Like that of myosis, the differential diagnosis of dilated pupils or mydriasis can best be developed by applying neuroanatomy (Table 24). “Knowing where the lesion is, tells us what the lesion is.” One simply follows the nerve pathway from the end organ up the oculomotor nerve to the termination in the brainstem. A dilated pupil, however, may also signify a lesion of the optic nerve and its pathways.
DILATED PUPILS (MYDRIASIS)
V I N D Vascular Inflammatory Neoplasm Degenerative and Deficiency Oculomotor Nerve End Organ Orbital cellulitis Peripheral portion of the oculomotor nerve Aneurysm Sinus thrombosis Tuberculosis Syphilis Cerebral abscess Pituitary and brain tumors Brainstem Weber syndrome Syphilis Encephalitis Brainstem glioma Wernicke encephalopathy Optic Nerve End organ Occlusion of ophthalmic artery Occlusion of internal carotid Keratitis Retinitis Retinoblastoma Cataract Retinitis pigmentosa Peripheral portion Cerebral aneurysm Optic neuritis Basilar arachnoiditis Pituitary and brain tumors Optic nerve glioma Weber optic atrophy Brainstem Aneurysm Sinus thrombosis Tuberculosis Syphilis Pituitary and brain tumors
DILATED PUPILS (MYDRIASIS)
I C A T E Intoxication Congenital Allergic and Trauma Endocrine Autoimmune Anticholinergic drug Glaucoma Trauma to the globe Pheochromocytoma Neosynephrine Myopia Hematomas Orbital fracture Pituitary tumor (advanced) Barbiturate Multiple sclerosis Cataract Temporal arteritis Cataract Methyl alcohol Tobacco Multiple sclerosis Orbital fracture Exophthalmos Multiple sclerosis Hematoma Cranial concussion
The clinical picture will often help to pinpoint the diagnosis. A history of drug use (narcotics, amphetamines, etc.) will suggest drug intoxication. Unilateral dilated pupil with ptosis would suggest oculomotor palsy, which may be due to a cerebral aneurysm or tumor or other space-occupying lesion. Early compression of the oculomotor nerve by a subdural hematoma or other mass may be indicated by a dilated pupil. Diabetic neuropathy may cause ptosis and extraocular muscle palsy without a dilated pupil. Unilateral or bilateral dilated pupils with blurred vision may be due to glaucoma or iritis. Dilated pupils may also be associated with blindness . A dilated pupil with other neurologic findings is a clear indication for referral to a neurologist or neurosurgeon. He or she can best decide whether a CT scan or MRI is indicated. Without focal neurologic signs the patient should have a drug screen. If that is negative, a referral to an ophthalmologist may be indicated. He or she may be able to do tonometry to rule out glaucoma and a slit lamp examination to evaluate for iritis and other conditions.
Read excerpts from these other book chapters related to Bilateral pupil dilatation:
Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
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Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8 
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