Ocular Disease Iii - Pupils

Front 1

In the dark, you see one pupil dilated and one pupil constricted. Which eye is defective? Is this a parasympathetic or sympathetic problem?

Back 1

Constricted pupil, because failed to dilate in the dark. Symp problem - remember dilation is symp response

Front 2

In the light, you see one pupil dilated and one pupil constricted. Which eye is defective? Is this a parasympathetic or sympathetic problem?

Back 2

Dilated pupil, because failed to constrict in light. Parasymp problem - remember constriction (sphincter muscle) is a parasymp response

Front 3

When the larger, normal pupil dilates faster than the smaller, abnormal pupil, what kind of problem does this show? What is this called?

Back 3

Interference to sympathetic pathway and relative weakness of dilator muscle - defect in movement of NE. Called Dilation Lag.

Front 4

T/F - You can enhance dilation lag with a sudden loud noise.

Back 4

True

Front 5

Describe how you would observe dilation lag.

Back 5

Place pt in dark. Observe the smaller pupil slowly dilating for 15 sec. Should see greatest anisocoria 4-5 sec after you shut off the light and will reduce as the pupil slowly dilates.

Front 6

T/F - You can have a dilation lag without sympathetic nerve problems.

Back 6

False - must have symp nerve problems in order to have dilation lag

Front 7

Which increases faster, area or diameter of the pupil? What is the relevance of this with pupil testing?

Back 7

Area - so pay attn to this more vs diameter when looking at dilation lag.

Front 8

What % conc for cocaine test?

Back 8

5%, or 10% for dark eyes

Front 9

T/F - You only need to put cocaine in one eye for the cocaine test.

Back 9

False - both eyes

Front 10

How long should you wait before checking pupils after instilling cocaine in the cocaine test?

Back 10

30-60 mins, dark eyes 1-2 hrs

Front 11

T/F - Pts doing the cocaine test must be sitting in the waiting room with minimal activity when waiting during the 30-60 mins.

Back 11

False - pt should be active i.e. walking around

Front 12

T/F - Bright light enhances the effect of the cocaine test.

Back 12

False - dim light

Front 13

__mm or greater is diagnostic for Horner's in the cocaine test.

Back 13

0.8

Front 14

The cocaine test is used to confirm...

Back 14

Horner's

Front 15

Cocaine blocks the reuptake of this NT at the neuromuscular junction.

Back 15

Norepi

Front 16

What is the neurotransmitter that acts on the dilator muscle?

Back 16

Norepi - makes sense b/c norepi is a sympathetic NT, and dilation is a sympathetic response

Front 17

During cocaine testing, you see both pupils dilated equally. This means...

Back 17

normal pupils

Front 18

During cocaine testing, the left eye dilated poorly. This means...

Back 18

left horner's

Front 19

A normal pupil dilates with cocaine because...

Back 19

cocaine blocks the reuptake of norepi, so the neuromuscular junction will have tons of norepi and will flood the dilator muscle's receptors

Front 20

A horner's pupil will not dilate with cocaine because...

Back 20

Normal = cocaine blocks the reuptake of norepi, so the neuromuscular junction will have tons of norepi, which will flood the dilator muscle's receptors

Horner's = dysfxnal nerve b/c axoplasmic flow is impaired, so norepi is not released to the junction in the first place, therefore no dilation

Front 21

Paredrine test confirms...

Back 21

where the lesion that is causing the Horner's is located (post or preganglionic)

Front 22

% paredrine used?

Back 22

1%

Front 23

Paredrine is aka...

Back 23

hydroxyamphetamine

Front 24

What ganglion is involved during the paredrine test? What is the significance?

Back 24

superior cervical ganglion - its fibers pass by the apex of the lung, and lesions here can be due to dangerous causes e.g. tumors

Front 25

Paredrine causes the release of ___ at the neuromusc jxn, which results in the (constriction/dilation) of the pupil.

Back 25

norepi, dilation

Front 26

Paredrine targets (post/pre)ganglionic neuron?

Back 26

postganglionic (3rd order)

Front 27

T/F - Paredrine will dilate both normal and Horner's with 1st or 2nd order lesions

Back 27

True - will not dilate with 3rd order lesion

Front 28

Why does a 1st or 2nd order (preganglionic) neuron lesion in Horner's cause dilation?

