5 It is this bilateral innervation of the Edinger-Westphal nucleus that results in both direct and consensual responses to light shone in one eye. 2 Information from the optic nerve passes to the ipsilateral pretectal nucleus and then on to the Edinger-Westphal nuclei on both sides. The pupillary light response involves both afferent (optic nerve) and efferent (oculomotor nerve and sympathetic) pathways. Examination should include assessment of visual acuity, visual fields to confrontation, pupil testing, extraocular motility and whether or not ptosis is present. 5 It is important to ask about previous or current malignancies and neck trauma. Associated visual and/or neurological symptoms should be sought, including visual blurring, visual loss, disturbance of visual fields, or diplopia. 2,5Ī thorough history should include asking about the use of new medications or inadvertent ocular contact with foreign substances by rubbing the eyes. 2–4 Non-physiological anisocoria indicates disease of the sympathetic or parasympathetic pathways supplying the pupil, or a problem with the iris itself. Physiological anisocoria is common: approximately 20% of normal people have different-sized pupils. 1 This article aims to guide management in both of these situations. Indeed, new onset anisocoria may be an early sign of a life-threatening emergency. The general practitioner (GP) may discover anisocoria during examination for a seemingly unrelated problem. The aetiology may be physiological, pathological or pharmacological. A difference in pupil size between the eyes is known as anisocoria.
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