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The pupillary light reflex (PLR) or photopupillary reflex is a reflex that controls the diameter of the pupil, in response to the intensity (
luminance Luminance is a photometric measure of the luminous intensity per unit area of light travelling in a given direction. It describes the amount of light that passes through, is emitted from, or is reflected from a particular area, and falls with ...
) of light that falls on the
retinal ganglion cell A retinal ganglion cell (RGC) is a type of neuron located near the inner surface (the ganglion cell layer) of the retina of the eye. It receives visual information from photoreceptors via two intermediate neuron types: bipolar cells and reti ...
s of the
retina The retina (from la, rete "net") is the innermost, light-sensitive layer of tissue of the eye of most vertebrates and some molluscs. The optics of the eye create a focused two-dimensional image of the visual world on the retina, which the ...
in the back of the eye, thereby assisting in
adaptation In biology, adaptation has three related meanings. Firstly, it is the dynamic evolutionary process of natural selection that fits organisms to their environment, enhancing their evolutionary fitness. Secondly, it is a state reached by the po ...
of vision to various levels of lightness/darkness. A greater intensity of light causes the pupil to constrict ( miosis/myosis; thereby allowing less light in), whereas a lower intensity of light causes the pupil to dilate ( mydriasis, expansion; thereby allowing more light in). Thus, the pupillary light reflex regulates the intensity of light entering the eye. Light shone into one eye will cause both pupils to constrict.


Terminology

The pupil is the dark circular opening in the center of the iris and is where light enters the eye. By analogy with a camera, the pupil is equivalent to
aperture In optics, an aperture is a hole or an opening through which light travels. More specifically, the aperture and focal length of an optical system determine the cone angle of a bundle of rays that come to a focus in the image plane. An ...
, whereas the iris is equivalent to the
diaphragm Diaphragm may refer to: Anatomy * Thoracic diaphragm, a thin sheet of muscle between the thorax and the abdomen * Pelvic diaphragm or pelvic floor, a pelvic structure * Urogenital diaphragm or triangular ligament, a pelvic structure Other * Diap ...
. It may be helpful to consider the ''Pupillary reflex'' as an Iris' reflex'', as the iris sphincter and dilator muscles are what can be seen responding to ambient light. Whereas, the pupil is the passive opening formed by the active iris. Pupillary reflex is synonymous with pupillary response, which may be pupillary constriction or dilation. Pupillary reflex is conceptually linked to the side (left or right) of the reacting pupil, and not to the side from which light stimulation originates. Left pupillary reflex refers to the response of the left pupil to light, regardless of which eye is exposed to a light source. Right pupillary reflex means reaction of the right pupil, whether light is shone into the left eye, right eye, or both eyes. When light is shone into only one eye and not the other, it is normal for both pupils to constrict simultaneously. The terms ''direct'' and ''consensual'' refers to the side where the light source comes from, relative to the side of the reacting pupil. A direct pupillary reflex is pupillary response to light that enters the ipsilateral (same) eye. A consensual pupillary reflex is response of a pupil to light that enters the contralateral (opposite) eye. Thus there are four types of pupillary light reflexes, based on this terminology of absolute laterality (left versus right) and relative laterality (same side versus opposite side, ipsilateral versus contralateral, direct versus consensual): # ''Left direct pupillary reflex'' is the left pupil's response to light entering the left eye, the ipsilateral eye. # ''Left consensual pupillary reflex'' is the left pupil's indirect response to light entering the right eye, the contralateral eye. # ''Right direct pupillary reflex'' is the right pupil's response to light entering the right eye, the ipsilateral eye. # ''Right consensual pupillary reflex'' is the right pupil's indirect response to light entering the left eye, the contralateral eye.


