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

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

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