Pupillary response to four concentrations of pilocarpine in normal subjects: application to testing for Adie tonic pupil

Dilute pilocarpine test for diagnosis of Adie's tonic pupil

We have compared the diagnostic ability of different concentrations of 0.125% and 0.0625% dilute pilocarpine for detecting denervation supersensitivity in unilateral Adie's tonic pupil. This retrospective, observational, case-control study involved 117 subjects, consisting of 56 patients with unilateral Adie's tonic pupil and 61 controls with other causes of unilateral dilated pupils. Subjects underwent the dilute pilocarpine test with one of the two concentrations, 0.125% or 0.0625%. Pupillary light reflex was recorded with a dynamic pupillometer at baseline and at 30-40 min after instilling one of the two concentrations of dilute pilocarpine. Diagnostic accuracy of two different concentrations of the dilute pilocarpine test, 0.125% group versus 0.0625% group, were compared by area under the receiver operating characteristic curve (AUC). Diagnostic ability of the dilute pilocarpine test for detecting denervation supersensitivity in unilateral Adie's tonic pupil was significantly better in the 0.0625% group than in the 0.125% group (AUC = 0.954 vs. 0.840, respectively, P = 0.047). In the 0.0625% group, the change in maximal pupil diameter of ≥ 0.5 mm after topical pilocarpine instillation showed 100% sensitivity and 82.8% specificity for detecting Adie's tonic pupil. This study confirmed that pupillary constriction with 0.0625% pilocarpine is better than 0.125% pilocarpine for detecting denervation supersensitivity in Adie's tonic pupil. Digital pupillometry is a reliable method for assessing denervation supersensitivity in Adie's tonic pupil.

Characteristics of pupillo-accommodative functions according to time of onset, gender and age in tonic pupil

AIM

To evaluate the characteristics of pupillo-accommodative functions in patients with idiopathic tonic pupil according to the time of onset, gender, and age.

METHODS

Totally, 15 males and 19 females were divided into 2 groups depending on the time of disease onset: group I (onset <2 months, n=20) and group II (onset >2 months, n=14). A supersensivity test was conducted by applying diluted pilocarpine 0.125% to the eye and accommodative functions were evaluated using the near-point of accommodation (NPA) as the cutoff point, at which the patient experienced blurred vision. Pupil size and the ratio of decrease in the affected pupil after instillation of 0.125% pilocarpine were investigated.

RESULTS

There was no significant difference between the 2 groups regarding the various pupillary reflex results, including data on the affected pupil size before and after 0.125% pilocarpine, anisocoria, and ratio of pupil decrease. No significant difference in NPA was found between the 2 groups. However, female patients were noted to have greater anisocoria and a faster constriction ratio than those of the male patients (P=0.02 and P=0.04). On subgroup analysis, female patients from group II had larger affected-pupil sizes before 0.125% pilocarpine instillation and longer NPAs than those of the male patients.

CONCLUSION

No relationship was found between time of onset and dysfunction of pupillo-accommodative functions. Pupillo-accommodative functions and age were not related, except for the NPA.

Tonic pupil following pars plana vitrectomy and endolaser

Tonic pupil was observed in a 67 year-old patient following a retinal detachment repair with pars plana vitrectomy, endolaser and silicone oil tamponade performed under retrobulbar anesthesia. The probable location of disturbance is the postganglionic parasympathetic fibers in the short ciliary nerves along their course to the pupil in the suprachoroidal space. A likely explanation for this phenomenon is injury to short ciliary nerves by endolaser treatment.