THE PUPIL Alpha Omega Pupil the PUPIL Alpha Omega Pupil
THE PUPIL Observation and Grading Alpha Omega Pupil
JohnJohn J. J. Pulaski,Pulaski, O.D.,O.D., FCSOFCSO
CollegeCollege ofof SyntonicSyntonic OptometryOptometry 101101 CourseCourse May 2020
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The Pupil And Syntonics
How do you know if a person needs Syntonic Treatment?
Pulaski AO Pupil
The Pupil And Syntonics Three keys elements in Syntonic Clinical evaluationevaluation andand treatmenttreatment application.application.
1. The Pupil - AO 2.2. The The FieldField -- Kinetic Kinetic 3.3. The The PatientPatient HistoryHistory
Pulaski AO Pupil
Pulaski AO Pupil The Pupil One of the most sensitive measures of ANS activity.
•• ANS/Brainstem ANS/Brainstem functionfunction
•• “Eyes “Eyes areare thethe windowwindow toto thethe Soul”Soul” TheThe PupilsPupils areare thethe window.window.
•• Portal Portal ofof EnergyEnergy ReceptionReception andand Projection.Projection. PortalPortal throughthrough whichwhich we interact with our world
•• Non-verbal Non-verbal CommunicationCommunication andand strongstrong emotionalemotional indicatorindicator ..
•• Reception Reception ofof “nutrition”“nutrition” - - LIGHT LIGHT
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The Pupil Neurological Pathways
ParasympatheticParasympathetic -- Constriction Constriction •The•The PupillaryPupillary LightLight ReflexReflex (PLR)(PLR) •Influence•Influence onon IrisIris SphincterSphincter •Light-Inhibited•Light-Inhibited SympatheticSympathetic PathPath •Trigeminal•Trigeminal NerveNerve –– sensory sensory stimulationstimulation toto eye/iriseye/iris SympatheticSympathetic –– Dilation Dilation •Direct•Direct stimulationstimulation ofof IrisIris DilatorDilator throughthrough 33 neuronneuron arcarc
•Inhibition•InhibitionPulaski AO Pupil ofof EWEW nucleusnucleus
Pulaski AO Pupil The Pupil Neurological Pathways PathwayPathway ofof DilationDilation •• Direct Direct StimulatoryStimulatory -- Iris Iris dilatordilator –– HypothalmusHypothalmus –– Nucleus Nucleus CoeruleusCoeruleus –– Superior Superior ColliculusColliculus –– Frontal Frontal EyeEye FieldsFields •• Inhibitory Inhibitory –– EW EW nucleusnucleus –– Nucleus Nucleus CoeruleusCoeruleus –– Superior Superior ColliculusColliculus –– Supernuclear Supernuclear InhibitionInhibition fromfrom thethe ReticularReticular ActivatingActivating Pulaski AOFormation FormationPupil inin brainstembrainstem
The Pupil InIn SyntonicsSyntonics
InIn SyntonicsSyntonics wewe areare interestedinterested inin thethe pupilpupil asas anan indicationindication ofof thethe statestate ofof thethe ANS.ANS. TheThe twotwo majormajor reactionsreactions observedobserved are:are:
•Alpha•Alpha OmegaOmega PupilPupil •Pupillary•Pupillary LightLight ReflexReflex
Pulaski AO Pupil
The Pupil Reactions Alpha Omega Pupil
•• An An AlphaAlpha OmegaOmega PupilPupil isis thethe abnormalabnormal re-dilationre-dilation ofof thethe pupilpupil duringduring direct,direct, constantconstant lightlight stimulation.stimulation. •• Unique Unique toto thethe practicepractice ofof SyntonicsSyntonics •• First First suggestedsuggested asas aa termterm byby Dr.Dr. PaulPaul JohnsonJohnson inin 1934.1934. •• The The abnormalityabnormality isis broughtbrought toto normalcynormalcy withwith phototherapyphototherapy treatmenttreatment •• There There isis anan inverseinverse relationrelation betweenbetween thethe sizesize ofof thethe functionalfunctional visualvisual fieldfield andand thethe degreedegree ofof thethe AOAO PupilPupil..
