Bilateral Tonic Pupils Research Articles

Bilateral tonic pupil during a migraine attack: a case report.

Tonic pupil or Adie's pupil occurs due to parasympathetic denervation, and it is characterized by mydriasis with little or no response to light, with pupillary contraction to accommodation. It is caused by eye pathologies, such as infections, trauma, neoplasms, inflammatory diseases, and systemic diseases with autonomic dysfunction. Few cases have been reported of bilateral tonic pupils associated with migraine attacks. Our aimed to describe the case of a young female patient with a history of chronic migraine without aura, who presented acutely with bilateral pupillary mydriasis during a migraine attack, characterized as tonic pupil, and to discuss the possible causes of mydriasis during a migraine attack.

Paraneoplastic syndromes in ophthalmology

Paraneoplastic syndromes consist on systemic manifestations associated with certain cancers which are not a direct consequence of tumor invasion or its metastases. It is known that autoimmunity and autoantibody synthesis play an important role in its pathophysiology due to a process of molecular mimicry. Paraneoplastic syndromes in ophthalmology are rare, but it is important to recognize them clinically because in some cases symptoms preceded the diagnosis of an underlying neoplasia. Most frequently involved cancer is small cell lung carcinoma, but there is also a relationship with other tumor etiologies such as thymoma, gynecological tumors or neuroblastoma in children. Paraneoplastic syndromes with ocular involvement can be divided into those that affect the afferent visual pathway, such as cancer-associated retinopathy, melanoma-associated retinopathy, or paraneoplastic optic neuropathy; and the ones that affect the efferent visual pathway, such as bilateral tonic pupils, Myasthenia Gravis, Lambert-Eaton syndrome or paraneoplastic cerebellar degeneration. The presence of autoantibodies is helpful in clinical practice but negativity does not exclude this diagnosis. Although evolution and prognosis is linked to primary disease, in some cases specific treatment, usually immunosuppressive therapy, can help improving patients quality of life.

An unusual case of pediatric isolated simultaneous bilateral Adie's tonic pupil

An unusual case of pediatric isolated simultaneous bilateral Adie's tonic pupil

Pupila tónica después de la infección por COVID-19

The latest global health threat is the ongoing outbreak of respiratory disease, which was named COVID-19 and multiple ever-evolving neurological complications have since been reported. We present the case of a patient with a bilateral tonic pupil in the postinfectious context of COVID-19. Brain magnetic resonance imaging and laboratory tests were normal, a 0.125% pilocarpine test confirmed the diagnosis

Ophthalmic and Neuro-ophthalmic Manifestations of Coronavirus Disease 2019 (COVID-19)

ABSTRACT Purpose To describe a case of inflammatory chorioretinopathy and Adie’s syndrome possibly associated with COVID-19. Methods Observational case report. Results A 51-year-old woman developed fever, cough, and headache followed by retro-ocular pain and reading impairment. She tested positive for SARS-COV-2 infection by qualitative real-time reverse-transcriptase-polymerase-chain-reaction. The slit-lamp and funduscopic exam revealed abnormal pupillary response and yellowish creamy deep chorioretinal lesions, which were not present in previous examinations. Instillation of pilocarpine demonstrated denervation supersensitivity, and it was suggestive of bilateral Adie tonic pupil. A comprehensive work-up ruled out other systemic, autoimmune, or infectious diseases. Conclusions This case illustrates the possible association between multifocal chorioretinitis and Adie’s syndrome, and the SARS-COV-2 infection in humans. Further investigation of virus infectivity specifically within ocular tissues has to be conducted.

Bilateral Tonic Pupils and Guillain-Barre Syndrome in a 6-Year-Old Boy

Bilateral Tonic Pupils and Guillain-Barre Syndrome in a 6-Year-Old Boy

Holmes-Adie syndrome

Holmes-Adie syndrome (HAS) is a rare neuro-ophthalmological disorder, which mostly presents in young females as a unilateral dilated pupil. We present a case of a 12-year-old girl with bilateral tonic pupils. She had vermiform movement of the iris with segmental palsy, as well as loss of ankle jerks. The diagnosis was confirmed with pilocarpine 0.125% test, and she was symptomatically treated with the same drops.

