importance of pupil in clinical applications.examination of pupil can highlight underlying afferent and efferent pathway defects.eg Argyl robertson pupil
The document provides an overview of the pupillary pathway, including its anatomy, physiology, and clinical aspects. It describes:
- The afferent and efferent pathways that control the pupillary light reflex and near response.
- Clinical tests to evaluate the pupillary light reflex, including for anisocoria, RAPD, and other defects.
- Causes and features of different types of pupillary defects affecting the afferent pathway (e.g. optic nerve lesions) or efferent pathway (e.g. Horner's syndrome, Adie's tonic pupil).
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 retinal detachment. It begins with an introduction to retinal detachment, defining it as a situation where the retina pulls away from its normal position, separating retinal cells from the blood vessels that provide oxygen. It then covers the epidemiology, etiology, pathophysiology, types, clinical manifestations, diagnostic evaluation, management, complications, and prevention of retinal detachment. A clinical vignette of a patient presenting with retinal detachment is also included, along with nursing responsibilities related to caring for such a patient.
This document discusses glaucoma, which is characterized by optic nerve damage and elevated intraocular pressure caused by congestion of fluid in the eye. It can cause vision loss or blindness but is usually asymptomatic until late in the disease. Risk factors include age, family history, diabetes, and corticosteroid use. Treatment aims to prevent further optic nerve damage through medication, laser treatment, or surgery. The document also discusses cataracts, which are lens opacities that are the leading cause of blindness. Cataracts develop due to aging, trauma, radiation exposure, or systemic conditions. Early cataracts are treated with glasses but later cataracts require surgical removal and lens replacement.
Central artery occlusion results in sudden, painless complete vision loss in one eye. Branch artery occlusion causes sudden, partial vision loss. Artery occlusion is diagnosed via eye examination. Unfortunately, there is no consistent treatment to restore lost vision, but very rare cases may recover if treated within an hour. Conditions like hypertension and diabetes increase risk. Retinal detachment occurs when retinal layers separate, and has three types. Signs include flashes, wavy vision, and floaters. Retinal detachments are usually detected early via eye exam for best vision recovery chances. Treatment depends on detachment type, severity and location, and may include pneumatic retinopexy or buckle surgery. Retinitis pigmentosa causes night and
this presentation is about causes of acute visual loss which i made for my seminar during ophthalmology posting.Hope that people can had a benefit from this slide especially medical student.
This document discusses the pupillary pathway and various pupillary disorders. It begins by describing the development of the pupil from the pupillary membrane. It then discusses the muscles that control pupil size and various reflexes like the light and accommodation reflex. It describes different types of pupil abnormalities including iris colobomas, aniridia, traumatic causes and neurological causes. Specific disorders like Horner's syndrome and Adie's tonic pupil are explained in detail. Pharmacological tests to localize lesions in different parts of the pupillary pathway are provided. The document concludes by mentioning some references.
The document provides an overview of the pupillary pathway, including its anatomy, physiology, and clinical aspects. It describes:
- The afferent and efferent pathways that control the pupillary light reflex and near response.
- Clinical tests to evaluate the pupillary light reflex, including for anisocoria, RAPD, and other defects.
- Causes and features of different types of pupillary defects affecting the afferent pathway (e.g. optic nerve lesions) or efferent pathway (e.g. Horner's syndrome, Adie's tonic pupil).
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 retinal detachment. It begins with an introduction to retinal detachment, defining it as a situation where the retina pulls away from its normal position, separating retinal cells from the blood vessels that provide oxygen. It then covers the epidemiology, etiology, pathophysiology, types, clinical manifestations, diagnostic evaluation, management, complications, and prevention of retinal detachment. A clinical vignette of a patient presenting with retinal detachment is also included, along with nursing responsibilities related to caring for such a patient.
This document discusses glaucoma, which is characterized by optic nerve damage and elevated intraocular pressure caused by congestion of fluid in the eye. It can cause vision loss or blindness but is usually asymptomatic until late in the disease. Risk factors include age, family history, diabetes, and corticosteroid use. Treatment aims to prevent further optic nerve damage through medication, laser treatment, or surgery. The document also discusses cataracts, which are lens opacities that are the leading cause of blindness. Cataracts develop due to aging, trauma, radiation exposure, or systemic conditions. Early cataracts are treated with glasses but later cataracts require surgical removal and lens replacement.
