Case of Anisocoria

[Ryan_eyeball]

So i had this one patient once, that presented with a case of Aniscoria. If you're wondering Aniscoria means two pupils that are unequal sizes. Wrut roh huh...time to start thinking about all those neuropathways. Alright, this patient was a 37 year old white caucasian female that said this wouldn't happen all the time but every few days it would appear. This was a problem focused examination, so no refraction was performed. Her medical history was unremarkable, and so was her ocular history. She denied use of any medications, and NKDA, NKMA. She said that her vision didn't appear to be decreased in either eye. Also, she's a stay at home mother.

For novice optometry newbies...you have two iris muscles controlling the aperature of the pupil. The iris sphincter (parasympathetic nerves), and the iris dilator (sympathetic nerves).

This was easier to spot since the patient was Causcasian, but African americans can be easily missed if you're not really paying attention (da*n those dark eyes).

In normal illumination the right eye was 3mm and the left was 5mm. On bright room illumination the right eye constricts to 1.5mm and the left one also. On dark room illumination the right dilates to 6mm and the left to about 7.5mm.


What could it be though....Adies Tonic...Argyle Robertson Pupil....anything else? Listen to the case history.....this isn't the first time, and it comes and goes. Sounds pharmacologically induced.

Turns out after again asking her again if she's taking any medications at all over the counter she's like..."Well, I am taking this Preparation H cream." I'm thinking, like ok, its not a crime to have hemorrhoids from time to time. It turns out that she uses it under her left eyelid skin because it tends to get a little puffy from time to time. She heard from her friends that this works, and didn't think to mention it. Turns out that one of the active ingrediants in Preparation H is phenylepipherine (a sympathomimetic), which can cause the pupil to dilate some. Also, Sympathomimetics probably will not cause distortion or vision or affect the ability to accommodate.

What I learned....Sometimes the answer just lies in the case history, and never be afraid to go back to the history again and ask more questions. Also, to think quickly and efficiently...

Have a good night.

---

Members don't see this ad.

 

[KHE]

So i had this one patient once, that presented with a case of Aniscoria. If you're wondering Aniscoria means two pupils that are unequal sizes. Wrut roh huh...time to start thinking about all those neuropathways. Alright, this patient was a 37 year old white caucasian female that said this wouldn't happen all the time but every few days it would appear. This was a problem focused examination, so no refraction was performed. Her medical history was unremarkable, and so was her ocular history. She denied use of any medications, and NKDA, NKMA. She said that her vision didn't appear to be decreased in either eye. Also, she's a stay at home mother.

For novice optometry newbies...you have two iris muscles controlling the aperature of the pupil. The iris sphincter (parasympathetic nerves), and the iris dilator (sympathetic nerves).

This was easier to spot since the patient was Causcasian, but African americans can be easily missed if you're not really paying attention (da*n those dark eyes).

In normal illumination the right eye was 3mm and the left was 6mm. On bright room illumination the right eye constricts to 1.5mm and the left doesn't constrict at all. On dark room illumination the right dilates to 6mm and the left to about 7.5mm. Our culprit is the left eye not constricting.

Whew...we don't have to worry about Horner's.

What could it be though....Adies Tonic...Argyle Robertson Pupil....anything else? Listen to the case history.....this isn't the first time, and it comes and goes. Sounds pharmacologically induced.

Turns out after again asking her again if she's taking any medications at all over the counter she's like..."Well, I am taking this Preparation H cream." I'm thinking, like ok, its not a crime to have hemorrhoids from time to time. It turns out that she uses it under her left eyelid skin because it tends to get a little puffy from time to time. She heard from her friends that this works, and didn't think to mention it. Turns out that one of the active ingrediants in Preparation H is phenylepipherine, which can cause the pupil to dilate some.

What I learned....Sometimes the answer just lies in the case history, and never be afraid to go back to the history again and ask more questions. Also, to think quickly and efficiently...

Have a good night.

Correct me if I'm wrong but I seem to recall that if the iris dilator is stimulated with a drug like epinephrine and the iris sphincter is NOT blocked by an anticholinergic drug, then you should get some constriction of the pupil if you shine a light into an eye.

Simply getting some Prep-H into an eye doesn't seem like it should be enough to cause a complete lack of iris sphincter activity.

 

[Ryan_eyeball]

Correct me if I'm wrong but I seem to recall that if the iris dilator is stimulated with a drug like epinephrine and the iris sphincter is NOT blocked by an anticholinergic drug, then you should get some constriction of the pupil if you shine a light into an eye.

Simply getting some Prep-H into an eye doesn't seem like it should be enough to cause a complete lack of iris sphincter activity.

Ugh your right...I'll have to change the above post...I was thinking of a different patient I saw. Thanks for the heads up.

 

[Andrew_Doan]

In normal illumination the right eye was 3mm and the left was 5mm. On bright room illumination the right eye constricts to 1.5mm and the left one also. On dark room illumination the right dilates to 6mm and the left to about 7.5mm.

What could it be though....Adies Tonic...Argyle Robertson Pupil....anything else? Listen to the case history.....this isn't the first time, and it comes and goes. Sounds pharmacologically induced.

Your measurements are more consistent with a Horner's pupil than the other diagnoses listed above. Was there ptosis?

Sometimes ptosis can be slight and over looked. In Horner's, the anisocoria is greater in the dark due to poor dilation (sympathetic) of the abnormal pupil. Your measurements don't actually support a Horner's, but if they are off a little, then you'll miss it.

Intermittant anisocoria can be worrisome in a young adult. While there are benign things that can cause Horner's, such as cluster headaches(http://webeye.ophth.uiowa.edu/eyeforum/case22.htm), you need to rule out the more serious causes. A few months ago, a young woman presented with anisocoria. I discovered that she had mild neck pain. She had a mild Horner's with neck pain which was the manifestation of a carotid dissection.

The following are inconsistent with the above measurements.

Adies tonic pupil: Both eyes constrict to 1.5 mm with bright lights. In Adies, the anisocoria is greater in bright light due to poor constriction of the abnormal Adies pupil.

Argyle Robertson Pupil: Poor reaction to light, but normal constriction with near accomodation. As indicated in your post, both pupils constrict to 1.5 mm in bright light.

This may also be physiologic. Without documentation (e.g., photos), her pupils may have always been asymmetric. She needs to be examined when they are normal, and then when they present again with anisocoria.

One thing that needs to be ruled out is pharmacologic dilation from chemical exposure, which you considered above.