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Pupil will constrict with instillation of weak (0.1%) pilocarpine, which will minimally or not affect a normal pupil.
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#Unequal pupil size why full
Full presentation includes mydriasis, ptosis, and restricted EOM’s often resulting in a “down and out” appearance of the affected eye.Third nerve palsy, Adie’s Tonic Pupil, and pharmacologic dilation are three common causes of “big pupil” problems. Pupil will not dilate normally with instillation of any medicationĪs opposed to small pupil problems, anisocoria in which the larger pupil is affected will be most exaggerated in bright lighting.Opioids/opiates can cause miosis, typically bilaterally.Most commonly, the patient has been exposed to pilocarpine.However, clinicians should remember that an internal carotid problem (aneurysm/dissection) can cause a third order Horner’s Syndrome. If hydroxyamphetamine fails to dilate your patient, they are likely safe from 1st and 2nd order problems, such as a Pancoast tumor or stroke. Will dilate the Horner’s pupil as long as the third order pathway is intact.To be used only after confirmation testing has been performed.A Horner’s pupil WILL dilate MORE than the normal pupil, reversing the anisocoria.A Horner’s pupil WILL NOT dilate after instillation (normal pupil will).Pharmacologic testing can be used to confirm Horner’s and indicate which part of the pathway has been affected.Typically presents with anisocoria (worse in dim lighting) and mild ptosis the smaller or miotic pupil is the affected pupil.Possible etiology: problem at the internal carotid cavernous sinus problem.Third order is anything beyond the superior cervical ganglion to the pupil dilators and lid.Second order refers to C8-T1 to the superior cervical ganglion.First order refers to the part of the pathway from the hypothalamus to C8-T1.Can be first, second, or third order depending upon which area of the pathway is affected.Interruption in the sympathetic nervous system pathway which controls mydriasis in normal circumstances.Two conditions to keep in mind that can lead to inability to dilate normally/miotic pupils are: 1.
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In order to do this, the clinician should check the pupil size in both dark and bright conditions.Īnisocoria that is greater in dim lighting indicates that the smaller pupil is unable to dilate to the degree of the larger pupil, and is therefore, the problem. When a patient presents with unequal pupils, it is integral to determine which pupil has the problem.
#Unequal pupil size why how to
In an effort to remind us of the importance of this exam element, this guide will review how to discern between different presentations of anisocoria, as well as touch on some of the other causes of abnormal pupil findings. However, in every day practice, this facet of the exam can be easily overlooked, particularly if technicians are checking instead of doctors. In optometry school, our professors often stress how important close observation of a patient’s pupils can be in assessing his or her ocular and systemic health.