Central artery occlusion results in sudden, painless complete vision loss in one eye. Branch artery occlusion causes sudden, partial vision loss. Artery occlusion is diagnosed via eye examination. Unfortunately, there is no consistent treatment to restore lost vision, but very rare cases may recover if treated within an hour. Conditions like hypertension and diabetes increase risk. Retinal detachment occurs when retinal layers separate, and has three types. Signs include flashes, wavy vision, and floaters. Retinal detachments are usually detected early via eye exam for best vision recovery chances. Treatment depends on detachment type, severity and location, and may include pneumatic retinopexy or buckle surgery. Retinitis pigmentosa causes night and
this presentation is about causes of acute visual loss which i made for my seminar during ophthalmology posting.Hope that people can had a benefit from this slide especially medical student.
This document discusses the pupillary pathway and various pupillary disorders. It begins by describing the development of the pupil from the pupillary membrane. It then discusses the muscles that control pupil size and various reflexes like the light and accommodation reflex. It describes different types of pupil abnormalities including iris colobomas, aniridia, traumatic causes and neurological causes. Specific disorders like Horner's syndrome and Adie's tonic pupil are explained in detail. Pharmacological tests to localize lesions in different parts of the pupillary pathway are provided. The document concludes by mentioning some references.
This document provides an overview of retinal detachment including its anatomy, definition, signs and symptoms, risk factors, management, complications, and education. Retinal detachment occurs when the retina pulls away from its underlying tissue and can cause vision loss if not repaired surgically. The document discusses the anatomy of the eye, defines retinal detachment, lists common signs like floaters and flashes, and risk factors like high myopia. It also covers surgical management approaches, potential complications, and the importance of patient education on promptly seeking treatment for retinal detachment symptoms.
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 provides an overview of cataracts including:
- Defining cataract as a clouding of the eye's lens obstructing light passage.
- Describing the four main types: nuclear, cortical, posterior subcapsular, and congenital.
- Listing causes like aging, diabetes, steroid use, sunlight exposure, and nutritional deficiencies.
- Explaining the pathophysiology involves disrupted lens protein structure from factors like glucose levels.
- Noting cataract prevalence increases with age and is more common in women.
- Outlining signs of blurred vision, light sensitivity, and decreased night vision.
- Treatment involves glasses initially and later surgery to remove the clouded lens
complete information about the refractive errors due to the problem in the acomodation of eye lense , disturbed image formation in the retina, contains -types of disease condition .
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 various conditions that affect the pupil, including Adie's tonic pupil, Argyll Robertson pupils, and pituitary adenomas. Adie's tonic pupil is caused by damage to the ciliary ganglion and results in a dilated, poorly reactive pupil. Argyll Robertson pupils are caused by neurosyphilis and show a dissociation between the light and near reflexes. Pituitary adenomas are tumors of the pituitary gland that can compress the optic chiasm and cause visual field defects such as bitemporal hemianopia. MRI is useful for evaluating these conditions.
The document provides information about the eye and ear exam procedures performed by medical assistants in an ophthalmology or audiology office. It describes how to examine the eye by assessing visual acuity using a Snellen chart, checking the interior of the eye with a slit lamp, and testing for color blindness. It also outlines procedures for irrigating and instilling eye medications. For the ear exam, it discusses inspecting the outer, middle, and inner ear structures and performing the Weber and Rinne tests to evaluate hearing. Common ear conditions and treatment procedures like irrigation are also summarized.
retinitis blindness slide about inflammation of retinaTikuSahu6
Retinal detachment refers to the separation of the retinal pigment epithelial layer from the sensory retina. The document summarizes the definition, causes, symptoms, risk factors, diagnosis, and management of retinal detachment. For diagnosis, tests including vision testing, history collection, physical examination, gonioscopy, slit lamp examination, and opthalmoscopy are performed. Management options for retinal detachment include cryotherapy, laser photocoagulation, pneumatic retinopexy, vitrectomy, and scleral buckling surgery. Nursing diagnoses associated with retinal detachment include disturbed sensory perception, anxiety related to the surgical procedure, and risk for injury related to poor vision.
The document provides information on evaluating and examining patients with strabismus. It discusses:
- The goals of strabismus evaluation including determining the cause, assessing binocular vision, and measuring deviation.
- The typical order of examination, including history, visual acuity tests, refraction, and sensory and motor tests.
- Details on examining sensory status through tests like Worth four-dot, Bagolini striated glasses, and synoptophore.
