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176 Right-sided relative afferent pupillary defectRight-sided relative afferent pupillary defect in a man with optic nerve glioma. When the unaffected left eye is stimulated by light, both pupils constrict (top). When the light is then swung over to the affected right eye, both pupils dilate (bottom). This indicates that pupillomotor conduction thr...Image/StillImage
177 Assessment of an afferent pupillary defect when only one iris is functionalAssessment of an afferent pupillary defect when only one iris is functional. In this example, a right-sided parasellar tumor is compressing both the optic and oculomotor nerves, causing an optic neuropathy and a pupil-involving third crainial nerve palsy. The pupil on the affected side has both an a...Image/StillImage
178 An enhancing bladder metastasis involving the tectum of the midbrainMagnetic resonance image of an enhancing bladder metastasis involving the tectum of the midbrain of a 56-year-old man who developed double vision resulting from skew deviation and divergence insufficiency. He also had a left-sided relative afferent pupillary defect measuring 1.4 log units but showed...Image/StillImage
179 Light-near dissociationLight-near dissociation in a 51-year-old woman with multiple sclerosis who experienced double vision for 1 week. Her pupils are 5 mm in diameter in room light (top), react poorly in response to direct light reaction (middle), but constrict promptly in response to near stimulation (bottom). She also ...Image/StillImage
180 Aberrant regeneration of the right pupilAberrant regeneration of the right pupil in a man with a large intracavernous sinus meningioma causing a pupil-involving, incomplete third cranial nerve palsy. His pupil is round when he gazes straight ahead (top). When he tries to rotate the eye medially, the pupil constricts, but a segment of the ...Image/StillImage
181 Pathophysiology of signs associated with a tonic pupilPathophysiology of signs associated with a tonic pupil. Normally, all parasympathetic fibers of the third cranial nerve synapse in the ciliary ganglion (top). Most postganglionic fibers innervate the ciliary muscle (dashed lines). After injury to the ciliary ganglion, the pupil becomes denervated an...Image/StillImage
182 Bilateral iris colobomas (B)Bilateral iris colobomas. B. Bilateral colobomatous defects of the inferonasal retina (black arrows) are also present, as shown in the right eye.Image/StillImage
183 Right-sided pseudo-Horner's syndromeRight-sided pseudo-Horner's syndrome in an 8-month-old infant referred because her mother had noted a larger pupil on the left for a few months and her pediatrician thought the right upper lid was droopy. Both pupils reacted normally to light and darkness, the degree of anisocoria was similar in bot...Image/StillImage
184 Left-sided internal carotid artery dissectionLeft-sided internal carotid artery dissection identified on T-1 weighted magnetic resonance image from a 52-year-old man who suddenly developed left-sided neck and orbital pain along with a droopy left upper eyelid while dragging a deer out of the woods during hunting season. The normal dark flow vo...Image/StillImage
185 Flow chart for sorting out anisocoria - direct light reaction of the pupilFlow chart for sorting out anisocoria based initially on the integrity of the direct light reaction of the pupil.Image/StillImage
186 Pupillogram demonstrating paradoxical pupillary constriction to darknessPupillogram demonstrating paradoxical pupillary constriction to darkness in four patients with congenital achromatopsia. Note that the pupils initially constrict when the light is extinguished. (Price MJ, Thompson HS, Judisch GF et al: Pupillary constriction to darkness. Br J Ophthalmol 1981;69:205-...Image/StillImage
187 Tadpole-shaped pupilTadpole-shaped pupil in a 20-year-old women with frequent episodes of blurred vision and achiness of the right eye lasting several minutes. The patient took a photograph of her eyes during an attack to document the peaked, segmental dilation of her right pupil (black arow). (Thompson HS, Zackon DH, ...Image/StillImage
188 Flow chart for sorting out anisocoria - bright light and darknessFlow chart for sorting out anisocoria based initially on how it is influenced by bright light and darkness.Image/StillImage
189 Left-sided dilation lag in a man with Horner's syndromeLeft-sided dilation lag in a 29-year-old man with Horner's syndrome caused by a posterior mediastinal ganglioneuroma. Note that the degree of anisocoria is greater after 5 seconds in darkness (top) compared with findings after 15 seconds in darkness (bottom).Image/StillImage
190 Enhanced mydriasis in response to hydroxyamphetamineEnhanced mydriasis in response to hydroxyamphetamine in a 77-year-old woman with a long-standing, preganglionic, right-sided Horner's syndrome that occurred following cervical neck dissection for thoracic outlet syndrome 30 years earlier. Miosis of the right pupil is apparent in room light (top). Th...Image/StillImage
191 Hand-held equipment used to measure a relative afferent pupillary defectHand-held equipment used to measure a relative afferent pupillary defect and to record pupil sizes. Four neutral density filters (0.3, 0.6, 0.9, 1.2 log units) are conveniently carried in a soft cloth carrying pouch. A bright light source (a Finhoff model illuminator is shown here) is ideal for stim...Image/StillImage
192 Dysthyroid optic neuropathy: A preventable cause of blindnessDysthyroid Optic Neuropathy (DON) is a treatable cause of visual loss in ~5% of pts w/ ted. Monitor closely those pts with risk factors (proptosis, tight orbit, restricted motility, strabismus, smoker, diabetic). Oral prednisone is often effective, but frequent relapses after tapering. Orbital xrt ...Image
193 The Wall-Eyed Potato FarmerYoung man presenting with apparent episodic neurologic evants that initially was thought to be multiple sclerosis, but as time went on, he had progressive changes in his neurologic exam and in his imaging findings. Brain biopsy revealed Gliomatosis cerebri.Image
194 MELAS and RPMELAS; Mitochondrial Encephalopathy with Lactic Acidosis, Stroke and Pigmentary Changes in retina-associated with a retinal dystrophy. This 53 year old man had seizures, encephalopathy and lactic acidosis typical of MELAS. His fundus examination showed granularity and some slight pigmentary changes ...Text
195 Hydroxychloroquine Maculopathy (Plaquenil)An overview of Chloroquine Maculopathy.Text
196 Parinaud's SyndromeTwo examples of patients with Parinaud's syndrome, a dorsal midbrain syndrome. Discussion of hallmarks of this syndrome, including convergence retraction nystagmus, vertical gaze palsies, light-near dissociation, and Collier's Sign. Discussion of age-dependent disorders associated with this syndrome...Image/MovingImage
197 Sector Palsies and Light-Near DissociationExample of patient with bilateral Adie's pupils. Exam is performed with a slit-lamp. Shows iris stroma and focal segments of iris sphincter that retain their contractilty. Suggests post-ganglionic parasympathetic denervation.Image/MovingImage
198 Pupil signs in a 32-year-old woman with right-sided Adie's pupilPupil signs in a 32-year-old woman with right-sided Adie's pupil. The right pupil is larger than the left pupil (top), reacts poorly to direct light stimulation (second panel), and better in response to near stimulation (third panel). The right pupil also shows a supersensitive response 30 minutes a...Image/StillImage
199 Argyll Robertson pupilsArgyll Robertson pupils in an elderly man treated for tabes dorsalis in 1952. His pupils are small and slightly irregular, constrict poorly in response to light stimulation (top), dilate poorly in darkness (middle), but constrict promptly in response to near stimulation (bottom).Image/StillImage
200 Basic Neurologic Exam: Station and GaitDemonstration of a station and gait examination.
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