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Pulaski AO Pupil THE NORMAL PUPIL
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The Pupil The “Normal” Pupil
•• Steady Steady statestate sizesize •• Dynamic, Dynamic, transienttransient responseresponse •• Neurons Neurons inin E-WE-W NucleusNucleus generategenerate steadysteady firingfiring raterate eveneven when no external inputs are involved. Balanced by cortical inhibition.inhibition. •• Slight Slight latentlatent periodperiod beforebefore contractscontracts •• Maximum Maximum contractioncontraction isis reachedreached inin aboutabout 22 sec.sec. •• When When stimulusstimulus removedremoved pupilpupil re-dilatesre-dilates muchmuch slowerslower thanthan itit contractedcontracted –– Recovery Recovery responseresponse •• Under Under prolongedprolonged stimulationstimulation therethere areare normalnormal oscillatiooscillationsns
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Pulaski AO Pupil The Pupil The “Normal” Pupil Pupillogram – 24 y.o. healthy male
•From Loewenfeld, “The Pupil”
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The Pupil The “Normal” Pupil
• Pupillary Unrest • Pupillary Fatigue • Pupillary Escape
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The Pupil The “Normal” Pupil Pupillary Unrest
•• Defined Defined byby LowenfeldLowenfeld asas “normal“normal pupillarypupillary oscillationsoscillations broughtbrought onon byby steadysteady lightlight andand absentabsent inin darkness.”darkness.” •• They They areare continuous,continuous, constantconstant ripplingrippling andand pumping,pumping, rapidrapid andand irregularirregular movementsmovements ofof thethe pupilpupil inin aa lightedlighted environmentenvironment thatthat ceasecease whenwhen thethe lightlight isis turnedturned off.off. •• Can Can varyvary fromfrom oneone individualindividual toto anotheranother butbut thethe patternpattern isis thethe samesame forfor thatthat individualindividual overover time.time. PostulatedPostulated thatthat itit isis uniqueunique duedue toto ourour geneticgenetic make-up.make-up. •• Their Their causecause remainsremains unknownunknown althoughalthough itit isis Lowenfeld’Lowenfeld’ss opinionopinion thatthat theythey originateoriginate inin thethe neuronsneurons ofof thethe Pulaskimidbrain. AO Pupil
Pulaski AO Pupil The “Normal” Pupil Pupillary Unrest Pupillogram of normal 24 y.o. female under sustained light (Loewenfeld, “The Pupil”) Stimulus begins
Stimulus ends
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The Pupil The “Normal” Pupil Fatigue Waves
•From Loewenfeld, “The Pupil” Pulaski AO Pupil
Pulaski AO Pupil (Loewenfeld “The Pupil”)
Pulaski AO Pupil The Pupil Reactions Pupillary Escape
•• Re-dilation Re-dilation ofof thethe pupilpupil afterafter exposureexposure toto aa moderatemoderate lightlight source.source. •• Stated Stated thatthat thethe re-dilationre-dilation isis duedue toto retinalretinal adaptationadaptation •• Pupillary Pupillary “Unrest”“Unrest” follows follows •• The The AlphaAlpha OmegaOmega pupilpupil mightmight bebe consideredconsidered asas aa formform ofof pupillarypupillary escapeescape byby non-lightnon-light therapiststherapists
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The Pupil Reactions Pupillary Escape
•• Duke-Elder, Duke-Elder, 11 inin 19591959 discussingdiscussing thethe clinicalclinical picturepicture ofof opticoptic neneuritis,uritis, mentions "a peculiar pupillary reaction common to allll formsforms ofof conductionconduction interference,interference, wherein,wherein, althoughalthough bothboth thethe directdirect andand consensualconsensual reactionsreactions areare presentpresent thethe contractioncontraction isis notnot maintainedmaintained underunder brightbright illuminationillumination soso thatthat thethe pupilpupil slowlyslowly dilatesdilates againagain while while thethe lightlight isis stillstill keptkept uponupon thethe eye.“eye.“ •“•“PupillaryPupillary escapeescape ”” is is anan abnormalabnormal pupillarypupillary responseresponse toto aa brightbright light,light, inin whichwhich thethe pupilpupil initiallyinitially constrictsconstricts toto lightlight andand thenthen slowlyslowly redilatesredilates toto itsits originaloriginal size.size. PupillaryPupillary escapeescape cancan occuroccur onon thethe sideside ofof aa diseaseddiseased opticoptic nervenerve oror retina,retina, mostmost oftenoften inin patientspatients withwith a a centralcentral fieldfield defect.defect.
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The Pupil Reactions Pupillary Escape
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Pulaski AO Pupil The Pupil Reactions Alpha Omega Pupil
•• An An AlphaAlpha OmegaOmega PupilPupil isis thethe abnormalabnormal re-dilationre-dilation ofof thethe pupilpupil duringduring direct,direct, constantconstant lightlight stimulation.stimulation.