Neural pathway anatomy

The pupillary light reflex neural pathway on each side has an afferent limb and two efferent limbs. The afferent limb has nerve fibers running within the optic nerve ( CN II). Each efferent limb has nerve fibers running along the oculomotor nerve ( CN III). The afferent limb carries sensory input. Anatomically, the afferent limb consists of the retina, the optic nerve, and the pretectal nucleus in the midbrain, at level of superior colliculus. Ganglion cells of the retina project fibers through the optic nerve to the ipsilateral pretectal nucleus. The efferent limb is the pupillary motor output from the pretectal nucleus to the ciliary sphincter muscle of the iris. The pretectal nucleus projects crossed and uncrossed fibers to the ipsilateral and contralateral Edinger-Westphal nuclei, which are also located in the midbrain. Each Edinger-Westphal nucleus gives rise to preganglionic parasympathetic fibers which exit with CN III and synapse with postganglionic parasympathetic neurons in the ciliary ganglion. Postganglionic nerve fibers leave the ciliary ganglion to innervate the ciliary sphincter. Each afferent limb has two efferent limbs, one ipsilateral and one contralateral. The ipsilateral efferent limb transmits nerve signals for direct light reflex of the ipsilateral pupil. The contralateral efferent limb causes consensual light reflex of the contralateral pupil.


Types of neurons

The
optic nerve In neuroanatomy, the optic nerve, also known as the second cranial nerve, cranial nerve II, or simply CN II, is a paired cranial nerve that transmits visual information from the retina to the brain. In humans, the optic nerve is derived fro ...
, or more precisely, the photosensitive ganglion cells through the
retinohypothalamic tract In neuroanatomy, the retinohypothalamic tract (RHT) is a photic neural input pathway involved in the circadian rhythms of mammals. The origin of the retinohypothalamic tract is the intrinsically photosensitive retinal ganglion cells (ipRGC), wh ...
, is responsible for the
afferent limb Afferent nerve fibers are the axons (nerve fibers) carried by a sensory nerve that relay sensory information from sensory receptors to regions of the brain. Afferent projections ''arrive'' at a particular brain region. Efferent nerve fibers ar ...
of the pupillary reflex; it senses the incoming light. The
oculomotor nerve The oculomotor nerve, also known as the third cranial nerve, cranial nerve III, or simply CN III, is a cranial nerve that enters the orbit through the superior orbital fissure and innervates extraocular muscles that enable most movements of ...
is responsible for the efferent limb of the pupillary reflex; it drives the iris muscles that constrict the pupil. #Retina: The pupillary reflex pathway begins with the photosensitive
retinal ganglion cell A retinal ganglion cell (RGC) is a type of neuron located near the inner surface (the ganglion cell layer) of the retina of the eye. It receives visual information from photoreceptors via two intermediate neuron types: bipolar cells and reti ...
s, which convey information via the
optic nerve In neuroanatomy, the optic nerve, also known as the second cranial nerve, cranial nerve II, or simply CN II, is a paired cranial nerve that transmits visual information from the retina to the brain. In humans, the optic nerve is derived fro ...
, the most peripheral, distal, portion of which is the
optic disc The optic disc or optic nerve head is the point of exit for ganglion cell axons leaving the eye. Because there are no rods or cones overlying the optic disc, it corresponds to a small blind spot in each eye. The ganglion cell axons form ...
. Some axons of the optic nerve connect to the pretectal nucleus of the upper
midbrain The midbrain or mesencephalon is the forward-most portion of the brainstem and is associated with vision, hearing, motor control, sleep and wakefulness, arousal ( alertness), and temperature regulation. The name comes from the Greek ''mesos'', ...
instead of the cells of the lateral geniculate nucleus (which project to the primary visual cortex). These ''intrinsic photosensitive ganglion cells'' are also referred to as ''
melanopsin Melanopsin is a type of photopigment belonging to a larger family of light-sensitive retinal proteins called opsins and encoded by the gene ''Opn4''. In the mammalian retina, there are two additional categories of opsins, both involved in the f ...
-containing'' cells, and they influence circadian rhythms as well as the pupillary light reflex. #Pretectal nuclei: From the neuronal cell bodies in some of the pretectal nuclei, axons synapse on (connect to) neurons in the Edinger-Westphal nucleus. Those neurons are the preganglionic cells with axons that run in the
oculomotor nerve The oculomotor nerve, also known as the third cranial nerve, cranial nerve III, or simply CN III, is a cranial nerve that enters the orbit through the superior orbital fissure and innervates extraocular muscles that enable most movements of ...
s to the ciliary ganglia. #Edinger-Westphal nuclei: Parasympathetic neuronal axons in the oculomotor nerve
synapse In the nervous system, a synapse is a structure that permits a neuron (or nerve cell) to pass an electrical or chemical signal to another neuron or to the target effector cell. Synapses are essential to the transmission of nervous impulses from ...
on ciliary ganglion neurons. #Ciliary ganglia: Short post-ganglionic ciliary nerves leave the ciliary ganglion to innervate the
Iris sphincter muscle The iris sphincter muscle (pupillary sphincter, pupillary constrictor, circular muscle of iris, circular fibers) is a muscle in the part of the eye called the iris. It encircles the pupil of the iris, appropriate to its function as a constricto ...
of the iris.


