PUPILS

ON to optic tract to brachium of superior colliculus synapsing in the pretectal nucleus the to bilateral EWN to CN3. Parsympathetic innervation from CN3 splits in anterior cavernous sinus pass through SO with inferior division of CN3. In orbital apex it synapses in ciliary ganglion then traveling with fibers going to IO to posterior ciliary nerves then to pupillary sphincter.

Hypothalamus synapse in cilospinal of budge ascends via sympathetic chain ganglion along lung apex to internal carotid then synapse in the superior cervical ganglion at angle of the jaw/carotid bifurcation. Sympathetics run with CN6/carotid in cavernous sinus then join nasocilliary of V. In orbital apex pass ciliary ganglion without synapsing t to the globe via long cilliary nerve to dilator muscle.

• iritis
• Horners
• miotics drop- Pilocarpine
• DM

• cocaine test then if both eyes dilate then it is physiologic
• if >1mm anisocoria= Horners syndrome. Then determine if it is 1st/2nd order or 3rd order.
• Hydroxyamphetamine= both eye dilate=1st/2nd order
• 3rd order small pupil unchanged

• Dim light
• Apraclonidine does not affect normal pupil. It only affect sympathetic deinnervated pupils. It causes dilation of the miotic eye indicating a horners.

It dilates a normal pupil and a 1st/2nd order horners. It doesnt affect a 3rd order lesion due to degeneration of the nerve terminal.

• birth trauma
• neuroblastoma from sympathetic chain in chest

carotid artery disection

0.1% pilocarpine ---pupil constriction= adie tonic pupil

• IF NO CONSTRICTION then
• 1% pilocarpine ---pupil constriction=3rd nerve
• no constriction with 1%= pharmacological mydriasis

• postganglionic parasympathetic damage-denervated iris sphrinter
• segmental iris atony
• decrease reflexes
• orthostatic hypertension

• Dorsal Midbrain
• Arygll Robertson pupil Tertiary syphllis
• PRP
• 3rd nerve aberrant reinnervation
• Peripheral neuropathy
• severe retinal/ON dz