Pupillary abnormalities
..................... Most cases in pupil examination are straight forward. Very often observation alone will give 
you the clue to the most likely diagnosis, for example in the absence of ptosis and anisocoria 
the most likely diagnosis is relative afferent pupillary defect. Whereas presence of ptosis 
suggests either Horner's (partial ptosis with constricted pupil best seen in dim light and 
possibly lighter iris in congenital cases) or third nerve palsy (presence of a more significant 
ptosis with larger pupil and ocular misalignment). Anisocoria in the absence of ptosis should 
suggests the possibility of Adie's pupil. 

Other possible cases include Argyll-Robertson's pupils and light-near dissociation but they 
are not as commonly seen as the four cases above. 

Extra points will be gained if you could volunteer to elicit further physical signs without 
prompting. For example: 

      • optic disc atrophy or old scar from previous temporal artery biopsy in 

        • a patient with relative afferent pupillary defect
      • neck scar in patient with Horner's syndrome
      • presence of neurosurgical scar in patients with third nerve palsy
      • absence ankle or knee jerk in Adie's pupil
Also remember to: 
      • learn the differential diagnosis of a relative afferent pupillary

        • defect,  unilateral large /  small pupil and  light/near dissociation
      • memorize the pharmacological testings for anisocoria
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