•• An An AlphaAlpha OmegaOmega PupilPupil differsdiffers fromfrom PupillaryPupillary UnrestUnrest inin thatthat itsits occurrenceoccurrence happenshappens beforebefore 8-98-9 secondsseconds havehave elapsed.elapsed. ItsIts amplitudeamplitude isis greatergreater thanthan 11 mmmm inin manymany cases.cases.
•• It’s It’s measurementmeasurement oror recordingrecording cancan bebe effectedeffected byby thethe ininfluencefluence ofof “Fatigue“Fatigue Waves”Waves” in in aa veryvery tiredtired personperson andand effecteffect thethe variabivariabilitylity ofof responseresponse duringduring testing.testing.
•• It It cancan bebe consideredconsidered aa formform ofof pupillarypupillary “escape”“escape” but but withowithoutut pathologypathology thatthat isis reversiblereversible withwith treatment.treatment. ThereThere areare alsoalso differencedifferencess inin frequencyfrequency andand amplitude.amplitude.
•• Conclusion Conclusion –– The The pupilpupil reactionreaction isis extremelyextremely complexcomplex
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The Pupil Sympathetic Influences on Pupillary Reflex Dilation The Normal Pupillary Reflex Dilation
Any sensory, emotional, or mental stimulus elicitselicits reflexreflex dilation.dilation. AnyAny sound,sound, touchtouch oror pain,pain, fear,fear, joyjoy oror angeranger oror spontaneousspontaneous thoughtsthoughts andand intentionalintentional effortsefforts allall dilatedilate thethe pupils.pupils. The amplitude of reaction depends on the degree of arousal caused by the stimulus and the subject’ssubject’s physicalphysical andand mentalmental statestate atat thethe timetime ofof stimulation.stimulation. Loewenfeld
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The Pupil Influences on Pupillary Reflex Dilation
IncreasedIncreased DilationDilation Increased Increased ConstrictionConstriction
IncreasedIncreased attentionattention Mind Mind wandering/Distractionwandering/Distraction Orienting Reflex Introspection IncreasedIncreased mentalmental efforteffort Poor Poor tasktask performanceperformance Mental arithmetic Disgust Memory formation Images of the sun PleasantPleasant soundssounds High High levellevel scenescene processingprocessing PerceptionPerception ofof odorsodors Memory Memory retrievalretrieval SexualSexual arousalarousal Dishonesty, Lying Enjoy/DislikeEnjoy/Dislike whatwhat isis seenseen Pulaski AO Pupil
Pulaski AO Pupil Pulaski AO Pupil
The Pupil
REACTIONS
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The Pupil Reactions
• Alpha Omega • Hippus • Afferent Pupillary Defect • Pupillary Light Response (PLR) • Near Reflex
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Pulaski AO Pupil The Pupil Reactions Alpha Omega Pupil
• Why is it not Hippus? • Why is it not an APD defect? • How do other reactions relate? • How does the field relate?
Pulaski AO Pupil
The Pupil Reactions Alpha Omega Pupil
•• An An AlphaAlpha OmegaOmega PupilPupil isis thethe abnormalabnormal re-dilationre-dilation ofof thethe pupilpupil duringduring direct,direct, constantconstant lightlight stimulation.stimulation.
•• It It isis relatedrelated toto imbalancesimbalances withinwithin thethe ANS.ANS. HypothalmusHypothalmus andand AdrenalAdrenal activityactivity areare important.important.
•• The The reactionreaction revealsreveals manymany aspectsaspects ofof thethe vitalityvitality ofof thethe huhuman being.
•• Rian Rian Shah,Shah, N.D.N.D. statesstates thatthat oscillationsoscillations areare duedue toto severesevere ssodiumodium depletiondepletion secondarysecondary toto decreaseddecreased adrenaladrenal function,function, specifispecificallycally diminisheddiminished aldosterone.aldosterone. AlsoAlso calledcalled “rebound”“rebound” pupil. pupil.
