Adie’s pupil: a case report

Abstract

Introduction: Adie’s pupil is a rare neurological disorder, which is caused by lesions in ciliary ganglion or postganglionic short ciliary nerves, followed by aberrant regeneration. This process causes unilateral or bilateral mydriasis, unresponsiveness to bright or dim light, slow constriction on accommodation. Most cases are idiopathic, affecting 25-45-year-old adults, more frequently women. Case report: 33-year-old female was admitted to the emergency department complaining of a dilated pupil of the right eye. The patient noted that the day before her colleagues noticed that her right pupil was wider than the left pupil. There were no other vision-related symptoms. The patient has been having headaches for a couple of years, which started after pregnancy, sometimes with hyperhidrosis. On ophthalmologic examination, the pupil of the right eye was 2-3 mm wider than the pupil of the left eye with a poor reaction to light. Ductions were full, palpebral fissures were symmetric. There was no nystagmus. The anterior segments were normal. Visual acuity was normal (20/20). Intraocular pressures were 17,3 mmHg OU. Fundoscopy showed normal optic discs. Cerebral and orbital computed tomography (CT) had shown no significant acute changes so the patient was redirected to an outpatient clinic for further ophthalmic examination. Based on the pictures of the patient anisocoria was first noticed a couple months ago. Optical coherence tomography showed no loss of the nerve fiber layer. Orbital ultrasonography of the right eye showed a 2 mm optic nerve drusen. Pharmacological testing with dilute pilocarpine 0.1 % resulted in constriction of the right pupil but there was no change in the left pupil, Adie’s pupil diagnosis was confirmed. Further examination for other causes of Adie’s syndrome included blood tests (CRP, ESR, ANA, ANCA for autoimmune cause), consultation with a neurologist, and examination of cervical blood vessels. Magnetic resonance imaging (MRI) of the brain showed no pathological changes. Conclusions: Adie’s pupil is a relatively rare disorder, diagnosed by clinical manifestations. A positive diluted pilocarpine test (0.06/ 0.1 /0.2 %) may be useful to demonstrate the cholinergic denervation supersensitivity in the tonic pupil. However, the condition frequently remains undiagnosed. CT or MRI tomography may help to rule out other conditions that can cause anisocoria.