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Anisocoria is a condition characterized by an unequal size of the eyes'
pupil The pupil is a black hole located in the center of the Iris (anatomy), iris of the Human eye, eye that allows light to strike the retina.Cassin, B. and Solomon, S. (1990) ''Dictionary of Eye Terminology''. Gainesville, Florida: Triad Publishing ...
s. Affecting up to 20% of the population, anisocoria is often entirely harmless, but can be a sign of more serious medical problems.


Causes

Anisocoria is a common condition, defined by a difference of 0.4 mm or more between the sizes of the pupils of the eyes. Anisocoria has various causes: * Physiological anisocoria: About 20% of population has a slight difference in pupil size which is known as physiological anisocoria. In this condition, the difference between pupils is usually less than 1 mm. *
Horner's syndrome Horner's syndrome, also known as oculosympathetic paresis, is a combination of symptoms that arises when a group of nerves known as the sympathetic trunk is damaged. The signs and symptoms occur on the same side (ipsilateral) as it is a lesion ...
* Mechanical anisocoria: Occasionally previous trauma, eye surgery, or inflammation (
uveitis Uveitis () is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and in ...
, angle closure glaucoma) can lead to adhesions between the iris and the lens. * Adie tonic pupil: Tonic pupil is usually an isolated benign entity, presenting in young women. It may be associated with loss of
deep tendon reflex The stretch reflex (myotatic reflex), or more accurately "muscle stretch reflex", is a muscle contraction in response to stretching within the muscle. The reflex functions to maintain the muscle at a constant length. The term deep tendon reflex is ...
(Adie's syndrome). Tonic pupil is characterized by delayed dilation of iris especially after near stimulus, segmental iris constriction, and sensitivity of pupil to a weak solution of pilocarpine. * Oculomotor nerve palsy: Ischemia, intracranial
aneurysm An aneurysm is an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also be a nidus ( ...
,
demyelinating disease A demyelinating disease is any disease of the nervous system in which the myelin sheath of neurons is damaged. This damage impairs the conduction of signals in the affected nerves. In turn, the reduction in conduction ability causes deficiency i ...
s (e.g.,
multiple sclerosis Multiple (cerebral) sclerosis (MS), also known as encephalomyelitis disseminata or disseminated sclerosis, is the most common demyelinating disease, in which the insulating covers of nerve cells in the brain and spinal cord are damaged. This ...
), head trauma, and brain tumors are the most common causes of oculomotor nerve palsy in adults. In ischemic lesions of the oculomotor nerve, pupillary function is usually spared whereas in compressive lesions the pupil is involved. * Pharmacological agents with
anticholinergic Anticholinergics (anticholinergic agents) are substances that block the action of the neurotransmitter called acetylcholine (ACh) at synapses in the central and peripheral nervous system. These agents inhibit the parasympathetic nervous sys ...
or
sympathomimetic Sympathomimetic drugs (also known as adrenergic drugs and adrenergic amines) are stimulant compounds which mimic the effects of endogenous agonists of the sympathetic nervous system. Examples of sympathomimetic effects include increases in hea ...
properties will cause anisocoria, particularly if instilled in one eye. Some examples of pharmacological agents which may affect the pupils include
pilocarpine Pilocarpine is a medication used to reduce pressure inside the eye and treat dry mouth. As eye drops it is used to manage angle closure glaucoma until surgery can be performed, ocular hypertension, primary open angle glaucoma, and to bring a ...
,
cocaine Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Am ...
,
tropicamide Tropicamide, sold under the brand name Mydriacyl among others, is a medication used to dilate the pupil and help with examination of the eye. Specifically it is used to help examine the back of the eye. It is applied as eye drops. Effects occ ...
,
MDMA 3,4-Methylenedioxymethamphetamine (MDMA), commonly seen in tablet form (ecstasy) and crystal form (molly or mandy), is a potent empathogen–entactogen with stimulant properties primarily used for recreational purposes. The desire ...
,
dextromethorphan Dextromethorphan (DXM) is a medication most often used as a cough suppressant in over-the-counter cold and cough medicines. It is sold in syrup, tablet, spray, and lozenge forms. In 2022, the FDA approved a formulation of it combined with b ...
, and
ergolines Ergoline is a chemical compound whose structural skeleton is contained in a variety of alkaloids, referred to as ergoline derivatives or ergoline alkaloids. Ergoline alkaloids, one being ergine, were initially characterized in ergot. Some of the ...
.
Alkaloids Alkaloids are a class of basic, naturally occurring organic compounds that contain at least one nitrogen atom. This group also includes some related compounds with neutral and even weakly acidic properties. Some synthetic compounds of similar ...
present in plants of the genera ''
Brugmansia ''Brugmansia'' is a genus of seven species of flowering plants in the nightshade family Solanaceae. They are woody trees or shrubs, with pendulous flowers, and have no spines on their fruit. Their large, fragrant flowers give them their common n ...
'' and ''
Datura ''Datura'' is a genus of nine species of highly poisonous, vespertine-flowering plants belonging to the nightshade family Solanaceae. They are commonly known as thornapples or jimsonweeds, but are also known as devil's trumpets (not to be co ...
'', such as
scopolamine Scopolamine, also known as hyoscine, or Devil's Breath, is a natural or synthetically produced tropane alkaloid and anticholinergic drug that is formally used as a medication for treating motion sickness and postoperative nausea and vomi ...
, may also induce anisocoria.. It is also seen in some people who consume diphenydramine (brand name "Benadryl") for an extended period of time, or if an astringent eye drop like Visine is used in one eye and not the other, often in concurrence with the presence of contact lenses. *
Migraines Migraine (, ) is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few h ...


