When Anisocoria Is Present… and the Larger 2 Q

 When anisocoria is present… and the larger 2 Q

 When anisocoria is present… and the larger

When faced with anisocoria, what do you want to know first and foremost? Which pupil (if either) is ‘the culprit’; ie, is the larger pupil failing to constrict properly, or is the smaller pupil not dilating properly?

How can you tell which pupil is the culprit? By determining the lighting condition under which the anisocoria is more pronounced. If the anisocoria is more pronounced in dim light, this indicates the smaller pupil isn’t dilating properly (and thus is abnormal). A pupil that fails to dilate is suggestive of a sympathetic pathway problem. Likewise, if the anisocoria is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympathetic pathway problem.

What if the anisocoria is the same under all lighting conditions? Then it is nonpathologic or physiological anisocoria--a common finding 3 A

 When anisocoria is present… and the larger

What if the anisocoria is the same under all lighting conditions? Then it is nonpathologic or physiological anisocoria--a common finding 4 Q

 When anisocoria is present… and the larger

What if the anisocoria is the same under all lighting conditions? Then it is nonpathologic or physiological anisocoria--a common finding 5 Q

 When anisocoria is present… and the larger

How can you tell which pupil is the culprit? By determining the lighting condition under which the anisocoria is more pronounced. If the anisocoria is more pronounced in dim light, this indicates the smaller pupil isn’t dilating properly (and thus is abnormal). A pupil that fails to dilate is suggestive of a sympatheticANS division pathway problem. Likewise, if the anisocoria is more pronounced in bright light, the larger pupil isn’t constricting properly, and is therefore abnormal. A pupil that doesn’t constrict as it should is suggestive of a parasympathetic pathway problem.

What if the anisocoria is the same under all lighting conditions? Then it is nonpathologic or physiological anisocoria--a common finding 6 A

 When anisocoria is present… and the larger

What if the anisocoria is the same under all lighting conditions? Then it is nonpathologic or physiological anisocoria--a common finding 7 Q

 When anisocoria is present… and the larger

What if the anisocoria is the same under all lighting conditions? Then it is nonpathologic or physiological anisocoria--a common finding 8 A

 When anisocoria is present… and the larger

What if the anisocoria is the same under all lighting conditions? Then it is nonpathologic or physiological anisocoria--a common finding 9 Q

 When anisocoria is present… and the larger

What if the anisocoria is the same under all lighting conditions? Then it is nonpathologic or physiological anisocoria--a common finding 10 A

 When anisocoria is present… and the larger

What if the anisocoria is the same under all lighting conditions? Then it is nonpathologic or physiological anisocoria--a common finding 11

 When anisocoria is present…and the larger pupil is the culprit… 12 Q

 When anisocoria is present…and the larger pupil is the culprit…

As an aside: A pupil that does not constrict owing to inadequate parasympathetic input is often referred to as a motor pupil 13 A

 When anisocoria is present…and the larger pupil is the culprit…

As an aside: A pupil that does not constrict owing to inadequate parasympathetic input is often referred to as a motor pupil 14 Q

 When anisocoria is present…and the larger pupil is the culprit…  Must rule out a… 15 A

 When anisocoria is present…and the larger pupil is the culprit…  Must rule out a…CN3 palsy 16 Q

 When anisocoria is present…and the larger pupil is the culprit…  Must rule out a…CN3 palsy  Always consider… 17 A

 When anisocoria is present…and the larger pupil is the culprit…  Must rule out a…CN3 palsy  Always consider…local iris pathology 18 Q

 When anisocoria is present…and the smaller pupil is the culprit…  Must rule out a… 19 A

 When anisocoria is present…and the smaller pupil is the culprit…  Must rule out a…Horner syndrome 20 Q

 When anisocoria is present…and the smaller pupil is the culprit…  Must rule out a…Horner syndrome  Always consider… 21 A

 When anisocoria is present…and the smaller pupil is the culprit…  Must rule out a…Horner syndrome  Always consider…local iris pathology 22 Q

 Pilocommon testing drop can be contributory in evaluating a possible motor pupil 23 A

