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145 Cards in this Set

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___________: pupils of unequal size
anisocoria

17% of normal pop have unequal pupil size

5% have greater than a 1 mm difference
To detect anisocoria, you must measure _____________
pupils in BOTH BRIGHT and DIM illumination
If Anisocoria is GREATER in bright light where is the problem?
PARASYMPATHETICS --> problem with the iris constrictor


(larger eye is abnormal)
T/F If anisocoria is greater in bright light the problem must be sympathetic
FALSE

parasympathetics
If Anisocoria is greater in dim light, it is a sign of what?
SYMPTHETIC involvement --> problems with dilator (smaller eye is abnormal)
Anisocoria in which one eye is LARGER in bright light and the other eye is LARGER in dim light is a sign of what?
PARASYMPATHETIC and SYMPATHETIC INVOLVEMENT --> TONIC PUPIL SYNDROME
What is Tonic pupil syndrome
Anisocoria in which one eye is LARGER in bright light and the other eye is LARGER in dim light

may be a lesion at the cavernous sinus since both para and sympathetic fibers are present
Anisocoria which is equl in both bright and dim illumination is known ass
Benign essential anisocoria-physiologica. Look at family album to se if its long standing
Simple Central "See-Saw" anisocoria characteristics
20% of normal population

anisocoria of the same amount of bright and dim, but may vanish in light--> switches from one eye to the other=see-saw
One of the most common causes of dilated pupils is what?
iadvertent or purposeful inistillation of drops in the eye -->
scolopamine that is used for motion sikness could get on hands and touch eye leading to dilated pupil
How do you determine if pupils are pharmacologicaly dilated?
in normal pt, the instillation of 1/8% pilocarpine shoudl NOT elicit a pupillary response.

HOWEVER, if there is a neurologica deficit, the 1/8% pilocarbine will cause CONSTRICTION after 30 minutes since the receptors respond to small concentrations of pilo if neuro problems exist.

NORMAL pts with a pharmocological dilated pupil will NOT respond to 1/8% pilocarpine
T/F NORMAL pts with a pharmocological dilated pupil will NOT respond to 1/8% pilocarpine
T

only neurological deficit pts due --> causes constriction
A women notices that under bright light, OD pupil is larger than left, however at near, both pupils constrict, this is known as?
Light near dissociation
What are the 5 causes that lead to LIGHT NEAR DISSOCIATION

IMPORTANT
1.Argyl-Roberts (sphyilis)
2.Doral Midbrain Syndrome
3 Amaurotic eye
4. Tonic pupils
5. Abberent regeneration


A TADA
Typical size of Argyll-Robertson pupil:
less than 2.5 mm
OS greater than OD in dim
OD greater than OS in bright

Diagnosis?
Tonic pupil syndrome
one eye does not dilate or constrict well.

HOWEVER:near constriction is NORMAL --> light near dossciation present

miosiss does occur when pilocarpine is admiinstered
T/F Tonic pupil syndrome pts have light-near dissociation present
T
4 common Tonic pupil immitators:
1. posterior synechia
2. acute angle closure glaucoma
3. bitemporal sphincter palsy/temporal iris ischemia
4. Tadpole pupils (during headache, pupil is oval, otherwise, it is round)
a tonic pupil is ________ and is the ___ pupil in bright light and the ___ pupil in dim light
mid-dilated
larger
smaller


also has light-near dissociation
Tadpole pupils are often seen due to what?
secondary to migranes. pupil shoes unsual dilation and lasts only about 2 minutes during headaches, pupil looks like a tadpole
3 cardinal signs of tonic pupil
Sector paralysis
Stromal spread
Stromal streaming
What is sector paralysis?
a tonic pupil looks different because part of the pupil is curved and part is flattened. The FLAT region is due to sectors of the iris that are paralyized.

Each sector is innervated by a branch of othe short posterior ciliary nerve
What is stromal spread?
the iris has roadial folds that reflects the tone between the sphincter and dilator muscles.

