Anisocoria Treatment & Management

Author: Eric R Eggenberger, DO, MS, FAAN; Chief Editor: Hampton Roy Sr, MD more...

Updated: Nov 18, 2010

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Medical Care

Medical care depends upon the underlying pathophysiology.

Surgical Care

Surgical care depends upon the specific etiology.

Consultations

Consultations depend upon the underlying cause. Compressive third nerve palsies may require neurosurgical intervention, while ophthalmologists may be helpful in other causes of anisocoria.

Proceed to Medication

Contributor Information and Disclosures

Author

Eric R Eggenberger, DO, MS, FAAN Professor, Vice-Chairman, Department of Neurology and Ophthalmology, Colleges of Osteopathic Medicine and Human Medicine, Michigan State University; Director of Michigan State University Ocular Motility Laboratory; Director of National Multiple Sclerosis Society Clinic, Michigan State University

Eric R Eggenberger, DO, MS, FAAN is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Osteopathic Association, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

James Goodwin, MD Associate Professor, Departments of Neurology and Ophthalmology, University of Illinois College of Medicine; Director, Neuro-Ophthalmology Service, University of Illinois Eye and Ear Infirmary

James Goodwin, MD is a member of the following medical societies: American Academy of Neurology, Illinois State Medical Society, North American Neuro-Ophthalmology Society, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jane W Chan, MD Professor of Neurology/Neuro-ophthalmology, Department of Medicine, Division of Neurology, University of Nevada School of Medicine

Jane W Chan, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Medical Association, North American Neuro-Ophthalmology Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

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Fan X, Miles JH, Takahashi N, Yao G. Sex-specific lateralization of contraction anisocoria in transient pupillary light reflex. Invest Ophthalmol Vis Sci. Mar 2009;50(3):1137-44. [Medline].
Thompson S, Pilley SF. Unequal pupils. A flow chart for sorting out the anisocorias. Surv Ophthalmol. Jul-Aug 1976;21(1):45-8. [Medline].
Freedman KA, Brown SM. Topical apraclonidine in the diagnosis of suspected Horner syndrome. J Neuroophthalmol. Jun 2005;25(2):83-5. [Medline].
Martin TJ. Horner's syndrome, Pseudo-Horner's syndrome, and simple anisocoria. Curr Neurol Neurosci Rep. Sep 2007;7(5):397-406. [Medline].
Kawasaki A, Borruat FX. False negative apraclonidine test in two patients with Horner syndrome. Klin Monatsbl Augenheilkd. May 2008;225(5):520-2. [Medline].
Wehbe E, Antoun SA, Moussa J, Nassif I. Transient anisocoria caused by aerosolized ipratropium bromide exposure from an ill-fitting face mask. J Neuroophthalmol. Sep 2008;28(3):236-7. [Medline].
Andreola B, Piovan A, Da Dalt L, Filippini R, Cappelletti E. Unilateral mydriasis due to Angel's trumpet. Clin Toxicol (Phila). Apr 2008;46(4):329-31. [Medline].
Cremer SA, Thompson HS, Digre KB, Kardon RH. Hydroxyamphetamine mydriasis in Horner's syndrome. Am J Ophthalmol. Jul 15 1990;110(1):71-6. [Medline].
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Lowenfeld IE. The Pupil. Anatomy, Physiology, and Clinical Application. Iowa State Press;1993.
Miller NR, Newman NJ, eds. Walsh & Hoyt's Clinical Neuro-ophthalmology. Vol 1. 5th ed. 1998.
Moster ML, Galiani D, Garfinkle W. False negative hydroxyamphetamine test in horner syndrome caused by acute internal carotid artery dissection. J Neuroophthalmol. Mar 2003;23(1):22-3. [Medline].
Pishdad GR, Pishdad P, Pishdad R. Pupillary autonomic neuropathy simulating partial Horner syndrome in diabetes mellitus and its reversal with control of blood glucose. J Neuroophthalmol. Sep 2008;28(3):241-2. [Medline].

Flowchart to assist in the diagnosis of anisocoria (modified with permission from Thompson and Pilley)

Horner syndrome secondary to carotid dissection. Note that degree of anisocoria is relatively mild in room light. Also, see the image below of the same patient.

Horner syndrome due to carotid dissection. Note the increase in degree of anisocoria under dark conditions.

Typical pupil in third nerve palsy, with mydriasis. Note the inability to adduct the right eye. This patient has a skull-based meningioma that is compressing the right third nerve. At rest, complete ptosis is present in the right eye; however, lid elevation with attempted adduction of the right eye is noted, which is consistent with aberrant regeneration.

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