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Concept: Anisocoria


Aims : To derive a reliable estimate of the frequency of pupillary involvement and to study the patterns and course of anisocoria in conjunction with ophthalmoplegia in diabetes-associated oculomotor nerve palsy. Materials and Methods: In this prospective analytical study, standardized enrolment criteria were employed to identify 35 consecutive patients with diabetes-associated oculomotor nerve palsy who were subjected to a comprehensive ocular examination. Standardized methods were used to evaluate pupil size, shape, and reflexes. The degree of anisocoria, if present and the degree of ophthalmoplegia was recorded at each visit. Results: Pupillary involvement was found to be present in 25.7% of the total number of subjects with diabetic oculomotor nerve palsy. The measure of anisocoria was < 2 mm, and pupil was variably reactive at least to some extent in all cases with pupillary involvement. Majority of patients in both the pupil-involved and pupil-spared group showed a regressive pattern of ophthalmoplegia. Ophthalmoplegia reversed much earlier and more significantly when compared to anisocoria. Conclusions: Pupillary involvement in diabetes-associated oculomotor nerve palsy occurs in about 1/4 th of all cases. Certain characteristics of the pupil help us to differentiate an ischemic insult from an aneurysmal injury to the 3 rd nerve. Ophthalmoplegia resolves much earlier than anisocoria in diabetic oculomotor nerve palsies.

Concepts: Eye, Cranial nerves, Oculomotor nerve, Pupil, Oculomotor nerve palsy, Edinger-Westphal nucleus, Anisocoria, Mydriasis


Ophthalmoplegic migraine is a rare disorder characterized by childhood-onset ophthalmoplegia and migraine headaches. The third cranial nerve is commonly involved, while involvement of the sixth and fourth cranial nerves is uncommon. We present the case study of a 15-year-old female teenager whose condition was diagnosed with ophthalmoplegic migraine when she was 9 years old and since then has experienced multiple and recurrent attacks. Since the diagnosis, she has exhibited a persistent right-eye mydriasis, despite resolution of migrainous episodes. Pupillary involvement in ophthalmoplegic migraine is the rule in children, with total recovery in the majority of cases. We will discuss some aspects related to the eventual association between this entity and other comorbidities, such as Adie tonic pupil, emphasizing the fact that the underlying mechanisms of this residual mydriasis are not fully understood.

Concepts: Cranial nerves, Nerve, Oculomotor nerve, Neurological disorders, Pupil, Anisocoria, Mydriasis, Miosis


Ptosis and anisocoria in a child may be subtle indications of occult pathology, and making the observation acutely in the emergency department (ED) is important in guiding patient management and treatment. Emergency physicians must evaluate patients to exclude serious or life-threatening emergencies and ensure correct disposition of patients. Horner syndrome in children may be considered congenital or acquired and may be from benign or malignant causes. When an isolated, acquired Horner syndrome is suspected in a pediatric patient, physical examination of the neck and abdomen for masses, as well as spot urine catecholamines, vanillylmandelic acid and homovanillic acid, and varying degrees of imaging are recommended as part of the initial evaluation. These evaluations may be performed in the ED or may require hospitalization, depending on the suspected anatomical localization and diagnostic considerations.

Concepts: Patient, Hospital, Physician, Ophthalmology, Medical school, Anisocoria, Horner's syndrome, Superior tarsal muscle


Horner syndrome results from an interruption of the oculosympathetic pathway. Patients with Horner syndrome present with a slightly droopy upper lid and a smaller pupil on the affected side; less commonly, there is a deficiency of sweating over the brow or face on the affected side. This condition does not usually cause vision problems or other significant symptoms, but is important as a warning sign that the oculosympathetic pathway has been interrupted, potentially with serious and even life-threatening processes. The oculosympathetic pathway has a long and circuitous course, beginning in the brain and traveling down the spinal cord to exit in the chest, then up the neck and into the orbit. Therefore, this syndrome with unimpressive clinical findings and insignificant symptoms may be a sign of serious pathology in the head, chest, or neck. This clinical review discusses how to identify the signs, confirm the diagnosis, and evaluate the many causes of Horner syndrome.