Back 28

Paredrine causes release of norepi specifically at 3rd order neuron, which is right before the dilator.

Normally, the 3rd order neuron gets triggered by the preganglionic neuron to release norepi, but since there's a lesion, no trigger.

Thus, Paredrine is the trigger to release norepi and causes dilation.

Front 29

Why does a 3rd order (postganglionic) neuron lesion in Horner's cause no dilation?

Back 29

Normally Paredrine causes release of norepi specifically at 3rd order neuron, which is right before the dilator.

The 3rd order neuron gets triggered by the intact preganglionic neuron to release norepi, but since the 3rd order neuron is broken, there's no norepi to release in the first place, so no dilation.

Front 30

How long do you wait before eval the pupils in the paredrine test?

Back 30

45 mins

Front 31

Your pt's left pupil dilates during the paredrine test. What does this indicate? Is this a bad situation?

Back 31

Dilation shows that the pt has a preganglionic (1st or 2nd order) lesion. Situation is more serious b/c could be a tumor at apex of lung

Front 32

Your pt's left pupil dilates poorly during the paredrine test. What does this indicate? Is this a bad situation?

Back 32

Dilation shows that the pt has a postganglionic (3rd order) lesion. Situation is less serious - can be migraine, Raeder's, etc (vs tumor in preganglionic)

Front 33

A pt has dilation on cocaine test, dilation on paredrine test. This shows...

Back 33

Normal pupils

Front 34

Your pt has no dilation on cocaine test, dilation on paredrine test. This shows...

Back 34

Horner's, preganglionic lesion

Mnemonic: "Paredrine can show a PREDILection (for tumors)" i.e. paredrine dilation = preganglionic

Front 35

% phenyl used in horner's testing?

Back 35

1% (remember supersensitivity to weak phenyl)

Front 36

Dilation on cocaine, dilation on phenyl shows...

Back 36

normal eye

Front 37

No dilation on cocaine, dilation on phenyl shows...

Back 37

horner's, postganglionic lesion

Front 38

T/F - Phenyl shows similar results as paredrine in horner's testing

Back 38

False - opposite

Front 39

Why will a normal eye not dilate on 1% phenyl?

Back 39

Not strong enough to dilate a normal pupil

Front 40

What % is used for apraclonidine for Horner's testing?

Back 40

0.5%

Front 41

What is an alternate test for cocaine testing?

Back 41

apraclonidine 0.5%

Note results are opposite of cocaine (dilation = positive for horner's)

Front 42

Apraclonidine MOA for horner's testing?

Back 42

stimulates presynaptic alpha-2 receptor which inhibits norepi release.

Front 43

Horner's syndrome signs?

Back 43

Triad: Miosis, Ptosis (upper lid droop 2-3 mm), Anhydrosis

Also reverse ptosis of lower lid, dilation lag, incr IOP, incr tear viscosity

acute = skin flushing, conj hyperemia

congenital = heterochromia of iris, loss of eyelid crease

Front 44

What causes the reverse ptosis in horner's?

Back 44

lack of sympathetic retraction of lower lid

Front 45

T/F - You see decr IOP in horner's.

Back 45

False - incr IOP

Front 46

T/F - Dilation lag is required to Dx horner's.

Back 46

True

Front 47

What possible result would you see in cocaine and 1% phenyl testing in your lung carcinoma pt?

Back 47

cocaine = no dilation in affected side

phenyl = no dilation on affected side

Front 48

Common causes of 1st order lesions are generally due to...

Back 48

brainstem and superior spinal cord lesions (rare)

[see slide 42]

Front 49

T/F - There is no anhydrosis in post-ganglionic horner's

Back 49

True

Front 50

T/F - Ptosis can be absent in 1st order horner's lesions.

Back 50

True

Front 51

T/F - You expect anhydrosis in the entire half of the body in 1st order horner's.

Back 51

True

Front 52

T/F - Neck pain, headaches, and dysphagia can be seen in 1st order horner's lesions.

Back 52

False - post-ganglionic

Front 53

Hoarseness, cough, and scapular pain can be involved in what type of horner's lesion?

Back 53

2nd order (think Pancoast's tumor - apical lung malignancy!)

Front 54

Pituitary tumors can cause this type of horner's lesion...

Back 54

1st order

Front 55

Postganglionic horner's are generally caused by...

