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PUPILLARY ABNORMALITIES and pupillary reflexes
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- 2. • Aperture atcentre of iris • Regulates the amount of light reaching the retina
- 4. PUPILLARY PATHWAYS • LIGHTREFLEX • CONVERGENCE • ACCOMODATION • SYMPATHETIC DISCHARGE
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- 9. PUPILLARY REFLEX • LIGHTRELEX • NEAR REFLEX • PSYCHOSENSORY REFLEX • LID CLOSURE REFLEX
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- 13. Abnormalities of Pupillary Reflexes AFFERENT PATHWAY DEFECTS TOTALAFFERENT PATHWAY DEFECT RELATIVE AFFERENT PATHWAY DEFECT WERNICKE’S HEMIANOPIC PUPIL EFFERENT PATHWAY DEFECTS TONIC PUPIL OCULOMOTOR NERVE PALSY PHARMACOLOGIC MYDRIASIS PUPILLARY LIGHT-NEAR DISSOCIATION ARGYLL ROBERTSON PUPIL SYMPATHETIC PARESIS HORNER’S SYNDROME
- 14. TOTAL AFFERENT PUPILLARYDEFECT AMAUROTIC PUPIL Complete optic nerve / retinal lesion PL –ve eye STIMULATING NORMAL EYE – Both pupils react normally STIMULATING AFFECTED EYE – No direct light reflex on affected side No consensual light reflex on normal side Diffuse illumination – equal size pupils Near reflex – normal in both eyes
- 15. RELATIVE AFFERENT PUPILLARYDEFECT Marcus-Gunn Pupil Incomplete optic nerve lesion/ severe retinal disease • RAPD cause a reduction in pupil contraction when one eye is stimulated by light compared with when the opposite eye is stimulated by light • Detected by swinging flash light
- 16. OPTIC NERVE DISORDERS • Opticneuritis • Ischemic optic neuropathies • Glaucoma • Traumatic optic neuropathy • Optic N compression • Optic atrophy • Surgical damage to N. RETINAL CAUSES • Ischemic retinal disease (CRVO, CRAO, BRAO) • Ischemic ocular disease • Retinal detachment • Severe macular degeneration • Severe retinal/ choroidal tumours • Retinitis – CMV, herpes simplex
- 17. • 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 dilation following 6 sec illumination Grade 5+: Immediate pupillary dilation with no constriction at all
- 18. NEUTRAL DENSITY FILTER •Estimation of the amount of RAPD in log units
- 19. WERNICKES HEMIANOPIC PUPIL •Optic tract lesion
- 20. LIGHT REFLEX ABSENTon stimulating – • Affected side – temporal half of retina • Opposite side – nasal half of retina LIGHT REFLEX PRESENT on stimulating – • Affected side – nasal half of retina • Opposite side – temporal half of retina
- 21. ANISOCORIA • Asymmetry ofefferent signals to the iris muscles produces inequality in the diameters of 2 pupil
- 22. ANISOCORIA PHYSIOLOGIC Anisocoria • Mostly <1 mm. difference • Light & Darkness reflex normal • Topical Cocaine-equal dilatation • No associated symptoms MIOSIS Of One Pupil • Local miotics • Systemic morphine • Iridocyclitis • Horner’s syndrome • Pontine hemorrhage • Argyll Robertson pupil • Strong light MYDRIASIS Of One Pupil • Local mydriatics • Sphincter damage (glaucoma) • 3rd CN palsy • Belladona poisoning • Tonic pupil
- 23. OCULAR EXAMINATION • Determinewhich pupil is abnormal by comparing pupil sizes in light and in dark • Test pupillary reaction – light & near • Look for ptosis , ocular motility • Examine the pupillary margin with a slit lamp
- 29. EFFERENT PATHWAY DEFECTS STIMULATINGAFFECTED EYE – Direct light reflex & near reflex absent Consensual reflex present STIMULATING NORMAL EYE – Direct light reflex & near reflex present Consensual reflex absent
- 30. Brainstem lesions Fascicular ThirdCranial Nerve lesions – compressive third nerve lesions Lesions of Ciliary Ganglion / Short Ciliary Nerves Iris damage Mydriatic Drug
- 31. TONIC PUPIL Lesion ofCiliary Ganglion / Short Ciliary Nerves Upregulation of postsynaptic receptor to allow re innervation Aberrant innervation / Regeneration Tonic miosis on near reflex along with accomodation
- 32. AFFECTED PUPIL Islarger Reaction to light – absent Near Reflex – very slow & tonic Accommodative paresis Cholinergic supersensitivity of denervated muscle (constricts with 0.125% pilocarpine