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The Pupil Testing Standards in Measurement Alpha Omega Pupil Pulaski, 2006
Observation and Recording of AO Pupil
1.1. Quickness Quickness ofof initialinitial stimulationstimulation –– PLR PLR 2.2. Time Time toto releaserelease 3.3. Amplitude Amplitude ofof releaserelease 4.4. Reactions Reactions afterafter initialinitial releaserelease –– fluctuations fluctuations 5.5. Change Change inin responseresponse withwith repeatedrepeated stimulationstimulation 6.6. Sensory Sensory reactionsreactions –– tearing, tearing, pain,pain, etcetc
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Pulaski AO Pupil The Pupil Grading Standardization Alpha Omega Pupil Alpha Omega Grading Standard (Pulaski 2010)
Grade Release Time Fluctuations Amplitude Normal ≥ 9 seconds Trace Trace
1+ AO 4 – 6 sec Moderate Mild
2+ AO 2 – 3 sec Marked Mild-Moderate
3+ AO 1 – 2 sec Mild-Moderate Moderate
4+Pulaski AO AO Pupil < 1 sec Mild Large
The Pupil Grading Summary OD OS 0 1 2 3 4 PLR 0 1 2 3 4 0 1 2 3 4 Near Reflex 0 1 2 3 4
Yes No Normal Direct Yes No Yes No Normal Consensual Yes No
______Pupillary Diameter ______Time of Release ______Amplitude of Release ______
0 1 2 3 4 Fluctuations 0 1 2 3 4 0 1 2 3 4 AO Pupil 0 1 2 3 4
______Change in repeated stimulation______Sensory reactions ______
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Pulaski AO Pupil The Pupil Reactions Hippus Per Lowenfeld it is a very confusing term • Nystagmus in ancient times • Lid fluttering • 18 th Century – wave-like pupillary movements • Nine categories (see addendum – pupillary oscillations) • Loewenfeld suggests that the name be dropped or defined as “vigorous pupil oscillations of various types” • Of interest are » Pupillary Unrest » Fatigue Waves » Pupillary Escape Waves
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The Pupil Afferent Pupillary Defect
1.1. Confusion Confusion withwith AlphaAlpha OmegaOmega
2.2. RAPD RAPD duedue toto UnilateralUnilateral OpticOptic NerveNerve Neuropathy.Neuropathy. IndicationIndication ofof retinalretinal diseasedisease oror opticoptic nervenerve pathologypathology 2.2. Re-dilation Re-dilation referredreferred toto inin literatureliterature asas “Pupillary“Pupillary Escape”Escape”
3.3. Normal Normal consensualconsensual withwith subnormalsubnormal direct.direct. DecreasedDecreased PLR.PLR. AnisocoriaAnisocoria atat timestimes
4.4. Swinging Swinging FlashlightFlashlight TestTest
5.5. Characteristic Characteristic observationobservation isis “release”“release” or or re-dilationre-dilation ofof bothboth pupilspupils whenwhen thethe lightlight isis movedmoved fromfrom thethe normalnormal toto thethe affectedaffected eye.eye. Pulaski AO Pupil
Afferent Pupillary Defect vs. Normal (Loewenfeld “The Pupil”)
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Pulaski AO Pupil The Pupil Reactions Pupillary Light Reflex
•• 10-20% 10-20% ofof RGCRGC axonsaxons relaterelate toto PLRPLR •• 1% 1% ofof ipRGC’sipRGC’s •• Speed/Strength Speed/Strength ofof contractioncontraction •• Coma, Coma, TBI,TBI, StrokeStroke •• Excited Excited PatientPatient •• Relation Relation toto ANSANS
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The Pupil Reactions Pupillary Light Reflex
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The Pupil Reactions Pupillary Light Reflex
MCA, MCV predictors for Alzheimer’s Parkinson’s ABI/TBI Autism Drugs/Alcohol InfectionInfection
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Pulaski AO Pupil The Pupil Reactions Pupillary Light Reflex
•• ipRGC’s ipRGC’s veryvery importantimportant inin recoveryrecovery phasephase (PIPR)(PIPR) •• Are Are bothboth inhibitedinhibited andand activatedactivated byby differentdifferent wavelength sensitive cones •• Important Important inin sustainedsustained constrictionconstriction
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The Pupil Reactions
Near Reflex
1.1. Observed Observed reactionreaction ofof PupilPupil whenwhen thethe patientpatient lookslooks fromfrom aa distancedistance toto nearnear object.object.
