Flashcards in Anisicoria and Ptosis Part 1 Deck (50):
_____ refers to unequal pupillary size. It may be physiologic or pathologic. Physiologic anisicoria is present in 20% of the patient. and it is usually
Pathological anisocoria is always caused by a defect in the ____ pathway and the iris _____ is the most common.
What is the pathway of the sympathetic chain to dilate your eyes
Start in hypothalamus through brain stem down spinal cord preganglionic 1st order neuron. Then synapse within the spinal cord, exit, travel up around the apex of the lung and then synapse in superior cervical ganglion at the level of your jaw-2nd order neuron, still preganglionic. 3rd order is postganglionic that will wrap around internal carotid, through carotid canal, through cavernous sinus and distributed via V1 (long ciliary nerve) mueller’s muscle dilator. Long ciliary nerve goes to dilator
______ ciliary nerves get distributed to your sympathetics. The _____ ciliary nerves get distrubuted to your parasympethics (iris sphincter and ciliary muscle) to constrict your eye.
long; short (subdivisions of trigeminal nerves)
short: bring afferent from surface of cornea and eyelids thats going back to your trigeminal ganglion and distribute the post ganglionic para sympathetics.
short and long: distrubute the sympathetics.
PS lesion can be anywhere from:
EW nucleus, CN III, ciliary ganglion, short ciliary nerves.
Anisicoria greater in bright is due to ______ lesion. Anisicoria greater in dim is due to _____ lesion. Anisicoria equal in bright and dark is physiologic.
An afferent lesion would indicate what?
the consensual will be better than direct.
An efferent lesion would indicate what?
Both direct and consensual will be absent.
What does pupil evaluation include?
1. direct vs consensual response
2. eyelid position
3. slit lamp evaluation
What are the 6 pupillary disturbances
1. Marcus Gunn pupil:
2. Horners syndrome
3. Postganglionic Denervation (Adies Tonic Pupil, Neurotrophic): something is happening after the ciliary ganglion
4. Pupil in Midbrain Disease- Dorsal midbrain syndrome and Argyll Robertson pupils (teriary syphillis)
5. Pupil in Third Nerve Palsy
6. Pharmacologic Blockade: pupil is blown (scopalamine)
Marcus Gunn pupil shows a relative asymmetry in the _____visual pathway. It NEVER causes anisicoria. And is usually accompanied by a reduction in VA, color vision, contrast sensitivity, or visual field on the affected side.
Horner's syndrome is damage to the sympathetic chain. _____ is the NT at the muscular junction of the sympathetic system.
___ order neuron lesion will be due to ischemic stroke (bc still in brain tissue) or demyelinating in young patients. _____ order neuron lesion will be usually a lung tumor or a carotid artery dissection (tear within wall of artery) where all the blood gets rushed into tear instead of going up and into the eye. ______order neuron lesion is due to carotid artery dissection and other benign causes.
What are some signs of Horner's Syndrome?
1. anisicoria greater in dim light
2. dilation lag of abnormal pupil
3. smaller pupil is abnormal and ipsilateral to lesion
4. normal pupillary light rxn (bc PS is in charge of this)
5. ipsilateral upper eyelid ptosis and lower lid reversed ptosis
The cocaine test is confirmatory test for Horner's syndrome. Describe how it works.
4-10% cocaine blocks reuptake of NE. NE is the NT at the NMJ, In this situation your eye is releasing NE, but not to a large extent. If you block the reuptake you get accumulation of NE at the NMJ, and the pupil starts dilating much better.
In _____ anisicoria the pupil will dilate because the sympathetic pathway is intact and the NE is being released. In ______ anisicoria there is no effect/minimal effect on the pupil because third order neuron is not being stimulated. Nothing is telling it to release NE therefore, no pupillary dilation and there is a lesion in your sympathetic chain.
What is the procedure for testing pathologic anisicoria
Place 10% diluted cocaine eyedropper into both eyes. Wait 45 mins. Examine the pupils in dark.
What are common and uncommon causes of acquired Horner's syndrome in the first order neuron (central)
common: lateral medullary stroke
uncommon: hypothalamic, midbrain, or pontine injury, spinal cord lesion
What are common and uncommon causes of acquired Horner's syndrome in the second order (preganglionic) neuron
common: pancoast tumor (lung)
brachial plexus injury
carotid artery dissection
uncommon: cervical disc disease
what are common causes of acquired Horners syndrome in third order (postganglionic) neuron
carotid artery dissection
cavernous sinus lesion
What is a carotid artery dissection. What is its etiology?
occurs when blood enters the arterial wall and separates its layers. This happens in acute Horner's and ipsilateral headache or pain and ipsilateral signs of ocular or cerebral ischemia.
-secondary to minor trauma
-collage disorders (marfans or ehlers danlos syndrome)
* if suspected, order STAT MRA
An iris heterochromia is usually congenital. Facial/neck pain is usually due to carotid dissection. Ipsilateral CN VI palsy is due to cavernous sinus lesion. Loss of sweating in entire half of body is due to _____ lesion. 2nd order neuron lesion will be loss of sweating to whole face and neck. A third order neuron lesion will cause loss of sweating to _____only Hand weakness/clawing is due to spinal cord lesion.
