Acute Oropharyngeal Palsy Following Bilateral Adie's Tonic Pupils Associated with Anti-GT1a and GQ1b IgG Antibodies.

A 36-year-old man was admitted to our hospital with complaints of dysphagia and photophobia. A neurological examination showed oropharyngeal palsy and bilateral mydriasis with loss of light reflexes in the absence of external ophthalmoplegia. Bilateral pupils were supersensitive to pilocarpine 0.1%, which was compatible with Adie's tonic pupils. Serum IgG reacted with GQ1b, GT1a, GalNAc-GD1a, and GD3. Intravenous high-dose immunoglobulin therapy improved his neurological symptoms within three weeks. To our knowledge, there is no medical literature describing acute oropharyngeal palsy with Adie's tonic pupils. We recommend evaluating antiganglioside antibodies to clarify the cause of oropharyngeal palsy and Adie's tonic pupils.

Concurrent tonic pupil and trochlear nerve palsy in COVID-19.

Since COVID-19 was first reported, different neurological complications have been acknowledged, but their description is constantly evolving. We report a case of concurrent tonic pupil and trochlear nerve palsy in this context. A 62-year-old man reported a 5-day history of binocular vertical diplopia and blurred vision in his left eye, noticing that his left pupil was dilated. He had suffered a flu-like syndrome 2 weeks before. Clinical exam showed a right trochlear nerve palsy and a left mydriatic pupil. MRI, X chest ray, and analytical results were normal. Antibodies for SARS-CoV-2 were positive (low IgM and high IgG titers). Antiganglioside antibodies were negative. A 0.125% pilocarpine test confirmed Adie's pupil diagnosis. The patient was treated with a tapered prednisone dose with resolution of his diplopia but no change in Adie's pupil. This is the first case reporting Adie's pupil as a postinfectious manifestation of COVID-19. An immune-mediated mechanism is presumed.

Adie's tonic pupil presenting with unilateral photophobia successfully treated with dilute pilocarpine.

A 40-year-old healthy man presented with a 4-month history of photophobia, blurred vision and a right dilated pupil. Examination revealed a right pupil that was not reactive to light but constricted strongly to a near target and slowly redilated when he looked back in the distance. Pharmacological testing with dilute pilocarpine 0.1% resulted in constriction of the right pupil but no change in the left pupil. This also resulted in resolution of his photophobia and blurry vision. Neurological examination was otherwise normal, and a diagnosis of Adie's tonic pupil was made. The main differential diagnosis to consider for a large pupil is a third nerve palsy, pharmacological mydriasis, tonic pupil and local iris processes, such as iris sphincter tears from trauma. Knowledge of the key features of these conditions can avoid wasted resources from unnecessary testing. Dilute pilocarpine 0.1% three times a day can be considered as a pharmacological therapy for symptomatic relief.

Tonic Pupil in Cytomegalovirus Anterior Uveitis in an Immunocompetent Adult Male - A Case Report.

PURPOSE: To report an interesting case of development of tonic pupil in an immunocompetent male with cytomegalovirus (CMV) anterior uveitis. METHODS: Retrospective case report Results: A 30-year-old Iranian healthy male was diagnosed to have Posner-Schlossman syndrome (OS). Aqueous tap was positive for CMV by multiplex Polymerase chain reaction (PCR). Adequate control of inflammation and Intraocular pressures (IOP) were achieved with topical steroids, ganciclovir gel, and antiglaucoma medications. On a follow-up visit, he complained of recent onset of blurring of vision (OS) despite appropriate refractive correction, quiet anterior chamber, and normal IOP. Pupillary examination showed anisocoria (larger pupil in OS). Pupillary constriction (OS) on instillation of 0.125% pilocarpine drops confirmed the diagnosis of a tonic pupil. CONCLUSION: We describe a unique finding of tonic pupil on a follow-up examination in an immunocompetent adult male with CMV anterior uveitis. A prior association has not been described in literature (Medline Search).

Tonic pupil in leprosy / Pupila tônica em doença de Hansen

Pupil abnormalities in leprosy usually result from chronic iritis with loss of stroma, iris miosis, a sluggish reaction to light, and poor dilation in response to anticholinergic mydriatics. We report two patients with long-standing lepromatous leprosy who developed tonic pupils characterized by mydriasis, absence of reaction to light and hypersensitivity to weak cholinergic solution. Examination revealed iritis and iris atrophy. In both cases, instillation of dilute 0.1% pilocarpine caused miosis in the affected eyes. Tonic pupil occurs in many conditions, but its association with leprosy had not been previously reported.

Anormalidades da pupila em pacientes com doença de Hansen, ocorrem mais comumente devido a irite crônica com perda do estroma iriano, miose, diminuição da reação à luz, e dificuldade de dilatação em resposta a colírios anticolinérgicos. Relatamos dois pacientes com doença de Hansen na forma lepromatosa que desenvolveram pupilas tônicas, caracterizadas por midríase, ausência de reação a luz e para perto e hipersensibilidade a fraca concentração de solução colinérgica. O exame revelou irite e atrofia iriana. Em ambos os casos a instilação de pilocarpina 0,1% causou miose nos olhos afetados. A pupila tônica tem sido relatada em muitas condições, mas sua associação com doença de Hansen ainda não havia sido descrita.

A rare presentation of neurosyphilis mimicking a unilateral Adie's tonic pupil.

