Pupillary Reactions

dr n. med. Anna Barbara Kłysik

Department of Ophthalmology of the Medical University of

Łódź

Functions of Pupillary reactions

Functions of Pupillary reactions

-

-

adaptation for various light conditions

adaptation for various light conditions

- reductions of aberrations in the optical system of the eye ( spherical,

- reductions of aberrations in the optical system of the eye ( spherical,

chromatical, coma and others)

chromatical, coma and others)

-

-

physiological pupil(1,5- 8mm, śr. 4mm)

physiological pupil(1,5- 8mm, śr. 4mm)

- pupillary reactions appear around 5 months of gestational age

- pupillary reactions appear around 5 months of gestational age

- pupil size decrease with age

- pupil size decrease with age

(Myopes have bigger pupils)

(Myopes have bigger pupils)

Pupillary reactions

Pupillary reactions

- From clinical poin of view, examination of pupillary reactions allows us

- From clinical poin of view, examination of pupillary reactions allows us

objective analysis of autonomic system supplying the eye

objective analysis of autonomic system supplying the eye

-Relative afferent pupillary defect gives a objective analysis of afferent

-Relative afferent pupillary defect gives a objective analysis of afferent

light reflex pathway which is also a visual pathway.

light reflex pathway which is also a visual pathway.

- myosis is a function of parasympathetic system

- myosis is a function of parasympathetic system

- mydriasis is a function of sympathetic system

- mydriasis is a function of sympathetic system

Anisocoria

Anisocoria

-

-

25% of normal population

25% of normal population

-

anisocoria bigger in the dark room, smaller pupil is pathological

anisocoria bigger in the dark room, smaller pupil is pathological

-

Anisocoria reduced in the dark room – bigger pupil likely to be

Anisocoria reduced in the dark room – bigger pupil likely to be

pathological

pathological

Afferent light reflex pathway

Afferent light reflex pathway

 Photoreceptors

>

 optic nerve

>



optic tracts

>



light fibres leave optic

tract before lateral geniculate nucleus

>



jądro dodatkowe n. III ( Westphal- Edingera

nucleus) po tej samej stronie

>



część

włókien przez spoidło tyle do jądra po

przeciwnej stronie

Efferent light reflex pathway

Efferent light reflex pathway

Edinger-Westfal nucleus> third

Edinger-Westfal nucleus> third

nerve>cavernous sinus> cilliary

nerve>cavernous sinus> cilliary

ganglion >

ganglion >

Cilliary nerves > musculus constrictor

Cilliary nerves > musculus constrictor

pupillae

pupillae

Problems:

Problems:



PICA aneurysm, cerebral uncus hernia

PICA aneurysm, cerebral uncus hernia



Cavernous sinus

Cavernous sinus

Parasympathetic damage

Parasympathetic damage



Third cranial nerve palsy.

Third cranial nerve palsy.



Pupil size depends on the sympathetic tonus (5- 8mm)

Pupil size depends on the sympathetic tonus (5- 8mm)



Maximal anisocoria in bright light

Maximal anisocoria in bright light



Midriasis as the only sign suggests uncus herniation, or

Midriasis as the only sign suggests uncus herniation, or

meningitis and encephalitis

meningitis and encephalitis



PICA or interior carotid artery aneurysm

PICA or interior carotid artery aneurysm



Pupillary sparing suggests that the lesion is not an aneurysm

Pupillary sparing suggests that the lesion is not an aneurysm



Miosis with eyemovement: aberrant regeneration of the third

Miosis with eyemovement: aberrant regeneration of the third

nerve

nerve

Causes of anisocoria

Causes of anisocoria



Sphincter pupillae damage

Sphincter pupillae damage



Pharmacological mydriasis

Pharmacological mydriasis



Pilocarpine does not reverse the action of

Pilocarpine does not reverse the action of

tropicamide

tropicamide



Adies tonic pupil, shows denervation

Adies tonic pupil, shows denervation

hypersensitivity phenomenon.

hypersensitivity phenomenon.