Loss of parasympathetic tons causes the stroma to disorganize and the laxity of the iris surface reflects the loss of tone.


cardinal sign of tonic pupil
What is stromal streaming?
to visualize, you must turn off the slit lap, tur the light on at 45 degrees and turn the light back on.

damage diris will stream towards the tight, functions part of the iris
The stromal streamign will appear to move like a draw string ba. When light is on iris, the nomra part stream will tighten, but the bad part does not move at all.
Clinical features of tonic pupil
flat edges of iris
vermiform iris movement (non-uniform constriction 260 degrees)
poor reponse to light and near or light-near dissociation
dilation lag followed prolonged near effort
paradoxical pupil- anisocorica greater in light and dim
What causes tonic pupil?
CILIARY ganglion is damaged
2 possible causes of adies tonic pupil?
ciliary ganglion damage OR
aberrant regenration of CB fibers to iris sphincter so that pupil constriction when pt tries to accomodaqqte
____ is the origion of the parasypathetic pupillomoter fiber pathway
edinger westphal nucelus


only 3% of the fibers from the Edinger Westphal nuclus are bound for the sphincter muscle
only __% of the fibers from the Edinger Westphal nuclus are bound for the sphincter muscle
3
________% of the edinger westphal fibers are used for accomodative function
90%
Why is there near-light dissociation?
there are 30x more fibers at the EW nuceus for accomodation than for dilation. Thus damage to the ciliar ganglion ther will be a smaller portion of accomodatve fibers and therefore, accomodation will be intact. However, damage to the few fibers constriction fiber will have a much larger effect
T/F Quinine can cause tonic pupil
T
____ tonic pupil is infetion in the orbit
local

due to chicken pox of the eye, retrobulbar masses, ocular surgery (PRP), oribtal tumor
Neuropathic causes of tonic pupii include:
DIABETES is the most common cause of light/near dissociation; can lead to bilateral tonic pupils

Syphilis
Sarcoids
Lyme

If you can rule out all these causes --> Adie's tonic
_________is the most common cause of light/near dissociation; can lead to bilateral tonic pupils
DIABETES
idiopathic cause of toinc pupil is know nas
Adies

20% are asymptomatic
90% have unilateral presentation
Fellow eye involvement is common at 4% per year
T/F Adies tonic pupil is commonly bilateral
FALSE

90% are unilateral!
T/F Adies Tonic pupil affects women more than wen
T

2.6:1
What affects does Tonic pupil have on corneal?
DIMINISHED corneal sensitivity

sensory fibers from the cornea travel through the ciliary ganglion but do not synapse

lesions of the ciliary ganglion not only affect sympathetic and parasymathetic motor fibers, ut aso sensory fibers form the cornea
What affect does Tonic pupil have on deep tendon reflexes?
Decreased deep tendon reflexes- demmonstrated by the absense of a leg movement we knee is tapped.
managmenet of adies tonic?
leave it alone

-can cycloplege both eyes to relieve discomfort of accomodation
If pt has a CN III palsy and the pupil is involved 86% of the time its due to ___________


If pt has a CN III palsy and has spared pupils 77% are due to ______
aneurysm


vasculopathic
A complete CN III palsy is what?
inability to move eye in or up
A complete CN III palysy and a dilated pupil is the result of ________-
aneurysm
A complete CN III palsy with a spared pupil is usually the result of
diabetes
An incomplete CN III palsy with a dilated pupil is usually the result of _____
ANEURYSM
If you your pt has an incomplete CN III palsy and a spared pupil what is the cause?
CANT TELL --> it may just mean that the pupil has not become involved
An ACUTE onset CN III palsy with puil involvement is an EMERGENCY. What is the cause?
aneursym t the junction of the posteiror communicating and internal carotid arteries


20% die in first 48 hours of subarachnoid hemorrhage.
Dorsal Midbrain Syndrome etiology
compression of dorsal, rostra midbrain in region of posterior commissure

tumor
CSF obstruction
Inflammatory
Infection
Signs of DMS
1.tectal pupils=mid-dilated, don't react well to light but will react to near
2. upgaze pareis= dorsal midbrain contains the upgaze center, patient may present with their chin because of downgaze paresis.
3.Retraction nystagmus- pt tries to look up but eyes go in or out instead of up
4. Eyelid retraction (Collier's sign)- eyes cannot look up but lids rise normally pt tries to
Clinical features of DMS
bilatera myddriasis
pupils fixed to light
preserved near response
suprnuclear paresis of upgaze- comes from the brain
lid retraction
defective convergence
accomodative paresis
possible CN4 palsy
Possible cause of DMS?
pineal gland tumor just posterior to dorsal midbrain.