- Details on examining motor status through measuring deviation using cover-uncover and alternate cover tests, and examining eye movements and limitations.
Retinal detachment occurs when the retina separates from the back of the eye. It is a medical emergency that can cause permanent vision loss if not repaired. The retina is made up of layers and receives images that the brain interprets as vision. Retinal detachment can be rhegmatogenous, tractional, or exudative and risks include nearsightedness, eye surgery or injury. Diagnosis involves eye exams and ultrasound. Treatment may involve laser, cryotherapy, scleral buckle surgery, pneumatic retinopexy or vitrectomy to seal retinal breaks and reattach the retina. Nursing care focuses on medication administration, activity safety, and education on signs of recurrence and postoperative care.
Glaucoma is a group of eye conditions characterized by optic nerve damage due to increased intraocular pressure caused by blocked drainage of the aqueous humor in the eye. It is a leading cause of blindness and risk increases with age, especially between 45-65 years old. Glaucoma is managed through medication, laser treatment, or surgery to facilitate drainage of aqueous humor and maintain safe intraocular pressure to prevent further optic nerve damage and vision loss. Strict lifelong treatment adherence and monitoring is important for glaucoma management and vision preservation.
Measurement visual function - external examination - slitlamp examination.pptxFaradhillah Adi Suryadi
This document discusses preoperative evaluation and measurements that should be performed for patients undergoing cataract surgery. It describes testing visual acuity under different lighting conditions, performing refraction, and using glare testing and contrast sensitivity testing to evaluate visual function. External examination of the eyes and adnexa and assessment of motility, pupils, conjunctiva, cornea, anterior chamber, and iris are also recommended to inform surgical planning and ensure patient safety.
glaucoma and cataract.pdf, After the class the students will be able :
Explain the structures and function of eye.
Explain the age affect on vision.
Describe the definition , etiology, risk factors, pathophysiology, medical management, surgical management and Nursing management of Glaucoma.
Describe the definition , etiology, risk factors, pathophysiology, medical management, surgical management and Nursing management of cataract.
List down the health education for Glaucoma and cataract.
cataract is clouding of the lens inside the eye..
it is very useful topic in medical filed...in this presentation all content is included about cataract like causes, symptoms and treatment...its very useful in your study.
This document provides an overview of inflammatory optic neuropathy, specifically optic neuritis. It begins with the anatomy of the optic nerve and its divisions. It then discusses the signs, classification, and common types of optic neuropathy, focusing on inflammatory optic neuritis. It covers the pathophysiology, risk factors, locations of involvement on the optic nerve, and etiological classifications of optic neuritis. The remainder of the document discusses demyelinating optic neuritis in more detail, including its association with multiple sclerosis, workup, symptoms, signs, visual field defects, course, treatment, and results from the ONTT and CHAMPS/CHAMPIONS studies.
The pupil is a circular opening in 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 muscle groups - the sphincter pupillae and dilator pupillae - that regulate pupil size. Abnormal pupils may be unequal in size (anisocoria), irregularly shaped, or have abnormal reactions to light or accommodation. Various diseases and drugs can cause pupil abnormalities.
diseases of eye may be related to a variety of systemic disorders. prompt management is important to prevent long term complictions. it includes diseases such as ROP, cataract, conjunctivitis, strabismus, refractive errors, retinoblastoma, congenital glaucoma, etc.
Joker Wigs has been a one-stop-shop for hair products for over 26 years. We provide high-quality hair wigs, hair extensions, hair toppers, hair patch, and more for both men and women.
At Malayali Kerala Spa Ajman, Full Service includes individualized care for every client. We specifically design each massage session for the individual needs of the client. Our therapists are always willing to adjust the treatments based on the client's instruction and feedback. This guarantees that every client receives the treatment they expect.
By offering a variety of massage services, our Ajman Spa Massage Center can tackle physical, mental, and emotional illnesses. In addition, efficient identification of specific health conditions and designing treatment plans accordingly can significantly enhance the quality of massaging.
At Malayali Kerala Spa Ajman, we firmly believe that everyone should have the option to experience top-quality massage services regularly. To achieve that goal we offer cheap massage services in Ajman.
If you are interested in experiencing transformative massage treatment at Malayali Kerala Spa Ajman, you can use our Ajman Massage Center WhatsApp Number to schedule your next massage session.
