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Tonic Pupils

Definition
Alternating anisocoria where one eye larger in bright light, and the other eye larger in dim.  Indicates damage of ciliary ganglion. (1 pupil non-reactive to light)

Differentials
Posterior Synechiae
Acute Angle Closure
Tadpole Pupils (irregular shape pupils associated with headaches)
Bitemporal Sphincter Palsy (vertically oriented pupils from OIS or PRP)

Signs
Sector paralysis
Stromal spread
Stromal streaming

Causes
         Local                  
      Varicella Zoster
      Ocular Mass/Retrobulbar Mass
      PRP

        Systemic               
      Diabetes Mellitus
 
    Syphillis
      Sarcoid
      Lyme Disease

Characteristics
Onset 20-40 years old, predominantly female (If Idiopathic)

Associated Symptoms
Diminished corneal sensitivity
Decreased deep tendon reflexes

Workup
MRI
FBS, HbA1C
Lyme Titre
FTA-ABS, RPR
CxR, ACE

If all tests are negative, the condition is called Adie's Tonic Pupil.
No treatment necessary