Pupillary Pathway

DR R PATEL

The iris (the coloured part of the eye) is a muscle which controls the size of the pupil.

The pupil changes size according to the amount of light available. When it is dark the pupil opens up wide (dilates) to let as much light as possible into the eye so you can see more clearly.
Another amazing fact

In bright light
Radial muscles of the iris relax. Circular muscles of the iris contract. Less light enters the eye through the contracted pupil.

In dim light
Radial muscles of the iris contract. Circular muscles of the iris relax. More light enters the eye through the dilated pupil.

Pupil
Circular hole in the middle of the iris. Acts like the shutter of a camera:
In darkness the iris dilator muscle causes the pupil to dilate and allowing more light to reach the retina. In brightness, the iris sphincter muscle (which encircles the pupil) constricts, causing the pupil to constrict and allowing less light to reach the retina.

Constriction also occurs during accommodation - the near reflex.

The muscles of the iris: 1- sphincter pupillae: circular in shape and are arranged around the margin of the pupil. Action: constrict the pupil in the presence of bright light.& during accomodation. Nerve supply : parasympathetic fibers from the oculomotor nerve (short ciliary branches of ciliary ganglion. 2- dilator pupillae: Radial fibers Action: Dilate the pupil in the presence of light of low intensity & excessive sympathetic stimuli as in fear. Nerve supply : sympathetic Dr. Azza Zaki fibers along long ciliary nerve.

Intra-Ocular Muscles

Muscles of iris
Dilator muscles
Origin: iris root Insertion :2 mm from pupillary margin Orientation :radial NS : myoepithelial cells innervated by sympathetics from superior cervical ganglia (V1 via the long ciliary nerve)

Iris sphincter
Orientation :circumferential around the pupil Lies withen 2-3 mm of pupil margin NS : smooth muscle innervated by postganglionic parasympathetic fibers from the ciliary ganglia (CN 3 via the short ciliary nerves)

Muscles of iris

Pupil
Normal size : In dark adaption : In light adaption : Miosis : Mydriasis : 2-4mm 4.5-7 mm 2.5-6 mm =/<3mm =/> 6mm

The iris constricts or dilates to adjust size of the pupil.

The pupil allows light to enter the posterior segment of the eye.

Pupil Dilation and Constriction, Anterior View

Light reflex
First (sensory) connects each retina with both pre-tectal nuclei in the midbrain at the level of
the superior colliculi. Impulses originating from the nasal retina are conducted by fibres which decussate in the chiasm and pass up the opposite optic tract to terminate in the contralateral pre-tectal nucleus. Impulses originating in the temporal retina are conducted by uncrossed fibres (ipsilateral optic tract) which terminate in the ipsilateral pre-tectal nucleus.

Second (internuncial) connects each pre-tectal nucleus to both Edinger-Westphal

nuclei.
Thus a uniocular light stimulus evokes bilateral and symmetrical pupillary constriction. Damage to internuncial neurons is responsible for light-near dissociation in neurosyphilis and pinealomas.
ganglion. The parasympathetic fibres pass through the oculomotor nerve, enter its inferior division and reach the ciliary ganglion via the nerve to the inferior oblique muscle nerves to innervate the sphincter pupillae. The ciliary ganglion is located within the muscle cone, just behind the globe. It should be noted that, although the ciliary ganglion serves as a conduit for other nerve fibres, only the parasympathetic fibres synapse there.

Third (pre-ganglionic motor) connects the Edinger-Westphal nucleus to the ciliary

.

Fourth (post-ganglionic motor) leaves the ciliary ganglion and passes in the short ciliary

Points of Interest
Within the second order neuron there are 30 near response fibers for every light response fiber. This allows for light - near dissociation. The third order neuron runs with cranial nerve III from the brain stem to the ciliary ganglion. Superficially located prior to the cavernous sinus.

4-neuron pathway:
i.Retinal ganglion cells optic nerve optic chiasm optic tract synapse in pretectalnuclei of dorsal midbrain ii.Pretectalnuclei Edinger-Westphalnuclei (bilateral innervation!) iii.Parasympathetic fibres travel along CN3 Ipsilateral ciliary ganglionwithin orbit iv.Postganglionic parasympathetic fibres- pupillary sphincter muscles

Visual pathway

Optic nerve Optic chiasma Optic tract

Lateral geniculate body

Optic radiation

Visual area

Pupillary reflexes
Sphincter pupil Ciliary muscle

Ciliary ganglia Occculomotor n.

