Pupils, sluggish
A sluggish pupillary reaction is an abnormally slow pupillary response to light. It can occur in one pupil or both, unlike the normal reaction, which is always bilateral. A sluggish reaction accompanies degenerative disease of the central nervous system and diabetic neuropathy. It can occur normally in elderly people, whose pupils become smaller and less responsive with age.
A sluggish reaction in one or both pupils indicates dysfunction of cranial nerves (CNs) II and III, which mediate the pupillary light reflex. (See Innervation of direct and consensual light reflexes, page 553.)
History
If the patient is conscious, obtain a brief history. Ask him what type of eyedrops he’s using, if any, and when they were last instilled. Also ask if he’s experiencing pain or other ocular symptoms.
Physical assessment
If you detect a sluggish pupillary reaction, determine the patient’s visual function. Start by testing visual acuity in both eyes. Then test the pupillary reaction to accommodation; the pupils should constrict equally as the patient shifts his glance from a distant to a near object.
Next, hold a penlight at the side of each eye and examine the cornea and iris for irregularities, scars, and foreign bodies. Measure intraocular pressure (IOP) with a tonometer, or estimate IOP by placing your fingers over the patient’s closed eyelid. If the eyeball feels rock hard, suspect elevated IOP. Also, ophthalmoscopic and slit-lamp examinations of the eye will need to be performed.
Medical causes
Diabetic neuropathy
A patient with long-standing diabetes mellitus may have a sluggish pupillary response. Additional findings include orthostatic hypotension, syncope, dysphagia, episodic constipation or diarrhea, painless bladder distention with overflow incontinence, retrograde ejaculation, and impotence.
Encephalitis
Encephalitis initially produces a bilateral sluggish pupillary response. Later, pupils become dilated and nonreactive, and decreased accommodation may occur, along with other cranial nerve palsies, suchas dysphagia and facialweakness. Within 24 to 48 hours after onset, encephalitis causes a decreased level of consciousness, headache, high fever, vomiting, and nuchal rigidity. Also, aphasia, ataxia, nystagmus, hemiparesis, and photophobia may occur. The patient may exhibit seizure activity and myoclonic jerks.
Herpes zoster
The patient with herpes zoster affecting the nasociliary nerve may have a sluggish pupillary response. Examination of the conjunctiva reveals follicles. Additional ocular findings include a serous discharge, absence of tears, ptosis, and extraocular muscle palsy.
Iritis (acute)
With acute iritis, the affected eye exhibits a sluggish pupillary response and conjunctival injection. The pupil may remain constricted; if posterior synechiae have formed, the pupil will also be irregularly shaped. The patient reports sudden onset of eye pain and photophobia and may also have blurred vision.
Multiple sclerosis
Multiple sclerosis may produce small, irregularly shaped pupils that react better to accommodation than to light. Additional ocular findings may include ptosis, nystagmus, diplopia, and blurred vision. In most patients, vision problems and sensory impairment, such as paresthesia, are the earliest indications. Later, various features may develop, including muscle weakness and paralysis; intention tremor, spasticity, hyperreflexia, and gait ataxia; dysphagia and dysarthria; constipation; urinary urgency, frequency, and incontinence; impotence; and emotional instability.
Myotonic dystrophy
With myotonic dystrophy, sluggish pupillary reaction may be accompanied by lid lag, ptosis, miosis and, possibly, diplopia. The patient may develop decreased visual acuity from cataract formation. Muscular weakness and atrophy and testicular atrophy may occur.
Wernicke’s disease
Initially, Wernicke’s disease produces an intention tremor accompanied by a sluggish pupillary reaction. Later, pupils may become nonreactive. Additional ocular findings include diplopia, gaze paralysis, nystagmus, ptosis, decreased visual acuity, and conjunctival injection. The patient may also exhibit orthostatic hypotension, tachycardia, ataxia, apathy, and confusion.
Special considerations
A sluggish pupillary reaction isn’t diagnostically significant, although it occurs with various disorders.
Pediatric pointers
Children experience sluggish pupillary reactions for the same reasons as adults.
Patient counseling
Encourage the patient with chronic illness to have regular ophthalmologic examinations to detect complications. Teach him about the course of his disease and the importance of avoiding stress, infection, and fatigue.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Pupil symptoms
Read excerpts from these other book chapters related to Pupil symptoms:
Medical Books Excerpts
- Mydriasis
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Mydriasis
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Mydriasis
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Mydriasis
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Pupil symptoms
» Next page: Mydriasis (Nursing: Interpreting Signs and Symptoms)
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