eyes,
(3) paradoxical head tilt toward the lower eye.
Caused by damage anywhere along the vestibular
pathways/connections.