![]() Typically, when encountering a dilated pupil, there will be some associated degree of anisocoria. A famous example is singer David Bowie, who received a permanently fixed, dilated pupil at age 13 during a fight over a girl. Should the patient have experienced ocular trauma, carefully examine the iris via biomicroscopy for contributory signs, such as iridodialysis or pupil sector paralysis, because trauma can result in a fixed and dilated pupil. A sympathetic agent will yield round, dilated pupils that likely will react––albeit sluggishly––to light and near stimulation.Ī history of trauma should be sought as well. A mydriatic agent will cause pupils to be round and unreactive to both light and near testing. A history of pharmacologic use must be ascertained. Further, pupils must be tested for response to both light stimulus (direct and consensual responses) and a near target (near synkinetic response). In this month’s column, we will describe how to evaluate patients who present with one or both pupils dilated.Įvaluating pupils in both bright and dim light is vitally important. This presented quite the clinical conundrum. Upon questioning, the patient denied trauma as well as use of any topical or systemic medications. Interestingly (and tellingly), binocular indirect ophthalmoscopy was performed without the use of any mydriatic agents, because of the size of her dilated and unreactive pupils. Her fundus evaluation revealed normal optic discs and retinae OU. Testing of the relative afferent visual system was impossible because of impaired pupillary reactivity. Her pupils measured 8.5mm OD and 9.0mm OS. Neither pupil reacted to light or near accommodative stimuli. However, of particular interest, we noted that she had bilaterally round, fixed and dilated pupils. Her eyelids were symmetrical, with no evidence of ptosis or eyelid retraction. Extraocular muscle testing showed no restrictions, and confrontation visual fields were normal in both eyes. Her uncorrected visual acuity was 20/200 in each eye. She was a healthy, well-nourished woman in no apparent physical distress. She had never worn glasses and rarely had her eyes examined, because her vision always had been “excellent.” ![]() ![]() She used no current medications and denied any drug allergies. Systemically, the patient was healthy and had no significant medical history. He immediately referred her for a consultation. When she woke up the next day, her vision was “terrible.” After it failed to improve over several hours, she saw her internist emergently. A 32-year-old woman believed that her vision was getting blurry the evening before, but ignored it and went to bed. He could be weaned off from tracheostomy and improved to GCS E4V5M6.It was a strange scenario. He received regular chest and limb physiotherapy. The patient underwent an early tracheostomy, gradually weaned off from the ventilator, and could be shifted to ward. Following the evacuation of the hematoma, the pupillary asymmetry resolved in immediate post-operative period. The patient underwent emergency right parieto-occipital craniotomy and evacuation of extradural hematoma. His blood investigations including coagulation profile were within normal range. A CT scan of the brain showed thick right parieto-occipital extradural hematoma with mass effect, underlying contusion, bifrontal patchy contusions (left > right), linear fracture of the right occipital bone with significant cerebral edema, mass effect, distortion, and displacement of the brain stem (Fig. In view of poor GCS, he was intubated and electively ventilated. The patient was spontaneously decerebrating with paucity of movement on the left side. The right pupil was 2 mm reacting to light, and the left pupil was 4 mm sluggishly reacting (Fig. On examination, he was afebrile, pulse rate was 87/min, and blood pressure was 120/70 mm/Hg. He was unconscious since the time of the incident and had multiple episodes of vomiting with ear and nasal bleed. A 22-year-old male skid and fell from a motorbike.
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