Mydriasis and Miosis - Differential Diagnosis Framework
Causes of Mydriasis:
Dilated pupils (mydriasis) more than 7mm
• Unilateral Mydriasis: CN Ill paralysis (PCA Aneurysm), Brainstem herniation (Comatose), Acute angle closure glaucoma, Adie's tonic pupil, Migraine Headache, Traumatic Mydriasis
• Bilateral Mydriasis:
- Medications: Opiate withdrawal, Antipsychotic medications, AntichoIinergic medications, Mirtazapine, MAO inhibitors, Organophosphate inhibitors, Atropine, Antihistamines, Dopamine, Barbituate toxicity
- Stimulants: MDMA (Ecstacy), TCA, Cocaine, LSD, Psilocybin mushrooms, PCP, Ketamine
- Dim light response, Serotonin syndrome, Carbon monoxide
- Fixed: Brain death, Hypothermia
Causes of Miosis:
Constricted pupils less than 2mm
• Unilateral Miosis: Horner's syndrome, Posterior Synechiae, Pilocarpine, Iris inflammation (iridocyclitis, uveitis)
• Bilateral Miosis:
- Bright light response
- Medications: Opiates, Clonidine, Benzodiazepines, Pilocarpine, Insecticides, Bromides, Valproic acid
- Others: Anticholinergics, Sympathomimetics, Organophosphates, Nicotine, Heat Stroke
- Neuro: Pontine hemorrhage, Pontine CVA, Syphilis (Argyll Robertson pupils), DM, SAH
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