 Pilo testing can be contributory in evaluating a possible motor pupil 24 Q

 Pilo testing can be contributory in evaluating a possible motor pupil  Step 1: Check response to dilute (1/8-1/16%)strength pilo. 25 A

 Pilo testing can be contributory in evaluating a possible motor pupil  Step 1: Check response to dilute (1/8-1/16%) pilo. If 26 Q

 Pilo testing can be contributory in evaluating a possible motor pupil  Step 1: Check response to dilute (1/8-1/16%) pilo. If pupil… . …constricts: is likely an… 27 A

 Pilo testing can be contributory in evaluating a possible motor pupil  Step 1: Check response to dilute (1/8-1/16%) pilo. If pupil… . …constricts: is likely an…Adie’s pupil 28

 Pilo testing can be contributory in evaluating a possible motor pupil  Step 1: Check response to dilute (1/8-1/16%) pilo. If pupil… . …constricts: is likely an…Adie’s pupil . …does not constrict: Go to Step 2  Step 2: check response to full-strength (1%) pilo. If pupil… . …does not constrict: Is a…drug pupil . …does constrict: Must image for a 34 A

 Pilo testing can be contributory in evaluating a possible motor pupil  Step 1: Check response to dilute (1/8-1/16%) pilo. If pupil… . …constricts: is likely an…Adie’s pupil . …does not constrict: Go to Step 2  Step 2: check response to full-strength (1%) pilo. If pupil… . …does not constrict: Is a…drug pupil . …does constrict: Must image for a…PCA aneurysm

(posterior communicating artery) 35 Q

 Pilo testing can be contributory in evaluating a possible motor pupil  Step 1: Check response to dilute (1/8-1/16%) pilo. If pupil… . …constricts: is likely an…Adie’s pupil . …does not constrict: Go to Step 2  Step 2: check response to full-strength (1%) pilo. If pupil… . …does not constrict: Is a…drug pupil . …does constrict: Must image for a…PCA aneurysm

What if a PCA aneurysm is ruled out by imaging (both MRI/MRA and angiography)? Is likely an Adie’s pupil 36 A

 Pilo testing can be contributory in evaluating a possible motor pupil  Step 1: Check response to dilute (1/8-1/16%) pilo. If pupil… . …constricts: is likely an…Adie’s pupil . …does not constrict: Go to Step 2  Step 2: check response to full-strength (1%) pilo. If pupil… . …does not constrict: Is a…drug pupil . …does constrict: Must image for a…PCA aneurysm

What if a PCA aneurysm is ruled out by imaging (both MRI/MRA and angiography)? Is likely an Adie’s pupil 37 Q

 Pilo testing can be contributory in evaluating a possible motor pupil  Step 1: Check response to dilute (1/8-1/16%) pilo. If pupil… . …constricts: is likely an…Adie’s pupil . …does not constrict: Go to Step 2  Wait a minute. According to Step 1, an Adie’s pupil constricts with dilute Step 2: check responsepilo. The reason towe testedfull-strength this pupil with full-strength(1%) pilo. pilo was that it If pupil… failed to constrict to dilute pilo. So how can it be an Adie’s pupil too? Adie’s syndrome involves interruption of the parasympathetics to the eye . …does not constrict:after the ciliary Is a…drug ganglion. The pupil absence of input produces denervation . …does constrict:supersensitivity Must image of the for receptors a…PCA at the pupillaryaneurysm constrictor muscle, so a chronic Adie’s pupil will respond to dilute pilo. However, denervation supersensitivity takes time to develop; thus, an Adie’s of recent onset What if a PCA aneurysm is(a ruled so-called out byacute imaging Adie’s (both) will not MRI/MRArespond toand dilute angiography)? pilo, but will to full Is likely an Adie’s pupil strength. 38 A