Concepts: Brain, Medical diagnosis, Syndromes, Warning sign, Anisocoria, Miosis, Horner's syndrome, System call


Intracisternal papaverine (iPPV) is a vasodilator used for prophylaxis of intra-operative vasospasm during aneurysmal clipping. Its post-operative side effects include transient cranial nerve palsies, most commonly mydriasis due to oculomotor nerve involvement with rapid resolution. We critically review the current literature on the adverse effects of iPPV in aneurysmal surgery, with a focus on oculomotor nerve involvement. In addition, this manuscript portrays the index case of prolonged bilateral mydriasis secondary to iPPV irrigation toxicity and its putative underlying mechanism. Papaverine toxicity occurs in the setting of its antimuscarinic action, and blood-CSF and blood-brain barrier compromise owing to aSAH and papaverine direct effect. Our patient also experienced severe vasospasm and a minor stroke, both contributing to further BBB disruption, and relatively acidic pH of the SAH milieu. We propose that these factors perpetuate papaverine crystals' phase dynamics, and thus facilitate a sustained slow release of papaverine within the cisternal system. Were it indicated, 0.3% iPPV would reasonably diminish the risk for neurotoxicity.

Concepts: Medical terms, Cranial nerves, PH, Subarachnoid hemorrhage, Oculomotor nerve, Trochlear nerve, Pupil, Anisocoria


A unilaterally fixed mydriasis, also known as a ‘blown pupil,’ is considered an ominous sign concerning for intracranial pathology. Causes of anisocoria can range from benign to immediately life-threatening. When a patient presents with anisocoria, the concern for a fatal diagnosis leads the clinician to obtain numerous tests, many of which may be unnecessary. The authors present a case of a healthy woman in her 30s who presented with an acute unilateral mydriasis likely secondary to inadvertent contact with a scopolamine patch. On examination, she had no other neurological deficits. Further investigation did not reveal any abnormality. In the event of a patient with an isolated mydriasis in an otherwise healthy and conversant patient with no other neurological deficits, it is essential to rule out other causes before pursuing aggressive and unnecessary testing and treatment.

Concepts: Hospital, Medical diagnosis, Pupil, Anisocoria, Mydriasis, Tropicamide, Scopolamine, Brugmansia


To evaluate the efficacy of digital pupillometry in the diagnosis of anisocoria related to Horner syndrome in adult patients.

Concepts: Syndromes, Ophthalmology, Anisocoria, Horner's syndrome, Johann Friedrich Horner


Multiple eccrine hidrocystoma (EH) has been treated with topical atropine with variable results. However, in rare cases, anticholinergic side effects have been seen after the use of the topical form of this drug. We presented a 50-year-old woman who developed recent onset of visual disturbance and photophobia from 2 weeks prior. The diagnosis of topical atropine-induced bilateral mydriasis was made. We reported a recognized but often overlooked case of bilateral mydriasis caused by application of topical 1% atropine for treatment of multiple EH.

Concepts: Anticholinergic, Atropine, Pupil, Anisocoria, Mydriasis, Miosis, Tropicamide, Scopolamine


Thoracic paravertebral block can provide analgesia for unilateral chest surgery and is associated with a low complication rate. Horner syndrome also referred to as oculosympathetic paresis, is a classic neurologic constellation of ipsilateral blepharoptosis, pupillary miosis, and facial anhidrosis resulting from disruption of the sympathetic pathway supplying the head, eye, and neck.

Concepts: Neurology, Syndromes, Ophthalmology, Anisocoria, Miosis, Pancoast tumor, Horner's syndrome, Superior tarsal muscle


Anisocoria may indicate a life-threatening neurosurgical emergency, unlike bilateral mydriasis. In patients with periorbital fracture, anisocoria can be caused by direct or indirect injury to the oculomotor nerve, excessive retraction of the orbital contents, or constriction of the muscles responsible for eyeball movement. Herein, the author reports a patient, 15-year-old boy, who developed anisocoria after an operation for a blowout fracture. The anisocoria was improved, self-limiting, and transient. The author has also reviewed the literature regarding anisocoria.

Concepts: Patient, Hospital, Muscle, Cranial nerves, Oculomotor nerve, The Orbital, Pupil, Anisocoria