Guillain-Barre syndrome with bilateral tonic pupils.
Department of Neurology, Urawa Municipal Hospital, Mimuro.
A 53-year-old patient with Guillain-Barre syndrome preceded by herpes simplex virus infection developed bilateral tonic pupils with light-near dissociation. Pharmacological tests for pupils suggested postganglionic involvement of the parasympathetic and sympathetic nerves. A demyelinating process of peripheral autonomic nerves was suspected to be the cause of the tonic pupils and autonomic dysfunction.
Bilateral tonic pupils associated with neurosyphilis.
Department of Ophthalmology, Jikei University School of Medicine, Tokyo, Japan.
BACKGROUND: To describe 4 patients with bilateral tonic pupils in neurosyphilis. CASES: Four young men had pupillary abnormalities, which involved irregular shapes, large sizes, tonic reactions, and vermiform movements of both pupils with light-near dissociation. Cholinergic supersensitivity defined bilateral tonic pupils. OBSERVATIONS: Neurosyphilis was diagnosed in these patients on the basis of ocular and laboratory findings. CONCLUSIONS: Bilateral tonic pupils may be important as initial findings in neurosyphilis. We conclude that patients with bilateral tonic pupils should undergo serologic tests for syphilis.
Tonic pupils in neurosyphilis.
Of 60 patients with tonic pupils, 29 had serologic tests for syphilis. Five patients had positive blood serology and confirmatory tests; four had other manifestations of neurosyphilis and positive CSF serology. All seropositive patients had bilateral tonic pupils with light-near dissociation and denervation hypersensitivity. Of the 10 tonic pupils, only 1 was miotic and 1 dilated. Although tonic pupils tend to become small and bilateral, they should be distinguished readily from Argyll Robertson pupils, which react briskly, not tonically, to near stimuli. Patients with bilateral tonic pupils should have serologic tests for syphilis.
Clinica Oftalmologica, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil. ffugimoto@yahoo.com.br
Lyme disease is a multisystemic disorder caused by Borrelia burgdorferi spirochete, transmitted by ticks. Mainly described in the northern hemisphere and rarely in Brazil. The purpose of this report is to describe a patient with Lyme disease who developed bilateral tonic pupil as the only remaining sign. A 13-year-old female with Lyme disease, presented with bilateral peripheral facial and oculomotor paralysis. After recovery from neurological abnormalities the patient sustained anisocoria, reduced fotomotor reflex, less than normal amplitude of accommodation, tonic pupil constriction for near objects and slow redialation in both eyes. Dilute 0.1% pilocarpine test was positive in both eyes, confirming the suspicion of bilateral tonic pupil. This is the first case report of bilateral tonic pupil caused by Lyme disease.
Pupillary abnormalities in congenital neurosyphilis.
Pupils in congenital neurosyphilis differ from the classic Argyll-Robertson pupil in acquired cases, and often tend to be large and unreactive. Constriction to pilocarpine in the reported patient would suggest that peripheral parasympathetic damage is responsible for such pupillary findings. Congenital neurosyphilis should be included among the causes of "tonic" pupil.
[Argyll-Robertson and other pupillary abnormalities in neurosyphilis--with special reference to the detection of peripheral lesions]
The pupillary disturbances in twenty five neurosyphilitic patients were investigated. Miotic, light-rigid pupils, i.e., Argyll-Robertson pupils were found in only three of these patients. One of three patients showed unilateral Argyll-Robertson pupil. Irregular margins of the iris were associated with these miotic, light-rigid pupils. Abnormal striations of the iris were found in four of eight non-miotic (medium size), light-rigid pupils. Cocaine or ephedrine produced dilatation of two of these pupils, and, following this mydriasis, the pupils were capable of constricting to light. These abnormalities of the iris were not found in slightly light-reactive pupil. The light-rigid pupil induced by long-term administration of neuroleptics and antiparkinson drug in comparison with Argyll-Robertson pupil was also mentioned, and the findings of many authorities who have proposed a peripheral nerve pathogenesis of the Argyll-Robertson syndrome were reviewed.
Pupillary abnormalities in congenital neurosyphilis.
Pupils in congenital neurosyphilis differ from the classic Argyll-Robertson pupil in acquired cases, and often tend to be large and unreactive. Constriction to pilocarpine in the reported patient would suggest that peripheral parasympathetic damage is responsible for such pupillary findings. Congenital neurosyphilis should be included among the causes of "tonic" pupil.
The Argyll Robertson pupil.
Neuro-opthalmology Unit, Department of Opthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, USA. thompson@ginniff.com
The Argyll Robertson (AR) pupil has been defined as a pupil that is small and constricts poorly to direct light but briskly when a target within reading distance is viewed ("light-near dissociation"). Most descriptions of the AR pupil do not mention segmental iris sphincter constriction, or slow, sustained constriction with a near vision effort. Such features are considered typical of the light-near dissociation of Adie syndrome and of neuropathic tonic pupils, where damage to the ciliary ganglion or ciliary nerves is believed to be the mechanism. Because the AR pupil lacks these features, it has been attributed to a dorsal midbrain lesion that interrupts the pupillary light reflex pathway but spares the more ventral pupillary near reflex pathway. However, lesions in this region have not been reliably demonstrated in syphilis. Resolving the issue about the location of the syphilitic lesion that produces the AR pupil will depend on careful examination of patients with techniques designed to disclose segmental palsy of the iris. If segmental iris sphincter palsy is found and the light-near dissociation has tonic features, one must conclude that the mechanism of the pupil disorder is a ciliary (peripheral) rather than a midbrain (central) denervation. Until better evidence settles the localization of the AR pupil, it is appropriate to screen patients with bilateral tonic pupils for syphilis.