Treatment of Bilateral Tonic Pupil Associated with Syphilis

Treatment of Bilateral Tonic Pupil Associated with Syphilis

A Case of Anti-GQ1b Antibody Syndrome Associated with Pure Bilateral Adie's Pupils

A 37 year-old Japanese male felt photophobia of both eyes one week following the onset of the common cold. His neurological examination revealed bilateral Adie's tonic pupils, no extraocular movement disorder, normal deep tendon reflexes, and no cerebellar signs. Based on markedly increased blood levels of anti-GQ1b IgG and anti-GT1a IgG antibodies, we diagnosed him as anti-GQ1b antibody syndrome. Bilateral Adie's tonic pupils were improved by IVIg drip infusion and methylprednisolone pulse therapy. This case suggests that we need to investigate anti ganglioside antibody when a patient presents with bilateral Adie's tonic pupils.

Idiopathic Harlequin Syndrome

Harlequin syndrome, Harlequin sign, Holmes-Adie syndrome, and Ross syndrome lie on a spectrum of partial dysautonomias affecting facial sudomotor, vasomotor, and pupillary responses. These syndromes have imprecise clinical boundaries and overlap syndromes are known. We report a 9-year-old girl who presented with anhidrosis over the right half of her face and the left side of her body, with compensatory hyperhidrosis on the contralateral side. She was noted to have bilateral tonic pupils and normal muscle stretch reflexes with other features suggestive of autonomic dysfunction. Investigations to rule out secondary causes were noncontributory. Her clinical presentation can be categorized as partial overlap between Harlequin syndrome and Holmes-Adie syndrome.

Bilateral Holmes–Adie syndrome as an early manifestation of the HIV neuropathy

A 38-year-old HIV-1 infected woman affected with bilateral tonic pupils. Ophthalmologic examination confirmed Holmes-Adie syndrome (HAS), and peripheral distal polyneuropathy, orthostatic hypotension and leg hyperhidrosis were detected on further workup. The HAS can be either idiopathic or associated with neuropathy of various etiology (autoimmune, paraneoplastic and infectious). In our patient, the pupillotonia was the first and early symptom of hitherto unrecognized HIV neuropathy. HAS has been previously observed in association with syphilis, Lyme borreliosis, herpes simplex and parvovirus B19 infection. Our case is the first report of HAS in a case of HIV infection.

Bilateral Tonic Pupil Secondary to Migraine in a Child

Bilateral idiopathic tonic pupil is characterized by enlarged pupils, poor response to light and accommodation, strong and tonic response to near stimuli, vermiform movements of the iris on slit-lamp examination, and cholinergic supersensitivity. The authors present a case of a 10-year-old girl who was referred with abnormal pupils and complained of headaches. After ophthalmological and neurological examination, she was diagnosed as having migraine and secondary idiopathic bilateral tonic pupils. To the authors' knowledge, this is the first case of a child with bilateral Adie's pupil secondary to migraine to be reported.

Neurosyphilis With Unilateral Optic Tract Lesion Causing Homonymous Hemianopia

Homonymous hemianopia is not a rare symptom. Many causative lesions and pathologies are known, although a unilateral optic tract lesion caused by syphilis is rare. A 56-year-old woman developed a congruous right homonymous hemianopia and bilateral tonic pupils with irregular shape. Brain T2-weighted and fluid attenuated inversion recovery magnetic resonance imaging (MRI) revealed a spindle-like high-intensity lesion in her left postchiasmal optic tract. The rim of this lesion enhanced with gadolinium without meningeal enhancement. Serum and cerebrospinal fluid venereal disease research laboratory tests were positive. Cerebrospinal fluid contained 71 white blood cells/microL (mononuclear cells = 97%) and 48 mg/dL of protein. The hemianopia disappeared after administration of benzylpenicillin. Neurosyphilis should be added to the list of differential diagnoses for an isolated optic tract lesion.