 Pilo testing can be contributory in evaluating a possible motor pupil  Step 1: Check response to dilute (1/8-1/16%) pilo. If pupil… chronic . …constricts: is likely an…Adie’s pupil ^ . …does not constrict: Go to Step 2  Wait a minute. According to Step 1, an Adie’s pupil constricts with dilute Step 2: check responsepilo. The reason towe testedfull-strength this pupil with full-strength(1%) pilo. pilo was that it If pupil… failed to constrict to dilute pilo. So how can it be an Adie’s pupil too? Adie’s syndrome involves interruption of the parasympathetics to the eye . …does not constrict:after the ciliary Is a…drug ganglion. The pupil absence of input produces denervation . …does constrict:supersensitivity Must image of the for receptors a…PCA at the pupillaryaneurysm constrictor muscle, so a chronic Adie’s pupil will respond to dilute pilo. However, denervation supersensitivity takes time to develop; thus, an Adie’s of recent onset What if a PCA aneurysm is(a ruled so-called out byacute imaging Adie’s (both) will not MRI/MRArespond toand dilute angiography)? pilo, but will to full Is likely an Adie’s pupil strength. 39 A

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 41 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 42 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 43 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 44 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 45 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 46 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 47 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 48 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 49 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 50 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 51 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent --Central --Peripheral 52 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent --Central --Peripheral 53 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent --Central --Peripheral 54 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent --Central --Peripheral 55 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent? Damage to which type/location is implicated in the light-near dissociation --Central? associated with an Adie’s? --Peripheral? Peripheral 56 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent Damage to which type/location is implicated in the light-near dissociation --Central associated with an Adie’s? --Peripheral Peripheral 57 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent Where is the lesion in an afferent near-light dissociation? --Central Anywhere in the anterior visual pathway --Peripheral 58 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent Where is the lesion in an afferent near-light dissociation? --Central Anywhere in the anterior visual pathway --Peripheral 59 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic

What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrain midbrainaccommodation: region region Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response  What specific structure of the dorsal midbrain is involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 60 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic

What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrain midbrainaccommodation: region region Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response  What specific structure of the dorsal midbrain is involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 61 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic

What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrain midbrainaccommodation: region region Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response  What specific structure of the dorsal midbrain is involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 62 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic

What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrain midbrainaccommodation: region region Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response  What specific structure of the dorsal midbrain is involved? Tonic nearThe pretectum,pretectum response: specifically the pretectal Chronic nuclei What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 63 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic

What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrain midbrainaccommodation: region region Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response  What specific structure of the dorsal midbrain is involved? Tonic nearThe pretectum,pretectum response: specifically the pretectal Chronic nuclei What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 64 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic

What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrain midbrainaccommodation: region region Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response  What specific structure of the dorsal midbrain is involved? Tonic nearThe pretectum,pretectum response: specifically the pretectal Chronic nuclei What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 65 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic

What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrain midbrainaccommodation: region region Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response  What specific structure of the dorsal midbrain is involved? Tonic nearThe pretectum,pretectum response: specifically the pretectal Chronic nuclei What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 66 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic

What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response  What specific structure of the dorsal midbrain is involved? Tonic nearThe pretectum response:, specifically the pretectal Chronicnuclei What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 67 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute

 PiloParinaud supersensitivity: syndrome has four classic clinical Chronicfeatures. One is light-near dissociation. What are the other three?  --Light-near dissociation Pupil-- fixed: Acute --  Light-near-- dissociation: Chronic

What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response  What specific structure of the dorsal midbrain is involved? Tonic nearThe pretectum response:, specifically the pretectal Chronicnuclei What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 68 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute

 PiloParinaud supersensitivity: syndrome has four classic clinical Chronicfeatures. One is light-near dissociation. What are the other three?  --Light-near dissociation Pupil--Impaired fixed:upgaze Acute --Lid retraction  Light-near--Convergence-retraction dissociation nystagmus : Chronic

What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response  What specific structure of the dorsal midbrain is involved? Tonic nearThe pretectum response:, specifically the pretectal Chronicnuclei What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 69 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute

 PiloParinaud supersensitivity: syndrome has four classic clinical Chronicfeatures. One is light-near dissociation. What are the other three?  --Light-near dissociation Pupil--Impaired fixed:upgaze Acute --Lid retraction  Light-near--Convergence-retraction dissociation nystagmus : Chronic

