The Irregular Pupil
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The Irregular Pupil. Randy Kardon M.D. Ph.D. Neuro-Ophthalmology Division Department of Ophthalmology and Visual Science VA and University Hospital, Iowa City, Iowa. Causes of an Irregular Pupil. the iris tissue itself – muscle and stroma

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Neuro ophthalmology division department of ophthalmology and visual science

The Irregular Pupil

Randy Kardon M.D. Ph.D.

Neuro-Ophthalmology Division

Department of Ophthalmology and Visual Science

VA and University Hospital, Iowa City, Iowa


Causes of an irregular pupil

Causes of an Irregular Pupil

  • the iris tissue itself – muscle and stroma

  • nerve causes – segmental denervation or aberrant re-innervation of either parasympathetic or sympathetic nerves

  • central nervous system (rare) – midbrain “corectopia” and brainstem herniation


Iris causes of an irregular pupil

Iris Causes of an Irregular Pupil

The iris tissue itself – muscle and stroma

ICE

Rieger’s

ICE

Axonfeld’s/Rieger’s

Sphincter tears

Ischemia

Zoster

Post surgical

Coloboma

Iris Synechia

Ectropian Uveae

Iris Tumor/Cyst


Nerve causes of an irregular pupil

Nerve Causes of an Irregular Pupil

postganglionic sympathetic denervation of the iris dilator

light

dark 3 seconds

dark 8 seconds


Nerve causes of an irregular pupil1

Nerve Causes of an Irregular Pupil

postganglionic sympathetic denervation of the iris dilator

and aberrant re-innervation of some dilator sectors

light

dark 5 seconds

in dark, “swallowing”


Nerve causes of an irregular pupil2

Nerve Causes of an Irregular Pupil

postganglionic sympathetic denervation of the iris dilator

and aberrant re-innervation of some dilator sectors

light

video in dark, swallowing cold water

dark 5 seconds


Nerve causes of an irregular pupil3

Nerve Causes of an Irregular Pupil

segmental sympathetic pulling on the dilator

“tadpole pupil”


Nerve causes of an irregular pupil4

Nerve Causes of an Irregular Pupil

segmental sympathetic pulling on the dilator

tadpole pupil video


Neuro ophthalmology division department of ophthalmology and visual science

Nerve Causes of an Irregular Pupil

abnormal parasympathetic innervation to the sphincter

Dark

Chronic “Little Old Adie’s Pupil”

Bright Light

Near


Neuro ophthalmology division department of ophthalmology and visual science

Infrared

front illumination

Infrared

transillumination

Dark

Near

0.5%

tropicamide


Cns causes of an irregular pupil

CNS Causes of an Irregular Pupil

rare

The oval pupil: relationship

to intracranial hypertension

Marshall et al, J Neurosurgery 58:566-568. 1983

Midbrain “Corectopia”

Selhorst et al, Arch Neurol 33,193, 1976

brainstem herniation


Causes of an irregular pupil1

Causes of an Irregular Pupil

  • the iris tissue itself – muscle and stroma

  • nerve causes – segmental denervation or aberrant re-innervation of either parasympathetic or sympathetic nerves

  • central nervous system (rare) – midbrain “corectopia” and brainstem herniation


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