|“One of my child’s pupils is larger than
|Third nerve palsy|
|Congenital iris anomalies|
|Variable (pupils sometimes equal)|
|Pupils always unequal|
|Worse in dim light|
|Ptosis on side of smaller pupil|
|Possible decreased sweating of face on affected
|Unequal pupil color in congenital or early acquired cases|
|Associated with some systemic disorders|
|Thoracic or cervical surgery|
|Birth trauma with cervical injury|
|History of direct ocular injury|
|History of juvenile idiopathic arthritis|
|Ocular pain, redness|
|Exposure to topical medications or plants that
|Third nerve palsy|
|Systemic diseases associated with third nerve
|Difference between pupils less than 1.0 mm|
|Variable, sometimes equal|
|Greater in dim light|
|Asymmetry greater in dim light|
|Mild ptosis on affected side|
|Possible unequal sweating on affected side|
|Possible difference in iris pigment (heterochromia)|
|Affected pupil may be smaller or larger than
|Other signs of ocular trauma|
|Pupil nonreactive, possibly irregular|
Mild (<0.5 mm) anisocoria in young children is usually normal,
particularly if it is variable. Anisocoria associated with other
disorders, particularly Horner syndrome and third nerve palsy, is
not an isolated finding. If a patient has ptosis along with anisocoria,
referral to a pediatric ophthalmologist is indicated for evaluation
of possible Horner syndrome or third nerve palsy. If the pupil does
not react at all, referral is also indicated.
Horner syndrome, particularly in
older children, may result from serious diseases such as neuroblastoma.
These patients require evaluation to look for these problems. Children
with iritis secondary to juvenile idiopathic
arthritis (JIA) may have no symptoms of ocular discomfort despite
severe inflammation. In some of these patients, abnormal pupils
due to scarring of the iris may be the first abnormality noted.
- 1. Physiological anisocoria. Mildly
asymmetric pupils may occur in otherwise normal infants. This may
be familial. The anisocoria is more noticeable in dim light. The
hallmark of physiological anisocoria is variability, with the pupils
sometimes appearing equal. Physiological anisocoria does not cause
any problems with development of vision.
- 2. Horner syndrome. Horner syndrome
occurs due to interruption of the oculosympathetic chain that begins
in the hypothalamus, travels through the spinal cord to the thorax,
and ascends along the internal carotid artery to the orbit. Lesions
anywhere along this pathway may cause Horner syndrome. The syndrome
is characterized by anisocoria (pupil smaller on the affected side),
mild ptosis, and anhidrosis (decreased sweating on the affected
side of the face) (Figure 18–1). It typically does not
cause vision problems. It is important because of its association
with other systemic conditions.
- 3. Iritis. Most patients with
iritis (intraocular inflammation) have marked eye discomfort and
seek medical attention because of this complaint. For unknown reasons,
children with iritis associated with JIA usually do not experience
significant eye pain. Because of this, even severe inflammation may
go unnoticed until substantial eye damage is present. Children with
JIA sometimes present with nonreactive pupils due to scarring of
the iris to the lens capsule (Figure 18–2).
- 4. Pharmacological. Several eye
drops or ...
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