eMedicine Specialties > Ophthalmology > Pupil

Anisocoria: Treatment & Medication

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
Contributor Information and Disclosures

Updated: Aug 18, 2009

Treatment

Medical Care

Medical care of patients with anisocoria is entirely dependent upon the etiology.

Surgical Care

Surgical care in anisocoria depends entirely upon the specific pathophysiology. Potential applications include neurosurgical care for aneurysm-related third nerve palsy mydriasis, ophthalmic surgical attention for traumatic iris defects, and vascular surgical consultation for Horner syndrome related to carotid dissection.

Consultations

Consultation may be useful depending upon the origin of the anisocoria.

Acute pupil-involved oculomotor palsy should be evaluated emergently by neuro-ophthalmology, neurology, or neurosurgery.

Neurology or neuro-ophthalmology consultation may assist in the evaluation of patients with Horner syndrome, especially if lateral medullary infarction or carotid dissection is in the differential diagnosis.

Medication

Medical therapy depends entirely upon etiology of the patient's anisocoria. Several drops are used in the diagnosis of anisocoria.

Anesthetics

Local anesthetics stabilize the neuronal membrane and prevent the initiation and transmission of nerve impulses, thereby producing the local anesthetic action.


Cocaine 4-10% ophthalmic solution

Dilates pupil if sympathetic innervation is intact. Decreases membrane permeability to sodium ions, which, in turn, inhibits depolarization and blocks conduction of nerve impulses. Typical dose is 1-2 gtt of 4-10% ophthalmic solution in both eyes; normal pupil serves as control. Corneal defects may result from repeated application or higher doses.

Adult

1-2 gtt 4-10% OU

Pediatric

1 gtt 4% OU

May increase toxicity of MAOIs when cocaine is overused

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Corneal toxicity may result from repeated application or overuse; corneal anesthesia related to cocaine drops may mask subsequent corneal injury-related pain; urine drug screens will be positive for at least 24 h after cocaine testing; wait 24 h between cocaine and hydroxyamphetamine testing

Cholinergic agents

Dosage and frequency of administration must be individualized.


Pilocarpine (Isopto)

Ophthalmic solution (1%) constricts a normal pupil and the dilated pupil of an oculomotor palsy or Adie pupil but does not constrict a pharmacologically dilated pupil.
Pilocarpine 1/8-1/16% is used as a diagnostic agent in an Adie pupil; a normal pupil reacts very little to dilute pilocarpine, while the supersensitivity associated with an Adie pupil render it responsive to this weak dilution of pilocarpine.

Adult

1-2 gtt OU

Pediatric

1 gtt OU

May be ineffective when used concomitantly with nonsteroidal anti-inflammatory agents

Documented hypersensitivity; acute inflammatory disease of anterior chamber; pupillary block glaucoma

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Miosis may cause dark adaptation and night driving difficulty; caution in acute cardiac failure, peptic ulcer, hyperthyroidism, GI spasm, bronchial asthma, Parkinson disease, recent MI, urinary tract obstruction, and hypertension or hypotension

Sympathomimetics

Lower intraocular pressure mainly by increasing outflow and reducing production of aqueous humor.


Hydroxyamphetamine 1% (Paredrine)

Dilates pupil if third order sympathetic neuron is intact, and fails to dilate pupil if third order neuron is impaired.

Adult

1-2 gtt OU

Pediatric

1 gtt OU

Systemic adverse effects may occur with coadministration of beta-blockers; up to 21 d after MAOIs, exaggerated adrenergic effects may result (supervise and adjust dosage carefully)

Documented hypersensitivity; narrow-angle glaucoma or anatomically narrow (occludable) angle without glaucoma

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypertension, diabetes, hyperthyroidism, cardiovascular abnormalities, and arteriosclerosis; rebound congestion may occur with frequent or extended use; rebound miosis may occur in older persons 1 d after phenylephrine treatment; reinstillation may produce a reduction in mydriasis

More on Anisocoria

Overview: Anisocoria
Differential Diagnoses & Workup: Anisocoria
Treatment & Medication: Anisocoria
Follow-up: Anisocoria
Multimedia: Anisocoria
References
Further Reading
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References

  1. Moeller JJ, Maxner CE. The dilated pupil: an update. Curr Neurol Neurosci Rep. Sep 2007;7(5):417-22. [Medline].

  2. 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].

  3. Poca MA, Benejam B, Sahuquillo J, et al. Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful?. J Neurosurg. Aug 7 2009;[Medline].

  4. Kardon RH, Denison CE, Brown CK, Thompson HS. Critical evaluation of the cocaine test in the diagnosis of Horner's syndrome. Arch Ophthalmol. Mar 1990;108(3):384-7. [Medline].

  5. Lowenfeld IE. "Simple central" anisocoria: a common condition, seldom recognized. Trans Am Acad Ophth & Oto. 1977;83:832.

  6. Lowenfeld IE. The Pupil: Anatomy, Physiology, and Clinical Applications. Iowa State University; 1993.

  7. Miller NR, Newman NJ, eds. Walsh and Hoyt's Clinical Neuro-ophthalmology. Vol 1. 1998:827-1042.

  8. Thompson HS. Light-near dissociation of the pupil. Ophthalmologica. 1984;189(1-2):21-3. [Medline].

  9. Thompson S, Pilley SF. Unequal pupils. A flow chart for sorting out the anisocorias. Surv Ophthalmol. Jul-Aug 1976;21(1):45-8. [Medline].

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Keywords

anisocoria, unequal pupils, pupil size, difference in pupil size, pupils, pupil control, pupil reactivity, pupil dilation, physiologic anisocoria, Horner syndrome, oculomotor nerve palsy, tonic pupil, pharmacologic anisocoria, iris damage, mechanical damage to iris, eye inflammation, uveitis

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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.

Medical Editor

Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto: Consulting Staff, Toronto East General Hospital
Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American College of Physician Executives, American Society of Contemporary Ophthalmology, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
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.

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