Schematic

Referring to the neural pathway schematic diagram, the entire pupillary light reflex system can be visualized as having eight neural segments, numbered 1 through 8. Odd-numbered segments 1, 3, 5, and 7 are on the left. Even-numbered segments 2, 4, 6, and 8 are on the right. Segments 1 and 2 each includes both the retina and the optic nerve (cranial Nerve #2). Segments 3 and 4 are nerve fibers that cross from the pretectal nucleus on one side to the Edinger-Westphal nucleus on the contralateral side. Segments 5 and 6 are fibers that connect the pretectal nucleus on one side to the Edinger-Westphal nucleus on the same side. Segments 3, 4, 5, and 6 are all located within a compact region within the midbrain. Segments 7 and 8 each contains parasympathetic fibers that courses from the Edinger-Westphal nucleus, through the ciliary ganglion, along the oculomotor nerve (cranial nerve #3), to the ciliary sphincter, the muscular structure within the iris. * Left direct light reflex involves neural segments 1, 5, and 7. Segment 1 is the afferent limb, which includes the retina and optic nerve. Segments 5 and 7 form the efferent limb. * Left consensual light reflex involves neural segments 2, 4, and 7. Segment 2 is the afferent limb. Segments 4 and 7 form the efferent limb. * Right direct light reflex involves neural segments 2, 6, and 8. Segment 2 is the afferent limb. Segments 6 and 8 form the efferent limb. * Right consensual light reflex involves neural segments 1, 3, and 8. Segment 1 is the afferent limb. Segments 3 and 8 form the efferent limb. The diagram may assist in localizing lesion within the pupillary reflex system by process of elimination, using light reflex testing results obtained by clinical examination.