MUST DO neuroimagin (MRI and MRV)
A blow out pupil is known as
Hutchinson Pupil


when intracranial pressure suddenly increases, the brain can shift downward cuasing the uncus of the parahippocampal gyrus to compress the teraclinoid ligament, wich in turn compresses CN III.
This causes pupil to be FIXED and DILATED
Can Uncal Syndrome be bilateral?
NO

will see unilateral fxed dilated pupil!!

uncus of temporal lobe wil lbe compressing third nerve.
Pupil size:

> BRIGHT = ________________
> DIM = _____________________
> BRIGHT, < DIM = ________________
PARASYMPATHETIC

OCULOSYMPATHETIC


BOTH, TONIC
Pharmacologic Testing for Adie’s Tonic Pupil:
Weak (1/8 or 1/10) pilocarpine
Miosis owing to “denervation supersensitivity”
Acquired phenomenon
LOCAL TONIC PUPIL causes:
VARICELLA
RETROBULBAR
ORBITAL TUMOR
ORBITAL SURGERY
NEUROPATHIC TONIC PUPIL causes:
DIABETES
SYPHILIS
SARCOID
How can you tell if its a tonic pupil?
ANSWER BY SIGNS ACCOMMODATION
TONIC PUPIL IMPOSTERS
POSTERIOR SYNECHIA
ACUTE ANGLE CLOSURE
BITEMPORAL SPHINCTER PALSIES
TADPOLE SHAPED PUPILS
5 Must knows about Tonic Pupils
-MID-DILATED
-LIGHT NEAR DISASSOCIATION
“3 S’s”
Sector paralysis
Stromal spread
Stromal steaming
Pathogenesis of Adie’s Tonic Pupil
Ciliary ganglion
90% CB
3% iris
Aberrant regeneration of CB fibers to iris sphincter (light-near/gaze pupil dissociation)
What do patients with tonic pupil also show signs of?
DIMINISHED CORNEAL SENSATION
DECREASED DEEP TENDON REFLEXES
Management of Tonic pupil:
PUPIL: LEAVE IT ALONE
ACCOMMODATION
(SUPERSENSTITIVITY CRAMP)
TONICITY = TROPINE
PARESIS = ESERINE
OCCLUSION
Phrenic Nerve Syndrome findings:
Usually females
Hoarse
Hiccough
Horner
Can be from metastatic breast CA
Pancoast Tumor TRIAD
Ptosis
Miosis
Arm Pain
CAROTID ARTERY DISSECTION CLASSIC TRIAD
PAIN ON SIDE OF FACE, HEAD OR NECK
OCULOSYMPATHETIC PARESIS WITHOUT ANHYDROSIS
DELAYED RETINAL OR CEREBRAL ISCHEMIA (50-95% of patients)
With pts with carotid artery dissection
_____ had painful Horner’s syndrome
and ______ % with initial presenting eye signs suffered a retinal or hemispheric stroke (average 6.2 days)
44%
36%
CAROTID ARTERY DISSECTION SIGNS
HORNER’S SYNDROME
NECK BRUIT OR SWELLING
CN VI, IX-XII
CRAO
CEREBRAL ISCHEMIA
You Need to consider this diagnosis in EVERY PAINFUL HORNER’s!!!
Carotid Artery Dissection

must send Pt to hospital (MRI, MRA, CTA, angiogram)
What is Vernet’s Syndrome?
Tumor at Base of Skull

