Tonic Pupil Research Articles

Adie's Pupil: A Diagnostic Challenge for the Physician.

Adie’s pupil, also called tonic pupil, is mainly seen in young women. Most patients have unilateral eye involvement. The pupil of the affected side is significantly larger than that on the healthy side. The direct and indirect light reflection from the pupil on the affected side disappears. The pupil on the affected side is sensitive to low concentrations of pilocarpine. The pathogeneses of Adie’s pupil are complex, some of which are insidious and lack corresponding specific diseases. Through a literature review, we found that Adie’s pupil is mainly associated with infectious diseases, most commonly syphilis, followed by immune diseases and paraneoplastic syndromes. The ophthalmological symptoms and pupil abnormalities can disappear after active treatment of the primary disease. Pilocarpine can be used to treat ophthalmologic symptoms, such as blurred vision, for which patients might visit an ophthalmologist or neurologist. It is essential for clinicians to improve their understanding of the disease to avoid misdiagnosis. Differential diagnosis between Adie’s pupil, oculomotor nerve palsy, anticholinergic drug overdose, Argyll-Robertson pupil, and congenital mydriasis need to be identified by the physician. Here, the clinical manifestations, pathogenesis, relationship between Adie’s pupil and diseases, and differential diagnosis of Adie’s pupil are reviewed.

The Unfolding of Cognitive Effort During Sentence Processing: Pupillometric Evidence From People With and Without Aphasia.

Arousal and cognitive effort are relevant yet often overlooked components of attention during language processing. Pupillometry can be used to provide a psychophysiological index of arousal and cognitive effort. Given that much is unknown regarding the relationship between cognition and language deficits seen in people with aphasia (PWA), pupillometry may be uniquely suited to explore those relationships. The purpose of this study was to examine arousal and the time course of the allocation of cognitive effort related to sentence processing in people with and without aphasia. Nineteen PWA and age- and education-matched control participants listened to relatively easy (subject-relative) and relatively difficult (object-relative) sentences and were required to answer occasional comprehension questions. Tonic and phasic pupillary responses were used to index arousal and the unfolding of cognitive effort, respectively, while sentences were processed. Group differences in tonic and phasic responses were examined. Group differences were observed for both tonic and phasic responses. PWA exhibited greater overall arousal throughout the task compared with controls, as evidenced by larger tonic pupil responses. Controls exhibited more effort (greater phasic responses) for difficult compared with easy sentences; PWA did not. Group differences in phasic responses were apparent during end-of-sentence and postsentence time windows. Results indicate that the attentional state of PWA in this study was not consistently supportive of adequate task engagement. PWA in our sample may have relatively limited attentional capacity or may have challenges with allocating existing capacity in ways that support adequate task engagement and performance. This work adds to the body of evidence supporting the validity of pupillometric tasks for the study of aphasia and contributes to a better understanding of the nature of language deficits in aphasia. Supplemental Material https://doi.org/10.23641/asha.16959376.

O31 Giant cell arteritis - a rare ocular presentation

O31 Giant cell arteritis - a rare ocular presentation

Rare health conditions 51: Aarskog syndrome, autoimmune hepatitis, Adie syndrome, Fowler's syndrome

The purpose of this series is to highlight a range of rare health conditions. Rare health conditions are those that affect no more, and usually fewer, than 1 person in every 2000. Many healthcare assistants and nurses will encounter some of these conditions, given the high number of them. This 51st article will briefly explore four of these conditions: Aarskog syndrome, Adie syndrome, autoimmune hepatitis and Fowler's syndrome.

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

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

Case report on migraine with photophobia – Is the pupil at fault?

Pupillary abnormalities can be a potential cause of migraine with photophobia. A 32-year-old female developed Adie's pupil following concussion injury which triggered severe episodes of migraine with extreme photophobia. We used diluted Pilocarpine drops (0.125%) for treatment and the patient had significant improvement in MIDAS (Migraine Disability Assessment) score after treatment. This case highlights the importance of pupillary examination in cases of migraine.

