![]() Third nerve disease can very rarely present with just a dilated pupil but almost always ptosis, motility disturbance or both signifies that a partial third nerve palsy is present. Parasympathetic chain disease (brain, third nerve, ciliary ganglion) Infrequently, the patient may have (purposefully or accidentally) instilled a dilating or constricting substance into the eye Previous blunt trauma can also cause persisting traumatic mydriasis. Overall, the most common cause of pathologic anisocoria seen by ophthalmologists is change in the iris itself, most often due to previous cataract or corneal surgery. In the neural pathway that causes pupil dilation (the sympathetic chain) In the neural pathway that causes pupil constriction (the parasympathetic chain) Pathologic anisocoria is due to disease in one of three places: Physiologic anisocoria can be recognized because the patient is asymptomatic, both pupils constrict briskly to light and dilate briskly to dark, there is no ptosis and ocular movements are normal. Physiologic anisocoria is common: one in five normal subjects has a slight but noticeable difference in the size of their pupils. Horner syndrome).Īnisocoria can be physiologic or pathologic. Holmes-Adie tonic pupil) or requires referral or investigation (e.g. On history and examination, we need to decide if the patient can be clinically diagnosed and reassured (e.g. Alternatively, you might notice anisocoria while examining the patient for another complaint.Īs ophthalmologists, we all need to have a practical plan for assessing patients with unequal pupils. Patients occasionally present because a difference in the sizes of their pupils has been noticed by their family, an examining practitioner or the patient themselves. Unequal pupils (anisocoria) may be caused by disease of the:
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