What is light-nearThe etiology dissociation?Where ofin athe Parinaud brain is the syndrome lesion in is a oftencentral a functionnear-light of dissociation? who the pt is.  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomenaFor in each which of pupilsthese miosepts with less Parinaud robustly’s, instate response the most to llikelyight than cause: they do as part of the near response --A child: Hydrocephalus  --A youngWhat man: specific A pineal structure tumor of the dorsal midbrain is involved? Tonic nearThe pretectum response: Chronic What are the--A three young general woman: types MS /locations of light-near dissociation? --An older man: CVA --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 70 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute

 PiloParinaud supersensitivity: syndrome has four classic clinical Chronicfeatures. One is light-near dissociation. What are the other three?  --Light-near dissociation Pupil--Impaired fixed:upgaze Acute --Lid retraction  Light-near--Convergence-retraction dissociation nystagmus : Chronic

What is light-nearThe etiology dissociation?Where ofin athe Parinaud brain is the syndrome lesion in is a oftencentral a functionnear-light of dissociation? who the pt is.  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomenaFor in each which of pupilsthese miosepts with less Parinaud robustly’s, instate response the most to llikelyight than cause: they do as part of the near response --A child: Hydrocephalus  --A youngWhat man: specific A pineal structure tumor of the dorsal midbrain is involved? Tonic nearThe pretectum response: Chronic What are the--A three young general woman: types MS /locations of light-near dissociation? --An older man: CVA --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 71 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute Parinaud syndrome is characterized by tonic downward displacement of the eyes, with impaired upgaze. There is a clinical Parinaud syndrome has four classic clinical features.  Pilo supersensitivity:entity that is the opposite Chronic of this, that is, tonic upward deviation of One is light-near dissociation. What are the other three? the eyes, with impaired downgaze. What is this condition? --Light-near dissociation  Oculogyric crisis Pupil--Impaired fixed: upgaze Acute --Lid retraction What is the etiology of oculogyric crisis?  Light-near--Convergence-retraction dissociation nystagmus : Chronic It is an idiosyncratic drug reaction What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils mioseWhich lesstwo robustlyclasses ofin drugsresponse are tomost light commonly than they implicateddo as part andof the near response which is number one?  What specificThe structure neuroleptics of the dorsal (#1), midbrainand the isantiemetics involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 72 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute Parinaud syndrome is characterized by tonic downward displacement of the eyes, with impaired upgaze. There is a clinical Parinaud syndrome has four classic clinical features.  Pilo supersensitivity:entity that is the opposite Chronic of this, that is, tonic upward deviation of One is light-near dissociation. What are the other three? the eyes, with impaired downgaze. What is this condition? --Light-near dissociation  Oculogyric crisis Pupil--Impaired fixed: upgaze Acute --Lid retraction What is the etiology of oculogyric crisis?  Light-near--Convergence-retraction dissociation nystagmus : Chronic It is an idiosyncratic drug reaction What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils mioseWhich lesstwo robustlyclasses ofin drugsresponse are tomost light commonly than they implicateddo as part andof the near response which is number one?  What specificThe structure neuroleptics of the dorsal (#1), midbrainand the isantiemetics involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 73 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute Parinaud syndrome is characterized by tonic downward displacement of the eyes, with impaired upgaze. There is a clinical Parinaud syndrome has four classic clinical features.  Pilo supersensitivity:entity that is the opposite Chronic of this, that is, tonic upward deviation of One is light-near dissociation. What are the other three? the eyes, with impaired downgaze. What is this condition? --Light-near dissociation  Oculogyric crisis Pupil--Impaired fixed: upgaze Acute --Lid retraction What is the etiology of oculogyric crisis?  Light-near--Convergence-retraction dissociation nystagmus : Chronic It is an idiosyncratic drug reaction What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils mioseWhich lesstwo robustlyclasses ofin drugsresponse are tomost light commonly than they implicateddo as part andof the near response which is number one?  