![]() ![]() These were associated with local damage to orbital nerves (penetrating wounds, surgery, hemorrhage, orbital tumors, or infections). Patients with various kinds of peripheral neuropathy also damage the innervation of their intraocular muscles in both eyes, including the sympathetic innervation to the dilator muscle ( 6).Ĭ) Local tonic pupils ( 5). When the ciliary ganglia of some of these patients with Adie syndrome were examined, a loss of ciliary ganglion cells was demonstrated ( 4).ī) Neuropathic tonic pupils ( 5). Both pupils would eventually become small. ![]() After some weeks, the constriction to a near stimulus would return, but it was strong and long-lasting (“tonic”), and with time the second eye would often become involved with the same process. Close examination showed segmental paralysis of the iris sphincter with the intact segments constricting to light, a feature that ruled out pharmacologic mydriasis. The pupil was large, and accommodative power was diminished. Usually at first, only one pupil was affected. These were not clinically associated with syphilis. The tonic response to near came in three varieties, all apparently orbital:Ī) Adie tonic pupil. These were frequently associated with syphilis, tended to be small, almost always bilateral, with little or no constriction to direct light, but prompt, apparently normal, pupil constriction to near targets. There appeared to be two different kinds of pupillary light-near dissociation in patients with good vision and normal eye movements and alignment-AR pupils and tonic pupils: By mid-century, many of the tonic light-near dissociated pupils that had previously been called AR pupils ( 3) were being called “Adie's tonic pupils.” TWO TYPES OF LIGHT-NEAR DISSOCIATION In the twentieth century, it became apparent to Adie and others ( 2) that some young patients without clinical or serologic signs of syphilis had this pupillary light-near dissociation and also an abnormally slow (“tonic”) pupillary constriction when changing fixation from a distant to a near target and back again. After 1908, when Wassermann's serologic test for syphilis became available and was found to be frequently positive in patients with Argyll Robertson (AR) pupils, the popularity of Argyll Robertson's pupillary sign increased. This observation was soon confirmed at a rate of three to four publications per year and was pronounced a useful clinical sign for syphilis ( 1). Nearly a century and a half ago, Argyll Robertson pointed out that some patients with tabes dorsalis had small pupils that constricted poorly if at all to light yet constricted promptly when the patients viewed a near object (“light-near dissociation”). Until better evidence settles the localization of the AR pupil, it is appropriate to screen patients with bilateral tonic pupils for syphilis. If segmental iris sphincter palsy is found and the light-near dissociation has tonic features, one must conclude that the mechanism of the pupil disorder is a ciliary (peripheral) rather than a midbrain (central) denervation. Resolving the issue about the location of the syphilitic lesion that produces the AR pupil will depend on careful examination of patients with techniques designed to disclose segmental palsy of the iris. However, lesions in this region have not been reliably demonstrated in syphilis. Because the AR pupil lacks these features, it has been attributed to a dorsal midbrain lesion that interrupts the pupillary light reflex pathway but spares the more ventral pupillary near reflex pathway. Such features are considered typical of the light-near dissociation of Adie syndrome and of neuropathic tonic pupils, where damage to the ciliary ganglion or ciliary nerves is believed to be the mechanism. Most descriptions of the AR pupil do not mention segmental iris sphincter constriction, or slow, sustained constriction with a near vision effort. ![]() ![]() The Argyll Robertson (AR) pupil has been defined as a pupil that is small and constricts poorly to direct light but briskly when a target within reading distance is viewed (“light-near dissociation”). ![]()
0 Comments
Leave a Reply. |