Pupil lecture

 

Hx:

onset, med exposure, ptosis, diplopia, ha, ipsilateral facial numbness, limb ataxia, dysarthria, vertigo, tobacco use, hemoptysis, neck trauma, neck/jaw pain, hemisensory loss, amaurosis, vision loss, weight loss

 

pupils round and regular?

eye trauma, including prior cataract surgery

intraocular inflammation

neovascularization

 

DDX: horner's

first order: brainstem stroke, cervical spinal cord trauma, syrinx, brainsteam/cervical spinal cord tumor, demyelination

 

2nd order:

lung apex/cervical paravertebral ca

misguided central lines

superior cervical ganglion blocks

thoracic, cervical, thyroid, intraoral, peritonsillar surgery

congenital or acquired injury of lower brachial plexus

neuroblastoma

 

3rd order:

carotid artery dissection

carotid endarterectomy

cluster ha

skull base, nasopharynx, cavernous sinus ca

skull base/orbital trauma

surgery involving retroparotid, parasellar region

giant intracavernous carotid artery aneurysm

herpes zoster ophthalmicus

perinatal trauma to the internal carotid plexus

 

anisocoria greatest in bright light:

suggests disorder in parasympathetic rxn

adie's tonic pupil, third-nerve palsy, pharmacologic mydriasis, iris damage

 

if don't have ptosis, likely not aneurysm

 

adie's pupil: parasympathetic fibers synapse in ciliary ganglion and then innervate ciliary muscle and iris sphincter in 30:1 ratio

 

if damage happens, aberrant regeneration gets to iris, have abnormal distribution

will also have tonic response with poor constriction and poor dilation

 

common in women 30-40 yo

sx: photosensitivity, blurred vision

signs: anisocoria, impaired light rxn, light-near dissociation, sector palsies of the iris, tonic redilation following accommodation xxx, cholinergic supersensitivity

so if adie's, will constrict with 0.1% pilocarpine

 

risk for stroke is within 2 weeks