RESUMEN
Anisocoria after induction of general anesthesia may indicate a severe cerebrovascular disorder. We encountered a case in which anisocoria in the left and right eyes was noticed after induction of general anesthesia, and the surgery was canceled. The patient was a 53-year-old woman with a history of hypertension. She received general anesthesia 10 years ago, but the details were unknown. Anesthesia was induced with propofol, remifentanil, and rocuronium, followed by nasal intubation. No significant change was observed in vital signs during the induction of anesthesia. After intubation, the pupils were checked according to the protocol for observing pupil diameter. The pupil size was found to be unequal, measuring 1 mm in the left eye and 4 mm in the right eye. A cerebrovascular disorder was suspected; thus, the surgery was canceled, and the patient was awakened and extubated. Neurological symptoms such as limb movements were checked after awakening, and no disorientation or motor dysfunction was detected in the patient. However, her pupils remained unequal, measuring 2 mm in the left eye and 4 mm in the right eye. Regarding light reflex, the left eye was miotic, but the right eye remained mydriatic. The pupillary symptom persisted even during discharge the next day. Since our hospital is a solely dental hospital, following discharge, after consulting the ophthalmology department of a nearby medical university hospital, the patient was diagnosed with pupillotonia, as she had been experiencing light dazzling in only her right eye for seven years, had no light reflex but near reflex, and was miotic due to the use of pilocarpine hydrochloride eye drops, which promotes miosis. The patient has had these symptoms in the right eye for seven years, and it is possible that she had anisocoria during the preoperative examination at this time. If anisocoria had been detected and examined carefully during the preoperative examination, there would have been no need to cancel the surgery. In this case, we strongly felt that the pupils must be checked during the preoperative examination.
RESUMEN
The aim of the work is to approach the examination of the pupil with a focus on anisocoria, its characteristics and approach to the diagnosis of pupillotonia and Adie's syndrome and its clinical evaluation. Pupil function is important not only in neurophthalmological examination but also in general ophthalmological examination. First of all, we need to know how the reflex arc works in order to be able to exclude or confirm whether the parasympathetic or sympathetic is affected. It is also necessary to know the exact characteristics of the pupil, such as size, shape, placement, function and reaction to light and at close range. Only on this basis can we distinguish pathological features. We do not often encounter this diagnosis, but it is necessary to keep it in mind, especially in the field of neurophthalmology but also in general ophthalmology. We also present three cases of pupilotonia and Adie's syndrome, which we diagnosed at the Department of Ophthalmology, Faculty of Medicine, Comenius University, after the patient himself came by emergency admission or was sent directly to ophthalmology clinic. In the discussion, we present various other diagnoses, where the reflex arc may not be affected, but the pathological pupil is caused by intraocular tumors, general systemic diseases and, last but not least, local therapy or alkaloids.