Pupillary Examination 
            1. Observe:
            • anisocoria ( the most cases being Horner's, Adie's, third nerve palsy. 

              • Less commonly siderosis bulbi and traumatic. Although physiological 
              anisocoria is the most common cause, it seldoms appear in the examination.)
            • heterochromia (congenital Horner's syndrome and siderosis bulbi)
            • ptosis (Horner's syndrome and third nerve palsy )
            2. Differences in pupil size in light and shade.

            3. Reaction to direct and consensual light.

             

            Why is the above technique frowned upon by 
            the examiner?
            Answer at the bottom.
            4. Swinging light test for afferent pupillary defects.
             

            Left afferent pupillary defect.
            5. Reaction to accommodation

            6. Additional examination depends on the above findings
             

            • RAPD (this indicate optic nerve disease or extensive retinal dysfunction. 

              • Look for optic disc pallor, advanced glaucoma cupping or total retinal detachment.)
            • Horner's syndrome (neck or chest scar )
            • Third nerve (ocular motility )
            • Adie's pupil (slit-lamp for vermiform iris movement and knee jerk )
            • Argyll-Robertson's pupil ( interstitial keratitis, deafness )


            In the absence of anisocoria, the most likely case is relative afferent pupillary defect and less commonly light/near dissociation.

            In the presence of anisocoria, you are likely to be asked about differential diagnosis and the pharmacological diagnosis of anisocoria. Always have a list of causes for abnormal small or large pupil and learn the pharmacological diagnosis for Horner's syndrome and Adie's pupil well.
            a
            Answer to the question:

            Miosis occurs with accommodation. 
            To see clearly the pupil reaction to light, the patient should be 
            instructed to look at a distant object to reduce accommodation. 
            By standing in front of the patient, the candidate stimulates 
            accommodation and hence miosis.
            Back to the index for final MRCOphth

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