Accessory oculomotor nuclei

Pretectal area

Anatomy of the parasympathetic outflow

Anatomy of the parasympathetic outflow

CORTICAL CONTROL
Excitatory path from frontal & occipital cortex Inhibitatory path from frontal cortex

PATHWAYS

Edinger-Westphalnuclei Parasympathetic fibres travel along CN3 inferior division branch to inferior oblique A- LIGHT REFLEX Short root of ciliary ganglion- ciliary ganglion short ciliary N. -sphincter of iris B-NEAR REFLEX : leaving CN3 at an unknown point ->? Accessory ganglion sphincter of iris

Parasympathetic pathway
First Order Retina to Pretectal Nucleus in B/S (at level of Superior colliculus) Second Order Pretectal nucleus to E/W nucleus (bilateral innervation!) Third Order E/W nucleus to Ciliary Ganglion Fourth Order Ciliary Ganglion to Sphincter pupillae (via short ciliary nerves)

Sympathetic Pathway
First Order Posterior Hypothalamus to Ciliospinal centre of Budge (C8-T2) (Uncrossed in Brainstem) Second Order Ciliospinal centre of Budge to Superior Cervical Ganaglion Third Order Superior Cervical Ganglion to dilator pupillae muscle. (Close to ICA and joins V1 intracranially)

Sympathetic Pathway
The sympathetic supply involves three neurons

First (central) starts in the posterior

hypothalamus and descends, uncrossed, down the brainstem to terminate in the ciliospinal centre of Budge, in the intermedio-lateral horn of the spinal cord, located between C8 and T2.

Second (pre-ganglionic) passes from the

ciliospinal centre to the superior cervical ganglion in the neck. During its long course, it is closely related to the apical pleura where it may be damaged by bronchogenic carcinoma (Pancoast tumour) or during surgery on the neck.

Third (post-ganglionic) ascends along the

internal carotid artery to enter the cavernous sinus where it joins the ophthalmic division of the trigeminal nerve. The sympathetic fibres reach the ciliary body and the dilator pupillae muscle via the nasociliary nerve and the long ciliary nerves.

Points of Interest
Second order neuron runs along the surface of the lung, can be affected by a Pancoast tumor Third order neuron runs with the carotid artery then with the ophthalmic division of cranial nerve V

Near reflex
Near reflex occurs on looking at a near
object. It consists of two components: (a) convergence reflex, i.e., contraction of pupil on convergence; & (b) accommodation reflex, i.e., contraction of pupil associated with accommodation.

Pathway of convergence reflex

Its afferent pathway is still not elucidated. from the medial recti travel centrally via the CN3 to the mesencephalic nucleus of the fifth nerve, to a presumptive convergence centre in the tectal or pretectal region. From this the impulse is relayed to the Edinger-Westphal nucleus and the subsequent efferent pathway of near reflex is along the 3rd nerve.

Afferent path

in the accessory ganglion before reaching the sphincter pupillae.

Efferent path fibres relay

Pathway of accommodation reflex

retina the optic nerve, chiasma, optic tract, lateral geniculate body, optic radiations, striate cortex (17) . parastriate cortex (19) From the parastriate cortex pontine centre occipito-mesencephalic tract EdingerWestphal nucleus (bilateral innervation!)

Afferent path impulses extend from the

Efferent path Edinger-Westphal

nucleus the efferent impulses travel along the 3rd nerve and reach the sphincter pupillae (miosis) ciliary muscle(accomodation) after relaying in the accessory and ciliary ganglions medial rectus (convergence of the eyes). Change in the lens (thickening) that occurs during accommodation. The pull of the ciliary muscle relaxes the zonular fibers and allows the lens to become more convex

The occulomotor nerve (cranial nerve III) controls some muscles on the outside of the eye (extrinsic) and some muscles on the inside of the eye (intrinsic).

