|Year : 2015 | Volume
| Issue : 1 | Page : 42-43
Amgad M Dowidar
Department of Ophthalmology, University of Alexandria, Alexandria, Egypt
|Date of Submission||02-Dec-2014|
|Date of Acceptance||10-Jan-2015|
|Date of Web Publication||29-May-2015|
Amgad M Dowidar
Department of Ophthalmology, University of Alexandria, Alexandria
Source of Support: None, Conflict of Interest: None
Keywords: anisocorea, blurred vision, unilateral mydriasis
|How to cite this article:|
Dowidar AM. Clinical quiz. Delta J Ophthalmol 2015;16:42-3
| History|| |
A 15-year-old girl presented with a 4-month history of variable anisocoria and fluctuating blurred vision. Past medical history was significant for migraines, which were well controlled with amlotriptan. She denied a history of trauma, use of topical medications, or worsening or change in her headaches. She also denied having visual phenomenon associated with her previous headaches.
| Examination|| |
On examination, her uncorrected near visual acuity was J1+ and her best-corrected visual acuity was 20/20 at distance and J1+ at near. Her glasses measured -4.50 + 0.50 × 98 in the right eye and −4.75 D in the left eye. Ocular motility was full, and the pupils were equal, round, and reactive to light and accommodation. Her pupils measured 5-3 mm with direct pupillary light reflex and 5-2.5 mm to near stimulus. Her near point of convergence was ∼4 cm from the nose, and her accommodative amplitude was assumed normal, given her ease of accommodation and excellent near visual acuity through her full myopic correction. Slit-lamp examination demonstrated normal pupils without iris atrophy, sectoral palsy of the iris sphincter, or vermiform movements.
The patient provided several photographs that illustrate fluctuating symptoms. [Figure 1] shows inappropriate dilation on a bright sunny day compared with other pictures of her on similar days. There is also subtle anisocoria greater in the right eye than in the left; either pupil could be involved during symptomatic episodes.
|Figure 1: Photographs demonstrating the variable anisocoria. (a) Bilateral mydriasis on a sunny day. (b) Right-sided mydriasis. (c) Left-sided mydriasis.|
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| Treatment|| |
We elected to proceed with pharmacologic testing with 0.125% pilocarpine. This demonstrated bilateral pupillary constriction suggestive of cholinergic receptor suprasensitivity in both eyes. She was diagnosed with a variant of Adie's tonic pupil in each eye, and she was reassured.
Three weeks later she was re-examined because of a worsening of her symptoms. On follow-up examination, her pupils were 8 mm and nonreactive to light, accommodation, or 1% pilocarpine. Distance visual acuity was 20/20 with correction, and near acuity was J7 with correction and J2 without correction.
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