December 4, 2013: Adie’s Tonic Pupil

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December 4, 2013

Adie's tonic pupil refers to a dilated and poorly reactive pupil which is thought to result from dysfunction of the postganglionic parasympathetic fibers from the ciliary ganglion. Patients typically present with gradual onset of light sensitivity or difficulty with focusing to near stimuli. Exam demonstrates a dilated pupil that is poorly reactive to light but reacts to near stimuli (i.e. light-near dissociation). Aberrant regeneration of the postganglionic fibers is thought to result in this hypersensitive near response which can be demonstrated by a dilute (0.0625%) pilocarpine test (1). Differential considerations of a dilated pupil include other serious causes including cerebral aneurysm, brainstem tumor or ischemia, neurosyphilis, and others (2).

  1. Leavitt JA, Wayman LL, Hodge DO, Brubaker RF. Pupillary response to four concentrations of pilocarpine in normal subjects: application to testing for Adie tonic pupil. Am J Ophthalmol 2002;133:333-336.
  2. Han SW, Ryu JH, Baik JS, Kim JY, Hwang YS, Park JH. Early Dorsal Midbrain Syndrome Mimicking an Adie's Tonic Pupil. J Clin Neurol 2010;6:38-40. 

Submitted by Roy Strowd, MD, Resident Physician, Wake Forest School of Medicine, Winston Salem, NC.

Dr. Strowd is a member of the Resident and Fellow Section of Neurology.

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