Optic nerve Optic chiasma

Optic tract
Lateral geniculate body Optic radiation

Visual area

The iris reflex

 In bright light, light enters eye, absorbed by

Function:

photoreceptor cells in retina Nerve impulses in neurones in optic nerve Impulses visual cortex vision Some impulses midbrain coordinating centre impulses along parasympathetic nerve (oculomotor nerve) to circular muscles contraction No impulses along sympathetic nerve relaxation of radial muscles stretch back to full length by antagonistic contraction of circular muscles.

To reduce the amount of light entering the eye in bright light to prevent damage to the retina and to avoid producing an over-exposed image.

 In dim light nerve impulses along the sympathetic

nerve contraction of radial muscles to widen iris
No impulses along parasympathetic nerve relaxation of circular muscles which are stretched back to their full length by the action of the antagonistic radial muscles Function To let more light in to provide sufficient stimulation of the retina to produce a clear image. Red eye reduction

REFLEXES: Accomodation
Pupils constrict when adjusting for accommodation vision for near objects Involves:
Pupillary miosis (sphincter pupillae) Convergence (medial rectus muscle) Accomodation (ciliary muscle)

Near: Pupil is constricted, lens is fat Far: Pupil is dilated, lens is thin All 3 have a common efferent pathway III (oculomotor)

ACCOMODATION VS. LIGHT

Accommodation pathway: visual cortex to CNIII nucleus Absent light, Intact accommodation
Midbrain lesion (i.e., Argyll Robertson, syphilis) Cilliary ganglion lesion (i.e. Adies pupil)

Failure of accommodation alone

Midbrain lesion (occasional) Cortical blindness

REFLEXES: Corneal Reflex

Blinking elicited by sensory stimulation of cornea A direct and consensual response Sensory: CNV1 (ophthalmic division of trigeminal) Motor: CN VII (facial)

PUPIL

Points to be noted in pupil

1. Number-normally there is one pupil. More than one pupil is called polycoria. 2. Location- normally almost central, slightly nasal. Eccentric pupil is called correctopia. 3. Size of pupils

Pupillary size
Size- 3-4 mm normal, depending on illumination Causes of abnormally small pupil - miosis Local miotic Drugs (parasympathomimetic) Systemic morphine Iridocyclitis- narrow, irregular, non-reacting pupil Morphine Horners syndrome Head injury (pontine hemorrhage) Senile miotic pupil Effect of strong light During sleep

Dilated pupil
Causes of abnormally dilated pupil - mydriasis
Sympathomimetic drugs- adrenaline, phenilephrine Parasympatholytic drugs- atropine, homatropine, cyclopentolate, tropicamide Acute congestive glaucoma (vertically oval, immobile pupil) Absolute glaucoma Optic atrophy Retinal detachment Internal ophthalmoplegia 3rd nerve paralysis Belladonna poisoning

Why medieval Italian women used Belladonna

Pupillary size assessment

Testing Pupillary Reactions

Pupillary Reflexes : Light reflex- direct /
Consensual

Near reflex- a) convergence reflex b)

accommodation reflex

Testing light near dissociation Testing RAPD: 1.Swinging flash light test
2.Kestenbaums number 3 Pulfrich phenomenon 4. testing edge-light pupil cycle time 5.pharmacology testing

Test Pupillary Reactions to Light

Dim the room lights as necessary.

Ask the patient to look into the distance.

Shine a bright light obliquely into each pupil in turn.

Look for both the direct (same eye) and consensual (other eye) reactions.
Record pupil size in mm and any asymmetry or irregularity. If abnormal, proceed with the test for accommodation.

Test Pupillary Reactions to Accommodation

1:Hold your finger about 10cm from the patient's nose. 2 :Ask them to alternate looking into the distance and at your finger. 3 :Observe the pupillary response in each eye.