What specificThe structure neuroleptics of the dorsal (#1), midbrainand the isantiemetics involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 74 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute Parinaud syndrome is characterized by tonic downward displacement of the eyes, with impaired upgaze. There is a clinical Parinaud syndrome has four classic clinical features.  Pilo supersensitivity:entity that is the opposite Chronic of this, that is, tonic upward deviation of One is light-near dissociation. What are the other three? the eyes, with impaired downgaze. What is this condition? --Light-near dissociation  Oculogyric crisis Pupil--Impaired fixed: upgaze Acute --Lid retraction What is the etiology of oculogyric crisis?  Light-near--Convergence-retraction dissociation nystagmus : Chronic It is an idiosyncratic drug reaction What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils mioseWhich lesstwo robustlyclasses ofin drugsresponse are tomost light commonly than they implicateddo as part andof the near response which is number one?  What specificThe structure neuroleptics of the dorsal (#1), midbrainand the isantiemetics involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 75 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute Parinaud syndrome is characterized by tonic downward displacement of the eyes, with impaired upgaze. There is a clinical Parinaud syndrome has four classic clinical features.  Pilo supersensitivity:entity that is the opposite Chronic of this, that is, tonic upward deviation of One is light-near dissociation. What are the other three? the eyes, with impaired downgaze. What is this condition? --Light-near dissociation  Oculogyric crisis Pupil--Impaired fixed: upgaze Acute --Lid retraction What is the etiology of oculogyric crisis?  Light-near--Convergence-retraction dissociation nystagmus : Chronic It is an idiosyncratic drug reaction What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils mioseWhich lesstwo robustlyclasses ofin drugsresponse are tomost light commonly than they implicateddo as part andof the near response which is number one?  What specificThe structure neuroleptics of the dorsal (#1), midbrainand the isantiemetics involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 76 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute Parinaud syndrome is characterized by tonic downward displacement of the eyes, with impaired upgaze. There is a clinical Parinaud syndrome has four classic clinical features.  Pilo supersensitivity:entity that is the opposite Chronic of this, that is, tonic upward deviation of One is light-near dissociation. What are the other three? the eyes, with impaired downgaze. What is this condition? --Light-near dissociation  Oculogyric crisis Pupil--Impaired fixed: upgaze Acute --Lid retraction What is the etiology of oculogyric crisis?  Light-near--Convergence-retraction dissociation nystagmus : Chronic It is an idiosyncratic drug reaction What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils mioseWhich lesstwo robustlyclasses ofin drugsresponse are tomost light commonly than they implicateddo as part andof the near response which is number one?  What specificThe structure neuroleptics of the dorsal (#1), midbrainand the isantiemetics involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndrome --Peripheral What are the two noneponymous names for Parinaud syndrome? 1) Dorsal midbrain syndrome 2) Pretectal syndrome 77 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute Parinaud syndrome is characterized by tonic downward displacement of the eyes, with impaired upgaze. There is a clinical Parinaud syndrome has four classic clinical features.  Pilo supersensitivity:entity that is the opposite Chronic of this, that is, tonic upward deviation of One is light-near dissociation. What are the other three? the eyes, with impaired downgaze. What is this condition? --Light-near dissociation  Oculogyric crisis Pupil--Impaired fixed: upgaze Acute --Lid retraction What is the etiology of oculogyric crisis?  Light-near--Convergence-retraction dissociation nystagmus : Chronic It is an idiosyncratic drug reaction What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils mioseWhich lesstwo robustlyclasses ofin drugsresponse are tomost light commonly than they implicateddo as part andof the near response which is number one?  What specificThe structure neuroleptics of the dorsal (#1), midbrain and the is antiemetics involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? Which neuroleptic is most commonly implicated? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndromeHaloperidol --Peripheral What are theWhich two noneponymous antiemetic is namesmost commonly for Parinaud implicated? syndrome? 