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Updated: Jul 1 2017

Pupillary Response

  • Overview
  • Introduction
    • Basic principle
      • the parasympathetic and sympathetic nervous system control the pupil
        • parasympathetic fibers lead to pupillary constriction (miosis)
        • sympathetic fibers lead to pupillary dilation (mydriasis)
          • as well as controlling the
            • superior tarsal muscle
              • elevates the upper lid
            • smooth muscle orbitalis
              • prevents eye sinking into the orbit
            • facial and neck cutaneous arteries and sweat glands
    • Miosis
      • light enters the eye which activates
        • retinal ganglion cells that will project axons into the optic nerve → optic chiasm → optic tract and then reach the
          • pretectal nucleus
      • fibers from the pretectal nucleus project to the Edinger-Westphal nucleus
        • pre-ganglionic parasympathetic fibers exit the Edinger-Westphal nucleus and synapse in the
          • ciliary ganglion
      • post-ganglionic parasympathetic fibers from the ciliary ganglion innervate the
        • pupillary constrictor muscles causing uniform bilateral miosis
    • Mydriasis
      • sympathetic fibers from many hypothalamic nuclei descend and reach T1 and T2 spinal cord levels
        • pre-ganglionic sympathetic fibers exit the T1 and T2 spinal cord level to join the paravertebral sympathetic chain (via the white ramus) and
          • synapse to the superior cervical ganglion
      • post-ganglionic sympathetic fibers ascend via the carotid plexus of the internal carotid artery, goes through the cavernous sinus, and synapses to the
        • pupillary dilator muscle
      • Select Pupillary Defects
      • Pupillary Defect
      • Comments
      • Horner syndrome
      • Pathogenesis inolves impairment in sympathetic pathways to the eye and face which results in
        • ptosis
          • secondary to impaired innervation into the upper lid smooth muscles
        • miosis
          • secondary to impaired innervation into the pupillary dilator muscles
        • anhidrosis
      • Marcus Gunn pupil
      • Describes an afferent pupillary defect resulting in
        • the affected eye is not sensitive to the light
        • there is minimal or absent pupillary constriction of the affected eye to light
      • A lesion may affect
        • eye
        • retina
        • optic nerve
      • Afferent pupillary defects can be detected with
        • swinging flashlight test which will show
          • the affected pupil dilate when exposed to the penlight
      • Argyll Robertson pupil
      • A type of light-near dissociation where
        • the eye does not constrict in response to light as much as it does with accomodation
      • Associated with neurosyphilis
      • Adie's myotonic pupil
      • A type of light-near dissociation where
        • the eye does not constrict in response to light as much as it does with accomodation
      • Secondary to
        • degeneration of the
          • ciliary ganglion
          • postganglionic parasympathetic neurons
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