Quantification of Pupillary Dynamics and Accommodative Response in Adie’s Tonic Pupil: A Case Report

Background: Objective quantification of pupillary dynamics in a clinical setting is of worth importance to rule out any pupillary abnormalities. However, despite normal binocular vision findings, a quantitative measurement of pupillary response and accommodation provides a better insight to understand the mechanism. Case Report: This case report illustrates the clinical presentation, binocular vision parameters, Pupillary dynamics and accommodative response in a 33-year-old diagnosed with Adie’s Tonic pupil following trauma. Conclusion: This report explains the role of the pupillometer and open field autorefractor in quantitative analysis of pupillary and accommodative function.

Acute exercise effects on inhibitory control and the pupillary response in young adults

Previous research has established an impact of acute exercise on cognitive performance, which has inspired investigations into neurobiological mechanisms that may underlie the observed benefits. Pupillary responses have been posited to reflect activation of such underlying neurobiological mechanisms. The current study recruited healthy young adults to investigate the effects of a single bout of moderate-to-vigorous intensity aerobic exercise on subsequent performance and pupillary responses during an inhibitory control task. Results showed that an acute bout of exercise was related to shorter reaction times and increased tonic pupil dilation during an inhibitory control task. Although pupillary responses did not mediate the acute exercise effect on inhibitory control, higher cardiorespiratory fitness was associated with greater phasic pupil dilation following exercise relative to seated rest. The current study supported the plausibility of the pupillary response as a marker of LC-NE system activation that is sensitive to acute exercise. Whether pupillary responses could account for transient benefits of acute exercise on brain and cognition remains unclear.

Adie's Tonic Pupil: An Uncommon Ophthalmological Emergency.

Adie's Tonic Pupil: An Uncommon Ophthalmological Emergency.

Pupillometry Reveals the Role of Arousal in a Postexercise Benefit to Executive Function.

A single bout of aerobic exercise improves executive function; however, the mechanism(s) underlying this improvement remains unclear. Here, we employed a 20-min bout of aerobic exercise, and at pre- and immediate post-exercise sessions examined executive function via pro- (i.e., saccade to veridical target location) and anti-saccade (i.e., saccade mirror symmetrical to a target) performance and pupillometry metrics. Notably, tonic and phasic pupillometry responses in oculomotor control provided a framework to determine the degree that arousal and/or executive resource recruitment influence behavior. Results demonstrated a pre- to post-exercise decrease in pro- and anti-saccade reaction times (p = 0.01) concurrent with a decrease and increase in tonic baseline pupil size and task-evoked pupil dilations, respectively (ps < 0.03). Such results demonstrate that an exercise-induced improvement in saccade performance is related to an executive-mediated “shift” in physiological and/or psychological arousal, supported by the locus coeruleus norepinephrine system to optimize task engagement.

A case of Adie’s tonic pupil

Adie's tonic pupil, the round unilateral tonic pupil, is a neuro-ophthalmologic disorder with dilation and no light response. Although usually idiopathic, it may be associated with infection, inflammation, and postganglionic paraneoplastic nerve damage. It is called Holmes-Adie syndrome when deep tendon reflex loss accompanies Adie’s tonic pupil. The diagnosis is made by observing a miotic response after dilated pilocarpine instillation. Spontaneous recovery depends on etiological factors.