Contact @ +971 529818279
Visit @ https://malayalikeralaspaajman.com/
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This document provides an overview of retinal detachment including its anatomy, definition, signs and symptoms, risk factors, management, complications, and education. Retinal detachment occurs when the retina pulls away from its underlying tissue and can cause vision loss if not repaired surgically. The document discusses the anatomy of the eye, defines retinal detachment, lists common signs like floaters and flashes, and risk factors like high myopia. It also covers surgical management approaches, potential complications, and the importance of patient education on promptly seeking treatment for retinal detachment symptoms.
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 provides an overview of cataracts including:
- Defining cataract as a clouding of the eye's lens obstructing light passage.
- Describing the four main types: nuclear, cortical, posterior subcapsular, and congenital.
- Listing causes like aging, diabetes, steroid use, sunlight exposure, and nutritional deficiencies.
- Explaining the pathophysiology involves disrupted lens protein structure from factors like glucose levels.
- Noting cataract prevalence increases with age and is more common in women.
- Outlining signs of blurred vision, light sensitivity, and decreased night vision.
- Treatment involves glasses initially and later surgery to remove the clouded lens
complete information about the refractive errors due to the problem in the acomodation of eye lense , disturbed image formation in the retina, contains -types of disease condition .
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 various conditions that affect the pupil, including Adie's tonic pupil, Argyll Robertson pupils, and pituitary adenomas. Adie's tonic pupil is caused by damage to the ciliary ganglion and results in a dilated, poorly reactive pupil. Argyll Robertson pupils are caused by neurosyphilis and show a dissociation between the light and near reflexes. Pituitary adenomas are tumors of the pituitary gland that can compress the optic chiasm and cause visual field defects such as bitemporal hemianopia. MRI is useful for evaluating these conditions.
The document provides information about the eye and ear exam procedures performed by medical assistants in an ophthalmology or audiology office. It describes how to examine the eye by assessing visual acuity using a Snellen chart, checking the interior of the eye with a slit lamp, and testing for color blindness. It also outlines procedures for irrigating and instilling eye medications. For the ear exam, it discusses inspecting the outer, middle, and inner ear structures and performing the Weber and Rinne tests to evaluate hearing. Common ear conditions and treatment procedures like irrigation are also summarized.
retinitis blindness slide about inflammation of retinaTikuSahu6
Retinal detachment refers to the separation of the retinal pigment epithelial layer from the sensory retina. The document summarizes the definition, causes, symptoms, risk factors, diagnosis, and management of retinal detachment. For diagnosis, tests including vision testing, history collection, physical examination, gonioscopy, slit lamp examination, and opthalmoscopy are performed. Management options for retinal detachment include cryotherapy, laser photocoagulation, pneumatic retinopexy, vitrectomy, and scleral buckling surgery. Nursing diagnoses associated with retinal detachment include disturbed sensory perception, anxiety related to the surgical procedure, and risk for injury related to poor vision.
The document provides information on evaluating and examining patients with strabismus. It discusses:
- The goals of strabismus evaluation including determining the cause, assessing binocular vision, and measuring deviation.
- The typical order of examination, including history, visual acuity tests, refraction, and sensory and motor tests.
- Details on examining sensory status through tests like Worth four-dot, Bagolini striated glasses, and synoptophore.
- Details on examining motor status through measuring deviation using cover-uncover and alternate cover tests, and examining eye movements and limitations.
Retinal detachment occurs when the retina separates from the back of the eye. It is a medical emergency that can cause permanent vision loss if not repaired. The retina is made up of layers and receives images that the brain interprets as vision. Retinal detachment can be rhegmatogenous, tractional, or exudative and risks include nearsightedness, eye surgery or injury. Diagnosis involves eye exams and ultrasound. Treatment may involve laser, cryotherapy, scleral buckle surgery, pneumatic retinopexy or vitrectomy to seal retinal breaks and reattach the retina. Nursing care focuses on medication administration, activity safety, and education on signs of recurrence and postoperative care.
Glaucoma is a group of eye conditions characterized by optic nerve damage due to increased intraocular pressure caused by blocked drainage of the aqueous humor in the eye. It is a leading cause of blindness and risk increases with age, especially between 45-65 years old. Glaucoma is managed through medication, laser treatment, or surgery to facilitate drainage of aqueous humor and maintain safe intraocular pressure to prevent further optic nerve damage and vision loss. Strict lifelong treatment adherence and monitoring is important for glaucoma management and vision preservation.