Can involve CN IX, X, XI, XII
Horner syndrome (oculosympathetics enter skull at foramen lacerum)
Lesion in nasopharyngeal CA
Droopy shoulder, droopy tongue, winged scapula
Weak trapezius, hoarse, tongue deviated to one side
What happens with Cavernous Sinus Syndrome?
Mixed cranial neuropathies (III, IV, V1, V2, VI)
Miosis (oculosympathetic paresis)
Pain
Dysesthesia
BRAINSTEM lesions that leads to CN III palsy include
TELODIECEPHALIC CNIV; VI; FOVILLE; WALLENBERG
CHEST lesions that lead to CN III palsy include
PANCOAST’S, KLUMPKE’S; PHRENIC

pt will have CHEST / ARM PAIN with pancoasts's


pt will be HOARSE if they have phrenic
NECK lesion that lead to CN III palsy include
CAROTID DISSECTION

NECK / EARACHE is another symptom
Head lesions that lead to CN III palsy include
OTITIS MEDIA; CLUSTER; VERNET’S, CAVERNOUS SINUS, TONSILLECTOMY

OTITIS MEDIA --> earache
How can you isolate where a CNIII palsy occurs?
ANSWER BY:
PAREDRINE

Paredrine test:- This test helps to localize the cause of the miosis. If the 3rd order neuron (the last of 3 neurons in the pathway which ultimately discharges norepinephrine into the synaptic cleft) is intact, then the amphetamine causes neurotransmitter vesicle release, thus releasing norepinephrine into the synaptic cleft and resulting in robust mydriasis of the affected pupil. If the lesion itself is of the aforementioned 3rd order neuron, then the amphetamine will have no effect and the pupil remains constricted. There is no pharmacological test to differentiate between a 1st and 2nd order neuron lesion.
Paredrine test:- is useful for?
helps to localize the cause of the miosis. If the 3rd order neuron (the last of 3 neurons in the pathway which ultimately discharges norepinephrine into the synaptic cleft) is intact, then the amphetamine causes neurotransmitter vesicle release, thus releasing norepinephrine into the synaptic cleft and resulting in robust mydriasis of the affected pupil. If the lesion itself is of the aforementioned 3rd order neuron, then the amphetamine will have no effect and the pupil remains constricted. There is no pharmacological test to differentiate between a 1st and 2nd order neuron lesion.

So if results are NORMAL that means the CNIII lesion is a 1st & 2nd order Horner Syndrome
OR ACUTE 3rd order Horner Syndrome
Normal paredrine test implies what?
CNIII lesion is a 1st & 2nd order Horner Syndrome
OR ACUTE 3rd order Horner Syndrome
What is NEUROBLASTOMA?
Cancer of neural crest cells
Accounts for 97% of all CA of sympathetic NS
Solid tumor cancer
Begins in nerve tissue in neck, chest, abdomen and pelvis
Usually begins in adrenal glands
Average age at dx is 2 years old
Testing for Neuroblastoma
Neuro-imaging (abdomen/chest)
Bone marrow tests
Blood tests
***Specific urine tests
(VMA) vanyllylmandelic acid
(HVA) homovanillic acid
Produced by tumor
A first order CN III palsy is usually do to
VASCULAR, TRAUMA
A third order CN III palsy is usually do to
NEOPLASIA
Cocaine drop test does what
Cocaine blocks the reuptake of norepinephrine resulting in the dilation of a normal pupil. Due to the lack of norepinephrine in the synaptic cleft, the pupil will fail to dilate in Horner's syndrome.
What is an AN ARGYLL-ROBERTSON PUPIL?
MIOSIS (2.5 mm in dark)
ABSENT DIRECT
BRISK NEAR (LND)
PRESERVED VISION
UNILATERAL, ASYMMETRIC OR UNEQUAL
DILATES POORLY
What is TREPONEMA PALLIDUM?
s a gram-negative spirochaete bacterium that causes sphylis

workup includes:RPR, FTA-ABS (VDRL)
management:
IV penicillin (neuro-syphilis)
Repeat serology
ALWAYS suspect recurrence!!!
T/F with a COMPLETE CN III – PALSY
Can use the pupil as a guide
T