1) Dorsal midbrainMetoclopramide syndrome 2) Pretectal syndrome 78 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute Parinaud syndrome is characterized by tonic downward displacement of the eyes, with impaired upgaze. There is a clinical Parinaud syndrome has four classic clinical features.  Pilo supersensitivity:entity that is the opposite Chronic of this, that is, tonic upward deviation of One is light-near dissociation. What are the other three? the eyes, with impaired downgaze. What is this condition? --Light-near dissociation  Oculogyric crisis Pupil--Impaired fixed: upgaze Acute --Lid retraction What is the etiology of oculogyric crisis?  Light-near--Convergence-retraction dissociation nystagmus : Chronic It is an idiosyncratic drug reaction What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils mioseWhich lesstwo robustlyclasses ofin drugsresponse are tomost light commonly than they implicateddo as part andof the near response which is number one?  What specificThe structure neuroleptics of the dorsal (#1), midbrain and the is antiemetics involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? Which neuroleptic is most commonly implicated? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndromeHaloperidol --Peripheral What are theWhich two noneponymous antiemetic is namesmost commonly for Parinaud implicated? syndrome? 1) Dorsal midbrainMetoclopramide syndrome 2) Pretectal syndrome 79 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute Parinaud syndrome is characterized by tonic downward displacement of the eyes, with impaired upgaze. There is a clinical Parinaud syndrome has four classic clinical features.  Pilo supersensitivity:entity that is the opposite Chronic of this, that is, tonic upward deviation of One is light-near dissociation. What are the other three? the eyes, with impaired downgaze. What is this condition? --Light-near dissociation  Oculogyric crisis Pupil--Impaired fixed: upgaze Acute --Lid retraction What is the etiology of oculogyric crisis?  Light-near--Convergence-retraction dissociation nystagmus : Chronic It is an idiosyncratic drug reaction What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils mioseWhich lesstwo robustlyclasses ofin drugsresponse are tomost light commonly than they implicateddo as part andof the near response which is number one?  What specificThe structure neuroleptics of the dorsal (#1), midbrainand the isantiemetics involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? Which neuroleptic is most commonly implicated? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndromeHaloperidol --Peripheral What are theWhich two noneponymous antiemetic is namesmost commonly for Parinaud implicated? syndrome? 1) Dorsal midbrainMetoclopramide syndrome 2) Pretectal syndrome 80 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute Parinaud syndrome is characterized by tonic downward displacement of the eyes, with impaired upgaze. There is a clinical Parinaud syndrome has four classic clinical features.  Pilo supersensitivity:entity that is the opposite Chronic of this, that is, tonic upward deviation of One is light-near dissociation. What are the other three? the eyes, with impaired downgaze. What is this condition? --Light-near dissociation  Oculogyric crisis Pupil--Impaired fixed: upgaze Acute --Lid retraction What is the etiology of oculogyric crisis?  Light-near--Convergence-retraction dissociation nystagmus : Chronic It is an idiosyncratic drug reaction What is light-near dissociation?Where in the brain is the lesion in a central near-light dissociation?  DecreasedThe dorsal midbrainaccommodation: region Acute A phenomena in which pupils mioseWhich lesstwo robustlyclasses ofin drugsresponse are tomost light commonly than they implicateddo as part andof the near response which is number one?  What specificThe structure neuroleptics of the dorsal (#1), midbrainand the isantiemetics involved? Tonic nearThe pretectum response: Chronic What are the three general types /locations of light-near dissociation? Which neuroleptic is most commonly implicated? --Afferent What is the eponymous name for the syndrome caused by a dorsal midbrain/pretectum lesion? --Central Parinaud syndromeHaloperidol --Peripheral What are theWhich two noneponymous antiemetic is namesmost commonly for Parinaud implicated? syndrome? 1) Dorsal midbrainMetoclopramide syndrome 2) Pretectal syndrome 81 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent Where is the lesion in peripheral near-light dissociation? --Central The ciliary ganglion, or the long ciliary nerves --Peripheral What is the pathophysiology of ciliary ganglion damage in Adie’s? Unknown; some authorities suspect a viral cause