T/F Sympathetic chain also distributes melanocytes which is why you may see iris hetrochromia with horners
how do you test for sweating?
have pt run in place and take prism bar and run over face. if no sweat, then it will go down smoothly.
Pharmacologic testing to localize site of lesion includes using hydroxyamphetamine (paredine) stimulates release of NE from presynaptic ____ order neuron which dilates normal pupil. It dilates 1st and 2nd order neuron. Failure to dilate indicates _____ order neuron lesion.
Phenylephrine has an effect on the ____ order neuron due to denervation super sensitivity. Does not dilate ____/preganglionic pupil
3rd; central (opposite of hyroxyamphetamine test)
what do we use for diagnosis of horner's syndrome?
what do we use for localization of horners syndrome
hydroxyamphetamine and phenylephrine
If its a central or preganglionic lesion in acute horners syndrome what do we need to do?
1. cervical spine MRI
2. Chest CT
3. MRI with detailed views of the brainstem
4. MRI/MRA or CT/CTA of neck (if we suspect ICA dissection)
If its acute horners syndrome due to postganglionic lesion what do we need to do?
MRI of brain with detailed views of cavernous sinus
MRI/MRA of neck to rule out carotid artery dissection
in congenital horner's we must rule out:
1. birth trauma
How do we manage horners syndrome in children? what about in adults?
children: image to rule out rumors
1st order: neuroimage with attention to brainstem
2nd order: image mid- thorax to angle of jaw
3rd order: MRI and MRA of neck, MRI of brain with attention to cavernous sinus.
A tonic pupil is due to postganglionic denervation caused by damage to _____ ganglion and/or short ciliary nerves
What are signs of a tonic pupil
1. mid dilated pupil
2. sluggish/unreactive to light and near
3. slow re dilation after constriction
4. sector iris paralysis with vermiform iris movement
5. constricts 0.1% pilocarpine
horner's is sensitive to dilute ____. tonic pupil is sensitive to dilute ______
Denervation supersensitivity is when an organ deprived of its _________nerve supply becomes supersensitive to transmitter substance. Its hungry for NT. The iris sphincter becomes super sensitive to acetylcholine (PS NT) and pilocarpine. Once constriction is obtained, super sensitivity prevents normal rapid redilation.
local tonic pupils damages ______ ______ and/or short ciliary nerves. This is due to tumor, trauma, inflammation (HZV) or could be idiopathic
systemic/neuropathic tonic pupil is due to ______, secondary syhpillis or myotonic dystrophy. Idiopathic would be Adies tonic pupil
Adies syndrome is typically unilateral, more common in women, usually in _____year olds. They will have reduced/absent accommodation, absent deep tendon reflexes, and pupil becomes ______ over time.
Features of Adies are that pupils are initially large and react poorly to light and slowly to near stimulus....redilates slowly after constriction. It is often accompanied by tonic accommodation (defective near response). Pupil also exhibits _____ paralysis with vermiform movement seen on slit lamp
Presentation of Adie's Tonic pupil includes:
1. sudden anisiocira noticed by patient or others
3. difficulty reading
4. difficulty reading
5. difficulty refocusing from near to far stimulus
6. May complain of photobopia (pupil is blown causing more light to get into eye)
7. More commen in women.
How do we pharmacologically test for adie's tonic pupil?
instill 0.1% pilo OU, measure pupils 45 min later, tonic pupil will constrict markedly, normal pupil will not constrict.
How do we manage Adie's tonic pupil?
For symptomatic patients:
1. cosmetic CL to reduce anisocoria
2. weak pilocarpine solution to relieve accommodative problems
3. bifocal correction for acommodative problems.
pupil in midbrain disease (pretectal pupils of the dorsal mid brain) are when you have mid dilated pupils unreactive to light, but briskly reactive to near stimulus. It is usually _____and usually due to ______ gland tumor or hydrocephalus. You get up gaze paresis, convergence retraction nystagmus on attempted up gaze, and eyelid rectraction.
Argyll Robertson Pupils also exhibit light near dissociation with brisk near response, but they are ______. They dilate poorly in the dark. This is due to damage in the ______midbrain due to neurosyphilis. Unlike neuropathic pupils caused by primary or secondary syphillis, argyll robertson pupils will react briskly to a near stimulus.
Pupil in CN III palsy will usually be _____ dilated, and is associated with ptosis, restricted adduction/supraduction/infraduction. This requires a STAT ER transport to r/o intracranial aneurysm.
pupil in pharmacologic blockade may be purposeful or accidental. Causes largest, fixed and dilated or smallest, fixed and miotic pupils. It cannot be overcome by topical agents. It is usually caused by ________ agents.
-anticholinergic nasal sprays
How do we test for pharmacologic blockade in a mydriatic pupil
1. instill 2 gtts 1% pilo OU
2. wait 45 mins
3. anything less than full constriction is a positive test
How do we test for pharmacologic blockade in a miotic pupil
1. instill 2 gtts 1% tropicamide OU
2. wait 45 mins
3. anything less than full dilation is a positive test