Mohammad Pakravan MD Associate Professor Labbafinejad Medical Center

Pupils Are a round and equal holes in the middle of iris which adjust light entrance into the eye. Sphincter by 3th N, dilators by sympathetic 3 to 6 mm in normal light. They are larger in children than eldery. Miosis is pupil diameter less than 3 mm. - cholinergics - morphine - sleeping Mydriasis when pupil diameter more than 6mm

Dyscoria Abnormalities of pupil shape Corectopia Polycoria Iridoplegia in response to light and near effort Iris bombe

Anisocoria physiologic less than 0.5mm - more prevalent in elderly Sphincter rupture PS in uveitis AACG 3th n palsy - compressive - microvascular Horner syndrome

Horner’s syndrome Miosis, ptosis, anhydrosis Any problem in sympathetic pathway - boroncogenic carsinoma of lung apex (pancost’s tumor) - neck trauma - syrengomyelia - aorta or carotid artery aneurysm - neck spinal tumor - idiopathic congenital (heterochromia iridis) - brain stem vascular abnormality

Pharmacologic tests for anisocoria Cocaine 4- 10% prevent reuptake of neurepinephrine and induce mydriasis in normal eye but not in Horner’s syndrome. Hydroxyamphetamine 1% releases neuradrenaline in synapsis and is effective in preganglionic type but not effective in postsynaptic type.

Sympathetic pathway Brain stem > medulla > C8, T1, T2 > apex of lung > aorta > superior cervical sympathetic chain > internal carotid > muller muscles and dilator muscle of pupil

Parasympathetic pathway Pupillomotor nerves > brain stem sublentiform nucleus > edinger westphal nucleuses> 3th N nasocilliary > ciliary ganglion > sphincter muscles of iris

TAPD (total afferent pupillary defect); amarotic pupil The eye in affected side is totally blind.

RAPD (relative afferent pupillary defect); Marcus Gunn Pupil In retinal or optic nerve disease Not seen in cataract Is graded from 0 to 4+

Argyll-Robertson pupil; Tabes dorsalis Small, irregular, unequal pupils Usually bilateral Response to light is small or negative. Remained response to accommodation Usually bilateral Pupils dilate poorly

Tonic pupil; Holmes Adie Innervations of Pupillary sphincter and or ciliary muscles are involved 80% unilateral Benign and more prevalent in females Involved pupil is dilated and irregular Poor response to light Remained response to near Maybe accompanied by deep tendon reflex involvement (Adie’s syndrome) Slow accomodation