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.
To assess pupillary reaction to light, first test the patient's direct light reflex. Darken the room, and cover one of the patient's eyes while you hold open the opposite eyelid. Using a bright penlight, bring the light toward the patient from the side and shine it directly into his opened eye. If normal, the pupil will promptly constrict. Next, test the consensual light reflex. Hold both of the patient's eyelids open, and shine the light into one eye while watching the pupil of the opposite eye. If normal, both pupils will promptly constrict. Repeat both procedures to test light reflexes in the opposite eye. A sluggish reaction in one or both pupils indicates dysfunction of cranial nerves II and III, which mediate the pupillary light reflex. (See Innervation of direct and consensual light reflexes, page 516.)
History and physical examination
If the patient is conscious, obtain a brief history. Ask about eyedrops or vision disturbances. Find out if the patient has had fever or complaints of headache or neck pain. Next, 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. Check the patient's neurologic status. Note decreased LOC, headache, or nuchal rigidity.
Medical causes
Adie's syndrome.Adie'ssyndrome produces an abrupt onset of unilateral mydriasis and a sluggish pupillary response that may progress to a nonreactive response. The patient may complain of blurred vision and cramplike eye pain. Eventually, both eyes may be affected. Musculoskeletal assessment also reveals hypoactive or absent deep tendon reflexes in the arms and legs.
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, such as dysphagia and facial weakness. Within 24 to 48 hours after onset, encephalitis causes a decreased level of consciousness, headache, a 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.Herpes zoster affecting the nasociliary nerve causes 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 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 a sudden onset of eye pain and photophobia and may also have blurred vision.
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.
Tertiary syphilis.A sluggish pupillary reaction (especially in Argyll Robertson pupils) occurs in the late stage of neurosyphilis, along with marked weakness of the extraocular muscles, visual field defects and, possibly, cataractous changes in the lens. The patient may complain of orbital rim pain, which worsens at night. He may also exhibit lid edema, decreased visual acuity, and exophthalmos. Tertiary lesions appear on the skin and mucous membranes. Liver, respiratory, cardiovascular, and additional neurologic dysfunction may also 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.
Nursing considerations
▪ Perform interventions to treat the underlying disorder.
▪ If vision is affected, provide for the patient's safety.
▪ Monitor for eye pain and changes in vision.
▪ Monitor neurologic status, if indicated.
Patient teaching
▪ Explain the underlying disorder and treatment plan.
▪ Stress the importance of regular ophthalmologic examinations.
▪ Discuss methods to reduce photophobia.
▪ Teach self-care for diabetes, if needed.
Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, 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: Nursing: Interpreting Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Pupil symptoms
» Next page: DILATED PUPILS (MYDRIASIS) (Differential Diagnosis in Primary Care)
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