Sympathetic supply to the eye

Sympathetic supply to the eye



hypothalamus

hypothalamus

>

>



midbrain and pons

midbrain and pons

>

>



cervical cord (C8-T2)

cervical cord (C8-T2)

(s)

>

>





>

>





superior

superior

cervical ganglion

cervical ganglion

(s)

>

>



internal carotid

internal carotid

artery

artery

>

>



cavernous sinus

cavernous sinus

>

>



Vth nerve

Vth nerve

> superior ophthalmic fissure

> superior ophthalmic fissure

(s)

>

>



long

long

cilliary nerves

cilliary nerves

>

>





musculus dilator pupillae

musculus dilator pupillae

Sympathetic palsy

Sympathetic palsy



At any level presents with Horner’s syndrome

At any level presents with Horner’s syndrome



Miosis, ptosis (palsy of the muscle of Mullera, enohthalmus),

Miosis, ptosis (palsy of the muscle of Mullera, enohthalmus),

hipochromia of the iris, anhydrosis

hipochromia of the iris, anhydrosis



Raection to light and acommodation remains normal

Raection to light and acommodation remains normal

Pharmacological diagnostics of Horner’s syndrome

Pharmacological diagnostics of Horner’s syndrome



Anhidrosis: CNS disturbance

Anhidrosis: CNS disturbance



Pharmacological-

Pharmacological-





c

c

okaine 4-10% stops norepinefryne uptake from synaptic space

okaine 4-10% stops norepinefryne uptake from synaptic space

Doesn’t dilate Horner’s pupil

Doesn’t dilate Horner’s pupil





hydroksyamfetamine (1% )- releases norepinefrynę from nerve endings

hydroksyamfetamine (1% )- releases norepinefrynę from nerve endings

- dilates normal pupil

- dilates normal pupil

,

,

- Does not dilate post-ganglionic Horner’s pupil

- Does not dilate post-ganglionic Horner’s pupil

- Dilates pre-ganglionic one.

- Dilates pre-ganglionic one.

Causes of Horner’s syndrome

Causes of Horner’s syndrome



Pre-ganglionic:

Pre-ganglionic:

- CNS problems (stroke, tumor),

- CNS problems (stroke, tumor),

- lung apex tumor ( Pancoast’s tumor)

- lung apex tumor ( Pancoast’s tumor)

- neuroblastoma

- neuroblastoma

- brachial plexus damage ( in babies )

- brachial plexus damage ( in babies )



Post-ganglionic

Post-ganglionic

- dissecting internal carotid artery aneurysm

- dissecting internal carotid artery aneurysm

Relative Afferent Pupillary Defect (RAPD)

Relative Afferent Pupillary Defect (RAPD)



Double decussation of the afferent light pathway explains

Double decussation of the afferent light pathway explains

consensual light reflex

consensual light reflex



Strong light causes marked constriction of both pupils and

Strong light causes marked constriction of both pupils and

subsequent slow dilatation

subsequent slow dilatation



Swinging light test reveals the abnormal side

Swinging light test reveals the abnormal side

Causes of RAPD

Causes of RAPD

:

:

neuritis,

neuritis,

Pupillary abnormalities

Pupillary abnormalities



Argyll- Robertson’s pupil

Argyll- Robertson’s pupil

( Syphylis of the CNS)

( Syphylis of the CNS)

- Small irregular pupils

- Small irregular pupils

-

No reaction to light

No reaction to light

-

Normal reaction to acommodation

Normal reaction to acommodation

-

-

Hypotrophy of the Iris stroma

Hypotrophy of the Iris stroma

- poor reaction to midriatic eyedrops

- poor reaction to midriatic eyedrops

Provided there was no syphylitic iritis in the past.

Provided there was no syphylitic iritis in the past.

Pupillary abnormalities

Pupillary abnormalities



Adie’s Pupil

Adie’s Pupil

-30- 40 years old women

-30- 40 years old women

No reaction to light

No reaction to light

Tonic reaction to acommodation

Tonic reaction to acommodation

---

---

Holmesa- Adie’ syndrome- pupillary abnormalities and reduced knee jerk

Holmesa- Adie’ syndrome- pupillary abnormalities and reduced knee jerk

Pupillary abnormalities;

Pupillary abnormalities;



Parinaud’s syndrome

Parinaud’s syndrome

(Pineal gland tumors, SM,

(Pineal gland tumors, SM,

hydrocephalus)

hydrocephalus)

-

-

wide pupils with poor light reaction

wide pupils with poor light reaction

- normal reaction to accomodation

- normal reaction to accomodation

- up-gaze palsy with nystagmus

- up-gaze palsy with nystagmus