Clinical significance

Pupillary light reflex provides a useful diagnostic tool for testing the integrity of the sensory and motor functions of the eye. Emergency physicians routinely test pupillary light reflex to assess brain stem function. Abnormal pupillary reflex can be found in optic nerve injury, oculomotor nerve damage, brain stem lesion (including brain stem death), and depressant drugs, such as
barbiturates Barbiturates are a class of depressant drugs that are chemically derived from barbituric acid. They are effective when used medically as anxiolytics, hypnotics, and anticonvulsants, but have physical and psychological addiction potential as we ...
. Examples are provided as below: *
Optic nerve In neuroanatomy, the optic nerve, also known as the second cranial nerve, cranial nerve II, or simply CN II, is a paired cranial nerve that transmits visual information from the retina to the brain. In humans, the optic nerve is derived fro ...
damage on the left (e.g. transection of left optic nerve, CN II, somewhere between retina and
optic chiasma In neuroanatomy, the optic chiasm, or optic chiasma (; , ), is the part of the brain where the optic nerves cross. It is located at the bottom of the brain immediately inferior to the hypothalamus. The optic chiasm is found in all vertebr ...
, therefore damaging the left afferent limb, leaving the rest of the pupillary light reflex neural pathway on both sides intact) will have the following clinical findings: **The left direct reflex is lost. When the left eye is stimulated by light, neither pupils constrict. Afferent signals from the left eye cannot pass through the transected left optic nerve to reach the intact efferent limb on the left. **The right consensual reflex is lost. When left eye is stimulated by light, afferent signals from the left eye cannot pass through the transected left optic nerve to reach the intact efferent limb on the right. **The right direct reflex is intact. Direct light reflex of right pupil involves the right optic nerve and right oculomotor nerve, which are both intact. **The left consensual reflex is intact. Consensual light reflex of left pupil involves the right optic nerve and left oculomotor nerve, which are both undamaged. *
Oculomotor nerve The oculomotor nerve, also known as the third cranial nerve, cranial nerve III, or simply CN III, is a cranial nerve that enters the orbit through the superior orbital fissure and innervates extraocular muscles that enable most movements of ...
damage on the left (e.g. transection of left oculomotor nerve, CN III, therefore damaging the left efferent limb) will have the following clinical findings: **The left direct reflex is lost. When the left eye is stimulated by light, left pupil does not constrict, because the efferent signals cannot pass from midbrain, through left CN III, to the left pupillary sphincter. **The right consensual reflex is intact. When the left eye is stimulated by light, the right pupil constricts, because the afferent limb on the left and the efferent limb on the right are both intact. **The right direct reflex is intact. When light is shone into right eye, right pupil constricts. Direct reflex of the right pupil is unaffected, The right afferent limb, right CN II, and the right efferent limb, right CN III, are both intact. **The left consensual reflex is lost. When the right eye is stimulated by light, left pupil does not constrict consensually. Right afferent limb is intact, but left efferent limb, left CN III, is damaged.


Lesion localization example

For example, in a person with abnormal left direct reflex and abnormal right consensual reflex (with normal left consensual and normal right direct reflexes), which would produce a left Marcus Gunn pupil, or what is called left afferent pupillary defect, by physical examination. Location of the lesion can be deduced as follows: # Left consensual reflex is normal, therefore segments 2, 4, and 7 are normal. Lesion is not located in any of these segments. # Right direct reflex is normal, therefore segments 2, 6, and 8 are normal. Combining with earlier normals, segments 2, 4, 6, 7, and 8 are all normal. # Remaining segments where lesion may be located are segments 1, 3, and 5. Possible combinations and permutations are: (a) segment 1 only, (b) segment 3 only, (c) segment 5 only, (d) combination of segments 1 and 3, (e) combination of segments 1 and 5, (f) combination of segments 3 and 5, and (g) combination of segments 1, 3, and 5. # Options (b) and (c) are eliminated because isolated lesion in segment 3 alone or in segment 5 alone cannot produce the light reflex abnormalities in question. # A single lesion anywhere along segment 1, the left afferent limb, which includes the left retina, left optic nerve, and left pretectal nucleus, can produce the light reflex abnormalities observed. Examples of segment 1 pathologies include left optic neuritis (inflammation or infection of the left optic nerve), detachment of left retina, and an isolated small stroke involving only the left pretectal nucleus. Therefore, options (a), (d), (e), (f), and (g) are possible. # A combined lesion in segments 3 and 5 as cause of defect is very unlikely. Microscopically precise strokes in the midbrain, involving the left pretectal nucleus, bilateral Edinger-Westphal nuclei, and their interconnecting fibers, could theoretically produce this result. Furthermore, segment 4 shares the same anatomical space in the midbrain as segment 3, therefore segment 4 will likely be affected if segment 3 is damaged. In this setting, it is very unlikely that left consensual reflex, which requires an intact segment 4, would be preserved. Therefore, options (d), (f), and (g), which all includes segment 3, are eliminated. Remaining possible options are (a) and (e). # Based on the above reasoning, the lesion must involve segment 1. Damage to segment 5 may accompany a segment 1 lesion, but is unnecessary for producing the abnormal light reflex results in this case. Option (e) involves a combined lesion of segments 1 and 5. Multiple sclerosis, which often affects multiple neurologic sites simultaneously, could potentially cause this combination lesion. In all probability, option (a) is the answer. Neuro-imaging, such as MRI scan, would be useful for confirmation of clinical findings.


