Adie's Tonic Pupil

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Title Adie's Tonic Pupil
Subject Pathology; Neuroanatomy; Signs and Symptoms
Creator Andrew G. Lee, MD, Chairman, Department of Ophthalmology, The Methodist Hospital, Houston, TX; Professor of Ophthalmology, Weill Cornell Medicine; Jaijo Vennatt, Baylor College of Medicine Class of 2021
Description Dr. Lee lectures medical students on Adie's tonic pupil.
Transcript So today we are talking about the Adie Tonic pupil. The key part is the tonic part and what tone means is the pupil constricts but then stays tonically constricted and that tonic constriction is the feature that differentiates the tonic pupil from other common causes of pupil dysfunction where the pupil doesn't react well to light. So in the Adie Tonic pupil, what we are looking for is the increased tone on the near response. So what we have is a light reaction that is either poor or absent, but a preserved near reaction and that finding is called light-near dissociation. So when we see a light-near dissociation of the pupils, we'd like to know is it unilateral or bilateral. In the Adie tonic pupil, it is usually unilateral initially and then becomes bilateral over time in some percentage of patients. When it is unilateral, it makes it a lot less likely to be central because the central causes of light-near dissociation are usually bilateral and not unilateral. And when you have a unilateral Adie tonic pupil or a bilateral, what we are looking for is a sector paresis so one part of the iris might be paralyzed and the other parts can still move and the other parts that still move have hippus, the normal change and reactivity of the pupil and that can look like there is a worm, a vermiform, a worm-like movement in the pupil and so when we see the combination of a sector paresis, a vermiform movement, and a tonic reaction of the pupil at near with a poor light reaction or no light reaction, these are the key differentiating features of Adie's tonic pupil. Now what we can't have because it's just involved with the pupils is you can't any ptosis and we can't have any other motility deficits because the Adie tonic pupil is a lesion in the ciliary ganglion and therefore we can't have any other third nerve findings so we have to make sure it's not a third nerve palsy because the third nerve palsy can actually cause something that looks like a tonic pupil resulting in light-near dissociation that's from aberrant regeneration. The differentiating feature, of course, is the sector paresis. So in a third nerve palsy, we would not expect a sector paresis and we can't have ptosis on motility deficits. So first make sure it's not a third, look for the sector paresis, and once we have light-near dissociation that is tonic, then we say this is probably an Adie's tonic pupil clinically and if you want to confirm this finding, we can put low dose pilocarpine into the eye so pilocarpine is a direct acting parasympathometic and so under normal conditions, a dilute amount of pilocarpine 1/10th percent in a normal pupil usually does nothing. But if you denervate the nerve or its ganglion as in Adie's tonic pupil, there will be upregulation of the postsynaptic receptors and that will lead to denervation supersensitivity so the administration of 1/10th percent pilocarpine in an Adie's tonic pupil will constrict the pupil. The problem of course is, it doesn't tell you where the denervation is so we should not use the pilocarpine low dose test to make the diagnosis of Adie's tonic pupil. That is a diagnosis made clinically based on the findings of light near dissociation, the tonic near reaction, the sector paresis, and the absence of third nerve palsy. We do not want to use this test alone to make the diagnosis because denervation from a third nerve also would produce also a supersensitivity because denervation of any source produces upregulation of postsynaptic receptors . And some patients with Adie's tonic pupil have the full Adie's Holmes syndrome and that means they have concomitant areflexia and the typical patient is a patient who is young and female and is otherwise healthy. So if we have the areflexia, we are going to be thinking about the Adie's Holmes and I told you most of the time that Adie's tonic pupil is reserved for the idiopathic variety so if you have a cause: trauma, surgery like optic nerve sheath fenestration, we would just call that the tonic pupil. Adie's tonic pupil is kind of like the idiopathic variety and because most of the time it's unilateral, the bilateral cases probably should be evaluated for light near dissociation on a central basis and the main mimickers are the Argyll Robertson pupil or the dorsal midbrain syndrome from compression and syphilis so I order a syphilis serology, RPR and FDA or TPA or syphilis IGG on every bilateral tonic pupil and I do an imaging study on patients who have bilateral simultaneous presentation of light-near dissociation for no other reason. So I hope that this explains what the Adie's tonic pupil is but the main feature is the tonic near reaction.
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Date 2019-02
Type Image/MovingImage
Format video/mp4
Rights Management Copyright 2019. For further information regarding the rights to this collection, please visit:
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E, SLC, UT 84112-5890
Collection Neuro-ophthalmology Virtual Education Library: NOVEL
Language eng
ARK ark:/87278/s6wd8cgk
Setname ehsl_novel_lee
Date Created 2019-03-01
Date Modified 2020-01-13
ID 1403660
Reference URL
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