2.2. Record Record strengthstrength ofof constrictionconstriction fromfrom 00 –– 4+ 4+ forfor eacheach eye.eye. 3.3. IsIs aa differentdifferent pathwaypathway andand cancan reactreact eveneven ifif nono PLRPLR
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The Pupil
TESTING
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Pulaski AO Pupil The Pupil TESTING
Conventional
Automated Pupillometry
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The Pupil Testing Standards in Measurement
Observation and Recording General Observations and Questions (Loewenfeld(Loewenfeld “The“The Pupil”)Pupil”)
1.1. Size Size -- too too large/smalllarge/small forfor age,age, illumination,etcillumination,etc 2.2. Direct Direct andand ConsensualConsensual responses.responses. 3.3. Are Are reactionsreactions toto lightlight andand toto nearnear equallyequally extensextensiveive 4.4. Are Are theythey equalequal inin sizesize 5.5. If If unequalunequal isis differencedifference greatergreater inin dimdim oror brightbright 6.6. Do Do bothboth constrictconstrict toto lightlight 7.7. Do Do bothboth redilateredilate asas lightlight removedremoved 8.8. Is Is reflexreflex toto sensorysensory stimulistimuli intactintact onon bothboth sidessides 9.9. Are Are therethere otherother motormotor oror sensorysensory defectsdefects relatingrelating toto thethe Pulaski AO Pupil pupillarypupillary syndromesyndrome
TheThe PupilPupil TestingTesting ConstantsConstants inin MeasurementMeasurement RigidRigid TestTest ProtocolProtocol
• Room Illumination • Patient Fixation • Light Source • Distance and Location • Duration
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Pulaski AO Pupil The Pupil Testing Constants in Measurement
Room Illumination • Dimly lit room in dark adapted state
Patient Fixation • At distance (non-accommodative to avoid near reflex) • Non-descript target – no cognition
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The Pupil Testing Constants in Measurement
Light Source
• Small, bright, concise,concise, withwith abilityability toto adjustadjust thethe lightlight intensityintensity
Pulaski AO Pupil
The Pupil Testing Constants in Measurement
Distance and Location
•• Approximately Approximately 6-8”6-8” from from eyeeye •• Light Light sourcesource turnedturned onon andand belowbelow oror temporaltemporal toto eyeeye beingbeing testedtested •• Light Light shouldshould bebe swungswung directlydirectly toto aa locationlocation straightstraight intointo thethe lineline ofof sightsight •• Lag Lag ofof 2-32-3 secondsseconds betweenbetween eyeseyes Pulaski AO Pupil
Pulaski AO Pupil The Pupil Testing Constants in Measurement
Duration
Normally up to 2-3 seconds in front of eye. Needs toto bebe atat leastleast 11 secondsecond toto getget fullfull constriction.constriction.
Alpha Omega evaluation
Observe the pupil under constant light stimulation forfor atat leastleast tenten secondsseconds oror untiluntil firstfirst sustainedsustained release.release. TestTest rightright eyeeye firstfirst andand thenthen immediatelyimmediately leftleft eyeeye Observe time to release, fluctuations and amplitude RepeatRepeat atat leastleast threethree timestimes observingobserving changeschanges withwith fatiguefatigue
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The Pupil Testing – Pupilometry Bright Lamp
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The Pupil Testing – Pupilometry Bright Lamp
Pulaski AO Pupil
Pulaski AO Pupil The Pupil Testing – Bright Lamp
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The Pupil Testing – Bright Lamp
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The Pupil Testing – Bright Lamp Pupil Parameter Normal Ranges
•• Avg. Avg. ConstrictionConstriction SpeedSpeed 0.45 0.45 -- 1.159 1.159 mm/sec •• Avg. Avg. DiameterDiameter 3.169 3.169 -- 3.816 3.816 mmmm •• Avg. Avg. DilationDilation VelocityVelocity 0.888 0.888 -- 2.699 2.699 mm/secmm/sec •• Constriction Constriction TimeTime 1.178 1.178 -- 2.217 2.217 secsec •• Latency Latency 0.138 0.138 -- 0.279 0.279 secsec •• Max. Max. ConstrictionConstriction SpeedSpeed 4.013 4.013 -- 9.136 9.136 mm/secmm/sec •• Max. Max. DiameterDiameter 3.662 3.662 -- 5.186 5.186 mmmm •• Min. Min. DiameterDiameter 2.861 2.861 -- 3.317 3.317 mmmm •• 75% 75% RecoveryRecovery TimeTime 3.945 3.945 -- 4.54 4.54 secsec Pulaski AO Pupil
Pulaski AO Pupil Questions or Comments? Matthew Southern Marketing Director [email protected] Phone: (317) 763-0786
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The Pupil
REACTIONS OF PUPIL RELATE TO SIZE OF FIELD
Pulaski AO Pupil
The Kinetic Visual Field The Normal Visual Field
Fox/Pulaski 12/17 101
Pulaski AO Pupil Kinectic (Functional) Visual Fields Abnormal
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Pulaski AO Pupil