Bilateral internal ophthalmoplegia as an initial sole manifestation of Miller Fisher syndrome

Although there have been reports regarding the frequent involvement of the pupils in Miller Fisher syndrome (MFS) and related syndromes, internal ophthalmoplegia has not been described as the initial sole manifestation of typical MFS. Recently, we encountered a woman with MFS whose initial manifestation was blurred vision because of bilateral tonic pupils. Investigations, including brain imaging, cerebrospinal fluid examination and nerve conduction studies were normal except for elevated serum levels of immunoglobulin G anti-GQ1b antibody. During the disease, she subsequently developed bilateral sixth and seventh nerve palsies, gait ataxia, and areflexia. We treated her with intravenous immunoglobulin and she showed a stepwise recovery from her illness. This case suggests that bilateral internal ophthalmoplegia can be a preceding sole manifestation of typical MFS.

Harlequin Syndrome: Still Only Half Understood

Sympathetic vasodilatory and sudomotor fibers from the stellate ganglion mediate the principal reflex control of human facial thermoregulatory flushing and sweating (1,2). Heat stress, exercise, or sudden emotion in the patient with hemifacial cutaneous sympathetic denervation may elicit a dramatic

Pupille tonique d’Adie et migraine : une association fortuite ?

Adie s tonic pupil is defined as a dilated pupil, constricting poorly to light and exhibiting light-near dissociation. The authors report an 18-year-old woman diagnosed with transient bilateral Adie's tonic pupil during a migraine attack. Work-up including neuroiaeaging disclosed no underlying detectable abnormalities. The association between tonic pupil and migraine is rarely reported. This type of transient mydriasis could result from postganglionic parasympathetic dysfunction, affecting the iris sphincter. This situation is different from the heterogeneous group with benign episodic unilateral mydriasis. Transient Adie's tonic pupil may be associated with migraine attacks. This association should be known to avoid unnecessary examinations.

Vogt-Koyanagi-Harada Disease Associated with Bilateral Tonic Pupils in a Pregnant Patient

Purpose: We report a case of bilateral tonic pupils and decreased corneal sensitivity in a patient with Vogt-Koyanagi-Harada (VKH) disease during pregnancy. Case summary: A 33-year-old Korean woman in the sixth month of pregnancy presented with visual impairment in both eyes. Her best corrected visual acuity was 0.2 in the right eye and 0.125 in the left. Slit-lamp examination revealed cells in the anterior chamber and serous retinal detachments in both eyes. The patient was treated with topical corticosteroid in both eyes and posterior subtenon injection of triamcinolone acetonide in the left eye. The serous retinal detachment resolved completely at 2 months in the left eye and at 3 months in the right. As pigmentation of the retina developed, VKH disease was confirmed. The patient complained of photophobia, and both pupils were found to be enlarged to 8 mm without dilation. Light reflex was absent and near reflex was suppressed and slow. After instillation of 0.125% pilocarpine, the pupils were constricted to 3.5 mm and were diagnosed as tonic pupils. Though the patient's corrected visual acuity improved to 0.8 in the right eye and 1.0 in the left at 6 months, her pupils remained unchanged. Corneal sensitivity was decreased. Conclusions: Tonic pupils may be complicated with VKH disease even during pregnancy. We recommend examinations of the pupils and corneal sensitivity in patients with VKH disease, especially those complaining of photophobia.

Bilateral tonic pupils: Holmes–Adie syndrome or generalised neuropathy?

Aim:To compare the pupil signs in patients with bilateral pupillotonia caused by Holmes–Adie syndrome or generalised peripheral neuropathy.Methods:Infrared video pupillographic techniques were used to measure a number of pupil variables...

Acute Ophthalmoplegia with Tonic Pupils

A 38-year-old female was diagnosed with atypical Miller Fisher syndrome (MFS) after she presented with bilateral ophthalmoplegia and bilateral tonic pupils without ataxia or areflexia following a flu-like infection. She had negative findings for a CSF examination, brain imaging and electrophysiological response; furthermore she was negative for serum ganglioside antibodies. We reported this interesting case and discuss the atypical presentation.

The Argyll Robertson Pupil

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"). Most descriptions of the AR pupil do not mention segmental iris sphincter constriction, or slow, sustained constriction with a near vision effort. 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. 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. However, lesions in this region have not been reliably demonstrated in syphilis. 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. 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. Until better evidence settles the localization of the AR pupil, it is appropriate to screen patients with bilateral tonic pupils for syphilis.