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Efferent Pupil Testing Flashcards

1
Q

What % of the normal population have a simple, central (see-saw) anisocoria?

A

20%

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2
Q

This type of syndrome is anisocoria with one eye larger in bright light and the other larger in dim light.

A

Tonic Pupil Syndrome

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3
Q

Tonic pupil syndrome is associated with damage where?

A

Ciliary Ganglion

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4
Q

What topical med is used to determine if a tonic pupil is present?

A

Pilocarpine 0.125%

- if tonic, pupil will constrict in 30 mins

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5
Q

If you place 0.125% of pilo in the eye and it does not constrict, what are your 2 differentials?

A
  1. Pharmacologically dilated pupil

2. CN III

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6
Q

If we use pilo 1%, what will happen to an eye with a CN III palsy?

A

Constricts pupil

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7
Q

What is a paradoxical pupil?

A

An anisocoria greater in light AND dim

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8
Q

What are the 3 S’s of Tonic pupil?

A
  1. Sector Paralysis
  2. Stromal Spread
  3. Stromal streaming
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9
Q

What are the 3 general causes of tonic pupil?

A
  1. Local disease
  2. Neuropathic (systemic) - diabetes
  3. . Idiopathic (Adie’s)
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10
Q

When is the only case an unequal add is indicated?

A

Unilateral tonic pupil

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11
Q

Adie’s tonic pupil is due to what?

A

Aberrant regeneration of CB fibers to the iris sphincter

  • pupil constricts when the patient attempts to accommodate
  • idiopathic (dx of exclusion)
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12
Q

An acute onset of CNIII palsy with pupil involvement is an anuerysm where?

A

At the junction of PCOM and ICA

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13
Q

What is the etiology of dorsal midbrain syndrome?

A

Compression of dorsal, rostral midbrain in region of posterior comissure

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14
Q

What is the 1st thing to do when you suspect a patient of having DMS?

A

Neuroimaging = MRI/MRV

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15
Q

In DMS, which pupil would be considered abnormal?

A

The large one

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16
Q

What are the 4 signs of DMS?

A
  1. Tectal Pupils
  2. Convergence Retraction Nystagmus
  3. Upgaze Paresis (dorsal midbrain contains upgaze center)
  4. Eyelid retraction (Collier’s sign)
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17
Q

Uncal herniation due to dudden increased ICP shifting cerebelar contents results in what?

A

Hutchinson Pupil (blown pupil)

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18
Q

What is the oculosympathetic triad for Horner’s?

A
  1. Ptosis
  2. Miosis
  3. Anhydrosis
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19
Q

In horner’s, we’re concerned about the ______ pupil with the ______ aperture.

A

small pupil, small aperture

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20
Q

When is the anisocoria greater in a horner’s patient?

A

Anisocoria greater in dim lighting

- horner’s pupil is small, won’t dilate

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21
Q

What is the gold standard diagnostic drop for Horner’s dx? Will the eye dilate?

A

Cocaine

- no the pupil won’t dilate

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22
Q

A horner’s pupil is a lazy dilator, meaning what?

A

The anisocoria will be greater at 5 seconds than at 12 seconds in darkness

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23
Q

When using apraclonidine to diagnose Horner’s, what is our endpoint?

A

Reversal of anisocoria

  • before = horner’s pupil was smaller
  • after = horner’s pupil is bigger
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24
Q

How long should you wait after instillation of apraclonidine to dx horners?

