Chapter 10: The Patient With Pupillary Abnormalities
Pupillary function is an important objective clinical sign in the assessment of patients with vision loss and neurologic disease. A relative afferent pupillary defect (RAPD) localizes the site of damage to the retina, optic nerve, optic chiasm, or optic tract. However, an RAPD does not produce anisocoria. Anisocoria may result from damage to or interruption of the innervation to the iris sphincter or dilator muscle or from external pharmacologic factors, reflecting asymmetric autonomic nerve input to each iris.
Pupillary anatomy and innervation are discussed in Chapter 1, and the evaluation of an RAPD is described in Chapter 3. This chapter reviews the clinical approach to patients with efferent pupillary disorders, including irregular pupils, anisocoria, and light–near dissociation.
Patients with pupillary disturbances, particularly anisocoria, might not be aware of any abnormality. This is especially true in individuals with dark-colored irides. Anisocoria is usually asymptomatic, but patients may report photophobia, difficulty focusing with changes in illumination, or blurring of vision. The clinician should inquire about any new medications, ocular infections, face or neck trauma, headache or facial pain, diplopia, or change in eyelid position. Examination of the patient should include an assessment of the orbit, eyelid position, and ocular motility.
Excerpted from BCSC 2020-2021 series: Section 5 - Neuro-Ophthalmology. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.