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Anisocoria

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101. Neuro-ophthalmic Examination (Overview)

of the few objective indicators of potential visual function, as the pupils are an important clue to patients with suspected functional visual loss; (2) subtle relative afferent pupillary defects are often difficult to detect; (3) Horner syndrome is easily missed unless the combination of anisocoria that is worse in the dark, pupil dilation lag, and ptosis can be correlated; (4) the presence or absence of pupil involvement markedly changes the management of new-onset third nerve palsy; and (5) the pupils (...) of the pupils (anisocoria) is present, determine if the anisocoria is greater in the dark or in the presence of light. If the anisocoria is less than 1 mm and remains the same in both the light and the dark and if the pupils are round and reactive, the patient may have physiologic anisocoria. Anisocoria greater in the dark suggests sympathetic disease, such as Horner syndrome. Anisocoria greater in the light suggests parasympathetic disease, such as Adie tonic pupil. Note that even if 1 eye is completely

2014 eMedicine.com

102. Oculomotor Nerve Palsy (Overview)

with the other eye. The primary symptom is caused by misalignment of the visual axes, and the pattern of image separation is the key to diagnosing which particular ocular motor cranial nerve (and extraocular muscle) is involved. With unilateral third cranial nerve palsy (ie, oculomotor nerve palsy), the involved eye usually is deviated "down and out" (ie, infraducted and abducted), and there may be partial or complete ptosis. In addition, pupillary dilatation can cause anisocoria (greater in the light (...) . 36 (5):548-51. . BOTTERELL EH, LLOYD LA, HOFFMAN HJ. Oculomotor palsy due to supraclinoid internal carotid artery berry aneurysm. A long-term study of the results of surgical treatments on the recovery of third-nerve function. Am J Ophthalmol . 1962 Oct. 54:609-16. . Dhume KU, Paul KE. Incidence of pupillary involvement, course of anisocoria and ophthalmoplegia in diabetic oculomotor nerve palsy. Indian J Ophthalmol . 2013 Jan-Feb. 61 (1):13-7. . Jacobson DM. Pupil involvement in patients

2014 eMedicine.com

103. Epilepsia Partialis Continua (Overview)

%) - Tetraparesis (4%), hemiparesis (23.3%), monoparesis (13.3%), oculomotor paresis (0.7%), facial paresis (10%), hypoglossal paresis (1.9%), soft palate paresis (0-3%) Sensory deficit (21%) - Hemihypoesthesia and hemianesthesia (9.7%), monohypoesthesia and monoanesthesia (4.4%), deep sensation (3.6%), stereognosis (3.3%) Anisocoria (1%) Conjugate deviation of eyes (1%) Homonymous hemianopsia (5%) Aphasia (14%) - Motor (8.3%), sensory (2.5%), amnestic (2.6%) Apraxia (1%) Alexia (2%) Neurological symptoms

2014 eMedicine.com

104. Epidural Hematoma (Overview)

, Braun J, Guilburd JN, et al. Delayed onset of traumatic extradural hematoma. J Neurosurg . 1985 Jul. 63(1):30-4. . Bozbuga M, Izgi N, Polat G, Gurel I. Posterior fossa epidural hematomas: observations on a series of 73 cases. Neurosurg Rev . 1999. 22(1):34-40. . Cohen JE, Montero A, Israel ZH. Prognosis and clinical relevance of anisocoria-craniotomy latency for epidural hematoma in comatose patients. J Trauma . 1996 Jul. 41(1):120-2. . de Andrade AF, Figueiredo EG, Caldas JG, Paiva WS, De Amorim RL

2014 eMedicine.com

105. Epidural Hemorrhage (Follow-up)

epidural formation has been reported. If a rapid size increase is noted and/or the patient develops anisocoria or a neurological deficit, then surgery is indicated. Middle meningeal artery embolization has been described in the early stages of EDH, especially when angiographic dye extravasation has been observed (see Future and Controversies). When treating patients with spontaneous EDH, the underlying primary disease process must be addressed in addition to the fundamental principles discussed above

2014 eMedicine Surgery

106. Distal Clavicle Osteolysis (Diagnosis)

theories concerning the etiology of DCO have been suggested: The first theory proposed an autonomic neurovascular origin; one author noted the presence of ipsilateral anisocoria in four of eight patients A theory set forth in another report proposed synovial invasion of the subchondral bone Cahill, noting the presence of microfractures in subchondral bone in 50% of his cases, proposed that repetitive microtrauma caused subchondral stress fractures and remodeling [ ] ; this theory is currently the most

2014 eMedicine Surgery

107. Horner Syndrome (Diagnosis)

and life-threatening disorder. Careful direction of the history to rule out such life-threatening disorders is vital. Given that malignancy is a prominent feature of recently diagnosed preganglionic Horner syndrome, patients may avoid an unnecessary extensive workup for carcinoma if the lesion can be shown to be old or long-standing. To prove that a lesion is long-standing, inspect old photographs of the patient that might show ptosis or anisocoria. If the affected iris is blue and the other is brown (...) of the sympathetic interruption, because of the absence of endogenous norepinephrine in the synapse. For optimal accuracy, test results should be evaluated 30 minutes or longer after cocaine is administered. The maximal response is seen 40-60 minutes after instillation of the drops. Postcocaine anisocoria greater than 0.8 mm is sufficient to diagnose Horner syndrome. The disadvantages of the topical cocaine test are as follows: The drops are difficult to obtain because they must be made at a compounding pharmacy

