DƯỢC LÍ Goodman & Gilman's The Pharmacological Basis of Therapeutics 12th, 2010

Table 64–2
Effects of Pharmacological Agents on the Pupil
CLINICAL SETTING DRUG PUPILLARY RESPONSE
Normal Sympathomimetic drugs Dilation (mydriasis)
Normal Parasympathomimetic drugs Constriction (miosis)
Horner’s syndrome Cocaine 4-10% No dilation
Preganglionic Horner’s Hydroxyamphetamine 1% Dilation
Postganglionic Horner’s Hydroxyamphetamine 1% No dilation
Adie’s pupil Pilocarpine 0.05-0.1% a Constriction
Normal Opioids (oral or intravenous) Pinpoint pupils
Topically applied ophthalmic drugs unless otherwise noted. a This percentage of pilocarpine is not commercially available and usually is prepared by
the physician administering the test or by a pharmacist. This test also requires that no prior manipulation of the cornea (i.e., tonometry for measuring
intraocular pressure or testing corneal sensation) be done so that the normal integrity of the corneal barrier is intact. Normal pupils will not respond
to this weak dilution of pilocarpine; however, an Adie’s pupil manifests a denervation supersensitivity and is, therefore, pharmacodynamically
responsive to this dilute cholinergic agonist.
lens is composed of fibers derived from proliferating lens epithelial
cells located under the anterior portion of the lens capsule. These
lens fibers are continuously produced throughout life. Aging, in
addition to certain medications, such as corticosteroids, and certain
diseases, such as diabetes mellitus, cause the lens to become opacified,
which is termed a cataract.
Posterior Segment. Because of the anatomical and vascular
barriers to both local and systemic access, drug delivery
to the eye’s posterior pole is particularly challenging.
Sclera. The outermost coat of the eye, the sclera, covers the posterior
portion of the globe. The external surface of the scleral shell is
good light
reaction
in both eyes
more anisocoria
in darkness
than in light
check light reaction
compare
anisocoria in darkness
and in light
more anisocoria
in light than
in darkness
poor light
reaction
in one eye
no dilation lag
both pupils
dilate
Simple Anisocoria
look for
“dilation lag”
of the smaller pupil
with flash photos
cocaine test
4%–10%
smaller pupil
fails to dilate
dilation
Preganglionic or
Central Horner’s
“dilation lag”
of smaller pupil
Horner’s Syndrome
1%
hydroxyamphetamine
test
no dilation
Postganglionic
Horner’s
impaired light reaction
but no sector palsy
of iris sphincter
or distortion of stroma
completely
immobile
pupil constricts
examine iris
sphincter at slit lamp
test for cholinergic
supersensivity with
methacholine 2.5% or
pilocarpine
0.05%–0.1%
sphincter
is not
supersensitive
test for
anticholinergic
blockade with
pilocarpine 1%
sphincter is
supersensitive
pupil fails to constrict
sector palsy
of iris sphincter
Adie’s Tonic Pupil
iris transilluminates
pupil margin torn
Iris Damage
III rd Nerve Palsy
“Atropinic”
Mydriasis
Figure 64–5. Anisocoria evaluation flowsheet. (Adapted with permission from Thompson and Pilley, 1976. Copyright © Elsevier.)