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It has been observed that, in patients affected by temporomandibular disorders (TMDs) and edentulism, a left-right asymmetry in electromyographic (EMG) activity of masseter muscles during clenching and in pupil size at rest (anisocoria) is present. Both are greatly reduced by an orthotic-prosthetic correction. In parallel, the correction significantly improves cognitive performance. These effects are possibly due to the recovery of a cortical balance, via Locus Coeruleus (LC) modulation, whose activity is powerfully affected by the sensorimotor trigeminal input. The role of this functional axis was further investigated in subjects without overt occlusal or dental problems. In these individuals, the EMG asymmetry was significantly correlated to anisocoria at rest, with the dental arches open or in contact. Also in normal subjects, both the EMG and the pupil asymmetry during clenching could be significantly reduced by an orthotic (bite) correction. Closing the arches without bite increased anisocoria and reduced performance in the Spinnler-Tognoni matrices test, as well as the mydriasis induced by a haptic task. When the bite was interposed, anisocoria was reduced, while both performance and task-related mydriasis were enhanced. Since pupil size is considered a proxy of the LC activity, these results suggest that asymmetric occlusion biases the LC discharge and the hemispheric excitability, possibly via a sensorimotor trigeminal imbalance. Removing the anisocoria through bite correction re-establishes a symmetric LC discharge, improving performance and enhancing task-related mydriasis. Therefore, occlusal balancing may represent a tool for improving subjective performance and may be exploited for training and rehabilitative purposes.

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PURPOSE: To evaluate the distribution of the pupil diameter and distance and the incidence of anisocoria in a screening setting for Chinese preschoolers 3-4 years of age. METHODS: This was a cross-sectional, population-based study conducted in children aged 3-4 years in Nanjing, China. Plusoptix photoscreening was conducted without cycloplegia. Additional assessments were conducted, including light reaction test, reevaluation for anisocoria (in dim and bright light), swinging-flashlight test, and cocaine test, if necessary. RESULTS: A total of 1,818 children were screened. Pupillary measurements were conducted successfully in nearly all children (99.3% for the pupil diameter; 98.4% for the interpupillary distance). The pupil diameters of both eyes of each individual were highly correlated (5.9 ± 0.7 mm in both eyes; P < 0.0001; r = 0.93). The mean interpupillary distance was 50.1 ± 3.1 mm. The pupil diameters (6.0 mm in boys; 5.8 mm in girls) and interpupillary distance (50.6 mm in boys; 49.5 mm in girls) were correlated with sex (all P < 0.0001) but not age (P = 0.22; P = 0.68). General anisocoria of 0.5-0.9 mm in 7.8% of children and 1.0-1.2 mm in 0.4% of children was found. No child was diagnosed with pathological anisocoria, craniofacial trauma, or congenital malformation syndrome. CONCLUSIONS: The Plusoptix photoscreener is a useful tool for obtaining pupillary measurements and detecting anisocoria in a screening setting. For Chinese preschoolers 3-4 years of age the mean pupil diameter and distance were 5.9 and 50.1 mm, respectively, with sex-related difference; anisocoria of 0.5-0.9 mm is present in 7.8% of children.

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Acute anisocoria requires timely examination to rule out intracranial pathology. This case report describes a 34-year-old nurse who experienced blurred vision and unilateral mydriasis. She had no other complaints, and neurological examinations were normal. Shortly before, she had removed a scopolamine (hyoscine) patch from a patient and had following inadvertently rubbed her eye. The symptoms remitted completely within 24 hours. Knowledge of this benign phenomenon is important in order to advise patients and caregivers when handling a scopolamine patch, and in order to avoid unnecessary investigations.

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AIM: To identify whether increased numbers of brainstem lesions are found in the presence of a post-traumatic pupillary function disturbance and classify them anatomically. MATERIALS AND METHODS: In this study, a diagnostic magnetic resonance imaging (MRI) examination was performed within 8 days after traumatic brain injury (TBI) in patients who had been unconscious for more than 24 hours post-TBI. The Glasgow Outcome Scale was evaluated 6 months after TBI. The data obtained from 140 consecutively enrolled patients between 2005 and 2011 were analysed. The clinical study parameter comprised the development of post-traumatic anisocoria at least once over the course between onset of trauma and diagnostic MRI, as a yes/no decision. Significance was presumed at p≤0.05. RESULTS: A total of 57 patients (41%) were found to have a lesion at MRI without involvement of the brainstem; in 83 (59%) the brainstem was (multiple) affected. Of the latter, 66 (46%) of patients had lesions in the midbrain, 38 (27%) in the pons, and seven (5%) in the medulla oblongata. By the time of MRI, anisocoria had been diagnosed in 45 (32%) patients. Mortality was highest, at 58%, in patients with anisocoria and a midbrain lesion, whilst it was 23% in those with anisocoria and no lesion in the midbrain. Mortality was 33% in relation to a midbrain lesion without anisocoria. CONCLUSION: Overall, the study demonstrated that there is a significant correlation between midbrain lesions and post-traumatic anisocoria in unconscious trauma patients. A brainstem lesion in this case can be assumed to be a pathomorphological correlate of anisocoria. The rate of damage to the midbrain was approximately 50% in cases of transient anisocoria. It can be assumed in this situation that there are functional disorders of the peripheral oculomotor nerve or identifiable/unidentifiable lesions of the brainstem.

