dr stephen best - cdn.auckland.ac.nz · 3 the pupil is the circular aperture in the centre of the...
TRANSCRIPT
Dr Stephen Best
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The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex
The size of the pupil is determined by the antagonistic action of the sphincter constrictor muscle vs the diffuse dilator pupillae
Parasympathetic vs Sympathetic innervation
Local factors may alter this
Pupil size is usually equal !!
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Miosis = small pupil
Mydriasis = large pupil
Anisocoria = difference in size
Polycoria = multiple apertures
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Light reflex – direct/consensual
Near reflex – miosis / accommodation / convergence
Relative afferent pupil defect
Pathologic pupil defects
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Topical medications – mydriatics/miotics/other agents
Trauma – traumatic mydriasis / sphincter rupture / surgical trauma / posterior synechia
Disease processes / iritis / uveitis / acute angle closure glaucoma
Systemic medications – narcotics = miosis
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Oculosympathetic paresis….interruption of the sympathetic supply along the three neuron pathway
Miosis
Ptosis
Apparent enophthalmous
Cutaneous anhydrosis
Other features – transient hyperaemia/iris hypopigmentation in congenital cases
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Diagnosis confirmed by topical cocaine test
Abnormal pupil fails to dilate whilst the normal pupil will dilate ( loss of noradrenaline at nerve junction )
Other associated clinical signs and symptoms….( headache / apical lung pathology / long tract neurology signs ) will determine appropriate investigations
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Postganglionic parasympathetic denervation
Glare / accommodative difficulties
Mydriasis
Light – near dissociation….slow constriction on prolonged near effort and slow re-dilation to distance
Usually young females – 90% unilateral initially , but often becomes bilateral
Decreased corneal sensation
Decreased deep tendon reflexes
Pupil becomes tonic with time….even miotic
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Oculosympathetic paresis….interruption of the sympathetic supply along the three neuron pathway
Miosis
Ptosis
Apparent enophthalmous
Cutaneous anhydrosis
Other features – transient hyperaemia/iris hypopigmentation in congenital cases
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Diagnosis confirmed by deinnervationhypersensitivity to weak cholinergic (pilocarpine 0.1%)……abnormal pupil will constrict whilst normal pupil remains un-effected
Aberrant re-innervation of pupillary sphincter muscle ….contractions of part of the pupil margin (vermiform movement)
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Pupil involved 3rd nerve palsy
Bilateral dilated pupils
Horner’s Syndrome
Adie’s Tonic Pupil
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The most common pupil abnormality is simple
Physiological Anisocoria
Benign!!!
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38 yr female
Severe burns- plastics admission for grafts
Early morning headaches
Some blurring of vision
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VA 6/12 OD, 6/9 OS
Pupillary examination – sluggish
Optic disc examination – abnormal
HVF= peripheral visual field constriction OU
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Neuro-imaging mandatory with papilloedemaRefer as appropriate
Note: PTC/BIH/IIH
Consecutive optic atrophy following resolution of papilleodema secondary to meningioma after neuro-surgical intervention
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