#ARGYLL ROBERTSON PUPIL BILATERAL PATCH#

In the presence of ptosis and an unequivocal increase in anisocoria in dim illumination, cocaine and apraclonidine testing may be unnecessary. If the abnormal pupil is small, a diagnosis of Horner syndrome may be confirmed by a cocaine or apraclonidine test (see 10.2, Horner Syndrome). Look for ptosis, evaluate ocular motility, and examine the pupillary margin with a slit lamp. Evaluate for the presence of a relative afferent pupillary defect. Test the pupillary reaction to both light and near. Anisocoria greater in light suggests the abnormal pupil is the larger pupil anisocoria greater in dark suggests the abnormal pupil is the smaller pupil. Ocular examination: Try to determine which pupil is abnormal by comparing pupil sizes in light and in dark. History: When was the anisocoria first noted? Associated symptoms or signs? Ocular trauma? Eye drops or ointments? Syphilis? Old photographs?Ģ. The size difference is usually, but not always, <2 mm in diameter.ġ. Physiologic anisocoria: Pupil size disparity is the same in light as in dark, and the pupils react normally to light. If the mydriatic exposure is recent, pupil will not react to pilocarpine 1%.ģ.

#ARGYLL ROBERTSON PUPIL BILATERAL PATCH#

Unilateral exposure to a mydriatic agent: Cycloplegic drops (e.g., atropine), scopolamine patch for motion sickness, ill-įitting mask in patients on nebulizers (using ipratropium bromide), possible use of sympathetic medications (e.g., pseudoephedrine). Third cranial nerve palsy: Always associated ptosis and/or extraocular muscle palsies. Adie (tonic) pupil: The pupil may be irregular, reacts minimally to light, and slowly and tonically to convergence. Iris sphincter muscle damage from trauma: Torn pupillary margin or iris transillumination defects seen on slit-lamp examination.

Long-standing Adie pupil: The pupil is initially dilated, but over time may constrict. Argyll Robertson (syphilitic) pupil: Always bilateral, irregularly round miotic pupils, but a mild degree of anisocoria is often present.

Horner syndrome: Mild ptosis on the side of the small pupil. Iritis: Eye pain, redness, and anterior chamber cells and flare. Unilateral exposure to a miotic agent (e.g., pilocarpine). Surv Ophthalmol 1976 21:45–48, with permission.) A flow chart for sorting out the anisocorias. Flow diagram for the work-up of anisocoria. Conveniently, a popular mnemonic to remember Argyll Robertson pupils is that, just like prostitutes, they 'accommodate but do not react'.FIGURE 10.1.1. Named after Douglas Argyll Robertson (1837–1909), a Scottish surgeon and ophthalmologist, who first described this condition in mid-1860s in patients with neurosyphilis.Īrgyll Robertson pupils are also sometimes called 'prostitute's pupils' because of their association with late neurosyphilis. The exact anatomical lesion behind this phenomenon is unknown but is thought to be caused by bilateral damage of the pretectal nuclei in the midbrain. When seen in these non-syphilitic etiologies, the pupil is termed ' pseudo-Argyll Robertson pupil'. It is a highly specific sign of late neurosyphilis, however can also occur in diabetic neuropathy, multiple sclerosis, alcoholic midbrain degeneration, and stroke. Argyll Robertson pupil is usually bilateral and presents as bilaterally miotic and irregular pupils, which constrict briskly with accommodation but do not react to bright light therefore displaying light-near dissociation.

Argyll robertson pupil bilateral