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Anisocoria same in light + dark

  • physiologic anisocoria
    • occurs in 15 – 20% of healthy individuals
    • may vary in size and side; usually same in light + dark (but may be more in dark)
    • no visual symptoms, no ocular motility disorders, no ptosis
    • no further investigations necessary
    • bilateral mydriasis 45min after application of 2x cocaine 4% or 10% eye drops

Anisocoria more in the dark

→ small pupil pathological

  • Horner’s syndrome
  • structural miosis: e.g. reactive miosis, synechiae
  • chronic Adie’s pupil
  • parasympathomimetic substances (->miosis) e.g. pesticides (organophosphates)
    • Test: 2 drops of 1% tropicamide -> after 45min: no (complete) mydriasis is evidence of drug-induced miosis

Anisocoria more in the light

→ large pupil pathological

  • Third Nerve Palsy
  • Iris sphincter injury = traumatic mydriasis
  • Tonic pupil
    • Adie pupil: idiopathic, mostly young females, in 80% unilateral
    • direct light reflex absent or sluggish; vermiform (worm-like) movement of pupillary margin, sectoral palsy of the iris sphincter, slow redilation, reduced accommodation
    • + diminished tendon reflexes in 50 – 75% = Holmes-Adie syndrome
    • Pilocarpine test
      • pilocarpine 0.1% gtt: miosis in Adie’s pupil
    • Lesion of the ciliary ganglion or the short ciliary nerves caused by:
      • tumour, trauma, inflammation (especially herpes zoster), iatrogenic (lateral orbital exploration), amyloidosis, diabetes mellitus, myotonic dystrophy, dysautonomia, paraneoplastic
  • Parasympatholytic substances (-> mydriasis)
    • e.g. atropine, scopolamine, anticholinergic nasal sprays/inhalations, plants (e.g. storn apple)
  • Benign episodic unilateral mydriasis
    • in the context of a migraine attack or as an isolated phenomenon, especially in young adults
    • Lasts for 15 min to hours
    • No ocular motility disorder, no ptosis, normal accommodation


  • EyeWiki Anisocoria
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)