2014 eMedicine.com

108. Epilepsia Partialis Continua (Diagnosis)

%) - Tetraparesis (4%), hemiparesis (23.3%), monoparesis (13.3%), oculomotor paresis (0.7%), facial paresis (10%), hypoglossal paresis (1.9%), soft palate paresis (0-3%) Sensory deficit (21%) - Hemihypoesthesia and hemianesthesia (9.7%), monohypoesthesia and monoanesthesia (4.4%), deep sensation (3.6%), stereognosis (3.3%) Anisocoria (1%) Conjugate deviation of eyes (1%) Homonymous hemianopsia (5%) Aphasia (14%) - Motor (8.3%), sensory (2.5%), amnestic (2.6%) Apraxia (1%) Alexia (2%) Neurological symptoms

2014 eMedicine.com

109. Epidural Hematoma (Diagnosis)

, Braun J, Guilburd JN, et al. Delayed onset of traumatic extradural hematoma. J Neurosurg . 1985 Jul. 63(1):30-4. . Bozbuga M, Izgi N, Polat G, Gurel I. Posterior fossa epidural hematomas: observations on a series of 73 cases. Neurosurg Rev . 1999. 22(1):34-40. . Cohen JE, Montero A, Israel ZH. Prognosis and clinical relevance of anisocoria-craniotomy latency for epidural hematoma in comatose patients. J Trauma . 1996 Jul. 41(1):120-2. . de Andrade AF, Figueiredo EG, Caldas JG, Paiva WS, De Amorim RL

2014 eMedicine.com

110. Horner Syndrome (Treatment)

and life-threatening disorder. Careful direction of the history to rule out such life-threatening disorders is vital. Given that malignancy is a prominent feature of recently diagnosed preganglionic Horner syndrome, patients may avoid an unnecessary extensive workup for carcinoma if the lesion can be shown to be old or long-standing. To prove that a lesion is long-standing, inspect old photographs of the patient that might show ptosis or anisocoria. If the affected iris is blue and the other is brown (...) of the sympathetic interruption, because of the absence of endogenous norepinephrine in the synapse. For optimal accuracy, test results should be evaluated 30 minutes or longer after cocaine is administered. The maximal response is seen 40-60 minutes after instillation of the drops. Postcocaine anisocoria greater than 0.8 mm is sufficient to diagnose Horner syndrome. The disadvantages of the topical cocaine test are as follows: The drops are difficult to obtain because they must be made at a compounding pharmacy

2014 eMedicine.com

111. Sports Physicals (Treatment)

clearance without intervention for any person with visual acuity of 20/40 or better using both eyes. Skin: Certain sports, such as wrestling, disqualify athletes who have infectious dermatoses, which include impetigo, herpes, and forms of tinea. Other conditions (eg, acne, scabies, nevi) can be detected, and the athlete should be counseled in such cases. Eyes: Pupil reactivity and anisocoria should be noted. Knowledge of preexisting abnormalities can be useful information at a later time in case (...) reactions, as with insect bites History of loss or dysfunction of 1 of a pair of organs History of chronic illness requiring regular physician intervention History of drastic weight change For females only – First menstrual period, menstrual irregularity, last menstrual period Parental signature on history forms for minors A focused physical examination should emphasize the following: Vital signs (eg, height, weight, BP) Visual acuity Infectious dermatoses Anisocoria Wheezing Heart murmurs or irregular

2014 eMedicine.com

112. Oculomotor Nerve Palsy (Treatment)

involvement, course of anisocoria and ophthalmoplegia in diabetic oculomotor nerve palsy. Indian J Ophthalmol . 2013 Jan-Feb. 61 (1):13-7. . Jacobson DM. Pupil involvement in patients with diabetes-associated oculomotor nerve palsy. Arch Ophthalmol . 1998 Jun. 116 (6):723-7. . Rush JA, Younge BR. Paralysis of cranial nerves III, IV, and VI. Cause and prognosis in 1,000 cases. Arch Ophthalmol . 1981 Jan. 99 (1):76-9. . RUCKER CW. Paralysis of the third, fourth and sixth cranial nerves. Am J Ophthalmol

2014 eMedicine.com

113. Neurosyphilis (Treatment)

proprioception, loss of vibratory sense, otosclerosis, vertigo, sensory ataxia, chorioretinitis) - 48% Pupillary changes (anisocoria, Argyll Robertson pupils, skew deviation) - 43% Cranial neuropathy - 36% Dementia, mania, or paranoia - 35% Romberg sign - 24% Charcot joint - 13% Hypotonia - 10% Optic atrophy 7% Neurosyphilis is divided into 2 general categories: (1) early involvement of the CNS limited to the meninges and (2) parenchymal involvement. The 6 delineated groups are as follows: Asymptomatic Acute