Measurement visual function - external examination - slitlamp examination.pptxFaradhillah Adi Suryadi
This document discusses preoperative evaluation and measurements that should be performed for patients undergoing cataract surgery. It describes testing visual acuity under different lighting conditions, performing refraction, and using glare testing and contrast sensitivity testing to evaluate visual function. External examination of the eyes and adnexa and assessment of motility, pupils, conjunctiva, cornea, anterior chamber, and iris are also recommended to inform surgical planning and ensure patient safety.
glaucoma and cataract.pdf, After the class the students will be able :
Explain the structures and function of eye.
Explain the age affect on vision.
Describe the definition , etiology, risk factors, pathophysiology, medical management, surgical management and Nursing management of Glaucoma.
Describe the definition , etiology, risk factors, pathophysiology, medical management, surgical management and Nursing management of cataract.
List down the health education for Glaucoma and cataract.
cataract is clouding of the lens inside the eye..
it is very useful topic in medical filed...in this presentation all content is included about cataract like causes, symptoms and treatment...its very useful in your study.
This document provides an overview of inflammatory optic neuropathy, specifically optic neuritis. It begins with the anatomy of the optic nerve and its divisions. It then discusses the signs, classification, and common types of optic neuropathy, focusing on inflammatory optic neuritis. It covers the pathophysiology, risk factors, locations of involvement on the optic nerve, and etiological classifications of optic neuritis. The remainder of the document discusses demyelinating optic neuritis in more detail, including its association with multiple sclerosis, workup, symptoms, signs, visual field defects, course, treatment, and results from the ONTT and CHAMPS/CHAMPIONS studies.
The pupil is a circular opening in 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 muscle groups - the sphincter pupillae and dilator pupillae - that regulate pupil size. Abnormal pupils may be unequal in size (anisocoria), irregularly shaped, or have abnormal reactions to light or accommodation. Various diseases and drugs can cause pupil abnormalities.
diseases of eye may be related to a variety of systemic disorders. prompt management is important to prevent long term complictions. it includes diseases such as ROP, cataract, conjunctivitis, strabismus, refractive errors, retinoblastoma, congenital glaucoma, etc.
Joker Wigs has been a one-stop-shop for hair products for over 26 years. We provide high-quality hair wigs, hair extensions, hair toppers, hair patch, and more for both men and women.
At Malayali Kerala Spa Ajman, Full Service includes individualized care for every client. We specifically design each massage session for the individual needs of the client. Our therapists are always willing to adjust the treatments based on the client's instruction and feedback. This guarantees that every client receives the treatment they expect.
By offering a variety of massage services, our Ajman Spa Massage Center can tackle physical, mental, and emotional illnesses. In addition, efficient identification of specific health conditions and designing treatment plans accordingly can significantly enhance the quality of massaging.
At Malayali Kerala Spa Ajman, we firmly believe that everyone should have the option to experience top-quality massage services regularly. To achieve that goal we offer cheap massage services in Ajman.
If you are interested in experiencing transformative massage treatment at Malayali Kerala Spa Ajman, you can use our Ajman Massage Center WhatsApp Number to schedule your next massage session.
Contact @ +971 529818279
Visit @ https://malayalikeralaspaajman.com/
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3. The Afferent Pathway
Optictract
Nasal Fibersdecussate in opticchiasm
Travelscentrallyalong theoptic nerve
Ganglioncells
Rods and cones AND
Melanopsin Retinal Ganglioncells
4. The Afferent Pathway(contd.)
The Accessory motar nuclei of
EW nucleus
New relay fibers partiallycross
over
Pretectal Nucleus
Midbrain from Lateral side of
Superiorcolliculus
5. The Efferent Pathway
Theaxonsof the EW nucleus extend
into the III n.
Lieon the superficial dorsomedial
aspectas it leave the brain stem
Passes laterally to petroclinod
ligamentand dorsum sellae
Located inferiorly as itenters the
orbit
8. Pathway of Convergence Reflex
Fibers form Medial Rectus m.
via III n.
Mesencephalic n. of V n.
Convergence Center in Tectal
or Pre Tectal Region
EW Nucleus
Efferent fibers travel along III
n.
