Adie's tonic pupil secondary to migraine

A 46-year-old woman observed transient unilateral mydriasis during a classic migraine attack. One week later she experienced a similar episode after which anisocoria was persistent. Subsequent examination showed the clinical and pharmacologic features of a postganglionic parasympathetic paresis (Adie's tonic pupil). This case confirms the hypothesis that transient mydriasis accompanying migraine is due to interruption of parasympathetic innervation rather than sympathetic overactivity.

Adie's pupil following Le Fort I maxillary osteotomy. A complication or coincidence?

A case is reported of right-sided tonic pupil in isolation (Adie's pupil) following Le Fort I maxillary osteotomy. It is difficult to identify whether this rare finding immediately postoperatively is either a pure coincidence or a genuine complication of surgery.

Pure sensory neuropathy in patients with primary Sjögren's syndrome: clinical, immunological, and electromyographic findings

A pure sensory neuropathy caused by lymphocytic infiltration of the dorsal root ganglia has been reported in a few patients with Sjögren's syndrome. The clinical, immunological, and electromyographic findings of five patients with this type of neuropathy and primary Sjögren's syndrome were reviewed. Typical clinical indications were the presence of a chronic asymmetrical sensory deficit, initial disease in the hands with a predominant loss of the vibratory and joint position senses, and an association with Adie's pupil syndrome or trigeminal sensory neuropathy. The simultaneous impairment of the central and peripheral evoked cortical potentials suggested that there was a lesion of the neuronal cell body. The neuropathy preceded the diagnosis of Sjögren's syndrome in four patients. Four patients were positive for Ro antibodies, but systemic vasculitis or malignancy was not found after a mean follow up of six years. These findings indicate that in patients with a sensory neuropathy the diagnosis of Sjögren's syndrome has to be considered, even if the patient denies the presence of sicca symptoms, and that appropriate tests must be carried out.

[Myasthenia gravis associated with tonic pupil]

A 41 year-old female patient with acquired autoimmune myasthenia gravis (MG, IIa type) and tonic pupil (Adie's pupil) of the right side was reported. Adie's pupil was pointed out at the same time of the clinical diagnosis of MG in September, 1988. She had the solitary thymoma identified by pneumo-mediastinograph and mediastinal CT scan. Results of the positive anti-nicotinic AChR antibody titer, the positive edrophonium test and the electrophysiological examination gave unambiguous evidences of acquired autoimmune MG with thymoma. Instillations to the eyes of cocaine, pilocarpine and epinephrine, and the pupillary response to the intravenous injection of edrophonium revealed the postganglionic abnormality mainly in the parasympathetic system. There were no other overt symptoms due to dysautonomia. She refused thymectomy. Her myasthenic and pupillary signs became gradually improving without any immunosuppressive medications. It is concluded that two diseases of the patient may be probably caused by multiple organ- or tissue-specific autoantibodies, in addition to pathogenetic significance of Adie's pupil.

Paraneoplastic tonic pupils

Tonic pupils developed in two patients with malignancies outside the nervous system. Symptoms and signs of more generalized somatic and autonomic nervous system involvement were also present. Although the exact morphologic basis for autonomic dysfunction in patients with paraneoplastic neurologic deterioration is uncertain, recent studies suggest that in some cases an autoimmune mechanism is responsible and may be directed against autonomic ganglion cells.

[A case of bilateral tonic pupil (Holmes-Adie syndrome)]

The authors present a case of bilateral tonic pupil and discuss clinical and physiopathological aspects of this syndrome. They discuss some elements necessary for the understanding of the etiopathogenesis of the disease.

Tonic pupil with giant cell arteritis

A patient with giant cell arteritis and ischaemic optic neuropathy developed bilateral tonic pupils. This pupillary abnormality may result from ischaemia of the ciliary ganglia. Despite the propensity for patients with giant cell arteritis to develop vascular occlusions in the eye and orbit, tonic pupils have rarely been described, and several reasons for this are proposed. The arteries supplying the ciliary ganglia are frequently involved in giant cell arteritis, but their anastomotic pattern may confer protection from ischaemia. Tonic pupils may also be overlooked amidst the more dramatic manifestations of giant cell arteritis.

[Adie's syndrome from a neurological standpoint (author's transl)]

The findings in 22 examinations of tonic pupils, 15 of which presented Adie's syndrome, are described. The neurological and chemical as well as liquor analyses are normal except for the well known tendon reflex anomalies. Neurophysiologically, in 7 of 10 examinations mild disruptions in the sensory nerve conduction velocity were observed. The literature of the last 10 years, where it is of interest from a neurological standpoint and where it relates to the site of damage or to the origin of the tendon reflex abnormalities in Adie's syndrome, is discussed. Adie's syndrome is interpreted as damage to the peripheral nervous system in a polyneuropathic form.

A search for serum antibodies in Adie's syndrome

Serum specimens from a large number of patients with Adie's syndrome were checked for virus antibody levels: Measles hemagglutination inhibition (HI), parainfluenza types I, II and III (HI), Epstein-Barr immunofluorescence, Mumps complement fixation (CF), Adenovirus (CF), Varicella-Zoster (CF), Herpes simplex (CF), Cytomegalovirus (CF), Mycoplasma hominis (CF), Toxoplasma gondii passive hemagglutination. These antibody levels were compared with specimens from a control group of similar age distribution and sex ratio. No statistically significant differences between the patients with Adie's syndrome and the control group could be demonstrated. This observation offers some indirect support to Harriman's idea that Adie's syndrome is not due to a viral ciliary ganglionitis but rather to an indolent neuronal degeneration in the ciliary and dorsal root ganglia.

Corneal sensation in Adie's syndrome

Using the Cochet-Bonnet esthesiometer, we evaluated the corneal sensation of 11 patients with unilateral Adie's tonic pupil. We eliminated six other patients with bilateral Adie's pupil or disease that lowered corneal sensation. An observed unfamiliar with each patient's condition tested 12 clock hour positions in the midperiphery in both eyes of all patients. We studied 30 normal subjects (60 eyes) in a similar fashion. Of those 11 patients with unilateral Adie's syndrome, ten had a regional decrease in corneal sensation. The 30 normal subjects examined did not exhibit any significant decrease in corneal sensation in any areas. Our study supports the concept that the lesion of Adie's tonic pupil is in the ciliary ganglion or short location where the innervation of the iris sphincter and corneal sensation are found together.

[Adie's syndrome]

The author has investigated patients suffering from disorders of the pupillary reflexes and of the tendon reflexes of the lower limbs which come under the heading of tonic pupil. Forty-five patients were followed up over a period of 15 years. The tendon reflexes of the lower limbs were recorded graphically and showed a very characteristic retardation of the second phase of the patellar reflex. The aetiopathogenesis of Adie's syndrome is discussed. The pathogenesis of Adie's syndrome has so far not been definitely established. We have merely tried to point out a few of the features which permit its early diagnosis and have drawn attention to the basic problem of the pathogenesis of certain neuro-muscular disorders on the basis of secondary considerations involved in this uncommon syndrome.