A
  • wait 30 mins

- if no reversal, wait another 30 mins

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25
Apraclonidine is contraindicated in what type of patients?
Patient's under 2; must use cocaine
26
What's muscle is affected in Horner's syndrome?
Muscle of Mueller
27
The muscle of mueller can only give how much of a ptosis?
1-2mm
28
The levator opens the eye how many mm?
17-20mm
29
If you soak a patient's finges in water and check the fingertips for wrinkling, but they don't. What does this indicate and what is it called?
- indicates poor sympathetic innervation | - called Brachial Plexus
30
If patient presents with a right Horner's and a right CN IV palso, where does the lesion localize to?
Cavernous sinus
31
If a patient presents with a right Horner's and a left CN IV palsy, where does the lesion localize to?
Midbrain (brainstem) issue
32
Foville syndrome is found at the level of the ___ and is an infarct of the ____.
- level of the pons (Pontine glioma can cause this) | - infarct of Anterior Inferior Cerebellar Artery (AICA)
33
Wallenberg syndrome is found at the level of the _____ and is an infarct of the _______.
- level of lateral medulla | - infarct of vertebral artery/posterior inferior cerebellar artery (PICA)
34
Phrenic Nerve syndrome is found at the level of the _____. What is the triad?
- level of spinal cord | - hoarseness, hiccups, Horner's
35
Phrenic nerve syndrome is usually found in whom with what dx?
- usually found in females with metastatic breast cancer
36
What is the triad of an apical lung tumor (Pancoast's tumor)?
1. Ptosis 2. Arm Pain 3. Miosis
37
A painful horner's is consider what until proven otherwise?
Carotid Artery Dissection
38
Why is a carotid artery dissectin a medical emergency? How is it managed?
- lack of blood flow to the brain due to a small lumen = stroke - immediate MRI/MRA of neck, CTA
39
Vernet's syndrome is a tumor where? What are the findings?
- Tumor at the base of the skull | - droopy shoulder, tongue deviates to one side, hoarse voice
40
What are the associated symptoms of Tonic pupil?
- Decreased deep tendon reflexes | - Diminished corneal sensitivity
41
What drug is used to determine pre from post ganglionic Horner's?
- 1% Paredrine (Hydroxyamphetamine)
42
In a (-) test, Paredrine will dilate the pupils in what instances?
- 1st or 2nd order (pre-gang) | - Acute 3rd order
43
In a (+) test, Paredrine will not dilate the pupils in what instances?
- non-acute 3rd order (post gang)
44
If you drop a patient with Paredrine and it dilates, what does this mean?
- Negative Test | - Preganglionic or Acute 3rd order
45
If you drop a patient with Paredrine and it doesn't dilate, what does this mean?
- Positive Test | - Postganglionic, Non-acute 3rd order
46
Adults: For 1st and 2nd order Horner's lesions, what should be imaged?
Mid-thorax to level of mandible
47
Adults: For 3rd order horner's lesions, what's the management?
Possibly no workup | - usually benign
48
Horner's is found in 17.5% of neuroblastoma cases. What's the average age of dx for this disease?
2 years old | - don't use aproclonidine to dx; must use cocaine
49
What specific urine test are needed for a neuroblastoma workup? Why?
- VMA = Vanyllymandelic Acid - HVA = Homovanillic acid (both of these are produced by the tumor)
50
For a 1st order Horner's, what 2 things are we concerned about. What do we check?
1. Vascular or Trauma | 2. Check brainstem
51
For a 2nd order Horner's, what are we concerned about and what do we check?
1. Neoplasia | 2. Apex of the lung (pancoast)
52
For a 3rd order Horner's, what are we concerned about?
- nothing, usually idiopathic | - benign
53
What is the causative agent in neuro-syphilis?
Treponema Pallidum
54
Argyll-robertson is caused by a syphilitic lesion of what?
- lesion of peri-aqueductal gray region in the midbrain | - most common lesion in neurosyphilis
55
What are the blood tests for syphilis?
``` RPR = current active infection FTA-ABS = pt had syphilis before, not active ```
56
How do we distinguish syphilis from neurosyphilis?
VDRL = Lumbar puncture
57
What is the tx for neurosyphilis?
IV PCN
58
What are the 5 causes of LND?
1. Tonic pupil 2. AG neurosyphilis 3. Amaurotic Pupil 4. CN III aberrant degen. 5. DMS (tectal pupil)
59
What are the 3 causes of a small pupil?
1. AG/Neurosyphilis 2. Horner's syndrome 3. Miotics
60
What are the causes of a large pupil?
1. Tonic Pupil 2. Mydriatics 3. CN III palsy 4. DMS/Tectal pupils 5. Uncal herniation (Hutchinson's pupil)

Neuro-Malloy (16 decks)

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