Relay in AccessoryGanglion
SphincterPupillae
9. Pathway of Accommodation Reflex
Retina
Via Optic nerve,
Chaisma Optic Tract
Lateral Geniculate
Body
Striate Cortex
From the Para
Striate Cortex
Via
Occipitomesencephalic
Tract and Pontine center
EW Nucleus
Via III n. to
Sphincter Pupillae
10. Function of the Pupil
Functions:
⚫ Control in retinal Illumination
⚫ Reduction in optical aberration
⚫ Depth of Focus
Clinical Importance
⚫ Objective indicator of Light Input
⚫ Anisocoria
⚫ Pharmacological Indicator
⚫ Indicated level of wakefulness
11. The Light Reflex
⚫The light reflex consist of simultaneous and equal
constriction of pupils in response to stimulation of
one eye by light
⚫Pupil constriction is elicited with extremely low
intensities and is proportional within limits to both
intensities and duration of stimulus.
13. Near Reflex
⚫Two components:
1. Convergence Reflex: Convergence of visual axis and
associated constriction of pupil
2.Accommodation Reflex: Increased accomodation and
associated constriction of pupil
⚫Near Reflex Traid consists of:
- Increased Accommodation
- Convergence of Visual Axis
- Constriction of pupils
⚫Both neurons in the EW nucleus stimulated from
SUPRANUCLEAR level
15. Method of Examination
Confirm that the pupils
respond to light
Compare the pupillary
diameters to one another.
The swinging flashlight test.
Normalresponses Pathological findings
Anisocoria with normal responses
RAPD
Monocularor bilateral deficit
16. Near Reflex Test
⚫Instruct the patient to look at the distant target
⚫The examiner holds up a target containing fine detail
approximately 25cm from the patient
⚫Ask the patient to fixate the near target and look for
pupil constriction
⚫Note the speed of the constriction and the roundness
of each pupil
17. Afferent pupillary defects
⚫ Assessment of afferent input from the retina, optic nerve, and chiasm, optic
tract and midbrain till LGB
⚫ Damage anywhere along this portion of the visual pathway reduces the
amplitude of pupil movement in response to a light stimulus
⚫ The pupillary light reflex summates the entire area of the visual field, with
some increased weight given to the central 10°, is roughly proportional to the
amount of working visual field.
18. •Otherobjective testsof visual function, such as theelectroretinogram
and visual evoked potential may be inadequate
Similarly, peripheral visual field defects caused by glaucoma or
anterior ischemic optic neuropathy may yield a normal visual
evoked potential, or false-negative result, but the pupillary light
reflex is reduced
19. Total Afferent Pathway Defect
⚫Absence of Direct light reflex on affected side and
absence of consensual light reflex on normal side
⚫When the normal is stimulated both pupils react
normally
⚫Diffuse illumination both pupils are equal in size
⚫Near reflex is normal in both eyes
20. RAPD (Relative Afferent Pupillary
Defect)
⚫ RAPD cause a reduction in pupil contraction when one eye is
stimulated by light compared with when the opposite eye is
stimulated by light.
⚫ RAPD may be associated with visual field orelectroretinographic
asymmetries between the two eyes.
⚫ Asymmetrical differences in retinal appearance or optic nerve
appearance may occur.
21. Grading Scale: RAPD
⚫ 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
⚫ However, most subjective grading of RAPDs has serious limitations,
such as some large-scale errors that arise from age variations in pupil
size and pupil mobility
22. Neutral Density Filters
⚫ Estimation of the amount of RAPD in log units provides an objective data.
⚫ Accurate quantification of RAPDs is accomplished by determination of the
log unit difference needed to “balance” the pupil reaction between the two
eyes
24. Wernicke’s Hemianopic Pupil
⚫ This phenomenon is caused by division of the optic tract that results
in a contralateral homonymous hemianopia.
⚫ The pupils fail to react when a narrow pencil of light is shone onto the
non-seeing part of the retina, but they do react if it falls onto the
seeing retinal areas.
⚫ It is also characterized by ptosis on the same side as the hemianopia
and anisocoria with the larger pupil also on the same side as the
hemianopia.
⚫ The macular area is often involved and optic atrophy may follow.
⚫ Wernicke's Hemianopic pupil occurs as a result of a lesion in the
optic tract in an area that precedes the splitting of the two types of
fibers.
25. Anisocoria
⚫ Anisocoria is defined by a difference in the size of the two pupils of 0.4
mm or greater.
⚫ Roughly one fifth of the normal population has an anisocoria, but the
difference in size is not more than 1mm.