Back 55

lesions in neck and anterior head

Front 56

2nd order horner's lesions cause anhydrosis where?

Back 56

face and neck

Front 57

1st order horner's lesions cause what kinds of signs?

Back 57

hemiparesis, hemianesthesia

Front 58

Internal carotid a. abnormalities can cause this kind of horner's

Back 58

postganglionic

*remember, sympathetic branches run along int carotid a.

Front 59

Unilat vascular HA syndromes like ____ and ____ can cause ___ type horner's.

Back 59

cluster HAs, paratrigem neuralgia, 3rd order

Front 60

Cause of horner's in birth-20 yrs usually...

Back 60

trauma

Front 61

Cause of horner's in 21-50 yrs usually...

Back 61

neoplasia, surgery

Front 62

Cause of horner's >50 yrs usually...

Back 62

neoplasia

Front 63

Congenital horner's can be caused by...

Back 63

- obstetric (perinatal forces injury to carotid plexus)
- sup cervical ganglion lesions
- surgical or obstetric trauma to brachial or thoracic plexus

Front 64

Most common cause of horner's in children?

Back 64

Birth trauma

Front 65

What is Klumpke's paralysis?

Back 65

hand/arm weakness with horner's in children

Front 66

What kind of horner's lesion is more dangerous, pre or postganglionic? Why?

Back 66

preganglionic; remember these fibers run near the apex of the lung where pancoast tumor can occur.

Mnemonic: "Paredrine can show a PREDILection (for tumors)" i.e. paredrine dilation = preganglionic

Front 67

You suspect a preganglionic horner's lesion...what is the work-up?

Back 67

Chest x-ray, cervical spine x-ray, referral to internist/thoracic surgeon

Front 68

You suspect a postganglionic horner's lesion...what is the work-up?

Back 68

eval HA Hx: typical/atypical cluster HA, consult with medical provider if warranted

Front 69

You suspect an acute onset horner's lesion with neck or facial pain...what is the Mx?

Back 69

R/O carotid dissection, same day referral

Front 70

You suspect recent onset horner's lesion with no pain...what is the Mx?

Back 70

Refer (?) within one week

[see slide 56]

Front 71

DDx of abnormally large pupil?

Back 71

1) mech probs w/ iris sphincter
2) adie's
3) CN III palsy
4) pharmacologic mydriasis

Front 72

Your pt has a miotic pupil and you suspect iritis...what do you look out for?

Back 72

Ant/post synechiae, KPs, iris nodules, cells & flare

Front 73

Sector paresis of the iris is often seen in...

Back 73

Adie's pupil

Front 74

What is stromal iris streaming?

Back 74

shifting of non-reactive iris stroma into the area of the constricting sphincter ("vermiform movement" of iris)

Front 75

What is stromal spread of the iris?

Back 75

lack of tautness

Front 76

T/F - Adie's tonic pupil is dilated, and tends to get smaller as incr age.

Back 76

True

Front 77

What drugs (and conc) are used in testing for large pupils?

Back 77

0.125% and 1% (or 0.5%) pilo

Front 78

Marked constriction of a dilated pupil with 0.125% pilo means? Why?

Back 78

Adie's

Adie's are hypersensitive to cholinergic agents (i.e. pilo), so a weak conc will result in constriction

Hypersens to cholinergic since ciliary ganglion (parasymp fxn hence constriction) is defunct, therefore not used to having cholinergic NT around

Front 79

T/F - It is inappropriate to do GAT before the 0.125% pilo test.

Back 79

True - avoid corneal epith compromise before test

Front 80

You should avoid BAK as a preservative in this test because corneal compromise is a factor before putting in the drops...

Back 80

0.125% pilo test

Front 81

0.125% pilo is placed in (one eye/both eyes) for dilated pupil testing. Why?

Back 81

both eyes, b/c testing the normal pupil ensures that adequate amt was used

Front 82

When would you use 1% pilo in dilation testing?

Back 82

If no marked constriction on 0.125% pilo found.

Front 83

Would a pharmacologically blocked pupil react to 1% pilo? Why or why not?

Back 83

No constriction b/c receptors blocked

Front 84

You see no constriction with 0.125% pilo but 1% pilo produces constriction. You suspect ___. Why?