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PURPOSE: To investigate pupil size and the incidence of anisocoria in children at a single community-based practice using the plusoptiX A04 and A09 photoscreeners (plusoptiX GmbH, Nuremberg, Germany). METHODS: The medical records of consecutive patients <1 to 17 years of age who had received a comprehensive ophthalmological examination that included photoscreening with the plusoptiX were retrospectively reviewed. Data collected included sizes of both pupils, age, sex, laterality, and magnitude of anisocoria. RESULTS: A total of 1,306 patient records were reviewed. Of these, 1,057 (80.9%) had 0-0.4 mm of anisocoria; 219 (16.8%), 0.5-0.9 mm; 20 (1.5%), 1.0-1.4 mm; and 10 (0.8%), ≥1.5 mm. Magnitude of anisocoria appears to increase with age (P = 0.0073). Pupil size and age were positively correlated (P < 0.0001), that is, older children had larger pupils. Average pupil size of children <1 year of age was 5.0 mm; of children ≥16 years of age, 6.1 mm. When sorted into age buckets of 0-3, 4-7, 8-11, 12-15, and 16-17, this increase becomes apparent. There is no significant relationship between pupil size and sex (P = 0.14). CONCLUSIONS: Our study of 1,306 children shows that pupil size increases through childhood, and that 19.1% of children in a clinical population have anisocoria >0.4 mm.

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OBJECTIVE: To describe basic epidemiological features, clinical characteristics and outcomes of asymmetrical focal neurological deficits identified in dogs and cats with naturally occurring tick paralysis (Ixodes holocyclus). DESIGN: A retrospective study. PROCEDURE: Computer records were reviewed for all dogs and cats treated for tick paralysis between July 1999 and June 2006 at a suburban veterinary hospital in Newcastle, New South Wales. RESULTS: Neurological deficits were identified in 17/197 dogs and 10/89 cats and included unilateral facial paralysis (14 dogs; 2 cats), anisocoria (4 dogs; 7 cats), unilateral loss of the cutaneous trunci reflex (1 dog; 1 cat) and Horner's syndrome in 2 cats with anisocoria. Occurrence of deficits was not linked to season, severity of tick paralysis, breed, age, sex or body weight. With facial paralysis and anisocoria, the site of tick attachment was invariably on the head or neck and always ipsilateral to the facial paralysis. By contrast, with anisocoria alone, no consistent relationship was noted between any one pupillary dimension and the side of tick attachment. With cutaneous trunci deficits the site of tick attachment was the ipsilateral caudal axilla. Compared with recovery times from generalised signs of tick paralysis, those for facial paralysis were significantly longer (days to weeks; P < 0.001), those for anisocoria showed no significant difference (P = 0.25) and those for cutaneous trunci deficits lagged by 6 and 7 days. CONCLUSIONS: Asymmetrical focal neurological deficits are a consistent finding in a proportion of dogs and cats with naturally occurring tick paralysis due to I. holocylcus.

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A 29-year-old man presented with diplopia, dysarthria, anisocoria, oculomotor nerve paralysis, abducens nerve paralysis, right facial palsy, and spastic hemiparetic gait. Magnetic resonance imaging (MRI) showed a homogenously enhanced mass in the midbrain. MRI-guided stereotactic biopsy was performed, and the histologic diagnosis was pure germinoma. The tumor disappeared after chemotherapy and radiotherapy. Germinoma should be included in the differential diagnosis of midbrain lesions in young adults. MRI-guided stereotactic biopsy provided a helpful diagnostic clue in a patient with a midbrain lesion.

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A male patient with the ocular manifestations of Allgrove or triple-A syndrome is described. The need for early diagnosis based on alacrima, anisocoria and optic atrophy of this potentially fatal condition is stressed.

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A 27-year-old female rhesus macaque (Macaca mulatta) developed anisocoria. The left pupil was dilated and unresponsive to light. The macaque was euthanized because of unrelated reasons and the body was submitted for necropsy. On gross examination, a berry aneurysm of the right middle cerebral artery causing marked compression of the right optic tract was found. Arteriosclerotic changes were observed microscopically in the right middle cerebral and in the internal carotid arteries. The left iris was markedly degenerated, with atrophy of the constrictor muscle. Compression of the right optic tract may cause homonimus hemianopsia. A dilated and unresponsive left pupil indicated a lesion in the ipsilateral parasympathetic efferent pathway. In the absence of appreciable lesions of the left oculomotor nerve, the most likely cause of mydriasis was the iridic lesion. Intracranial aneurysms are common in humans (2 to 5%), but not in other species. Only about 10% of unruptured aneurysms are associated with neurologic deficits related to mechanical compression, such as visual deficits or anisocoria. Meticulous investigation of the ocular vascular and neural pathways led us to conclude that the anisocoria was unrelated to the aneurysm. To our knowledge, this report represents the first documented case of a naturally occurring intracranial aneurysm in nonhuman primates.

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A case of Waardenburg syndrome with unusual features such as anisocoria, exotropia is reported.

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The pupillary diameter was checked in illumination of various intensity in 20 patients with unilateral retinal detachment. The healthy and the diseased eye were examined separately. The authors discovered a latent anisocoria the amount of which was dependent on the condition of the macular area and on the extent of the detachment.

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Pupillary diameters in the affected and unaffected eyes of 327 patients with uniocular red eye were assessed during fixation of a distant target. The mean pupillary diameters were similar in the unaffected eyes in each of eight diagnostic groups, but were significantly different (F = 3.84, p less than 0.001) in the diseased eyes. With corneal abrasions (p less than 0.001), marginal keratitis (p less than 0.05), and acute anterior uveitis (p less than 0.001) the mean pupillary diameter for the affected eye was significantly smaller than that of the unaffected eye. The observed differences of pupillary diameter probably reflect the role of neuronal and autocoid mechanisms in the unilateral control of pupillary size.

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