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 the elderly, 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 656.)
History and physical examination
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
Adie’s syndrome
This syndrome produces 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 (DTRs) in the arms and legs.
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
This disorder 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. Aphasia, ataxia, nystagmus, hemiparesis, and photophobia may also occur. The patient may exhibit seizure activity and myoclonic jerks.
Familial amyloid polyneuropathy
A patient with this disorder exhibits sluggish or nonreactive pupils, miosis, and corneal opacities that may affect visual acuity. He may also develop anhidrosis, orthostatic hypotension, alternating diarrhea and constipation, and impotence. Initially, he’ll experience paresthesia and possibly pain inthe feet and lower legs. Later, absent DTRs and thinning legs may hamper walking.
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 this disorder, 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
This disorder 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 this disorder, 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, this disorder 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.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 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: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Pupil symptoms
» Next page: Mydriasis (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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