Pupillary Reactions
dr n. med. Anna Barbara Kłysik
Department of Ophthalmology of the Medical University of
Łódź
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
---
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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