Cognitive influences

The pupillary response to light is not purely reflexive, but is modulated by cognitive factors, such as
attention Attention is the behavioral and cognitive process of selectively concentrating on a discrete aspect of information, whether considered subjective or objective, while ignoring other perceivable information. William James (1890) wrote that "Att ...
, awareness, and the way visual input is interpreted. For example, if a bright stimulus is presented to one eye, and a dark stimulus to the other eye, perception alternates between the two eyes (i.e., binocular rivalry): Sometimes the dark stimulus is perceived, sometimes the bright stimulus, but never both at the same time. Using this technique, it has been shown the pupil is smaller when a bright stimulus dominates awareness, relative to when a dark stimulus dominates awareness. This shows that the pupillary light reflex is modulated by visual awareness. Similarly, it has been shown that the pupil constricts when you covertly (i.e., without looking at) pay attention to a bright stimulus, compared to a dark stimulus, even when visual input is identical. Moreover, the magnitude of the pupillary light reflex following a distracting probe is strongly correlated with the extent to which the probe captures visual attention and interferes with task performance. This shows that the pupillary light reflex is modulated by visual attention and trial-by-trial variation in visual attention. Finally, a picture that is subjectively perceived as bright (e.g. a picture of the sun), elicits a stronger pupillary constriction than an image that is perceived as less bright (e.g. a picture of an indoor scene), even when the objective brightness of both images is equal. This shows that the pupillary light reflex is modulated by subjective (as opposed to objective) brightness.


Mathematical model

Pupillary light reflex is modeled as a physiologically-based non-linear delay differential equation that describes the changes in the pupil diameter as a function of the environment lighting: :\begin M(D) &= \tanh^ \left(\frac\right) \\ \frac\frac + 2.3026 \tanh^ \left(\frac\right) &= 5.2 - 0.45 \ln \left(\frac \right) \end where D is the pupil diameter measured in millimeters and \Phi(t - \tau) is the luminous intensity reaching the retina in a time t, which can be described as \Phi = IA: luminance reaching the eye in lumens/mm2 times the pupil area in mm2. \tau is the pupillary latency, a time delay between the instant in which the light pulse reaches the retina and the beginning of iridal reaction due nerve transmission, neuro-muscular excitation and activation delays. \mathrmM, \mathrmD and \mathrmt are the derivatives for the M function, pupil diameter D and time t. Since the pupil constriction velocity is approximately 3 times faster than (re)dilation velocity, different step sizes in the numerical solver simulation must be used: :\begin \mathrmt_ &= \frac \\ \mathrmt_ &= \frac \end where \mathrmt_c and \mathrmt_d are respectively the \mathrmt for constriction and dilation measured in milliseconds, T_c and T_p are respectively the current and previous simulation times (times since the simulation started) measured in milliseconds, S is a constant that affects the constriction/dilation velocity and varies among individuals. The higher the S value, the smaller the time step used in the simulation and, consequently, the smaller the pupil constriction/dilation velocity. In order to improve the realism of the resulting simulations, the
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 ...
effect can be approximated by adding small random variations to the environment light (in the range 0.05–0.3 Hz).


See also

* Pupil * Pupillary response * Slit lamp


References


External links


Animation of pupillary light reflex
*

demonstrating the changes in pupil reactions for various nerve lesions. {{DEFAULTSORT:Pupillary Light Reflex Ophthalmology Reflexes Articles containing video clips Pupil