Pupils

A condition where the two pupils have different diameters?

Anisocoria

Is anisocoria always related to pathology?

No

A condition where the post-ganglionic parasympathetic supply is impared.

Efferent pupillary defect

In an efferent pupillary defect, the pupil cannot (constrict/dilate) and is abnormally (small/large).

Constrict

Large

In an efferent pupillary defect, the path from the ________ _______ nucleus to the iris (sphincter/dilator) is impared.

Edinger Westphal

Sphincter

A condition where there is a lesion to the sympathetic supply to the iris?

Horner's syndrome

In Horner's syndrome, the pupil cannot (constrict/dilate) and is abnormally (small/large).

Dilate

Small

A condition where one pupil is less responsive to light than the other?

Afferent pupillary defect

Will an APD create an anisocoria?

No

How do we reveal an APD?

Swinging flashlight test

Where is an APD-causing lesion most common?

Optic nerve

Normal pupil diameter in light?

1-2 mm

Normal pupil diameter in dark?

7-9 mm

Our pupil (increases/decreases) in size as we age.

Decreases

Latency of pupillary response varies with _____ ________.

Light intensity

The pupil is positioned (nasal/temporal) and (superior/inferior) within the iris

Nasal

Inferior

The position is (nasal/temporal) in reference to the visual axis

Nasal

_________ ______ is the normal physiological "unrest" that oscillates more with more light

Pupillary hippus

Pupillary muscles embryonic origin?

Neuro ectoderm

Nerves that innervate sphincter iridis?

Short ciliary nerves

Nerves that innervate dilator pupillae?

Long ciliary nerves

Which iris muscle is stronger?

Sphincter iridis

The neurological pathway for pupillary constriction begins at the ______________

Photoreceptors

Afferent pathway of pupillary constriction? (6)

Optic chiasm

Optic tract

Bifurcation of pupillomotor fibers in superior colliculus

Pretectal area

Bilateral interneurons

Edinger Westphal nuclei

Efferent pathway of pupillary constriction? (5)

Caudal Edinger Westphal nucleus

CN III inferior division

Ciliary ganglion

Short ciliary nerves

Iris sphincter of both eyes

Does pupillary constricting involve cerebral cortex processing?

No

Are there more accommodative or pupillomotor fibers in the ciliary ganglion?

Accommodative

________________ loops to pupillary constriction pathway inhibit it when we are awake.

Corticomesencephalic

Does pupillary constriction to a light stimulus cause change in the other 2 of the near triad?

No

Where does the pathway of pupillary dilation begin?

Posterolateral hypothalamus

Path of central fibers in pupillary dilation? (3)

Descend ipsilaterally

Terminate in intermediolateral cell column

Synapse in ciliospinal center of Budge

Path of second order/pre-ganglionic fibers in pupillary dilation? (5)

Exit via T1

White rami commuicantes

Sympathetic chain of paravertebral column

Inferior and middle cervical ganglia

Synapse at superior cervical ganglion

Path of third order/post-ganglionic fibers in pupillary dilation? (5)

Travel with internal carotid

Joins ophthalmic division of trigeminal nerve

Forms a cavernous plexus in the sinus

Through superior orbital fissure

Long ciliary nerves reach iris dilator

Are third order oculosymathetic fibers myelinated?

No

________________________ projections to pupillary dilator pathway stimulate it when we are awake.

Hypothalamomesencephalic

______ anisocoria is a difference of <.5 mm and present in 1/5 of the population

Simple/Essential

Simple anisocoria is more present in (bright/dim) light

Dim

When the larger pupil is the abnormal one, the defect is usually (afferent/efferent)

Efferent

What can cause a large abnormal pupil? (5)

Midbrain damage

Damage to CN III

Damage to ciliary ganglion/nerves

Damage to sphincter muscle

Mydriatic drugs

Characteristics of a tonic pupil? (4)

Poor response to light

Stronger response to near target

Accommodative paresis

Cholinergic supersensitivity

Most common efferent pupillary defect?

Adie's tonic pupil

Adie's tonic pupil affects (men/women) more

Women (ladies get Adies!)

Near targets elicit a more robust pupillary response than light response?

Light/near dissociation

Horner's Syndrome characteristics? (4)

Pupil miosis

Eyelid ptosis

Anhydrosis of half the face/body

Ocular hypotony

_______ Horner's syndrome occurs with damage to the first-order neuron of the pathway

Central

What can cause a central Horner's syndrome? (2)

Medullary infection

Cervical cord injury or disease

Distinguishing symptoms of a central Horner's syndrome? (3)

Vertigo

Sensory defects (audition)

Insufficient sweating on BODY

______________ Horner's syndrome occurs with damage to the second-order neuron.

Pre-Ganglionic

If an infant acquires a Horner's syndrome after a few months of life, why would we refer them for a chest x-ray?

Possible carcinoid tumor and pleuropulmonary blastoma

Tumor that can cause a pre-ganglionic Horner's in adults?

Thoracic/cervical blastoma

________________ Horner's syndrome occurs with damage to the third order neuron.

Post-ganglionic

Symptoms that a patient may have along with a post-ganglionic Horner's? (2)

Cluster headache

Migraine

Diseases that may result in a post-ganglionic Horner's? (2)

Cavernous sinus disease

Carotid dissection

An eye that is positive for APD will have a (direct/consensual) response but will NOT have a (direct/consensual) response to light.

Consensual

Direct

Rare cause of APD?

Optic tract disease

What does retrobulbar mean?

Behind the eye, like ON damage behind lamina cribosa

What begins as optic neuritis may become _____ ______.

Optic atrophy

Can we regenerate function following optic atrophy?

Not usually

Which 3 factors decide if a retinal disease can cause an APD?

One eye must be more affected

Over 1/2 of retinal function affected

Significant macular involvement

What are some examples of retinal diseases that could cause an APD? (4)

Retinal detachment

Macular disease (AMD)

Amblyopia

Posterior staphyloma

"Most famous" example of a light/near dissociation?

Argyll Robertson pupil

Characteristics of an Argyll Robertson pupil? (4)

Light sensitive retina

Little to no light response

Brisk response to accommodative target

Small, difficult to dilate pupil

Argyll Robertson pupil was commonly found in patients with _____ _____.

Tabes dorsalis (a dysfunction associated with syphillis)

Is an Argyll Robertson pupil common?

No

Other causes that can mimic an Argyll Robertson pupil? (3)

Vascular anomalies in cerebral aqueduct

Diabetes

Alcoholic neuropathy

Dorsal midbrain syndrome that can cause a light/near dissociation?

Parinaud's syndrome

What is the cause of Parinaud's syndrome?

Lesion, typically in dorsal midbrain centered on paraqueductal gray

Other symptoms of Parinaud's syndrome?

Vertical gaze paralysis

Eyes converge and retract

pseudo-Argyll Robertson pupil