2014 eMedicine.com

114. Neurological History and Physical Examination (Treatment)

error of metabolism typically associated with mental retardation (usually severe) and intimal thickening and necrosis of the media of blood vessels, resulting in strokes and coronary artery disease. See the image below. Pes cavus deformity can be associated with many conditions including spina bifida, other spinal dysraphisms, and homocystinuria. Ancillary Signs Anisocoria This refers to pupillary asymmetry, which may result from sympathetic or parasympathetic dysfunction. Sympathetic dysfunction

2014 eMedicine.com

115. Sports Physicals (Overview)

clearance without intervention for any person with visual acuity of 20/40 or better using both eyes. Skin: Certain sports, such as wrestling, disqualify athletes who have infectious dermatoses, which include impetigo, herpes, and forms of tinea. Other conditions (eg, acne, scabies, nevi) can be detected, and the athlete should be counseled in such cases. Eyes: Pupil reactivity and anisocoria should be noted. Knowledge of preexisting abnormalities can be useful information at a later time in case (...) reactions, as with insect bites History of loss or dysfunction of 1 of a pair of organs History of chronic illness requiring regular physician intervention History of drastic weight change For females only – First menstrual period, menstrual irregularity, last menstrual period Parental signature on history forms for minors A focused physical examination should emphasize the following: Vital signs (eg, height, weight, BP) Visual acuity Infectious dermatoses Anisocoria Wheezing Heart murmurs or irregular

2014 eMedicine.com

116. Idiopathic Orthostatic Hypotension and other Autonomic Failure Syndromes (Overview)

the following: Constipation Nausea Urinary retention Erectile dysfunction Pure autonomic failure More specifically, symptoms of PAF include the following: Orthostatic hypotension: With an inappropriate lack of compensatory increase in heart rate with standing Gastroparesis: Associated with nausea or constipation Urinary retention: May cause bladder distention Decreased sweating: Manifesting as heat or exercise intolerance Ophthalmologic manifestations: Including ptosis, anisocoria, Horner syndrome

2014 eMedicine.com

117. Headache: Pediatric Perspective (Overview)

neurologic deficits, such as aphasia, anisocoria, and memory deficits, may also be seen. Benign paroxysmal torticollis of infancy is characterized by episodes of a head tilt, and benign paroxysmal vertigo of childhood is characterized by recurrent episodes of vertigo and ataxia. The torticollis typically occurs during the first year, whereas the vertigo occurs in young children (usually aged 2-3 years). Cyclic vomiting and recurrent abdominal pain frequently are considered migraine variants. Before

2014 eMedicine.com

118. Headache, Children (Overview)

neurologic deficits, such as aphasia, anisocoria, and memory deficits, may also be seen. Benign paroxysmal torticollis of infancy is characterized by episodes of a head tilt, and benign paroxysmal vertigo of childhood is characterized by recurrent episodes of vertigo and ataxia. The torticollis typically occurs during the first year, whereas the vertigo occurs in young children (usually aged 2-3 years). Cyclic vomiting and recurrent abdominal pain frequently are considered migraine variants. Before

2014 eMedicine.com

119. Horner Syndrome (Overview)

and life-threatening disorder. Careful direction of the history to rule out such life-threatening disorders is vital. Given that malignancy is a prominent feature of recently diagnosed preganglionic Horner syndrome, patients may avoid an unnecessary extensive workup for carcinoma if the lesion can be shown to be old or long-standing. To prove that a lesion is long-standing, inspect old photographs of the patient that might show ptosis or anisocoria. If the affected iris is blue and the other is brown (...) of the sympathetic interruption, because of the absence of endogenous norepinephrine in the synapse. For optimal accuracy, test results should be evaluated 30 minutes or longer after cocaine is administered. The maximal response is seen 40-60 minutes after instillation of the drops. Postcocaine anisocoria greater than 0.8 mm is sufficient to diagnose Horner syndrome. The disadvantages of the topical cocaine test are as follows: The drops are difficult to obtain because they must be made at a compounding pharmacy

2014 eMedicine.com

120. Horner Syndrome (Overview)

and life-threatening disorder. Careful direction of the history to rule out such life-threatening disorders is vital. Given that malignancy is a prominent feature of recently diagnosed preganglionic Horner syndrome, patients may avoid an unnecessary extensive workup for carcinoma if the lesion can be shown to be old or long-standing. To prove that a lesion is long-standing, inspect old photographs of the patient that might show ptosis or anisocoria. If the affected iris is blue and the other is brown (...) of the sympathetic interruption, because of the absence of endogenous norepinephrine in the synapse. For optimal accuracy, test results should be evaluated 30 minutes or longer after cocaine is administered. The maximal response is seen 40-60 minutes after instillation of the drops. Postcocaine anisocoria greater than 0.8 mm is sufficient to diagnose Horner syndrome. The disadvantages of the topical cocaine test are as follows: The drops are difficult to obtain because they must be made at a compounding pharmacy

2014 eMedicine.com

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