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BRIEF COMMUNICATION
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 119-121

Adie’s pupil – Case series


Department of Pediatric Ophthalmology and Strabismus, Sankara Eye Hospital, Bengaluru, Karnataka, India

Date of Submission01-Jan-2020
Date of Decision06-Feb-2020
Date of Acceptance17-Feb-2020
Date of Web Publication4-Dec-2020

Correspondence Address:
Sowmya Raveendra Murthy
Sankara Eye Hospital, Varthur Main Road, Kundlahalli Gate, Bengaluru - 560 035, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_1_20

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  Abstract 


Adie’s pupil, also called as Adie’s tonic pupil is the common cause of anisocoria or unequal pupils in clinics. It is used to denote the parasympathetic denervation of the pupil with absent light responses and retained near reflex. We describe a case series of patients diagnosed with Adie’s pupil. We retrospectively reviewed the case records of patients diagnosed with Adie’s pupil between January 2016 and December 2017. The diagnosis was made based on light-near dissociation of pupils, vermiform movements of the iris, and supersensitivity to dilute pilocarpine. Routine blood investigations, venereal disease research laboratory test was ordered in all patients. Out of the forty patients included, there were 23 male and 17 female. It was bilateral in 6 and unilateral in 34 cases. Most cases were between 20 and 50 years. There were 3 cases <20 years and 4 cases >50 years. Hypothyroidism and diabetes were noted in 2 cases each. Interestingly, the erythrocyte sedimentation rate (ESR) was raised in 9 cases. Our series points toward the common occurrence of Adie’s pupil and needs to be looked for during the examination. Although the etiology seems not clear in our review, it gives a clue to investigate further in view of raised ESR suggesting inflammation.

Keywords: Near reaction, pilocarpine test, pupil


How to cite this article:
Murthy SR. Adie’s pupil – Case series. J Clin Ophthalmol Res 2020;8:119-21

How to cite this URL:
Murthy SR. Adie’s pupil – Case series. J Clin Ophthalmol Res [serial online] 2020 [cited 2021 Jan 25];8:119-21. Available from: https://www.jcor.in/text.asp?2020/8/3/119/302190



The tonic pupil is caused by the damage to the postganglionic parasympathetic fibers, i.e., at the level of the ciliary ganglion or short ciliary nerves.[1],[2],[3] Tonic pupils refer to pupil with the following features: (a) poor reaction to light with segmental iris palsy, (b) accommodative paresis which improves with time, (c) with unusually strong and tonic near reaction with slow redilation after constriction to near stimuli, and (d) cholinergic supersensitivity.[2],[4],[5]

Tonic pupils belong to one of three categories: local, neuropathic, and Adie’s pupil:[2],[4],[6]

  1. Local tonic pupil is due to orbital or systemic conditions affecting the ciliary ganglion or short ciliary nerves in isolation as in herpes zoster virus, sarcoidosis, vogt-koyanagi-harada, rheumatoid arthritis, blunt injury to globe, or various intraocular surgeries[2],[7]
  2. Neuropathic tonic pupils are usually bilateral and occur as a part of widespread peripheral or systemic autonomic neuropathy. Various condition includes Miller Fisher variant of Gullian-Barre syndrome,  Charcot-Marie-Tooth disease More Details,  Shy-Drager syndrome More Details and many others[1],[2],[8],[9]
  3. Adie’s syndrome refers to tonic pupil of idiopathic etiology. It is commonly seen in females (around 70%) and in the age group of 20–50 years. Unilateral affection is more common (around 80%) with 4%/year having the other pupil also involved.[2],[4],[5]


Symptoms are usually due to iridoplegia and cycloplegia such as photophobia, difficulty with dark adaptation, headache with near activities, and blurred near vision.

The pathophysiology of an Adie pupil is acute denervation followed by inappropriate reinnervation of the ciliary body and iris sphincter. Clinical features will vary depending on the stage of reinnervation at the time of examination. Accommodation paresis improves with reinnervation of the ciliary body.[2],[10] Further, the reinnervating fiber to the ciliary body misinnervate the iris sphincter causing tonic response to near stimuli.[2],[11],[12]

The denervated iris sphincter is supersensitive to topical parasympathomimetic solutions. Pilocarpine drops (0.125% or 1/8th concentration) can be used to demonstrate this, as the normal pupil will constrict slightly, if at all. About 80% of patients with a tonic pupil show cholinergic denervation supersensitivity.[2],[11],[12]


  Materials and Methods Top


The case records of patients diagnosed with Adie’s pupil in a tertiary hospital between January 2016 and December 2017 were retrospectively reviewed.

The diagnosis of Adie’s pupil was made based on the following observations; poor pupillary light response, tonic near response, vermiform movements of iris noted on slit-lamp examination, and supersensitivity to diluted pilocarpine (0.5 ml of 2% pilocarpine diluted in 7.5 ml of saline).

The following data such as presenting symptoms, demographic data, results of diluted pilocarpine test, laterality of occurrence, investigation results, treatment given, and follow-up period were collected. Data of other systemic conditions recorded in case records were also noted.