Diagnosis

Causes of anisocoria range from benign (normal) to life-threatening conditions. Clinically, it is important to establish whether anisocoria is more apparent in dim or bright light to clarify if the larger pupil or smaller pupil is the abnormal one. * Anisocoria which is worsened (greater asymmetry between the pupils) in the dark suggests the small pupil (which should dilate in dark conditions) is the abnormal pupil and suggests Horner's syndrome or mechanical anisocoria. In Horner's syndrome sympathetic nerve fibers have a defect, therefore the pupil of the involved eye will not dilate in darkness. If the smaller pupil dilates in response to instillation of apraclonidine eye drops, this suggests Horner's syndrome is present. * Anisocoria which is greater in bright light suggests the larger pupil (which should constrict in bright conditions) is the abnormal pupil. This may suggest Adie tonic pupil, pharmacologic dilation, oculomotor nerve palsy, or damaged iris. A relative afferent pupillary defect (RAPD) also known as a Marcus Gunn pupil does not cause anisocoria. Some of the causes of anisocoria are life-threatening, including Horner's syndrome (which may be due to carotid artery dissection) and oculomotor nerve palsy (due to a brain aneurysm, uncal herniation, or head trauma). If the examiner is unsure whether the abnormal pupil is the constricted or dilated one, and if a one-sided drooping of the eyelid is present then the abnormally sized pupil can be presumed to be the one on the side of the ptosis. This is because Horner's syndrome and oculomotor nerve lesions both cause ptosis. Anisocoria is usually a benign finding, unaccompanied by other symptoms (physiological anisocoria). Old face photographs of patients often help to diagnose and establish the type of anisocoria. It should be considered an emergency if a patient develops acute onset anisocoria. These cases may be due to brain mass lesions which cause oculomotor nerve palsy. Anisocoria in the presence of confusion, decreased mental status, severe headache, or other neurological symptoms can forewarn a neurosurgical emergency. This is because a hemorrhage, tumor or another intracranial mass can enlarge to a size where the third cranial nerve (CN III) is compressed, which results in uninhibited dilatation of the pupil on the same side as the lesion.


Popular culture

* English singer
David Bowie David Robert Jones (8 January 194710 January 2016), known professionally as David Bowie ( ), was an English singer-songwriter and actor. A leading figure in the music industry, he is regarded as one of the most influential musicians of the ...
exhibited anisocoria, owing to a teenage injury. * In the season 10 Big Bang Theory Comic-Con special, Steve Molaro told a story about how he first met actor Judd Hirsch and was taken aback by his dilated pupil. One of the other writers researched it and discovered that Judd Hirsch has anisocoria. * American actress
Melissa Benoist Melissa Marie Benoist ( ; born October 4, 1988) is an American actress, singer and producer. Her first major role was Marley Rose on the Fox musical comedy drama '' Glee'' (2012–2014), where she was a series regular during the fifth season. ...
developed this condition in 2015. * American artist
Ze Frank Hosea Jan "Ze" Frank (; born March 31, 1972) is an American online performance artist, composer, humorist and public speaker based in Los Angeles. Personal life Frank was born to German-American parents (his father is Chemistry Nobel Laureate ...
has the condition. He was listed as second author on a paper published in ''
The Journal of Neuroscience ''The Journal of Neuroscience'' is a weekly peer-reviewed scientific journal published by the Society for Neuroscience. It covers empirical research on all aspects of neuroscience. Its editor-in-chief is Marina Picciotto (Yale University). According ...
'', which was featured briefly in episode 21 of the show named '' a show'' on May 25, 2012 called My Pupils, explaining that his study of neuroscience of vision was motivated by his harmless anisocoria condition.


Etymology

Anisocoria is composed of prefix, root and suffix: * prefix: aniso- from the Greek language (meaning: ''unequal''), which in turn comes from ''an'': meaning ''not'' and ''iso'': meaning ''equal'' * the root word: cor, from the Greek word "korē" meaning: pupil of the eye * -ia, which is a Latin suffix meaning: disease; pathological or abnormal condition Thus, anisocoria means the condition of unequal pupil(s).


See also

*
Cycloplegia Cycloplegia is paralysis of the ciliary muscle of the eye, resulting in a loss of accommodation. Because of the paralysis of the ciliary muscle, the curvature of the lens can no longer be adjusted to focus on nearby objects. This results in sim ...
* Miosis *
Mydriasis Mydriasis is the dilation of the pupil, usually having a non-physiological cause, or sometimes a physiological pupillary response. Non-physiological causes of mydriasis include disease, trauma, or the use of certain types of drugs. Normally, a ...
* Parinaud's syndrome *
Hippus Pupillary hippus, also known as pupillary athetosis, is spasmodic, rhythmic, but regular dilating and contracting pupillary movements between the sphincter and dilator muscles.Cassin, B. and Solomon, S. ''Dictionary of Eye Terminology''. Gainesv ...


References


Further reading

* "Anisocoria." "Stedman's Medical Dictionary, 27th ed." (2000). * Victor, Maurice and Allan H. Ropper. "Adams and Victor's Principles of Neurology, 7th ed." (2001).


External links

{{Eye pathology Eye diseases Oculomotor nerve