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Flashcards in Abnormal pupils Deck (18):
1

Horner's syndrome signs on examination

Face: PEAS
Partial ptosis (superior tarsal muscle)
Enophthalmos
Anhydrosis
Small pupil
NO ophthalmoplegia
Neck scars:
Central lines
Carotid endarterectomy
Hands:
Complete claw hand + intrinsic hand weakness
Reduced or absent sensation in T1

2

Completion of a Horner's examination

Cerebellar exam
CNS and PNS

3

Differential diagnosis for Horner's

Central:
Multiple sclerosis
Lateral medullary syndrome
Pre-ganglionic (neck):
Pancoast's tumour (T1 nerve root)
Trauma from central venous access insertion or carotid endarterectomy
Post-ganglionic:
Cavernous sinus thrombosis - usually secondary to spreading facial infection via the ophthalmic veins; would include CN 3,4,5,6 palsies.

4

Features of oculomotor nerve palsy

Complete ptosis (levator palpebrae superioris)
Eye points down and out: unopposed superior oblique and left rectus
Dilated pupil, doesn't react to light (unless spared in early medical oculomotor palsy)
Ophthalmoplegia and diplopia

5

Medical versus surgical oculomotor nerve palsy

Parasympathetic fibres originate in Edinger-Westphal nucleus and run on periphery of the oculomotor nerve.
They receive rich blood supply from the external plial vessels.
These fibres are affected late in ischaemic causes (medical) but early in compression (surgical).

6

Causes of medical oculomotor nerve palsy

MMMM
Mononeuritis, e.g. DM
Multiple sclerosis
Midbrain infarction
Migraine

7

Causes of surgical oculomotor nerve palsy

Raised ICP (transtentorial herniation compresses uncus)
Cavernous sinus thrombosis
Posterior communicating artery aneurysm

8

Describe Holmes-Adie pupil

AKA myotonic pupil
Dilated pupil that has no response to light and sluggish response to accommodation
Reduced or absent ankle and knee jerks.
Benign condition more common in young females.

9

Features of Argyll Robertson pupil

Small, irregular pupils
Accommodate but doesn't react to light
Atrophied and depigmented iris

10

Extra tests for Argyll Robertson pupil

Offer to look for sensory ataxia (Romberg's test): tabes dorsalis
Dipstick urine: glucose (DM)

11

Causes of Argyll Robertson pupil

Quaternary syphilis
DM

12

Synonym for relative afferent pupillary defect (RAPD)

Marcus Gunn pupil

13

Features of RAPD

Minor constriction to direct light
Dilatation on moving light from normal to abnormal eye

14

Features of optic atrophy

Reduced visual acuity
Reduced colour vision: especially red desaturation
Central scotoma
Pale optic disc
RAPD

15

Causes of optic atrophy

Commonest: multiple sclerosis, glaucoma
CAC VISION
Congenital
Alcohol and other toxins
Compression
Vascular (DM, GCA, thromboembolic)
Inflammatory: optic neuritis (MS, Devic's, DM)
Sarcoid
Infection (VZV, TB, syphilis)
Oedema (papilloedema)
Neoplastic infiltration: lymphoma, leukaemia

16

Congenital causes of optic atrophy

Leber's hereditary optic neuropathy (mitochondrial, onset in 20s, presents with attacks of acute visual loss)
CMT
Friedrich's ataxia
DIDMOAD

17

Toxins causing optic atrophy

Alcohol
Ethambutol
Lead
B12 deficiency

18

Compressive causes of optic atrophy

Neoplasia: optic glioma, pituitary adenoma
Glaucoma
Paget's