Tonic pupil secondary to varicella-zoster-virus (VZV) keratouveitis in a child

Abstract Introduction: An unusual case of tonic pupil in a 4-year-old male child secondary to Varicella-Zoster-Virus (VZV) keratouveitis is described in this case report. To the best of our knowledge, our report is the thirtieth case of tonic pupil following chickenpox infection in the literature. Patient concerns: A 4-year-old male child presented at our department in June 2019 with anisocoria and feeling generally unwell. The right pupil was noted by his mother to be larger than the left in normal, bright and dim illumination conditions. Of note, the child at the same time was suffering from chickenpox and the symptoms started approximately 4 days prior to the attendance at Accident and Emergency with a generalized vesicular rash. The mother also reported that the right eye was mildly red and uncomfortable and her son was complaining of photophobia. Diagnosis: Tonic pupil secondary to VZV keratouveitis. Interventions: Full past medical and ocular history was obtained. The patient underwent full ophthalmic examination including dilated fundoscopy. Visual acuity was recorded with Snellen Chart and Keeler chart of Minimum Angle of Resolution chart. Patient had Magnetic Resonance Imaging due to anisocoria to exclude intracranial pathology. The child was treated with intravenous Acyclovir and had a good recovery, though the anisocoria persisted. Outcomes: During the follow-ups in the Paediatric Ophthalmology Clinic, 0.125% pilocarpine test revealed profound miosis of the affected right pupil and normal response from the healthy left pupil. In addition, the range of accommodation was reduced in the affected right eye. The child was closely observed to prevent right eye amblyopia and the plan was to issue bifocals to maximize both near and distant visual acuity. Nevertheless, during close follow-up the accommodation reflex in the right eye recovered on its own and the child was eventually discharged from the clinic without executive bifocals. Conclusion: VZV keratouveitis leading to tonic pupil is a rare complication. The proposed pathophysiological mechanism is retrograde dissemination of the infection through the parasympathetic nerve fibers from the iris via the inferior branch of the third nerve to the ciliary ganglion. Our case emphasizes the potential amblyogenic consequences of tonic pupil.

Effects of transcutaneous auricular vagus nerve stimulation on reversal learning, tonic pupil size, salivary alpha-amylase, and cortisol.

This study investigated whether transcutaneous auricular vagus nerve stimulation (taVNS) enhances reversal learning and augments noradrenergic biomarkers (i.e., pupil size, cortisol, and salivary alpha-amylase [sAA]). We also explored the effect of taVNS on respiratory rate and cardiac vagal activity (CVA). Seventy-one participants received stimulation of either the cymba concha (taVNS) or the earlobe (sham) of the left ear. After learning a series of cue-outcome associations, the stimulation was applied before and throughout a reversal phase in which cue-outcome associations were changed for some (reversal), but not for other (distractor) cues. Tonic pupil size, salivary cortisol, sAA, respiratory rate, and CVA were assessed at different time points. Contrary to our hypothesis, taVNS was not associated with an overall improvement in performance on the reversal task. Compared to sham, the taVNS group performed worse for distractor than reversal cues. taVNS did not increase tonic pupil size and sAA. Only post hoc analyses indicated that the cortisol decline was steeper in the sham compared to the taVNS group. Exploratory analyses showed that taVNS decreased respiratory rate but did not affect CVA. The weak and unexpected effects found in this study might relate to the lack of parameters optimization for taVNS and invite to further investigate the effect of taVNS on cortisol and respiratory rate.

State regulation in adults scoring high versus low on ADHD symptomatology: A pupillometry study.

According to the state regulation deficit account, attention deficit/hyperactivity disorder (ADHD) is associated with difficulties in maintaining an optimal level of cognitive arousal. As the precise locus of this problem is yet unknown, the present study investigated this through behavioral and pupillometry indices. Adults scoring high versus low on ADHD symptomatology carried out a target detection task at three event rate (ER) levels. Phasic pupil dilation was used as an index of cognitive effort, and tonic pupil size as an index of tonic arousal. Performance and self-reports indicated state regulation difficulties in the high-ADHD group. Phasic pupil dilation was increased during slow ER, indicating additional effort allocation. Surprisingly, tonic pupil size was smallest in the fast ER, and group effects were absent for both pupil measures. The high-ADHD group showed state regulation difficulties despite similar levels of additional effort allocation as reflected by phasic pupil responses. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The effects of transcutaneous auricular vagal nerve stimulation on pupil size