INCOMPLETE CN III – PARESIS
Can NOT use the pupil as a guide
IF a CN III palsy has pupil INVOLVED = it usually due to a ______(86%)

if SPARED = ____________ (77%)
ANEURYSM


VASCULOPATHIC
A __________ sign shows a lagging of the upper eyelid on downward rotation of the eye, but is due to aberrant regeneration of fibres of the oculomotor nerve (III) into the elevator of the upper lid
pseudo Graefe's
ABERRANT REGENERATION OF CN III can be caused by
Aneurysm, Tumor, Trauma but
NEVER ______- !
Diabetes
A CN III palsy in an adult requires what workup
20-50 YEARS
CT, MRI, MRA, A-GRAM
A CN III palsy in a pt over 50 includes what workup
(pupil, palsy, pain)
NEUROIMAGING
VASCULOPATHIC EVALUATION
A CN III palsy in children requires what kind of workup?
CONGENITAL (MRI)

ACQUIRED
EXCLUDE TRAUMA OR MIGRAINE
CONSIDER LP IF MRI (-)
IF MRI & LP ARE NEGATIVE > 10 years, ARTERIOGRAM TO LOOK FOR ANEURYSM
Etiology of DMS?
Compression of dorsal, rostral midbrain in region of posterior commissure
Tumor
CSF obstruction
Inflammatory
Infection

ORDER Neuro-imaging ( MRI, MRV)
DORSAL MIDBRAIN SYNDROME (SIGNS)
TECTAL PUPILS
UPGAZE PARESIS
(DOWNGAZE PARESIS, OR BOTH)
RETRACTION NYSTAGMUS
EYELID RETRACTION
Features of DMS:
1. bilateral_____
2. pupils fixed to____
3. preserved ____ response (early)
progression to involve ___ response
4. supranuclear paresis of upgaze
lid retraction ( ____ sign)

defective convergence (“wall-eyed”)
5. convergence/divergence retraction ____

accommodative paresis

6. CN__ palsy (superior medullary velum)
1. mydriasis
2. light
3. near
4.Collier’s
5. nystagmus
6. IV
What syndrome is characterized by:

RESPONSES INTACT
ANISOCORIA > DIM
“LAZY DILATOR”
NO COCAINE DILATION
Horner's
A POSITIVE cocaine test result means
4-10% COCAINE

( + )TEST = NO DILATION!!!

Cocaine blocks the re-uptake of Norepinephrine at nerve terminal
Where can a Horner AND CN IV palsy occur?
At locus ceruleus (next to CN IV nucleus)
A nuclear CN IV palsy
CONTRALATERAL CN IV palsy (crossed)
What is Foville Syndrome?
Level of pons
Infarct of AICA
Gaze palsy (nuclear CN VI)
CN VII palsy
Horner syndrome


Signs:
LATERAL, GAZE PARALYSIS (VI)
FACIAL PALSY (VII)
LOSS OF TASTE (ant 2/3 of tongue) (VII)
FACIAL ANALGESIA (V)
HORNER’S (oculosympathetics)
HEARING LOSS (VIII
Signs of Foville syndrome?
LATERAL, GAZE PARALYSIS (VI)
FACIAL PALSY (VII)
LOSS OF TASTE (ant 2/3 of tongue) (VII)
FACIAL ANALGESIA (V)
HORNER’S (oculosympathetics)
HEARING LOSS (VIII
Signs of a Brainstem Stroke (Wallenberg’s syndrome)?
Vertebral A / PICA infarct
Loss of pain / temp (ipsilateral face, contralateral trunk & limbs)
Dysarthria / dysphagia
Ataxia (ipsilateral limbs)
Vertigo - “tilted world”
Nystagmus
avg size of argyl-robinson pupils?
VERY small <2.5 mm
most COMMON imposter of tonic pupils?
POSTERIOR synechia
a bitemporal sphincter palsy will result in ________ oriented pupils

What causes this?
vertically

(leads to funny lookin pupils)

caused by ISCHEMIC ocular syndrome (especially in diabetics) OR ischemia secondary to PRP in diabetes

