A 15-year-old girl with variable anisocoria

Abstract

HistoryA 15-year-old young woman presented with a 4-month history of variable anisocoria and fluctuating blurred vision. Past medical history was significant for migraines, which were well controlled by amlotriptan. She denied a history of trauma, use of topical medications, or a worsening or change in her headaches. She also denied having visual phenomenon associated with her previous headaches. ExaminationOn examination, her uncorrected near visual acuity was J1+ and her best-corrected visual acuity was 20/20 at distance and J1+ at near. Her glasses measured −4.50 +0.50 × 98 in the right eye and −4.75 D in the left eye. Ocular motility was full, and the pupils were equal, round, and reactive to light and accommodation. Her pupils measured 5 mm to 3 mm with direct pupillary light reflex and 5 mm to 2.5 mm to near stimulus. Her near point of convergence was approximately 4 cm from the nose, and her accommodative amplitude was assumed normal given her ease of accommodation and excellent near visual acuity through her full myopic correction. Slit-lamp examination demonstrated normal pupils without iris atrophy, sectoral palsy of the iris sphincter, or vermiform movements.The patient provided several photographs that illustrate fluctuating symptoms. Figure 1 shows inappropriate dilation on a bright sunny day compared to other pictures of her on similar days; there is also subtle anisocoria greater in the right eye than in the left and either pupil could be involved during symptomatic episodes. TreatmentWe elected to proceed with pharmacologic testing with 0.125% pilocarpine. This demonstrated bilateral pupillary constriction suggestive of cholinergic receptor suprasensitivity in both eyes. She was diagnosed with a variant of Adie's tonic pupil in each eye, and she was reassured.Three weeks later she was reexamined because of a worsening of her symptoms. On follow-up examination, her pupils were 8 mm and nonreactive to light, accommodation, or 1% pilocarpine. Distance visual acuity was 20/20 with correction and near acuity was J7 with correction and J2 without correction. Differential DiagnosisEvaluation of unilateral mydriasis can be a diagnostic dilemma and could be a medical emergency in the set-