ObjectiveMechanisms of action and optimal stimulation parameters of transcutaneous auricular vagus nerve stimulation (taVNS) are currently unknown. Pupil size has gained attention as a promising biomarker of vagal activation in different studies on animal models. The aim of this study is to investigate the effects of taVNS on pupil diameter in healthy subjects. MethodsAll subjects received taVNS at the left external acoustic meatus and control stimulation at the left earlobe during the same experimental session. Different intensities (0.5 mA; 1.0 mA; 2.0 mA; 3.0 mA) for both conditions were tested. Tonic pupil size was recorded in both eyes at baseline and during each stimulation using an infrared-automated pupillometer in three different illuminance conditions (scotopic, mesopic, photopic). ResultsIn scotopic illuminance condition, a significant interaction between intensity and condition (real vs control) was found for the left eye. Post-Hoc analysis showed that during real taVNS at 2 mA, pupil size was significantly larger in comparison to baseline and 2 mA control stimulation. ConclusionsOur study demonstrates that taVNS induces pupil dilation under specific illuminance conditions and at specific stimulation intensity. SignificanceThe effects of taVNS are strictly dependent on technical aspects, such as stimulation parameters and experimental set-up.

"Post Coronavirus Disease (COVID-19) Reactivation of a Quiescent Unilateral Anterior Uveitis".

Coronavirus disease (COVID-19) can be associated with ophthalmic manifestations like conjunctivitis, retinal haemorrhages, retinal vascular occlusions, papillophlebitis, and Adie’s syndrome. We herein report for a case of a unilateral acute anterior uveitis which was quiescent for 13 years and was reactivated post COVID-19 infection in a 43-year-old Asian Indian male. He had a past history of recurrent unilateral granulomatous anterior and intermediate uveitis in the right eye (RE), and all the investigations done 14 years ago were negative and had been on treatment with topical and oral steroids. He developed cataract 6 months later in the RE and underwent surgery. Patient was in remission for the past 13 years. Uveitis investigations for the present episode were all negative. Topical steroid and cycloplegic helped in resolution of the uveitis. This may be the first instance of reactivation of a quiescent unilateral anterior uveitis following COVID-19 infection.

Sustained Pupil Responses Are Modulated by Predictability of Auditory Sequences.

The brain is highly sensitive to auditory regularities and exploits the predictable order of sounds in many situations, from parsing complex auditory scenes, to the acquisition of language. To understand the impact of stimulus predictability on perception, it is important to determine how the detection of predictable structure influences processing and attention. Here, we use pupillometry to gain insight into the effect of sensory regularity on arousal. Pupillometry is a commonly used measure of salience and processing effort, with more perceptually salient or perceptually demanding stimuli consistently associated with larger pupil diameters. In two experiments we tracked human listeners' pupil dynamics while they listened to sequences of 50-ms tone pips of different frequencies. The order of the tone pips was either random, contained deterministic (fully predictable) regularities (experiment 1, n = 18, 11 female) or had a probabilistic regularity structure (experiment 2, n = 20, 17 female). The sequences were rapid, preventing conscious tracking of sequence structure thus allowing us to focus on the automatic extraction of different types of regularities. We hypothesized that if regularity facilitates processing by reducing processing demands, a smaller pupil diameter would be seen in response to regular relative to random patterns. Conversely, if regularity is associated with heightened arousal and attention (i.e., engages processing resources) the opposite pattern would be expected. In both experiments we observed a smaller sustained (tonic) pupil diameter for regular compared with random sequences, consistent with the former hypothesis and confirming that predictability facilitates sequence processing.SIGNIFICANCE STATEMENT The brain is highly sensitive to auditory regularities. To appreciate the impact that the presence of predictability has on perception, we need to better understand how a predictable structure influences processing and attention. We recorded listeners' pupil responses to sequences of tones that followed either a predictable or unpredictable pattern, as the pupil can be used to implicitly tap into these different cognitive processes. We found that the pupil showed a smaller sustained diameter to predictable sequences, indicating that predictability eased processing rather than boosted attention. The findings suggest that the pupil response can be used to study the automatic extraction of regularities, and that the effects are most consistent with predictability helping the listener to efficiently process upcoming sounds.

