www.goodhope.nhs.uk/departments/eyedept/

Pupils, for professionals

David Kinshuck, some notes from teaching sessions etc

Horner's

examine in room light, dim light, and as the light changes....the Horner's pupil dilates a lot more slowly as the light is dimmed
4% cocaine prevents nor-adrenaline uptake...it dilates the normal pupil, but has no effect on a Horner's pupil
iopidine 0.5% (apraclonidine and here) should dilate the Horner's pupil but not the normal pupil (unless the Horner's is very recent). Best to photograph before and after.
1% hydroxyamphetamine (available from Moorfields Pharmacy) will dilate 1st and 2nd order neurones, not 3rd (as I remember)

there are different causes depending whether 1st, 2nd or 3rd neurones affected.
1st CVA, demyelination
2nd neoplasm, trauma
3rd base of skull lesion, internal carotid dissection/aneurysm (e.g. after neck injury playing rugby)

an excellent review (adults)
generally (98%) the diagnosis was known at time of diagnosis of the Horner's. In 83% the diagnosis was made. Problems included previous neck/skull surgery, brainstem CVA, chest or skull base masses or trauma.
Carotid dissection was identified because the Horner's was PAINFUL (with/without trauma).
Cavernous sinus masses were related to other %5 or 6th) cranial nerve palsy.
Cervical spine mass (scapular pain/upper limb sensory problems).
None targeted imaging (no focal signs etc) was not that helpful.
One patient had a thyroid Ca.
Central Horners..MS/CVA/tumour
pre-ganglionic ...trauma, tumour
post ganglionic...carotid, trigeminal, cavernous sinus

no light response; sector palsy with slit lamp
initially pupil is larger than the normal pupil
normal near reflex
bilateral 4%/year
66% reduced accommodation...difficult reading
pilocarpine 0.1% constricts an Adies pupil, not a normal pupil.
eventually the pupil becomes smaller
often called a 'tonic pupil'
if part of Holme's-Adies ankle jerks reduced, no transillumination (HZO...transilluminates)
may have bilateral peripheral neuropathy

measure pupil in bright light
in dim light
check near reflex
examine iris & pupil on slit lamp...other disease?
if the light reflex is normal
<1.0mm difference, perhaps physiological (same all illumination)
otherwise, and if ptosis present, suspect Horner's (different according to illumination as above)
if the light reflex is abnormal, suspect Adies
pupils get smaller with age
constrict with light and accommodation

Unequal pupils (Pane/Burden/Miller)
	Do pupils react briskly?

	yes	no

Smaller pupil is abnormal. Are the following present? mild ptosis dilation lag of the affected pupil in dark anisocoria increased in dark		Larger pupil is abnormal history of trauma, intraocular surgery (with iris damage visible on slit lamp)

yes	no	yes	no

possible Horner's (?cocaine/apraclonidine test)	probably physiological	likely traumatic	no
			are either of the following present ptosis on the side of the larger pupil diplopia or abnormal mobility?

		yes	no

		?partial third nerve palsy	are both the following present? slow constriction to near? spiraling of the pupil on slit lamp exam

			yes	no

			likely tonic pupil (Adies)	Possible pharmacological dilation

Horner's tests (Pane/Burden/Miller)
	diagnosis		localization
site	cocaine	apraclonidine	hydroxyamphetamine	1% phenylephrine
normal	dilates	no change	dilates	no change
central or preganglionic	no/minor change	dilates	dilates	no change
post-ganglionic	no change	dilates	no change	dilates

many drugs dilate pupil..eg atrovent inhaler. Pilocaprine will constrict such a pupil and exclude 111n palsy
none-ophthalmologists should remember that many eye conditions cause unequal or unresponsive pupils