  Results Top


The demographic profile, laterality, presenting symptoms, treatment data, and investigation results were analyzed. A total of 40 patients were included. There were 23 male and 17 female contrary to the description of being common in females. Most cases were between 20 and 40 years (30/40 cases). There were 3 cases <20 years and 4 cases >50 years [Table 1].
Table 1: Age and sex distribution of cases with adie’s pupil

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Unilateral involvement as seen in 34 cases (85%) with the right eye being affected commonly than the left eye (18:16) [Figure 1]. Bilateral involvement as noted in 6 cases, with asymmetrical involvement in all except one case [Figure 2]. Among the bilateral cases, there were 3 male and female and most of them in the range of 20–40 age group (3/6 cases).
Figure 1: Upper picture shows (OD) Adie’s pupil. (OD) pupil constricts with near reaction in lower picture

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Figure 2: Upper picture shows (OU) Adie’s pupil. (OU) pupil constricts with near reaction in lower picture

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Considering the presenting complaints; difficulty with near tasks was the most common (17 cases), headaches in 7 cases, photophobia in 3 cases, and 10 cases were noted as part of the routine eye examination. Interestingly, 3 cases presented with difference in pupillary size as noted by the patient themselves.

Routine investigation recorded was noted to be within the normal range in all cases except raised erythrocyte sedimentation rate (ESR) noted in 9 cases. Hypothyroidism and diabetes were noted in two cases each.

All patients showed supersensitivity to dilute pilocarpine except one patient, which remained the same at 1-month follow-up.

Treatment data were analyzed. Most (22/40 cases) of the given routine refractive correction, diluted pilocarpine was given in 2 cases (one bilateral involvement) and unilateral progressive lenses in 3 cases and rest needing no treatment. On analyzing the follow-up data, 7 cases had <6 months follow-up and 7 cases were followed up for >1 year. Interestingly, there was no change in pupil size on follow-up.


  Discussion Top


In this retrospective study, we looked at the demographic and clinical profile of patients with Adie’s pupil. Age group affected was commonly between 20 and 40 years in our series; similar to as reported in the literature. The occurrence is reported to be more common in females than males[1],[2],[4] but our study showed males to be commonly affected. Involvement was unilateral in 85% cases comparable to that reported.[1],[2] Nearly one-fourth of cases were diagnosed with part of clinical examination suggesting the need for a careful pupillary examination. In our study, difficulty with near tasks was the most common (17 cases), headaches in 7 cases, photophobia in 3 cases, and 10 cases were noted as part of the routine eye examination. Interestingly, the difference in pupillary size was also a complaint in a few patients.

Our series points toward the common occurrence of Adie’s pupil and needs to be looked for during the examination. Although the etiology seems not clear in our review, it gives a clue to investigate further in view of raised ESR suggesting inflammation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kline LB, Bajandas FJ. Neuro-ophthalmology Review Manual. 5th ed. Thorofare, NJ: Slack; 2004.  Back to cited text no. 1
    
2.
Miller NR, Biousse V, Newman NJ, Kerrison JB. Walsh and Hoyt’s Clinical Neuroophthalmology: The Essentials. 2nd ed. Philadelphia.Lippincott Williams and Wilkins: 2008. p. 307-14.  Back to cited text no. 2
    
3.
Martinelli P. Holmes-Adie syndrome. Lancet 2000;356:1760-1.  Back to cited text no. 3
    
4.
Thompson HS. Adie’s syndrome: Some new observations. Trans Am Ophthalmol Soc 1977;75:587-626.  Back to cited text no. 4
    
5.
Wilhelm H. Neuro-ophthalmology of pupillary function-practical guidelines. J Neurol 1998;245:573-83.  Back to cited text no. 5
    
6.
Thompson HS, Bell RA, Bourgon P. The natural history of Adie’s syndrome. In: Thompson HS, Daroff R, Frisan L, editors. Topics in NeuroOphthalmology. Baltimore: Williams and Wilkins; 1979. p. 99.  Back to cited text no. 6
    
7.
Kim JS, Yun CH, Moon CS. Bilateral tonic (Adie’s) pupils in Vogt-Koyanagi-Harada syndrome. J Neuroophthalmol 2001;21:205-6.  Back to cited text no. 7
    
8.
Nitta T, Kase M, Shinmei Y, Yoshida K, Chin S, Ohno S. Mydriasis with light-near dissociation in Fisher’s Syndrome. Jpn J Ophthalmol 2007;51:224-7.  Back to cited text no. 8
    
9.
Kajikawa S, Ohi T, Fujita A, Kusunoki S. A case of anti-GQ1b antibody syndrome associated with pure bilateral Adie’s pupils. Brain Nerve 2016;68:93-6.  Back to cited text no. 9
    
10.
Bell RA, Thompson HS. The symptoms of Adie’s syndrome. In: Thompson HS, Daroff R, Frisan L, editors. Topics in Neuro-Ophthalmology. Baltimore: Williams and Wilkins; 1979. p. 104.  Back to cited text no. 10
    
11.
Kardon RH, Corbett JJ, Thompson HS. Segmental denervation and reinnervation of the iris sphincter as shown by infrared videographic transillumination. Ophthalmology 1998;105:313-21.  Back to cited text no. 11
    
12.
Thompson HS. Segmental palsy of the iris sphincter in Adie’s syndrome. Arch Ophthalmol 1978;96:1615-20.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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