Temporal iris is supplied by SUPERIOR and INFERIOR divisions of the anterior ciliary artery
What leads to tadpole pupils?
sy,[athetoc orroatopm seem om cpmkimctopm woth ,ograomes/
What is sector paralysis?
one of the 3 signs of tonic pupil- part of the pupil is CURVED and part is FLATTENED. The flat region is due to iris that is paralyzed.
What is stroma spread?
one of the 3 cardinal signs of tonic pupil

iris has folds that reflect thetone etween iris sphincterand dilator muscles. LOSS of parasympathetic tone causes straom to disorganize and the lax of theiris surface reflects this
What is stromal streaming?
one of the 3 signs of tonic pupil

damaged iris will STREAM towards functioning part of the iris. Normal part will tighten up, but damaged part does not.
On slit lamp, move 45 degress and turn light on.
T/F Tonic pupils get smaller over time
T
Why is accomodation not affected in tonic pupl?
ciliary ganglion has 97% of fibers used for ACCOMODATION (30x more than constriction)
Major cause of tonic pupil?
ciliary anglion damage! (location of pre and post synaptic PARAsympathetic neurons).

The EdingerWestphal nucleus is origin of parasymp fibers. Only 3% are bound to sphincter muscle. Other 97% go to accommodation.
If ciliary ganglion is damaged, some iris sphincter nerves will grow back to normal and some will abberantly grow back to accomodation. However there are so few nerves at the sphincter, it will not be able to cause constriction.
With the damage, some accomodative fibers will grow back normal and some will abberently grow back to iris sphincter. There are enough fibers present at both locations to cause the constriction of the pupil when looking at a near target.
The defining features of a tonic pupil:

(1) The pupil does not react to ________. The original neurons have been destroyed.

(2) Tonic constriction with attempted _________. Aberrant regeneration of nerve fibers intended for the ciliary muscle causes abnormal, tonic ________ of the pupil with accommodation.

(3) Segmental iris _____. When carefully examined under magnification, the iris does not _________uniformly with attempted near vision. Only the re-innervated segments contract, producing a slightly irregular contour to the pupil.

(4) Denervation supersensitivity. Like any denervated muscle, the iris becomes supersensitive to its normal neurotransmitter (in this case, acetylcholine). Very weak solutions of cholinergic substances such as _________(that have no effect on the normal iris) cause the denervated iris to constrict.
1. light

2. near vision, contraction

3. constriction,constrict

4.pilocarpine
Local causes/infection in the orbit that lead to tonic pupils increlase
chicken pox in the eye
retrobulbar masses
PRP
ocular tumor/dermoid
Neuro caues of tonic pupil
DIABETES most common

spyhilis
sarcoids
lyme
Idiopathic tonic pupil is know as
Adie's Tonic

90% unilateral present

fellow eye involvement is common at 4% per year. (in 20 years, 50% of pts have both eyes affected)
T/F Lesions of ciliary ganglion not only affect sympathetic and parasympathetic motor fibers, BUT also sensory fibers from the cornea
T!!!
nasociliary nerve of CN V1 travel thru ciliary ganglion and are responsible for CORNEAL sensitivity. Hence, in TONIC pupils, ciliary ganglion damage causes DECREASED corneal sensitivity
T/F A CN III palsy caused by diabetes should NOT be painful
T

pain implies aneurysm 95% of the time, GCA, pituitary apoplexy, and SOMETIMES diabetes
T/F A CN III palsy due to diabetes leads to aberrant nerve regeneration
FALSE NEVER diabetes

Aneursym, Tumor or Trauma can lead to abberent regeneration, but NOT diabetes.
What are tectal pupils?
bilateral MYDRIASIS
pupils FIXED to light
near response preserved early
UPGAZE paresis (although downgaze is possible)
Convergence reatraction nystagmus
Eyelid retraction
CN 4 palsy

AKA DORSAL MIDBRAIN SYNDROME
Causes of DMS
* Sporadic
* Causes: obstructive hydrocephalus, mesencephalic hemorrhage, multiple sclerosis, A/V malformation, trauma, compression from tumor (pineal tumors)
Supranuclear paresis of upgaze is a problem where? is it muscle, nerve, or brain?
BRAIN
3 signs required in order to diagnose Horners?
miosis, ptosis, and anhyrosis
T/F you can get a complete ptosis with Hornder's syndrome
FALSE

because the tarsal muscle is only responsible for a few mm of elevation.... superior levator does most of the work

