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)


1. How can one confirm Adie's pupil?

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

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

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