Adie's pupil
 

. Segmental palsy of the sphincter muscles (arrows). Best  seen on slit-lamp. . Right dilated pupil Right pupil has no light reflex. Pupils react to accommodation Note: The arrow represents the light.

The patient (usually a female) has anisocoria with the enlarged pupil failing to react to light. However, the pupil constricts in response to accommodation with delayed dilatation (this results in reversal of anisocoria).  Note: Adie's pupil is bilateral in 15% of cases and in long-standing cases the pupil may be miosed. Further examination: mention you would like to examine the iris on the slit-lamp for segmental palsies and vermiform movement of the iris mention that you would like to test the tendon reflexes. This is absent in 70% of patient (Holme-Adie's syndrome)

Questions:

1. How can one confirm Adie's pupil?

Answer
The iris shows denervation hypersensitivity. A low concentration of pilocarpine for example 0.1% can cause pupil constriction in Adie's pupil but not in the normal. However, this test may not be confirmatory in acute cases.

2. How can you differentiate a dilated pupil from third nerve palsy from that caused by Adie's pupil or drug-induced?

Answer
In the clinical examination, light responses are absent in all the three conditions. However, accommodation reflex will be seen in Adie's pupil but not in the other two conditions. The mydriasis in third nerve palsy is usually associated with ptosis and ocular motility abnormalities.
Using 0.1% pilocarpine topically on each pupil, only the Adie's pupil will constrict. With 1% pilocarpine, both Adie's pupil and third nerve palsy will constrict but not in drug-induced mydriasis.

3. What is responsible for the signs seen in Adie's pupil?

Answer
There is denervation of the post-ganglionic supply to the sphincter pupillae and the ciliary muscle. This may follow infection such as herpes-zoster or trauma but is usually idiopathic. The ciliary ganglion has 30 times more neurons for the ciliary muscle than for the iris sphincter. Thus, following recovery, most of the sprouting new axons arise from the accommodation cells but may end up in the iris sphincter (ie. aberrant regeneration). The vermiform movements represent contractile activity of those iris sectors which remain connected to the light sensitive neurons.

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