If you see COMPLETE ptosis --> CN III palsy
What is dilator lag?
when anisocria is GREATER at 5 seconds than at 12 seconds into darkness in horners syndrome. Affected dilator is slow to dilate and catch up to the normal eye
T/F A POSITIVE result from the cocaine test means NO dilation
T

Cocaine blocks the reuptake of norepinephrine so that if added to a pt with normal eyes, eyes will be dilated and stay dilated longer
a person with horners wont have the release of norepinephrine (no sympathetics) so even if cocaine blocks the uptake, there still isn't any norepinphrine there to cause dilation --> + test means NO dilation
T/F Apraclonidine will have the opposite effect as cocaine
T

DILATES horner's pupil
REVERSES anisocria. Horner pupil looked smaller before drops, and then after drops, looks bigger than other pupil.
T/F For Horner's syndrome, eyelid crease will be present and will be ABSENT in Myasthenia gravis
T!!

in horner's LEVATOR is still NORMAL (NOT a CN III palsy)

MG effects LEVATOR function
The presences of an _____ ptosis can help pick up Horner's
INVERSE

lower lid looks elevated due to inability of Muueller to pull lower lid down.

MG and CN III palsy do NOT present with ptosos
Heterochromia iridis is present in congential ______-
Horner's

in children before age 2
iris is lighter on side of horner's syndrome
Most COMMON cause of Horner's in young pt is
NEUROblastoma
The oculosympathetif fibers originate in the __________ and descend to the mirain and then to the pons at the __________, which is very close to the CN IV nucleus. The fourth nevre crosses in the midbrain and when lesioned, could cause a contralateral ________________.
Posteiror lateral hyothalmus

locus cereuleus (adrenergic nucleus)

Horn'ers syndrome


IF a Horner's syndreom is present, look for a CN IV palsy on the other side!!!
IF a Horner's syndrome is present, look for a ______ palsy on the other side!!!
CN IV
IF fibers from the caudal pons are lesioned by an infrarct of the anterior inferior cerebrallar artery, it may lead to ____________ syndrome with a gazle palsy, a CN ___ palsy, and a Horner's syndrome
Foville

CN VII
A lesion of the _______ can cause INTERnuclear ophthamloplegia, with an APD, adductinf defect and abducting nystagmus
MLF
A lesion or infract of the ________ may cause Wallenerg Syndrome, which can present with Horners syndrome
Wallenberg

see contralateral loss of pain and temp
ipselateral facial pain and temp
swallign and speech diffculties
ipselateral loss of hearing
What is a Phrenic nerve syndrome?
lesion at the spinal cord, offten associated with metastic breast cancer
Causes hoarse, hiccups and HORNER's

3 H's!!!
Klumpke's sign is associated with a lesion where, that also causes Horner's ?
level of the brachial plexus
At level of the lung you can get a ________ tumor leading to an IPSELATERAL horn'ers
pancoast

Triad: ptosis, miosis, arm pain
At tumor at the base of the skull is known as ____ and involves CN IX,X,XI, XII and produces a Horner's
Vernet's syndrome
_____ headaces can also cause a horner's
Cluster
Triad of a cartoid artery dissection causing a Horner's
pain on side of face, head or neck
oculosympathetic paralysis without anhydrosis
delaye retinal or cerebral ischemia

MEDICAL emergency
1% _________ "Squeezes out" the norephineprine from the presynaptic nerve terminal into the synapse, so if the lesion is at the first or second orer neuron below the mandible (aka preganglionic), the pupil WILL dilate
Paredrine

however, its its a postganglionic lesion, the pupil will not dilate
40% of Horner's are due to
idiopathic

13% malignant tumor!! usually Pancoast
Rule of thumb for Horner's

1st order neuron lesion, thinks its due to __________
2nd order, think _______
3rd order neuron lesion, think ________
vascular disease or trauma
neoplasma
benign or headache syndrome