The College of Optometrists

Px, about 70 yrs old, c/o severe frequent but brief headaches(about 10 minutes) around LE. Past 2years only.

everything unremarkable, except very vague (?hysterical type?) field defect, and enlarged pupil on ipsilateral side for the duration of the headache only. Reactions are relatively brisk, and when headache passes the pupils are equal again.

Please, what am I missing? any ideas welcome

It may be a variant of a condition I experience, which is that when I am stressed one of my pupils dilates. Its response to light remains brisk - no dilation lag. I do not know why.

This was first pointed out to me during my PQEs by a fellow student, who enthusiastically suggested I may have a brain tumour. You can no doubt imagine my delight at discovering a photograph of myself at aged 4 yrs with glaring anisocoria following a tussle with my older brother. My suspicion is that I have an asymmetric gain in my sympathetic response, though whether this represents a deficiency or hyperactivity I am unsure.

Incidentally, after becoming aware of this I have discovered another individual with the condition.

Silly suggestion, probaly unlikely but: brief attacks of CAG (or nearly!) causing pain & temporary mid-dilation? Might be worth referring for gonioscopy?

this is not unusual in migraines and it maybe be worth discussing with px about their headache history. A transient pupil defect - often mildly dilated can occur at time of headache. Alternatively, this could be a form of transient RAPD with one eye having a slightly ischaemic retina occasionally - I wonder what the BP is - and if they are doing anything pre-attack. Certainly serious things get worse - so this does not sound too alarming - but this perhaps should be investigated to be clearer with a possible cause.

hey - Michael your CET article on magnifiers was brilliant - but gave me a seriously hard time (all the maths !!!). I not sure if I got the questions right or not.

It is now stored for reference!

amazing and helpful article - needed that info for a long time - palfo

Ive heard of this with migranes too.

I've had a little look at the literature, and it seems to support the views above, except for me having a brain tumour.

Transient anisocoria has been reported in numerous case studies, though as one author commented, the problems is that by the time they attend for examination it had invariably gone. A review on the subject wrote:

"...there is a heterogeneous group of conditions that fall under the rubric of benign episodic unilateral

mydriasis that has been described in young(usually) women who frequently have migraines and experience recurrent episodes of isolated anisocoria

that last several hours. The episodes may occur during a migraine or independent of headache. During

an episode, patients often report ipsilateral visual blurring, head or eye pain, and often photophobia and eye redness. When examined during an episode, some patients have impaired near visual acuity, impaired accommodation, and anisocoria that is greater in added light, features that implicate impaired parasympathetic

innervation of the intraocular muscles.

Reversible vasospasm or some other circulatory impairment of the ciliary ganglion is an attractive hypothesis

to account for the phenomenology of this

syndrome. Alternatively, exaggeration of physiologic anisocoria may account for the signs and symptoms in other affected patients. Regardless of the mechanism, the prognosis is excellent. As long as the episodes are neurologically isolated, no further neurodiagnostic evaluation is required."

Evans RW, Jacobson DM. Transient anisocoria in a migraineur. Headache. 2003 Apr;43(4):416-8.

n.b. note, and try and use tomorrow, the words rubric and phenomenology, in the above passage, both underused in my opinion.

interestingly enough - I have a lady px od 30y old who has the phenomenology of her right eye becoming cloudy for several hours after strenous exercise. The left eye is never affected. I have never had the opertunity to check this myself - never being present during her strenous exercises.

She has no associated headaches and pupil function is normal. It is not PVD, or slipping contact lenses. Perhaps this too can be a mild right pupil dilation due to a change in cranial blood perfusion.

Had a lecture from someone a while ago who says that pupil defects are not a problem if there is no field defect.... Im not convinced though. Anyone else heard this?

What about Horner's syndrome ?

thanks again allof you, much comforting there

Palfi,

Thank you for your flattering comments on my article Palfi. The math content was significantly reduced from the first draft as I was told by one reviewer that only "egg heads" like myself and him would appreciate it!

Regarding your 30 yr old lady patient, you should consider:

1) Multiple sclerosis - Uhthoff's Phenomenon

2) Pigment dispersion syndrome - exercise induced pigment release with resulting corneal oedema

3) Diabetes - lens swelling due to elevated glucose

However, it may well be vascular, with blood being pumped to the working muscles leaving the brain/optic nerve/retina relatively hypoxic. I have experienced a dimming of my peripheral vision during the final push in a running race, which I assumed was caused by this mechanism. This has been reported before, along with blur and flickering, and was presumed an "exercise-induced migraine equivalent" following normal examination in,

Imes RK, Hoyt WF. Exercise-induced transient visual events in young healthy adults. J Clin Neuroophthalmol. 1989 Sep;9(3):178-80.

Ann C,

In Horner's syndrome the affected pupil is miotic. At least in my case, the affected pupil is dilated - 8mm+ is not normal for me. I also do not have any ptosis or the characteristic dilation lag with an increase in anisocoria in the dark. Moreover, Horner’s is not (usually) transient, although a transient Horner's has been described during cluster HA, probably due to a vascular aetiology. I would like to confirm with cocaine, but to safeguard myself from incriminating questions about supply, I could not tell you the results anyhow.