Swinging flash light test

Patient is made to sit in a room with diffuse background illumination Direct torch into one pupil and note constriction Quickly move to contra-lateral pupil note the reaction Repeat this to and fro swinging, rhythmically, several times while observing response Normally both pupils constrict equally In presence of rapid afferent pupillary defect (RAPD) or Marcus Gunn pupil, the affected pupil shows a reduced amplitude of constriction and accelerated dilatation (recovery) as compared to contralateral eye

RAPD or Marcus Gunn pupil

Examination of the pupils PERRL

P E R RL

Pupils Equal Round Reactive to Light

Horners Syndrome

PERRL (Ptosis, Miosis and Anhydrosis)

 Sympathetic Pathways to the eye

Anisocoria PERRL(unequal pupils)

Horners Syndrome Third Cranial Nerve Palsy Damage to the Iris and Pupil Eye Trauma Surgical Trauma

PERRL

Irregular pupils

Argyl-Robertson Possible other manifestation of CNS disease

BUT most commonly due to Intraocular Congenital Anomaly Inflammation Trauma Surgery

Irregular Pupil after IOL implantation

Pupillary Light Reflex

PERRL

Pupil Light Reflexes

Direct Response constriction of pupil when light shined into that eye Consensual Response constriction of pupil of non-stimulated eye

Consensual Response of Pupils to Light

In normal subject Both Pupils will constrict equally to light shined in one eye Basis for Swinging Flashlight test Marcus Gunn (Sign of possible optic nerve disease)

Poor Pupil Reaction to Light

Diabetics Neurologic Disease Optic Nerve Disease

Sign of possible serious ocular problem Acute Angle Closure Uveitis Damage to Pupil from Surgery Trauma

PERRL

Afferent Pupillary Defect

Swinging light test Afferent Papillary Defect

Relative Afferent Pupil Defect

V.A.

20/20

20/20

Left RAPD

Pupillary exam: APD

sft.jpg

AFFERENT PUPILLARY DEFECT

Total loss of the AFFERENT reflex pathway
Blind eye, i.e. severe retinal damage or optic nerve pathology

For a LEFT APD

Light into left eye: no direct light reflex (L) Light into left eye: no consensual reflex (R) Light into right eye: normal direct and consensual reflex

RELATIVE AFFERENT PUPILLARY DEFECT

Incomplete damage to AFFERENT pathway
Partial retina or optic nerve damage

For LEFT RAPD

Light into left eye: left and right pupil constrict Light into right eye: both pupils constrict further Back to left eye: both pupils dilate, but not completely Light away: both pupils dilate completely

GRADING OF RAPD

1st animation

Watch I will describe what is happening You describe Where is the problem, and why?

13/04/2012

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Right optic nerve disease

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Direct reflex on right Consensual reflex on left

Note the pathway for light reflex

Is this light reflex normal?

Yes. Note direct and consensual light reflex

Is this light reflex normal?

Afferent path on left eye is abnormal.

Efferent vs Afferent defect

Oculomotor Nerve CN III Edinger - Westphal Nucleus

Location? Midbrain

What is different about the things this nucleus, versus the oculomotor, projects to? 1. Parasympathetic innervation Synapse in ciliary ganglion, which leave as the short ciliary Note: The long ciliary nerve carries sensory fibers from the cornea (V1) and sympathetics to dilate the iris 2. Smooth Muscles innervation
Projects to? Ciliary ganglion Ciliary Muscle Function = ? Accomadation for near vision Sphincter pupillae Function = ? Constriction Both these are parasympathetic (constriction) and smooth muscle.

Ciliospinal reflex
The ciliospinal reflex (pupillary-skin reflex) consists of dilation of the ipsilateral pupil in response to pain applied to the neck, face, and upper trunk. If the right side of the neck is subjected to a painful stimulus, the right pupil dilates (increases in size 1-2mm from baseline). This reflex is absent in Horner's syndrome and lesions involving the cervical sympathetic fibers. Mediated by inhibitition of EW nucleus

Visual Acuity
Newborn
20/200, sees best in 2-75 cm range

3 months
20/60

6 months
20/20

2 years
Acute near vision-fine motor skills develop

 Toxic pupil in neuromuscular blockde Adies tonic pupil due to ciliary gangilion block Paralytic pupil-inCN3 nerve palsy Argyll Robertson pupil pretectal nucleus lesion Marcus Gunn pupiloptic nerve involvement

Rotating Snake Illusion

Effect: Illusory motion

Kitaoka A, Ashida H (2003) Phenomenal characteristics of the peripheral drift illusion. VISION 15:261-262