Back 84

CN III palsy. 0.125% is too weak, but since receptors not blocked, 1% strong enough to close paretic pupil

Front 85

Your pt is a 25 yo female with a dilated pupil, but no HA or ptosis. Without further testing you can suspect

Back 85

Adie's

"Silly ladies get adies" (silly = ciliary ganglion)

Front 86

What structure is affected in Adie's?

Back 86

Ciliary ganglion - remember it provides parasymp hence dilation

(however remember symp nerves run THRU it as well)

Front 87

T/F - It's Possible to get bilateral Adie's.

Back 87

True - 4% per yr goes bilat over 1st decade

Front 88

Adie's is known for what pupil characteristics?

Back 88

Enlarged pupil with BOTH poor light and accom response (also has L-N dissoc)

Pupil reacts sluggishly in sections of the pupil, as seen with slit lamp

Also sluggish re-dilation from near target back to dist target

Front 89

Systemic Sx of adie's?

Back 89

Diminished tendon reflex (Adie's syndrome)

Front 90

What visual problems can an Adie's pt encounter?

Back 90

- Blur b/c accom affected
- Asthenopia due to unbalanced accom; near-far focusing abilities
- Possible photophobia due to large pupil

Front 91

Etiology of Adie's?

Back 91

Some unspecified damage to ciliary ganglion; possibly orbital trauma, tooth extraction, following dental anesthesia

Assoc w/ viral infections, URIs, chronic tonsilitis, sinusitis

Front 92

What pupil dysfxn is considered an aberrant degenration due to the L-N dissociation present? Why?

Back 92

Adie's - some of the accom fibers regenerated and misdirected to supply of sphincter instead.

Front 93

T/F - Adie's pupil may become normal or get even smaller over time.

Back 93

True - "Little Old Adies"

Front 94

T/F - In Adie's, accom response is more likely to return over light response.

Back 94

True - recovery of accom within 2 yrs

Front 95

How long does accom recovery take in Adie's?

Back 95

within 2 yrs

Front 96

T/F - Tendon reflexes recover over time in Adie's.

Back 96

False - worsen

Front 97

In near testing of the pupils, you notice the right pupil is smaller. If this was Adie's, which eye is the problem?

Back 97

The larger eye (LE), since has a sluggish constriction at near

Front 98

Most common cause of CN III palsy with HA?

Back 98

DM

Front 99

T/F - DM causing CN III palsy involves the pupil.

Back 99

False - DM causes pupil-sparing CN III palsy (still has EOM involvement and ptosis)

Front 100

What plant mentioned can cause pharmacologic mydriasis?

Back 100

Jimson weed (has atropine and scopolamine)

Front 101

T/F - Timolol can cause mydriasis.

Back 101

True

Front 102

T/F - Albuterol can cause mydriasis.

Back 102

True

Front 103

DDx of L-N pupils?

Back 103

Pupils react better to near vs light:
- Adie's
- Blind eye (Amaurotic)
- Aberrant regen of CN III
- Tectal pupils - dorsal midbrain
- Argyll Robertson

Front 104

Argyll Robertson is caused by...

Back 104

tertiary syphilis - spirochete attacks intercalated neurons b/w pretectal and E-W nuclei

Front 105

Argyll Robertson pupils are characterized by...

Back 105

- Miosis 2.5 mm or less
- Anisocoria
- L-N dissoc: impaired or absent light reflex, brisk near reflex
- irreg pupil shape
- poor dilation

"ARP-PRA" Accom reflex present, Pupillary rxn absent

Front 106

What is the significance of pupils and Sjogren's???

Back 106

Pilo is a Tx, which causes small pupils

Front 107

If you see Argyll Robertson, what lab testing should you do?

Back 107

Syphilis testing - treponemal and non-treponemal tests (see slide 103)

Front 108

T/F - Benign Episodic Pupillary Dilation affects young men.

Back 108

False - young women

Front 109

Benign Episodic Pupillary Dilation involves (unilat/bilat) pupil dilation lasting ___.

Back 109

unilat, several mins

Front 110

Benign Episodic Pupillary Dilation can be accompanied by...

Back 110

discomfort, HA

Front 111

T/F - Benign Episodic Pupillary Dilation has no long term effect.

Back 111

True

Front 112

3rd order lesions assoc with inflammation of adjacent structures due to (as seen on slide)...

Back 112

Tolosa-Hunt syndrome
Otitis Media
Trigeminal HZV
Sinusitis