- 33. CAUSES LOCAL TONIC PUPIL •Viral ciliary ganglionitis (herpes zoster) • Orbital or choroidal tumours or trauma NEUROPATHIC TONIC PUPIL • Diabetes ,Alcoholism IDIOPATHIC TONIC PUPIL WITH BENIGN AREFLEXIA(ADIE’S TONIC PUPIL)
- 34. ADIE’S TONIC PUPIL Denervationof postganglionic supply of sphincter pupillae & ciliary muscles of unknown etiology 80% U/L Affects healthy young women > men Absent knee jerk Affected pupil is large & irregular Light reflex is absent 0r slow Near reflex is slow & tonic Accomodative paresis
- 35. OCULOMOTOR NERVE PALSY •Pupil mid dialated • Light ,consensual , near reflexes – affected
- 36. Pupillary Light-Near Dissociation •NEAR RELEX PRESENT , LIGHT REFLEX ABSENT
- 37. CAUSES B/L TAPD Lesions inmidbrain TNP with aberrant regeneration of medial rectus innervation into sphincter innervation pathway- PSEUDO –ARGYLL ROBERTSON PUPIL Ciliary ganglion/ short ciliary nerve lesions with aberrant regeneration of accomodation
- 38. Argyll Robertson Pupil Dorsalmidbrain lesion Cause – Neurosyphilis
- 39. Usually B/L &assymetrical involvement Vision is good Pupils – small & irregular Light Reflex absent Near Reflex present Cocaine Test- mydriasis
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- 41. CENTRAL Horner’s Synd • Lesionlocated b/w hypothalamus to Ciliospinal centre of Budge (C8-T2) PREGANGLION IC Horner’s Synd • Lesion located b/w C8 - T2 to superior cervical ganglion POSTGANGLION IC Horner’s Synd • Lesion located b/w superior cervical ganglion to innervation of dilator pupillae
- 42. PTOSIS INFERIOR PTOSIS MIOSIS PUPILLARY REACTIONSNORMAL DILATION LAG FACIAL ANHYDRIOSIS HETEROCHROMIA IRIDES
- 44. PHARMACOLOGICAL TESTS COCAINE 4%or 10% TEST • Blocks the reuptake of norepinephrine – increased sympathetic activity – dialatation of pupil
- 46. APRACLONIDINE 0.1% TEST •Alpha 2 adrenergic agonist , weak alpha 1 agonist • Sympathetic denervation hypersensitivity
- 48. LOCALIZING THE LESION HYDROXYAMPHETAMINE1% TEST • Release of stored epinephrine from the 3rd order neuron junction with the iris • IN 3RD Order neuron lesion – no stored NE No dilatation – post-ganglionic Horner’s syndrome Miotic pupil dilatation – central & preganglionic Horner’s syndrome
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- 50. Apraclonidine (0.5%) Test •Dilatation to apraclonidine – Horner’s syndrome Cocaine (4%) Test • No dilatation to 4% cocaine – Horner’s syndrome Phenylephrine (1%) Test • Dilatation to phenylephrine – only post-ganglionic Horner’s syndrome Hydroxyamphetamine (1%) Test • Miotic pupil dilatation – central & preganglionic Horner’s syndrome No dilatation – post-ganglionic Horner’s syndrome
- 51. PILOCARPINE TEST Pupil constriction to0.125% pilo • Adie’s tonic pupil Pupil constriction to 1 – 2% pilo • 3rd CN palsy No constriction with pilo • Mydriatic drugs • Traumatic mydriasis • Fixed pupils in Iritis
- 52. ABNORMAL PUPIL MYDRIASIS NORMAL LIGHT REACTION ESSENTIAL ANISOCORIA ABNORMAL LIGHT REACTION LIGHT-NEAR DISSOCIATION NOLIGHT-NEAR DISSOCIATION MIOSIS
- 53. LIGHT-NEAR DISSOCIATION BILATER AL -CONVERGENCE- RETRACTION NYSTAGMUS -VERTICAL GAZE DEFICIT -CONVERGENCEDEFICIT -LID RETRACTION PARINAU D SYNDRO ME UNILATER AL -SEGMENTAL PUPILLARY CONSTRICTION -IMPAIRED DARK ADAPTATION –IMPAIRED NEAR REFLEX –TONIC REDILATION BILATER AL ADIE’S PUPIL UNILATE RAL ADIE’S PUPIL
- 54. NO LIGHT-NEAR DISSOCIATION 0.125% PILOCARPIN E CONSTRICT ION RECHECK FOR TONIC PUPILS NO RESPONSE 1% PILOCARPINE CONSTRICTI ON 3RDCN PALSY NO RESPONSE DRUG- INDUCED
- 55. MIOSI S NORMAL LIGHT REACTION 4% COCAIN E DILATION ESSENTIAL ANISOCORIA NO RESPONS E HORNER SYMPATHETIC PARESIS -ABNORMAL LIGHT REACTION -IRRREGULARPUPIL -LIGHT-NEAR DISSOCIATION ARGYLL ROBERTSO N PUPILS
- 56. HORNER SYMPATHETIC PARESIS 1% HYDROXYAMPHETA MINE DILATION CENTRAL / PREGANGLI ONIC LESION NO RESPONS E POSTGANGLI ONICLESION HETEROCH ROMIA IRIDIS CONGENITAL HORNER’S SYNDROME