Adie’s Tonic Pupil on Physical Exam A young female was referred in for a sudden onset anisocoria. Her ocular exam was essentially unremarkable with the exception of anisocoria (OS>OD) that was most prominent in bright light conditions (top image) and slightly reduced near vision in the left eye. She was otherwise healthy and had no history of recent illness or trauma. Typical evaluation of anisocoria begins with emphasis on where the anisocoria is most prominent. In this case, the asymmetry was most prevalent (greater than 3mm in this case) with bright or direct light, suggesting the parasympathic nervous system isn’t working correctly. Adie’s tonic pupil denotes anisocoria worse in bright lights with light near dissociation (meaning the pupil still constricts when accommodating). It is generally unilateral and affects young females most commonly. The etiology is usually unknown but assumed to be damage to the ciliary ganglion which is responsible for the post ganglionic parasympathetic control of the iris sphincter. Clinical confirmation involves diluted pilocarpine (approximately 0.125%) instilled in both eyes. Because the postganglionic synapse is hypersensitive to acetylcholine, the affected eye will constrict while the unaffected eye will remain the same (image 4). Over time, the affected pupil will become smaller in size relative to the other pupil, occasionally it can occur bilaterally. Syphilis should be suspected in those rare bilateral cases. Failure of the pupil to respond to diluted pilocarpine typically warrants retesting before proceeding to 1% pilocarpine which if positive (constriction) would suggest oculomotor nerve palsy. Bennett & Bloom Eye Center @anterior_seg_rocks #Adies #Tonic #Pupil #anisocoria #clinical #video #ophthalmology #physicalexam #neurology
