PUPIL ABNORMALITIES
PUPIL ABNORMALITIES: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the Following Questions:
- Are both pupils dilated? The presence of dilated pupils in an otherwise normal subject would suggest drug intoxication such as phenobarbital, marijuana, and PCP. However, the patient may not know that he or she had a concussion recently. Also, glaucoma may cause dilatation of both pupils.
- Are both pupils constricted? The presence of constricted pupils would suggest narcotic intoxication.
- Is one pupil dilated? The presence of a dilated pupil should suggest oculomotor nerve palsy such as may be due to a ruptured aneurysm or intracranial hematoma. However, if the pupil reacts to light and accommodation, a local condition such as iritis, glaucoma, anisocoria, or irritation of the cervical sympathetic nerves must be considered. If the pupil reacts to accommodation but not to light, then central nervous system syphilis must be suspected. If there is no reaction to light or accommodation, blindness must be considered due to optic nerve lesions.
- If one pupil is dilated, does it react to light and accommodation? This finding would suggest a local condition such as iritis, glaucoma, anisocoria, or irritation of the cervical sympathetic nerves.
- Is one pupil constricted? The presence of a constricted pupil would suggest Horner's syndrome.
- Is there ptosis? The presence of ptosis with a constricted pupil would suggest Horner's syndrome. If there is no ptosis with the constricted pupil, a brain stem lesion such as syringomyelia, tumor, abscess, or encephalitis must be considered.
- Is there blindness? The presence of blindness with a dilated pupil would suggest optic nerve lesions.
DIAGNOSTIC WORKUP
Patients with bilateral dilated or constricted pupils should have a urine drug screen and possibly a blood test for alcohol level. If there is fever or a history of trauma with dilated or constricted pupils or other pupillary abnormalities, a neurologist or neurosurgeon should be consulted immediately before ordering expensive diagnostic tests.
Primary eye conditions can be excluded by tonometry, slit lamp examination, or ophthalmology consultation. Intracranial neoplasms and aneurysms must be excluded by CT scans, MRIs, and possibly angiography. A spinal tap will help diagnose central nervous system lues or multiple sclerosis. VEP studies will help diagnose multiple sclerosis. The workup for Horner's syndrome can be found on
page 227
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Book Source Details
- Book Title: Algorithmic Diagnosis of Symptoms and Signs
- Author(s): R. Douglas Collins
- Year of Publication: 2003
- Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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