We describe a case of a female patient who presented with anisocoria and was initially diagnosed with a right acute Adie's pupil on the basis of a right tonic pupil with absent oculomotor or neurological findings and hyper-responsiveness to dilute Pilocarpine. Two months later, the patient returned with bilateral tonic pupils and limitation of extraocular movement in the right eye. Subsequent laboratory testing revealed neurosyphilis. Our case, only the second ever reported, emphasizes the importance of considering the diagnosis of neurosyphilis in patients presenting with an isolated acute tonic pupil.

Tonic pupil in leprosy.

Pupil abnormalities in leprosy usually result from chronic iritis with loss of stroma, iris miosis, a sluggish reaction to light, and poor dilation in response to anticholinergic mydriatics. We report two patients with long-standing lepromatous leprosy who developed tonic pupils characterized by mydriasis, absence of reaction to light and hypersensitivity to weak cholinergic solution. Examination revealed iritis and iris atrophy. In both cases, instillation of dilute 0.1% pilocarpine caused miosis in the affected eyes. Tonic pupil occurs in many conditions, but its association with leprosy had not been previously reported.

[Unilateral dilated light-unresponsive pupil in Guillain Barré syndrome]. / Dilateret og lysstiv pupil ved Guillain-Barrés syndrom.

We report a case of Guillain Barré syndrome presenting with a unilateral internal ophthalmoplegia and unilateral minor sensory impairment, followed by respiratory failure, missing reflexes, tetraparesis and bilateral facial weakness. All symptoms responded to immunoglobulin. The diagnosis was confirmed by cerebrospinal fluid analysis and electroneurography. This case was especially unusual because the pupil abnormality was unilateral and appeared prior to motor impairment.

Bilateral optic neuropathy and unilateral tonic pupil associated with acute human herpesvirus 6 infection: a case report.

BACKGROUND: Human herpesvirus 6 (HHV-6), a widespread virus and causative agent of exanthema subitum in children, has been associated with a number of neurologic disorders including cranial nerve palsies, seizures, encephalitis, meningitis, and multiple sclerosis. PATIENT: A 31-year-old man presented with bilateral optic neuropathy, disc edema, and unilateral tonic pupil, which were found to be associated with acute HHV-6 infection. The patient had been suffering from juvenile diabetes for 5 years. One week after onset of intravenous antiviral therapy with foscarnet, disc edema subsided, and tonic pupil reaction was no longer detectable. CONCLUSIONS: HHV-6 infection may play a role as a causative agent in patients with optic neuropathy and tonic pupil.

Neuro-ophthalmological findings in sarcoidosis.

PURPOSE: This review emphasizes the importance of neuro-ophthalmological signs and symptoms in sarcoidosis. The presence of ophthalmological and neuro-ophthalmological findings may lead to diagnosis of the disease and the initiation of adequate treatment. MATERIAL AND METHODS: Patients who had been diagnosed with neurosarcoidosis during the period 1990 - 2001 were identified from the departmental diagnostic index. The history, clinical, laboratory and imaging data of patients were analysed. RESULTS: Fifteen patients were identified, four men and 11 women, with a mean age of 44.1 years (range 26-65 years). In six of the 15 (40%), neurological deficits were the initial symptoms. Nine (60%) had known sarcoidosis at the time of presentation. Ten patients (66%) had ophthalmological/neuro-ophthalmological symptoms and signs. CONCLUSION: Neuro-ophthalmological symptoms may develop early in neurosarcoidosis. If neuro-ophthalmological symptoms arise in patients with established biopsy-proven sarcoidosis, the diagnosis is usually easy to make. However, a number of patients with neurosarcoidosis may present with neuro-ophthalmic symptoms before systemic involvement becomes obvious. In this situation the diagnosis is challenging, and the major goal is to establish the presence of systemic sarcoidosis.

A case of angle closure glaucoma caused by plateau iris and adie's pupil.

PURPOSE: To describe a case of plateau iris associated with bilateral Adie's pupil. DESIGN: Interventional case report. METHODS: A 54-year-old woman presented with pain in her right eye and headache. Intraocular pressure was 34 mm Hg in the right eye. Light reflex was defective bilaterally. RESULTS: Ultrasound biomicroscopic imaging revealed normal anterior chamber depth and narrow angle. The ciliary processes were situated anteriorly. The eyes showed supersensitivity to 0.125% pilocarpine. The patient was diagnosed as having bilateral angle-closure glaucoma induced by Adie's pupil and plateau iris. CONCLUSION: Mild pupillary dilation caused by Adie's pupil may have played a role in the development of angle closure in the plateau iris configuration of our patient.

Acute sensorimotor polyneuropathy with tonic pupils and an abduction deficit: an unusual presentation of polyarteritis nodosa.

A tonic pupil may occur in isolation or as part of a systemic disorder. We report a patient who developed tonic pupils and an abduction deficit in the setting of polyarteritis nodosa. The combination of a tonic pupil and an abduction deficit should suggest the possibility of a vasculopathic disorder, because the ciliary ganglion and lateral rectus muscle are both supplied by the lateral muscular artery. Widespread small artery and arteriolar narrowing and occlusion are the hallmarks of polyarteritis nodosa. Unusual ischemic syndromes may occur, such as this rare combination of neuro-ophthalmic signs, by involvement of both the nutrient artery and its collaterals. We are unaware of other reports of neuropathic tonic pupils in association with polyarteritis nodosa.

Guillain-Barré syndrome with bilateral tonic pupils.

A 53-year-old patient with Guillain-Barré 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.