MT1

Question 1

Name for sympathetic problem- pupil won’t dilate in dim lighting

Answer 1

Oculosympathetic paresis/horners

Question 2

Name for parasympathetic problem- pupil won’t constrict in bright lighting

Answer 2

Internal ophthalmoplegia

Question 3

Au sign

Answer 3

Think pt is malingering about uveitis. Shine light in normal eye- uveitis eye should still hurt from constriction.

Question 4

Pathway of neurons from GC axons to edinger westphal

Answer 4

GC axons– optic nerve – chiasm – optic tract (Dessecate)
Some go to LGN, others go to pretectal nucleus in the midbrain.

From pretectal nucleus, fibers travel and descassate at the posterior commissure, then half go to ipsi EW and half go to contra EW

Question 5

(+) APD? Where is the disease

What should you do if the nerve looks normal?

Answer 5

Anywhere from ganglion cell to anterior knee of the chiasm

Order MRI of the orbits

Question 6

Indirect APD test

Answer 6

If one pupil is fixed because posterior synechiae or something else- if you shine light into it, look at the consensual response of the other eye. Compare it with direct response of the other eye.

Direct > Consensual of the same, good eye? APD of fixed eye.

Question 7

2 other ways to determine if pt has an APD

Answer 7

Pupil cycle time- count 100 cycles. 954msec is normal.

RAPDX

Question 8

Light near dissociated pupil occurs in

Answer 8

• Amaurotic pupil (APD/marcus gun??????)
• Tonic Pupil (affecting ciliary ganglion, large pupil abnormal)
• Argyll Robertson (affecting brainstem, small pupil abnormal)
• Tectal pupils
• Tabes diabetica
• Aberrant regeneration of CNIII

Question 9

3 steps to eval anisocoria

Answer 9

1. Is it pathological or congenital? (Primary essential anisocoria in 15% of population)
2. Which eye is abnormal?
3. Is it due to the muscle, NMJ, nerve, or brain?

Question 10

Amaurotic pupil

Answer 10

Completely blind eye with APD/Marcus Gunn

Has light near dissociation

Question 11

APD is a monocular or biolcular phenomenon

Answer 11

Bi-ocular because when you shine light in the bad eye, both eyes will dilate

Question 12

Pt presents with poor VA and no APD? 6 things could be causing decreased acuity

Answer 12

1. Refractive error
2. Media opacities
3. Suppression amblyopia
4. Stress syndrome
5. Macular lesion
6. Anterior chiasmal syndrome

Question 13

What could be the causes of an abnormally dilated pupil?

Answer 13

Paresis of the sphincter (more common)

Dilator irritation- less common

Question 14

What could be the causes of an abnormally constricted pupil?

Answer 14

Paresis of the dilator (Horners)

Sphicter irritation- common in anterior uveitis

Question 15

large pupil due to a muscle problem

Answer 15

Posterior Synechiae
Narrow angle glaucoma
Ocular trauma (irido-dialysis)

Question 16

Law of denervation supersensitivity

When to do this?

Answer 16

Do this if you think your patient has a pharmacological induced dilated pupil!!!! or Tonic pupil!!
Low concentration of pilo.
Normal or pharmacologically dilated eye? No constriction.
Tonic pupil? Constriction

Defect in CN III? NMJ becomes very sensitive to low concentration of ach. Will react more- constrict more than the normal eye.
BUT don’t ever put drops in the eye of someone who has a CN III palsy!!!!!!!!!!!!!!!

Tonic pupil will constrict

So. Abnormally dilated pupil. P sure its not CN III palsy. Do dilute pilo test. No constriction? No synechiae, cyclo-dialysis or glaucoma? 99% sure its due to pharm

Dilute pilo test:
Normal or pharm- no constriction
Tonic or palsy- constriction

Question 17

What is the most common cause of a fixed dilated pupil?

Answer 17

Drugs

Question 18

Large pupil due to a nerve problem

Answer 18

1. Tadpole pupil. Spasm of the dilator muscle. Goes away in 1-2 weeks
2. Tonic pupil
3. CN IIII palsy

Question 19

3 types of tonic pupils that all look the same

Answer 19

1. Local- Tumor, varicella infection, damage due to surgery
2. Neuropathic - Syphillis, DM, sarcoidosis (people are usually aware they have a disease)
3. Aides/Idiopathic

Question 20

Stats about Aides

Answer 20

Women 20-40
90% unilateral
80% symptomatic - 72% aniso, 35% blurry vision and ciliary muscle related problems

Question 21

4 qualities to look at size and shape of tonic pupils

Answer 21

Sector paralysis - flat is abnormal
Stromal stream- dynamic. Stream towards working sphincter.
Pigment seam- ectropion is normal
Stromal spread- tight stromal fibers are normal

Question 22

Ciliary ganglion 30: 1

Answer 22

30 accommodative fibers: 1 pupilomotor

Question 23

A tonic pupil does not always mean a problem with the ciliary ganglion. Other cause?

Answer 23

Traumatic iridoplegia- damage to short ciliary nerves
Post or preganglionic denervation
Regeneration of CN III
Midbrain oculomotor sign

Question 24

Supersensitivity testing using accommodation

Answer 24

1. Refract to 20/20
2. Drop with pilo
3. Refract to 20/30
   Affected eye will have greater increase in myopia

Question 25

Pt with aides - how do you treat Accommodative paralysis? Accommodative spasm?

Answer 25

pilo | Tropicamide

Question 26

Holme's Aides | Ross's

Answer 26

Aides + Diminished deep tendon reflex | Aides + Diminished deep tendon reflex + excessive sweating

Question 27

Acute onset of painful CN III palsy with pupil involvement

Answer 27

Aneurysm of posterior communicating artery *Can start out small, but then blows. Compresses CN III-pupil fibers on the periphery of the nerve.

Question 28

Acute onset of painful CN III palsy withOUT pupil involvement

Answer 28

DM of ischemic vascular etiology Needs medical referral to internist This occurs because infarct occurs in the core of CNIII, pupil fibers run on the outside of CNIII.

Question 29

See mixed cranial nerve palsies in 1 eye?

Answer 29

Think MG then cavernous sinus then diabetes

Question 30

OD larger in bright, and OD smaller in dim? | with and without EOM involvement. Where is the lesion?

Answer 30

With EOM involvement? Think cavernous sinus. | WithOUT EOM involvement? Think ciliary ganglion

Question 31

Large pupil due to a brain problem

Answer 31

Uncal- Truma, hemorrhage of the uncus in the temporal lobe, which compresses the brainstem/CN III. Likely to lead to death. Always get brain scan after head trauma. Hutchinsons pupil- fixed dilated pupil associated with Uncal Parinaud syndrome- Tumor of the pineal gland. See earlier puberty. Near light dissociation.

Question 32

Hutchinsons pupil is a fixed dilated pupil associated with what

Answer 32

Uncal syndrome- Uncus hemorrhage due to trauma, causing CN III palsy. Initially, pupil is mitotic, then becomes dilated on the same side as the mass. Can eventually become bilateral.

Question 33

Signs of parinauds syndrome

Answer 33

Light near dissociated pupil Convergence retraction nystagmus - attempt to look up, get convergence and nystagmus. Lid retraction (Colliers sign) Precocious puberty