![]() Pupillary constriction is initiated in the brainstem and is controlled by parasympathetic signals. Unequal pupils found on examination consistent with anisocoria. For that reason, the emergency clinician must understand how to obtain the appropriate history, examination, and workup when anisocoria is found on examination.įigure 1. 1-6 However, anisocoria can point to dangerous pathologies, so its presence on physical examination should prompt a thorough evaluation. 1-4 Physiologic anisocoria is not associated with a disease process and can be persistent or self-limiting and unilateral or of variable laterality. 1-3,5 Physiologic anisocoria is the most common cause of anisocoria, with a pupillary size difference most commonly less than or equal to 1 mm. 3,4 It is estimated that physiologic anisocoria, also called simple or essential anisocoria, is present in 10-30% of the population. 1-4 The possible etiologies for anisocoria are broad and can range from benign conditions to potentially life-threatening pathologies. What is the relevance of the patient’s pupillary size difference and how does it pertain to this patient’s workup? How is anisocoria evaluated in the ED and how is the clinician to determine the relevance of this physical examination finding?Īnisocoria is a condition defined by pupils of unequal sizes (Figure 1). When asked about the difference in pupil size, the patient reports that she first noticed it this morning. The rest of her neurologic examination is normal, and the patient’s visual acuity is at her baseline. On examination, she has lid lag of her left eye. Examination is notable for bruising over her left neck and asymmetrical pupils, with her left pupil measuring 2 mm, and her right 6 mm. ![]() Her pain developed overnight and was still present upon waking this morning. The patient was able to ambulate after the incident and declined EMS transport for medical evaluation. She was wearing her seatbelt and did not lose consciousness. The patient reports that last night she was the driver involved in a moderate-speed motor vehicle collision in which airbags did not deploy. The pain is unilateral, moderate, and has been progressive over the last 24 hours. Louis) Marina Boushra, MD (Cleveland Clinic Foundation, EM-CCM Attending) CaseĪ 33-year-old female with no significant past medical history presents to the emergency department (ED) with left-sided face and neck pain. Louis) // Reviewed by: Jessica Pelletier, DO (EM Education Fellow, Washington University School of Medicine in St. Louis) Aaron Lacy, MD EM Attending Physician, Washington University School of Medicine in St. Coma or brain death: Severe brain damage may cause a change in the size and reactivity of the pupils.Authors: Emilie Lothet, MD (EM Resident Physician, Washington University School of Medicine in St.Surgery: Eye surgery may result in alterations in pupil size, which can be permanent.Seizure: Sometimes seizures (a disruption of electrical activity in the brain) can cause changes in the pupils, which may be equal or unequal.Migraine: While it is not common, migraines can cause anisocoria.Vision loss: Significant vision defects can affect pupil size and reactivity.Increased intracranial pressure: This can result from a brain tumor, meningitis (inflammation of the fluid around the brain), or a stroke.Trauma: An injury affecting the eye or the brain may cause the pupils to be unequal.Inflammatory conditions, such as MS and sarcoidosis, also can do this. Inflammation: An infection affecting the eye or the cranial nerves can cause anisocoria.Cranial nerve damage: This can occur due to a stroke (a blockage of blood flow or bleeding in the brain), brain aneurysm (defect in a blood vessel), or a brain tumor.Multiple sclerosis (MS): MS is a chronic neurological disorder that causes symptoms affecting vision, movement, sensation, and more.
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