What is the most common cause of damage to the long ciliary nerves? Panretinal photocoagulation 82 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent Where is the lesion in peripheral near-light dissociation? --Central The ciliary ganglion, or the long ciliary nerves --Peripheral What is the pathophysiology of ciliary ganglion damage in Adie’s? Unknown; some authorities suspect a viral cause

What is the most common cause of damage to the long ciliary nerves? Panretinal photocoagulation 83 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent Where is the lesion in peripheral near-light dissociation? --Central The ciliary ganglion, or the long ciliary nerves --Peripheral What is the pathophysiology of ciliary ganglion damage in Adie’s? Unknown; some authorities suspect a viral cause

What is the most common cause of damage to the long ciliary nerves? Panretinal photocoagulation 84 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent Where is the lesion in peripheral near-light dissociation? --Central The ciliary ganglion, or the long ciliary nerves --Peripheral What is the pathophysiology of ciliary ganglion damage in Adie’s? Unknown; some authorities suspect a viral cause

What is the most common cause of damage to the long ciliary nerves? Panretinal photocoagulation 85 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent Where is the lesion in peripheral near-light dissociation? --Central The ciliary ganglion, or the long ciliary nerves --Peripheral What is the pathophysiology of ciliary ganglion damage in Adie’s? Unknown; some authorities suspect a viral cause

What is the most common cause of damage to the long ciliary nerves? Panretinal photocoagulation 86 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic What Decreased is light-near dissociation? accommodation: Acute A phenomena in which pupils miose less robustly in response to light than they do as part of the near response Tonic near response: Chronic What are the three general types/locations of light-near dissociation? --Afferent Where is the lesion in peripheral near-light dissociation? --Central The ciliary ganglion, or the long ciliary nerves --Peripheral What is the pathophysiology of ciliary ganglion damage in Adie’s? Unknown; some authorities suspect a viral cause

What is the most common cause of damage to the long ciliary nerves? Panretinal photocoagulation 87 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 88 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 89 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 90 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic 91 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

What does it mean to say the near response is tonic? It means the pupil’s miotic near response persists even after the eye is no longer engaged in attempting to see at near, with re-dilation occurring s-l-o-w-l-y

Under what circumstance does a tonic pupil earn the distinction of being an ‘Adie’s’? When it is idiopathic, ie, when no identifiable cause can be found 92 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

Under what circumstance does a tonic pupil earn the distinction of being an ‘Adie’s’? When it is idiopathic, ie, when no identifiable cause can be found 93 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

Under what circumstance does a tonic pupil earn the distinction of being an ‘Adie’s’? When it is idiopathic, ie, when no identifiable cause can be found 94 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

Under what circumstance does a tonic pupil earn the distinction of being an ‘Adie’s’? When it is idiopathic, ie, when no identifiable cause can be found 95 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

Under what circumstance does a tonic pupil earn the distinction of being an ‘Adie’s’? When it is idiopathic, ie, when no identifiable cause can be found 96 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

Under what circumstance does a tonic pupil earn the distinction of being an ‘Adie’s’? When it is idiopathic, ie, when no identifiable cause can be found 97 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

What will an acute Adie’s patient complain of? 1) Loss of accommodationDifficulty reading 2) Pupil dilationphotophobia15 98 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A/Q a chronic Adie’s pupil, or both

What will an acute Adie’s patient complain of? 1) Loss of accommodationDifficulty reading 2) Pupil dilationphotophobia 99 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

What will an acute Adie’s patient complain of? 1) Loss of accommodationDifficulty reading 2) Pupil dilationphotophobia 100 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A/Q a chronic Adie’s pupil, or both

What will an acute Adie’s patient complain of? 1) Loss of accommodationDifficulty reading 2) Pupil dilationphotophobia 101 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

What will an acute Adie’s patient complain of? 1) Loss of accommodationDifficulty reading 2) Pupil dilationphotophobia 102 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic Adie’s pupil stems from disruption of postganglionic parasympathetics in the orbit. Acutely, this results in a loss of both pupillary constrictor function (hence the fixed dilated pupil) and accommodation (hence the difficulty at near). However, over time several developments change the clinical picture. Denervation supersensitivity may develop, as described previously. In addition, aberranttwo regeneration words can occur.

