|Year : 2016 | Volume
| Issue : 2 | Page : 233-234
Isolated dilated pupil: Is it adie's pupil?
Uma Sinharoy, Durga Prasad Chakraborty, Shankar Prasad Saha, Joydeep Mukherjee
Department of Neurology, Nilratan Sircar Medical College, Kolkata, West Bengal, India
|Date of Web Publication||20-Dec-2016|
IA-298/3, Sector 3, Salt Lake City, Kolkata - 700 097, West Bengal
Source of Support: None, Conflict of Interest: None
Adie's tonic pupil, though well known in literature is a rarity in practice. Few case reports have mentioned the occurrence of Adie's pupil during a migraine attack. We report a young female with a history of migraine without aura presenting with asymmetric pupils during migraine attack. Her right pupil was dilated, unresponsive to light with poor response to near reflex. She also had a bilateral loss of ankle jerks. In 0.125% pilocarpine test, the affected pupil responded significantly, and Holmes Adie's syndrome was diagnosed. The patient remained asymptomatic after adjustment of refraction of the right eye for the near vision. It is usually a benign condition. Early clinical detection of such condition is necessary to prevent unnecessary and costly investigations as well to reassure the patient.
Keywords: Holmes-Adie syndrome, Tonic pupil, Pupillary dysautonomia
|How to cite this article:|
Sinharoy U, Chakraborty DP, Saha SP, Mukherjee J. Isolated dilated pupil: Is it adie's pupil?. Arch Med Health Sci 2016;4:233-4
| Introduction|| |
An isolated case of acute papillary dilation with the loss of light reflex in healthy individuals is more often a benign entity rather than acute third nerve palsy. Adie's pupil is such an entity. Adie's tonic pupil is a dilated pupil that shows no response to light but constricts slowly after prolonged accommodation (light-near dissociation). Diagnosis does not require costly investigations. It can be readily diagnosed by clinical and pharmacological testing (rapid mitotic response of the affected pupil to 0.125% pilocarpine drop). Few cases of occurrence of Adie's pupil during migraine attack have been reported in literature.,
| Case Report|| |
A 29-year-old Hindu female from West Bengal presented to us in the summer season with acute onset right-sided visual blurring for 3 months before admission. Initially, she had a headache which subsided on its own after 3 days. She developed light sensitivity of her right eye and had more difficulty for near vision. The condition was neither associated with any a headache, retro-orbital pain, redness, swelling, tearing of the affected eye nor there was any history suggestive of double vision, photopsia, scotoma, or altered color vision. The other eye was apparently normal. Her symptoms remained static without any progression, regression, fluctuation, or diurnal variation. She did not have facial pallor, dry mouth, or any abnormal sweating of any body parts. She denied any history of prior trauma or fever.
The patient was a homemaker with a 9-year-old son. She was nondiabetic and nonhypertensive. She had no history of regular medication or oral contraceptives or any addiction. She used to have a chronic throbbing headache of moderate intensity particularly on winter seasons suggestive of migraine since last 8 years, but she never took any medication. A headache was holocranial, started with sunset lasting for 4–6 h at a time, aggravated with exposure to sunlight, smells of soaps and shampoo and relieved with sleep. It was infrequently associated with nausea, vomiting, and photophobia and each episode resolved spontaneously without any treatment. She had no history of migraine in her family. She had never suffered from any major illness in past.
Her general survey was unremarkable. On neurological examination, her right pupil was dilated (approximately 4.5 mm), round and left pupil was normal in size (approximately 2.5 mm) [Figure 1]. Right, pupil did not react to light, but poor contraction was noted during test for accommodation (light-near dissociation). Visual acuity of the right eye was much diminished for near vision, and distant vision was 6/9 unaided. Fundus and ocular movements were also normal bilaterally. There was no focal neurological deficit except the bilateral loss of ankle jerks.
|Figure 1: Right-sided dilated pupil with minimal reaction to light suggestive of tonic pupil and a normally reacting left pupil.|
Click here to view
A provisional diagnosis of Adie's tonic pupil was made. It was confirmed bedside with pilocarpine test. The right pupil showed a remarkable reduction in the size (approximately 3 mm) within 15 min of local administration of 0.125% pilocarpine [Figure 2]. Detailed work-up (complete blood count, sedimentation rate, blood biochemistry, venereal disease research laboratory, vasculitis profile) including neuroimaging (magnetic resonance imaging brain with magnetic resonance angiography, visual evoked potential) disclosed no underlying detectable abnormalities.
|Figure 2: Right pupil shows constriction (denervation supersensitivity) and no constriction in left pupil with 0.125% pilocarpine.|
Click here to view
The condition was explained to the patient with reassurance. Her symptoms improved a lot after taking a glass for near vision in the right eye. Her recent follow-up visits remained uneventful.
| Discussion|| |
Adie's pupil is usually a benign and idiopathic condition. Damage to the postganglionic parasympathetic pathways leading to denervation supersensitivity of iris is the proposed mechanism of such disorder. Rarely, it may be secondary to giant cell arteritis, malignancy, primary Sjögren syndrome, paraneoplastic disease process, or infection. It may be the part of the Holmes Adie's syndrome (HAS) in which, tonic pupil is associated with absent or reduced deep tendon reflexes. HAS may be associated with a range of autonomic disturbances including orthostatic hypotension, segmental hyperhidrosis, impaired cardiovascular reflexes, and chronic diarrhea. Our patient had HAS without any feature of autonomic involvement. She did not have any clinical findings to support predisposing systemic illnesses, or any primary ophthalmologic diseases, such as open angle glaucoma or uveitis.
The association of Adie's pupil with migraine is still not very evident. In 2011 Tafakhori et al. from Iran has nicely analyzed the characteristics of reported patients with concomitant migraine and Adie's pupil. The association may be caused by infarction of parasympathetic fibers secondary to prolonged vasospasm which sometimes occurs in migraine. However, this hypothesis needs more studies to establish any independent association of Adie's pupil with migraine. Our case is different from all other cases in the fact that the patient developed Adie's pupil during her usual migraine attack which became persistent for 3 months. However, the proposed ischemic theory cannot explain the whole thing. Whether both the conditions with localized autonomic dysfunction share the same pathophysiology is still quite unknown.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Iannetti P, Spalice A, Iannetti L, Verrotti A, Parisi P. Residual and persistent Adie's pupil after pediatric ophthalmoplegic migraine. Pediatr Neurol 2009;41:204-6.
Jacome DE. Status Migrainosus and Adie's syndrome. Headache 2002;42:793-5.
Drouet A, De Carvalho A, Mage F, Guilloton L, Felten D. Adie's tonic pupil and migraine: A chance association? J Fr Ophtalmol 2008;31:e5.
Martinelli P. Holmes-Adie syndrome. Lancet 2000;356:1760-1.
Foroozan R, Buono LM, Savino PJ, Sergott RC. Tonic pupils from giant cell arteritis. Br J Ophthalmol 2003;87:510-2.
Shin RK, Galetta SL, Ting TY, Armstrong K, Bird SJ. Ross syndrome plus: Beyond horner, Holmes-Adie, and harlequin. Neurology 2000;55:1841-6.
Kimber J, Mitchell D, Mathias CJ. Chronic cough in the Holmes-Adie syndrome: Association in five cases with autonomic dysfunction. J Neurol Neurosurg Psychiatry 1998;65:583-6.
Tafakhori A, Aghamollaii V, Modabbernia A, Pourmahmoodian H. Adie's pupil during migraine attack: Case report and review of literature. Acta Neurol Belg 2011;111:66-8.
[Figure 1], [Figure 2]