Pupillary abnormalities

Pupillary abnormalities Chemosis Eyelid swelling Pain... 

Cruz J, Minoja G, Okuchi K, Facco E. Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale scores of 3 and bilateral abnormal pupillary widening a randomized trial. J Neurosurg 2004 100(3) 376-383. 

Overdose may produce temporary paralysis of ciliary muscle pupillary dilation tachycardia palpitations hot, dry, or flushed skin absence of bowel sounds hyperthermia increased respiratory rate EGG abnormalities nausea vomiting rash over face or upper trunk CNS stimulation and psychosis (marked by agitation, restlessness, rambling speech, visual hallucinations, paranoid behavior, and delusions, followed by depression). 

The pupillary light reflex may help differentiating metabolic cause from structural brainstem lesion in comatose patients (Tokuda et al. 2003). The light reflex is very resistant to metabolic dysfunction. An abnormal light reflex, especially when unilateral, points to a midbrain lesion. Bilateral diencephalic lesions or metabolic coma may cause bilateral small pupils well reacting to light ( diencephalic pupils ). 

Patients who have had cataract extraction with implantation of an intraocular lens (lOL) often have pupils that dilate less well than they did preoperatively.The poorer pupillary response probably relates to the amount of iris trauma occurring at surgery. The difference in mydriatic response may affect evaluating and treating peripheral retinal abnormalities in aphakic and pseudophakic eyes. However, even with maximally dilated pupils often the capsulotomy is the limiting fector. 

In tests of the response to direct light, a pupil that responds poorly clearly indicates the abnormal pupil.The differential diagnosis includes third-nerve palsy, anticholinergic mydriasis, Adie s pupil, or local iris disease. If each eye exhibits a good pupillary light reaction, differential diagnosis includes Horner s syndrome and physiologic anisocoria (Table 22-1). 

In Down s syndrome, atropine produces an abnormally large degree of pupillary dilatation, probably because of a genetically abnormal response there is also a much greater acceleration of the heart rate than that produced by atropine in healthy subjects. 

In addition to an assessment of language and cognitive abilities, the physical examination also should assess motor, sensory, and reflex abnormalities and pupillary response, asymmetry, and posturing on neurologic examination. Because generalized seizures may cause physical injury, the patient should be examined for secondary injuries (e.g., tongue lacerations, shoulder dislocations, head trauma, and facial trauma). 

Evidence of head or other CNS injury (bradycardia, tachypnea, and hypertension poor pupillary response asymmetry on neurologic examination abnormal posturing... 

Cruz J, Minoja G, Okuchi K. Major clinical and physiological benefits of early high doses of mannitol for intraparenchymal temporal lobe hemorrhages with abnormal pupillary widening A randomized trial. Neurosurgery 2002 51 628-637. 

CAG withont pupillary block occurs in patients with an abnormality called a plateau iris. The ciliary processes in these cases are situated anteriorly, which indent the iris forward and canse closure of the trabecular meshwork, especially during mydriasis. The mydriasis prodnced by anticholinergic dmgs or any other drng resnlts in precipitation of both types of CAG glancoma, whereas dmg-indnced miosis may prodnce pnpfllary block. 

Ocular abnormalities Dilated and fixed pupils, distorted blurred vision, ptosis, extraocular muscle paralysis. Constricted pupils, dim vision (if vapor), little if any change if exposed via skin. Weak effects if usual doses given causing pupillary dilation and paralysis of accommodation. 

Hreidarsson, A. B., Gundersen, H. J. (1988). Reduced pupillary unrest Aulonorrtic nervous system abnormality in diabetes mellitus. Diabetes, 37,446-451. Jattisse, M. P (1977). Pupillometry The psychology ofthe pupillary response. New York Wiley. 

Eyes Pupillary equality, reaction to light, accommodation, ocular 8. Vascular System Abnormal pulse and amplitude, carotid or arterial bruits. ... 

Neurologic findings include cerebellar ataxia and extrap3rramidal rigidity which are not as common in TSD. A cherry-red spot is rarely seen, but retinitis pigmentosa as well as abnormal pupillary reactions are frequent. Cases without ophthalmologic abnormalities have been reported (Corberi 1926, Liebers 1927, Schneck et al. 1965b). 

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