NMS
6/30/99
Pupillary Reflex
- Anisorcoria--pupils that are unequal
- Generally, unequal pupil size there is a problem
- How can you make a pupil dilate if in a dark room and the right dilates and the left remains constricted
- Ciliospinal reflex—dilate a pupil by forcibly pinch a neck on the same side, sufficiently irritate the skin—Somatovisceral reflex
- Need the sympathetics to work
- Will not work
- Lesion of the sympathetics ipsilateral to the side
- Horner's syndrome (pupil)
- A very serious considered
- Serious things can cause it
- Ex: Pancoast tumor—see on x-ray—most common area to metastasize from the breast
- Pt develops TOS
- Changes in the pupil
- Has no affect on Cardinal signs of gaze
- Sympathetic atonia
- Look for loss of other sympathetics to the face
- Pupil constricted—myosis
- Ptosis—drooping of the eyelid—has control to raise the eyelid, it only droops when he is not thinking about—muscle is levator palpebrae which is controlled by CNIII (SE), keep eyes open unconsciously by sympathetics
- Intertwined w/levator palpebrae is a muscle under the control of the sympathetics called Muller
- This is why the eye droops w/Horner's syndrome
- VE fibers
- Anhydrosis—loss of ability to sweat on one side of the face
- Experience itching and dryness
Brightly Lit Room
- Right pupil remains dilated and left constricts
- Shine light directly into the right and doesn't react
- Make a dark room—no change in right, left constricts
- Right direct is absent and consensual is absent
- Left direct is intact and consensual is intact
- Right occulomotor nerve
- Parasympathetics from Edengar-Westfall nucleus
- Parasympathetic atonia
- Mydriasis—pupil that will not constrict
- Will the pupil accommodate? Constrict on accommodation, if it does it is not a lesion of CNIII
- Argyle-Robertson Pupil—will accommodate, will not react to light—found in syphilis, Tabes Dorsalis problem in proprioceptive and mechanoreceptive—not a CNIII lesion
- Fixed and dilated pupils after a car accident—sympathetics are working, the parasympathetics are not
- Cerebral edema—pressure on the cranial nerves esp. CNIII
- Serious neurologic problems
- Hippus Reaction—not a symmetrical contraction of the pupil, it is constricting just irregularly
- 80% of pt w/this are female
- strongly associated w/MS
- MS commonly affects CNII early
- They have visual disturbances in that eye—the fibers functioning fatigue and others are not transmitting so not getting a smooth signal into Edengar-Westfall nucleus
- Hypothyroidism can cause this
- High stress
- Tonic pupil—common in young women, sluggish pupil that takes a while to react (Adies' Syndrome)—not only in the pupillary reflex and also DTR
Exam
- CES—irritation—
- sclerotome (SA-SA)—Fenstein/Inman
- mechanism
- differential Dx
- afferentation—bombardment
- sympatheticotonia-increase in sympathetic output
- Korr
- Where is it located? Lateral horn
- Relationship to asthma
-
symp =
bronchoconstriction
- NE doesn't cause bronchodilation
- NE in an area enhances the tissue function
- Pupillary Light
- Accomodation