⚫ Anisocoria or a difference in pupil size may be normal but may be a
sign of ocular or neurologic disease.
⚫ It should be considered a neurosurgical emergency if a patient has
anisocoria with acute onset of third-nerve palsy and associated with
headache or trauma.
26. Evaluation of anisocoria
⚫To evaluate anisocoria, the examiner must determine
which pupil is abnormal by noting pupil size under light
and dark illumination.
⚫If the difference in pupil size in both light and dark
illumination is constant, then it is called Physiologic or
Essential anisocoria
⚫Helps differentiate and localize a lesion to one of the PS or
Sympathetic Pathway
27. ⚫But does not localize the lesion’s location within
those pathways.
⚫Afferent pathways not affected
⚫A lesion in the midbrain produces a subtle and
transient anisocoria.
⚫ However, most neurologic causes of anisocoria
involve lesions in the parasympathetic (efferent) and
sympathetic pupillary pathways.
28. ⚫If the Larger pupil is abnormal (poor constriction), the
anisocoria is greatest in Bright illumination, as the normal
pupil becomes small.
⚫This is caused from the disruption of the
Parasympathetic (efferent) pupillary pathway. [BPL]
⚫If the Smaller pupil is abnormal (poor dilation), the
anisocoria is greatest in Dark illumination, as the normal
pupil becomes large.
⚫It is caused from the disruption of the Sympathetic
pupillary pathway.
32. Iris Trauma
⚫ An abnormal dilated pupil could be alarming to an examiner because
you must rule out third-nerve palsy from pharmacologic pupil dilation
and traumatic dilated pupil.
⚫ A traumatic dilated pupil could be ruled out clinically by careful
history and biomicroscopic examination.
⚫ A patient with traumatic iris sphincter damage will present with torn
pupillary margin or iris illumination defects seen on biomicroscopic
examination.
33. Adie’s Tonic Pupil
⚫ Adie’s tonic pupil refers to an idiopathetic tonic pupil
⚫ Adie’s syndrome is applied when both tonic pupil and associated
hyporeflexia are present
⚫ Causes:
Idiopathic/ Trauma
Local Disorders: Tumor, Inflammation, Surgery, Infection
within the orbit affecting ciliary ganglion
Systemic Neuropathies: DM, GB syndrome, Ross’s syndrome,
Riley Day syndrome
⚫ Unilateral in 80% to 90% of cases and may become bilateral at a rate
of 4% per year.
34. Adie’s Tonic Pupil (contd.)
⚫ Due to damage to the ciliary ganglion or postganglion fibers of the
short posterior ciliary nerves.
⚫ This subsequently leads to dilated pupil and anisocoria (light > dark).
⚫ It has minimal or no reaction to light but slow reaction to
accommodative response due to damage to the parasympathetic
innervation to the eye.
35. ⚫ Intact near pupillary reflex due to the ratio of fibers that control
the near pupillary reflex is much greater as compared to those
that control the light pupillary reflex.
⚫ Preservation of the pupil constriction in accommodation may be
result of accommodative fiber aberrant regeneration
⚫ Some accommodative fibers formerly destined for the ciliary
body now travel to the pupil becoming misdirected and supply
the iris sphincter.
36. Features:
⚫ Symptoms:
Difference in the size of the pupils
Unilateral blurred vision
May be asymptomatic
⚫ Critical Signs:
Anisocoria (Light > Dark)
Slow pupillary constriction to near response and slow redilation
Iris sphincter sector palsy
Segmental pupil response – “vermiform” pupil response
movement.
⚫ Other Characteristics:
Decreased amplitude of accommodation
Diminished deep tendon reflexes of the knee and ankle – Holmes-
Adie syndrome.
37. Oculomotor Nerve (CN III)
Palsy with or without Pupil
Involvement
⚫ Neuro Surgical Emergency
⚫ Presentation:
Complete or Partial Palsy with or without pupil involvement
Complete or Partial Ptosis which may mask the diplopia
⚫ Its clinical presentation depends on the location of the dysfunction
along the pathway between the oculomotor nucleus in the midbrain
and its branches of the oculomotor nerve
38. ⚫ DDx: ischemia, aneurysm, tumor, trauma, infection, inflammation or
congenital anomalies.
⚫ Diagnosis is critical if pupil in involved
⚫ Sparing of the pupil is an important diagnostic sign for ruling out a
more serious etiology such as aneurysm or tumor.
