Pupillary Disorder

Anatomy of pupil
A black circular opening in the center of the iris
It is surrounded by the pupillary margin of the
iris
Function : To control the amount of light
entering the eye

They are round in shape and relatively equal in size
Their size vary from 1 to 8mm in diameter
Normal pupils range from 3 to 5mm in ambient light
conditions
Miotic pupils are less than 3mm
Mydriatic pupils are greater than 7mm



Pupil Contraction and Dilation
Controlled by two muscles of the iris
Circular muscle (pupil constriction)
Innervated by the parasympathetic nervous system
Radial muscle (pupil dilation)
Innervated by the sympathetic nervous system


PUPILLARY PATHWAY: LIGHT REFLEX
Sensory: connects each retina with both pretectal nuclei in
the midbrain at the level of superior colliculi.
Internuncial: connects each pretectal nucleus to both
Edinger-Westphal nuclei.
Pre-ganglionic motor: connects the Edinger-Westphal
nucleus to ciliary ganglion.
Post-ganglionic motor: leaves the ciliary ganglion and passes
in the short ciliary nerves to innervate the sphincter pupillae.
NEAR RESPONSE
Pupils constrict while the eyes are looking at a near
object.
Consists of 2 components:
Convergence reflex
Accommodation reflex

PHYSIOLOGICAL ANICOSURIA
(UNEQUAL PUPIL SIZE)
This can be distinguished from pathological anisocoria by
observing the pupil size in the dark and then in the light
physiological anisocoria which is usually subtle should not
change dramatically in different levels of illumination
(as opposed to Horner's syndrome which looks worse in the
dark)
Assymmetric
pupils
Physiological
anisocoria
(20% of population)
Small pupil
(miosis)
Horners syndrome
Uveitis
Drugs (ie:pilocarpine)
Neurosyphilis (ie : Argyl Robertson)
Long standing Holmes-Adle pupil
Congenital miosis or microcoria
Large pupil
(mydriasis)
3
rd
nerve palsy
Sphincher damage
Drugs
Dorsal midbrain syndrome
Holes-adle pupil
MYDRIASIS

A prolonged abnormal dilation of the pupil, regardless of light levels.
Physiologically: normal response
Sympathetic stimulation
Dark lightning conditions
Non-physiologically - remain excessively large in bright environment.
Bilateral dilated pupil
Unilateral dilated pupil

Causes
AUTONOMIC NEUROPATHY Damaged to parasympathetic nervous
supply by cranial nerve III damage .
TRAUMATIC Head injury or orbit trauma -> damage iris
sphincter -> reduce or eliminate consensual
reactivity to light.
DRUGS Anticholinergics (atropine)
Antihistamines
Antidepressant (tricyclic antidepressants)
Sympathomimetics (cocaine,
amphetamines)
MYDRATICS Tropicamide used in examination of
retina and other deep structure.
GLAUCOMA Damaged the iris

INFLAMMATION OR TEAR OF THE IRIS
INVESTIGATION
Slit lamp examination

Opthalmoscopy

Tonometry determine whether glaucoma is present

TREATMENT
Based on causes
Symptomatically :
phenylephrine (1-adrenergic receptor agonist)
Scopolamine (muscarinic antagonist)
Relative Afferent Pupillary Defect
(RAPD)
Also known as Marcus Gunn pupil, which indicates
an afferent defect.
Usually at the level of the retina or optic nerve.
The ability to perceive the bright light is diminished.
Pupillary response to light : on affected side is
reduced


CAUSES RAPD
Optic nerve disorder
Unilateral optic neuropathies are common cause
of an RAPD.
If condition is bilaterally symmetrical, there will
not be RAPD.
Retina diseases
It had to be quite severe for RAPD to be clinically
evident.


SWINGING FLASHLIGHT TEST
RAPD +ve : affected eye cause only
mild constriction (therefore appearing
dilate) of both pupils
dt decrease response to light from
afferent defect
light shone in the affected eye will
produce less pupillary constriction
than light shone in the unaffected eye.

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