Approach to the patient with anisocoria
- Sachin Kedar, MD
Sachin Kedar, MD
- Associate Professor of Neurology and Ophthalmology
- University of Nebraska Medical Center and Truhlsen Eye Institute
- Valérie Biousse, MD
Valérie Biousse, MD
- Cyrus H. Stoner Professor of Ophthalmology
- Professor of Ophthalmology and Neurology
- Emory University
- Nancy J Newman, MD
Nancy J Newman, MD
- Leo Delle Jolley Professor of Ophthalmology
- Emory University
Causes of anisocoria range in seriousness from a normal, physiologic condition to one that is immediately life threatening. When a patient presents with anisocoria, the fear of a serious condition, such as an intracranial aneurysm, often leads clinicians to obtain numerous tests, which are not always necessary. A logical clinical approach appreciating the mechanisms of anisocoria permits prompt recognition of true emergencies and often obviates the need for invasive and costly testing (algorithm 1) .
NEUROANATOMY AND PHYSIOLOGY
Pupillary size is governed by the balance of actions of two opposing muscle groups of the iris: the dilator and sphincter pupillae. Regulation of the pupillary size is predominantly achieved by reflex mechanisms in response to the amount of ambient light. Other factors influencing pupillary size include patient age, emotional state (adrenergic tone), state of arousal, and intraocular pressure [1,2].
Constriction — Pupillary constriction to light and near stimuli is mediated via parasympathetic (cholinergic) nerve fibers that travel along the third cranial nerve. The pupillary light reflex pathway is a four neuron pathway (figure 1) [1,2]:
●Light information from retinal ganglion cells travels though the optic nerves, optic chiasm (where the nasal fibers decussate), and the optic tracts, before synapsing in the pretectal nuclei of the dorsal midbrain. Both pretectal nuclei receive input from both eyes.
●Each pretectal nucleus sends axons to both Edinger-Westphal nuclei. This duality of pathways provides the anatomic basis for the consensual response to light (ie, the fact that both pupils constrict equally in response to a light stimulus in one eye).
- Biousse, V, Newman, NJ. Neuro-Ophthalmology Illustrated, Thieme Verlag, Germany 2009.
- Kardon, R. Anatomy and physiology of the autonomic nervous system.. In: Walsh and Hoyt Clinical Neuro-ophthalmology, 6th, Miller, NR, Newman, NJ, Biousse, V, Kerrison, JB (Eds), Williams & Wilkins, Baltimore 2005. p.649.
- Johnston JA, Parkinson D. Intracranial sympathetic pathways associated with the sixth cranial nerve. J Neurosurg 1974; 40:236.
- Digre, KB. Principles and techniques of examination of the pupils, accommodation and lacrimation. In: Walsh and Hoyt Clinical Neuro-ophthalmology, 6th ed, Miller, NR, Newman, NJ, Biousse, V, Kerrison, JB (Eds), Williams & Wilkins, Baltimore 2005. p.715.
- Pilley SF, Thompson HS. Pupillary "dilatation lag" in Horner's syndrome. Br J Ophthalmol 1975; 59:731.
- Ettinger ER, Wyatt HJ, London R. Anisocoria. Variation and clinical observation with different conditions of illumination and accommodation. Invest Ophthalmol Vis Sci 1991; 32:501.
- Lam BL, Thompson HS, Corbett JJ. The prevalence of simple anisocoria. Am J Ophthalmol 1987; 104:69.
- Lam BL, Thompson HS, Walls RC. Effect of light on the prevalence of simple anisocoria. Ophthalmology 1996; 103:790.
- Kawasaki, A. Disorders of pupillary function, accommodation and lacrimation. In: Walsh and Hoyt Clinical Neuro-ophthalmology, 6th ed, Miller, NR, Newman, NJ, Biousse, V, Kerrison, JB (Eds), Williams & Wilkins, Baltimore 2005. p.739.
- Lin YC. Anisocoria from transdermal scopolamine. Paediatr Anaesth 2001; 11:626.
- Iosson N. Images in clinical medicine. Nebulizer-associated anisocoria. N Engl J Med 2006; 354:e8.
- Lust K, Livingstone I. Nebulizer-induced anisocoria. Ann Intern Med 1998; 128:327.
- Openshaw H. Unilateral mydriasis from ipratropium in transplant patients. Neurology 2006; 67:914.
- Savitt DL, Roberts JR, Siegel EG. Anisocoria from jimsonweed. JAMA 1986; 255:1439.
- Meng K, Graetz DK. Moonflower-induced anisocoria. Ann Emerg Med 2004; 44:665.
- Havelius U, Asman P. Accidental mydriasis from exposure to Angel's trumpet (Datura suaveolens). Acta Ophthalmol Scand 2002; 80:332.
- Biousse V, Newman NJ. Third nerve palsies. Semin Neurol 2000; 20:55.
- NEUROANATOMY AND PHYSIOLOGY
- EXAMINATION OF THE PUPIL
- Light reflex
- Near reflex
- CLINICAL APPROACH
- Identifying the abnormal side
- Associated clinical features
- Physiologic anisocoria
- Structural defects
- The small pupil is abnormal
- The large pupil is abnormal
- - Traumatic mydriasis
- - Tonic pupil
- - Pharmacologic mydriasis
- - Third nerve palsy
- SUMMARY AND RECOMMENDATIONS