Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the...
Transcript of Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the...
![Page 1: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/1.jpg)
Dr Stephen Best
![Page 2: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/2.jpg)
2
?
?
?
?
![Page 3: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/3.jpg)
3
The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex
The size of the pupil is determined by the antagonistic action of the sphincter constrictor muscle vs the diffuse dilator pupillae
Parasympathetic vs Sympathetic innervation
Local factors may alter this
Pupil size is usually equal !!
![Page 4: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/4.jpg)
4
![Page 5: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/5.jpg)
Miosis = small pupil
Mydriasis = large pupil
Anisocoria = difference in size
Polycoria = multiple apertures
5
![Page 6: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/6.jpg)
Light reflex – direct/consensual
Near reflex – miosis / accommodation / convergence
Relative afferent pupil defect
Pathologic pupil defects
6
![Page 7: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/7.jpg)
7
![Page 8: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/8.jpg)
![Page 9: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/9.jpg)
Topical medications – mydriatics/miotics/other agents
Trauma – traumatic mydriasis / sphincter rupture / surgical trauma / posterior synechia
Disease processes / iritis / uveitis / acute angle closure glaucoma
Systemic medications – narcotics = miosis
9
![Page 10: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/10.jpg)
![Page 11: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/11.jpg)
11
![Page 12: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/12.jpg)
12
![Page 13: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/13.jpg)
Oculosympathetic paresis….interruption of the sympathetic supply along the three neuron pathway
Miosis
Ptosis
Apparent enophthalmous
Cutaneous anhydrosis
Other features – transient hyperaemia/iris hypopigmentation in congenital cases
13
![Page 14: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/14.jpg)
Diagnosis confirmed by topical cocaine test
Abnormal pupil fails to dilate whilst the normal pupil will dilate ( loss of noradrenaline at nerve junction )
Other associated clinical signs and symptoms….( headache / apical lung pathology / long tract neurology signs ) will determine appropriate investigations
14
![Page 15: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/15.jpg)
![Page 16: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/16.jpg)
![Page 17: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/17.jpg)
Postganglionic parasympathetic denervation
Glare / accommodative difficulties
Mydriasis
Light – near dissociation….slow constriction on prolonged near effort and slow re-dilation to distance
Usually young females – 90% unilateral initially , but often becomes bilateral
Decreased corneal sensation
Decreased deep tendon reflexes
Pupil becomes tonic with time….even miotic
17
![Page 18: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/18.jpg)
Oculosympathetic paresis….interruption of the sympathetic supply along the three neuron pathway
Miosis
Ptosis
Apparent enophthalmous
Cutaneous anhydrosis
Other features – transient hyperaemia/iris hypopigmentation in congenital cases
18
![Page 19: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/19.jpg)
Diagnosis confirmed by deinnervationhypersensitivity to weak cholinergic (pilocarpine 0.1%)……abnormal pupil will constrict whilst normal pupil remains un-effected
Aberrant re-innervation of pupillary sphincter muscle ….contractions of part of the pupil margin (vermiform movement)
19
![Page 20: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/20.jpg)
20
![Page 21: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/21.jpg)
Pupil involved 3rd nerve palsy
Bilateral dilated pupils
Horner’s Syndrome
Adie’s Tonic Pupil
21
![Page 22: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/22.jpg)
The most common pupil abnormality is simple
Physiological Anisocoria
Benign!!!
22
![Page 23: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/23.jpg)
23
![Page 24: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/24.jpg)
38 yr female
Severe burns- plastics admission for grafts
Early morning headaches
Some blurring of vision
24
![Page 25: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/25.jpg)
VA 6/12 OD, 6/9 OS
Pupillary examination – sluggish
Optic disc examination – abnormal
HVF= peripheral visual field constriction OU
25
![Page 26: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/26.jpg)
![Page 27: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/27.jpg)
![Page 28: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/28.jpg)
28
![Page 29: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/29.jpg)
29
![Page 30: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/30.jpg)
30
![Page 31: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/31.jpg)
31
![Page 32: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/32.jpg)
![Page 33: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/33.jpg)
33
![Page 34: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/34.jpg)
34
![Page 35: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/35.jpg)
![Page 36: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/36.jpg)
![Page 37: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/37.jpg)
37
![Page 38: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/38.jpg)
38
![Page 39: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/39.jpg)
Neuro-imaging mandatory with papilloedemaRefer as appropriate
Note: PTC/BIH/IIH
Consecutive optic atrophy following resolution of papilleodema secondary to meningioma after neuro-surgical intervention
39
![Page 40: Dr Stephen Best - cdn.auckland.ac.nz · 3 The pupil is the circular aperture in the centre of the iris, usually black in appearance---and seen as red reflex The size of the pupil](https://reader030.fdocuments.us/reader030/viewer/2022041203/5d5094c988c993dc038bdc12/html5/thumbnails/40.jpg)
All material contained in this presentation is copyright of The University of Auckland, Department of Ophthalmology and
should not be reproduced without written permission