Supranuclear Lesions

Lesions above the oculomotor nucleus tend to cause bilateral pupillary dysfunction; the most common cause is dorsal compression of the midbrain (Parinaud syndrome; p. 358). Neurosyphilis produces Argyll-Robertson pupils— unequal, irregularly miotic pupils with a variable degree of iris atrophy, and light-near dissociation.

The cause of coma may be structural, metabolic, or toxic. Pupilloconstriction is produced by opiates, alcohol, and barbiturates, pupillary dilatation by atropine poisoning (mushrooms, belladonna), tricyclic antidepressants, botulinum toxin, cocaine, and other drugs. Focal lesions (clivus, midbrain) may cause unilateral or bilateral pupillary areflexia and mydriasis. Unilateral miosis is seen in central Horner syndrome, and bilateral miosis (pinpoint pupils) in acute pontine dysfunction.

Amaurosis (right)

Ciliary ganglionitis

Clivus syndrome

Amaurosis (right)

Ciliary ganglionitis

Clivus syndrome

Horner Syndrome Subclavian

Infiltrating malignant tumor

Spinal lesion (syringomyelia, trauma, tumor)

Indirect light response

Amaurosis (right)

Complete right third nerve palsy

- Argyll-Robertson pupils

— Parinaud syndrome

Cavernous sinus lesion

Hemispheric lesion (infarct, hemorrhage)

Brain stem lesion

Carotid dissection

Infiltrating malignant tumor

Spinal lesion (syringomyelia, trauma, tumor)

Indirect light response

Direct light response Spontaneous ^

Convergence response m &

Lesion of brachial plexus, thoracic apex, mediastinum; subclavian venous thrombosis

Sympathetic denervation

Amaurosis (right)

Complete right third nerve palsy

Pupillotonia

Light-near dissociation

Atropine eye-drops, right eye

Clivus syndrome, intoxications

Parinaud syndrome

Acute pontine lesion, intoxications

Right Left

Pupillary dysfunction

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