Professor and Director of Neuro-ophthalmology, Department of Ophthalmology and Visual Sciences, University of Iowa and Veterans Administration Hospital, Iowa City, Iowa
Subject
Abnormality irregular shaped pupil; Pupillary pathology; the irregular pupil; structural causes; synechia of the iris to the lens after surgery or inflammation (iritis); Axonfeld-Rieger Syndrome; iris atrophy (ICE syndrome); iris coloboma; sphincter damage due to ischemia; sphincter damage due to trauma (tears of sphincter or diffuse damage to muscle); sphincter damage due to herpes Zoster uveitis; sphincter damage due to high intraocular pressure; iris tumor or cyst; ectropian uveae; innervational causes; sympathetic segmental; renervation of dilator muscle; sympathetic segmental aberrant regeneration (rare); sympathetic nerve segmental dilator activation (tadpole pupil); Adie's pupil; third nerve aberrant regeneration of the iris sphincter; central causes - central corectopia; Management of Anisocoria
Description
The infrared video segment shows the irregular pupil becoming larger and more rounded when the patient swallows cold water. The captured images to the right of the video show how the irregular pupil rounds up by aberrant activation of the dilator muscle at the 10 o'clock and 4 o'clock meridians during swallowing, designated by the arrows. History: This patient had a cystic benign tumor in her left lower neck that was removed. Immediately after surgery she was noted to have a left Horner's syndrome and an irregular pupil. 6 months later the patient noticed that when she swallowed cold liquid she experienced a strange sensation around her left eye. When she observed herself in the mirror, she noticed that the irregular out of round pupil would round up and become circular when she was in the act of swallowing cold water. We believe that she initially suffered a preganglionic oculosympathetic palsy from the surgical trauma and this was followed by aberrant regeneration of cholinergic nerves that supplied the muscles for swallowing. Some of these nerves are believed to have re-innervated the nicotinic cholinergic receptors at the superior cervical ganglion. Therefore, when she activated these nerves by swallowing cold fluids, there was simultaneous aberrant stimulation of the superior cervical ganglion sympathetic postganglionic neu. Anatomy: Location of lesion is preganglionic sympathetic nerve (segmental) with aberrant re-innervation. Disease/Diagnosis: Horner' syndrome, oculosympathetic nerve palsy, postganglionic, anisocoria, irregular pupil, aberrant regeneration. Clinical: Miosis, ptosis, upside down ptosis of lower eyelid.