⚫ Most pupil sparing cases are microvascular in origin such as diabetes
or hypertension.
39. ⚫ As a rule of thumb, a patient with sudden onset of painful third-nerve
palsy with pupil involvement and no history of trauma or vascular
disease should assume an intracranial aneurysm until proven
otherwise.
⚫ The most common site of an intracranial aneurysm causing third-
nerve palsy is :
The posterior communicating artery
Internal carotid artery and basilar artery
⚫ Life-threatening emergency : Potential of rupturing and leading to
subarachnoid hemorrhage (within hours or days)
40. Sympathetic Pupillary
Defects
⚫ Disruption along the sympathetic pupillary fibers from hypothalamus to iris
dilator.
⚫Causes of Miotic Pupils:
Horner's Syndrome (Oculosympathetic paralysis)
Argyll Robertson Pupils
Long-Standing Adie's Pupil
⚫ Pharmacologic Agents:
⚫ Unilateral use of miotic drops:
⚫ Pilocarpine
⚫ Drugs causing miosis : Narcotics, Barbiturates, Chloral hydrate, Morphine,
Propoxyphene,Tamsulosin
⚫ Uveitis, pseudoexofoliation syndrome and recent eye surgery
42. FirstOrder Second Order Third Order
Arnold-Chiari malformation Pancoast tumor Internal carotid artery dissection
Basal meningitis (e.g., syphilis) Birth traumawith injury to lower
brachial plexus
Carotid cavernous fistula
Basalskull tumors
Pitutary Tumor
Aneurysm/dissection of aorta
Subclavianorcommon carotid
artery
Raeder syndrome (paratrigeminal
syndrome) - Oculosympathetic
paresis and ipsilateral facial pain
with variable involvementof the
trigeminal and oculomotor nerves
Cerebral vascularaccident
(CVA)/Wallenberg syndrome
(lateral medullarysyndrome)
Lymphadenopathy (Hodgkin
disease, leukemia, tuberculosis,
mediastinal tumors)
Herpes zoster
Demyelinating disease (e.g.,
multiplesclerosis
Central venouscatheterization
Intrapontine hemorrhage Mandibular tooth abscess
Lesions of the middleear (e.g.,
acute otitis media)
Neck trauma Neuroblastoma
43. Features
• Symptoms:
• Difference in the size of the pupils
• Droopy eyelid
• Often asymptomatic Critical
Signs:
• Anisocoria (dark illumination > light illumination) Miotic
pupil with intact light and near reactions Mild ptosis
(less than 2 mm due to Muller’s muscle)
. Reverse ptosis (lower lid elevation on same side)
Anhidrosis (first and second-order neuron) lesions
Apparent enophthalmos
Other Characteristics:
Iris heterochromia (lighter iris color in congenital cases)
Increased amplitude of accommodation
Ocular hypotony
44. Pharmacologic Testing:
⚫ Negative 4% or 10% cocaine testing (no pupillary dilation)
⚫ 1% hydroxyamphetamine: Localizing the lesion
⚫ First and secod-order neuron lesions (preganglionic) show
pupillary dilation
⚫ Third-order neuron lesions (postganglionic) show NO pupillary
dilation
⚫ The dilation of Horner’s pupil is due to the denervation
hypersensitivity of the postsynaptic alpha-1 receptor in the pupil
dilator muscles.
45. Pupillary Light-Near
Dissociation
⚫ LND refers to any situation where the light reaction is absent and
pupillary near reaction is present
⚫ The near reflex fibers are more ventrally located than the light reflex
fibers, thus the near reflex fibers are spared even with afferent light
reflex fiber lesions.
⚫ IF unilateral or bilateral and it’s associated ocular manifestations such
as extra-ocular muscle abnormalities and nystagmus (Parinaud’s
syndrome).
47. Argyll Robertson Pupils
⚫ Argyll Robertson pupils are miotic pupils with irregular in shape.
⚫ It is usually bilateral, but asymmetric.
⚫ The light reflex is absent or very sluggish, but the near reflex is normal
(light-near dissociation).
⚫ Rule out Tertiary Syphillis
48. Features of ARP
⚫ Involvement is usually Bilateral but Asymmetrical
⚫ The retinae are sensitive to light
⚫ The pupils are small in size and irregular in shape
⚫ The light reflex is absent but near reflex is present
⚫ Dilate poorly with mydriatics like Atropine
⚫ Physiostigmine may cause further constriction