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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 Pulaski AO Pupil 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 Pulaski AO Pupil Pulaski AO Pupil 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.. Pulaski AO Pupil Pulaski AO Pupil THE NORMAL PUPIL Pulaski AO Pupil 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 Pulaski AO Pupil Pulaski AO Pupil Pulaski AO Pupil The Pupil The “Normal” Pupil Pupillogram – 24 y.o. healthy male •From Loewenfeld, “The Pupil” Pulaski AO Pupil The Pupil The “Normal” Pupil • Pupillary Unrest • Pupillary Fatigue • Pupillary Escape Pulaski AO Pupil 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 Pulaski AO Pupil 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 Pulaski AO Pupil 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. Pulaski AO Pupil The Pupil Reactions Pupillary Escape Pulaski AO Pupil 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 Pulaski AO Pupil 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
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