Dilute pilocarpine test for diagnosis of Adie\u2019s tonic pupil

We have compared the diagnostic ability of different concentrations of 0.125% and 0.0625% dilute pilocarpine for detecting denervation supersensitivity in unilateral Adie’s tonic pupil. This retrospective, observational, case–control study involved 117 subjects, consisting of 56 patients with unilateral Adie’s tonic pupil and 61 controls with other causes of unilateral dilated pupils. Subjects underwent the dilute pilocarpine test with one of the two concentrations, 0.125% or 0.0625%. Pupillary light reflex was recorded with a dynamic pupillometer at baseline and at 30–40 min after instilling one of the two concentrations of dilute pilocarpine. Diagnostic accuracy of two different concentrations of the dilute pilocarpine test, 0.125% group versus 0.0625% group, were compared by area under the receiver operating characteristic curve (AUC). Diagnostic ability of the dilute pilocarpine test for detecting denervation supersensitivity in unilateral Adie’s tonic pupil was significantly better in the 0.0625% group than in the 0.125% group (AUC = 0.954 vs. 0.840, respectively, P = 0.047). In the 0.0625% group, the change in maximal pupil diameter of ≥ 0.5 mm after topical pilocarpine instillation showed 100% sensitivity and 82.8% specificity for detecting Adie’s tonic pupil. This study confirmed that pupillary constriction with 0.0625% pilocarpine is better than 0.125% pilocarpine for detecting denervation supersensitivity in Adie’s tonic pupil. Digital pupillometry is a reliable method for assessing denervation supersensitivity in Adie's tonic pupil.

Afferent and Efferent Neuro-Ophthalmic Complications of Coronavirus Disease 19.

To provide a summary of the neuro-ophthalmic manifestations of coronavirus disease 19 (COVID-19) documented in the literature thus far. The PubMed and Google Scholar databases were searched using the keywords: Neuro-Ophthalmology, COVID-19, SARS-CoV-2, and coronavirus. A manual search through reference lists of relevant articles was also performed. The literature on COVID-associated neuro-ophthalmic disease continues to grow. Afferent neuro-ophthalmic complications associated with COVID-19 include optic neuritis, papillophlebitis, papilledema, visual disturbance associated with posterior reversible encephalopathy syndrome, and vision loss caused by stroke. Efferent neuro-ophthalmic complications associated with COVID-19 include cranial neuropathies, Miller Fisher syndrome, Adie's pupils, ocular myasthenia gravis, nystagmus and eye movement disorders. Proposed mechanisms of neurologic disease include immunologic upregulation, vasodilation and vascular permeability, endothelial dysfunction, coagulopathy, and direct viral neurotropism. When patients present to medical centers with new onset neuro-ophthalmic conditions during the pandemic, COVID-19 infection should be kept on the differential.

SARS-CoV-2 Impairs Vision.

Affection of the central nervous system and the eyes is increasingly recognized as manifestations of a SARS-CoV-2 infection (COVID-19). This review aims at summarizing and discussing recent advances concerning causes and locations of impaired vision because of an infection with SARS-CoV-2. On a literature search through PubMed and ScholarOne, all available publications about COVID-19 patients with impaired vision were retrieved. Visual impairment in SARS-CoV-2-infected patients may be due to infection of lacrimal glands (dacryoadenitis), conjunctivitis, tonic pupils, vitritis, central retinal artery/venous occlusion, retinitis, retinal bleeding, panuveitis, anterior ischemic optic neuropathy, optic nerve stroke, optic neuritis, optic perineuritis, or occipital ischemic stroke. Visual impairment may be the initial manifestation of SARS-CoV-2. This mini review shows that impaired vision may be the initial manifestation of COVID-19, that all sections of the visual tract may be affected and causative for visual impairment in COVID-19 patients, and that SARS-CoV-2 manifests along the visual tract with ischemia, focal infection, and immunological reactions.