To what does aberrant regeneration refer in this context? The vast majority of orbital postganglionic parasympathetic fibers are dedicated to accommodation. Because of this, regeneration results in a number of accommodation-fiber-to-constrictor-muscle connections. This results in the tonic near response, miosis, and light-near dissociation of the chronic Adie’s pupil. 103 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic Adie’s pupil stems from disruption of postganglionic parasympathetics in the orbit. Acutely, this results in a loss of both pupillary constrictor function (hence the fixed dilated pupil) and accommodation (hence the difficulty at near). However, over time several developments change the clinical picture. Denervation supersensitivity may develop, as described previously. In addition, aberrant regeneration can occur.

To what does aberrant regeneration refer in this context? The vast majority of orbital postganglionic parasympathetic fibers are dedicated to accommodation. Because of this, regeneration results in a number of accommodation-fiber-to-constrictor-muscle connections. This results in the tonic near response, miosis, and light-near dissociation of the chronic Adie’s pupil. 104 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic Adie’s pupil stems from disruption of postganglionic parasympathetics in the orbit. Acutely, this results in a loss of both pupillary constrictor function (hence the fixed dilated pupil) and accommodation (hence the difficulty at near). However, over time several developments change the clinical picture. Denervation supersensitivity may develop, as described previously. In addition, aberrant regeneration can occur.

To what does aberrant regeneration refer in this context? The vast majority of orbital postganglionic parasympathetic fibers are dedicated to accommodation. Because of this, regeneration results in a number of accommodation-fiber-to-constrictor-muscle connections. This results in the tonic near response, miosis, and light-near dissociation of the chronic Adie’s pupil. 105 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

 Affected pupil smaller: Chronic  Affected pupil larger: Acute  Pilo supersensitivity: Chronic  Pupil fixed: Acute  Light-near dissociation: Chronic  Decreased accommodation: Acute  Tonic near response: Chronic Adie’s pupil stems from disruption of postganglionic parasympathetics in the orbit. Acutely, this results in a loss of both pupillary constrictor function (hence the fixed dilated pupil) and accommodation (hence the difficulty at near). However, over time several developments change the clinical picture. Denervation supersensitivity may develop, as described previously. In addition, aberrant regeneration can occur.

To what does aberrant regeneration refer in this context? 97% of orbital postganglionic parasympathetic fibers are dedicated to accommodation. Because of this, regeneration produces a number of inadvertent accommodation-fiber-to-constrictor-muscle connections. This results in the tonic near response, miosis, and light-near dissociation of the chronic Adie’s pupil. 106 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

Is there a gender predilection in Adie’s pupil? Yes--the majority ( 70% ) of pts are female

Does Adie’s tend to be unilateral, or bilateral? It is unilateral in the majority ( 80% ) of cases 107 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q/A a chronic Adie’s pupil, or both

Is there a gender predilection in Adie’s pupil?

Yes--the majority ( 70%% ) of pts are femaleM vs F

Does Adie’s tend to be unilateral, or bilateral? It is unilateral in the majority ( 80% ) of cases 108 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

Is there a gender predilection in Adie’s pupil? Yes--the majority ( 70% ) of pts are female

Does Adie’s tend to be unilateral, or bilateral? It is unilateral in the majority ( 80% ) of cases 109 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q a chronic Adie’s pupil, or both

Is there a gender predilection in Adie’s pupil? Yes--the majority ( 70% ) of pts are female

Does Adie’s tend to be unilateral, or bilateral? It is unilateral in the majority ( 80% ) of cases 110 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, Q/A a chronic Adie’s pupil, or both

Is there a gender predilection in Adie’s pupil? Yes--the majority ( 70% ) of pts are female

Does Adie’s tend to be unilateral, or bilateral? It is unilateraluni- vs bilateral in the majority ( 80%% ) of cases 111 Speaking of Adie’s…For each sign and symptom, identify whether it is associated with an acute Adie’s pupil, A a chronic Adie’s pupil, or both

Is there a gender predilection in Adie’s pupil? Yes--the majority ( 70% ) of pts are female

Does Adie’s tend to be unilateral, or bilateral? It is unilateral in the majority ( 80% ) of cases