image by: WikimediaCommons

HWN Suggests

Argyll Robertson: Better Be His Pupil, Than Have It!

Argyll Robertson pupils (“AR pupils”) are bilateral small pupils that constrict when the patient focuses on a near object (they “accommodate”), but do not constrict when exposed to bright light (they do not “react” to light). This condition is colloquially referred to as the “Whore’s Eye” because of the association with tertiary syphilis and because of the convenient mnemonic that, like a prostitute, they “accommodate but do not react” also because the pupils are “small and irregular.” They are a highly specific sign of neurosyphilis. In general, pupils that “accommodate but do not react” are said to show light-near dissociation

read full article

Featured

 From the “Small Doll” until “Protitute's Pupil” through Argyll Robertson: The Argyll Robertson´s Sign, One Hundred Fifty Years From His Findings (1869)

A tiny structure, the pupil, attracts too much attention, since the antiquity. The pupil as part of the “‘window of/to the soul”, the eyes, it can demonstrate a clinical disorder sign, or simply a psychological expression. In this paper, it is studied the situation in which the pupillary reflex to light is compromised, but the accommodation reflex is preserved, what is named after Argyll Robertson, the first Scottish ophthalmologist, who besides described the signal (1869), he also tried to defined its clinical significance. Afterwards, it was clearly demonstrated its relationship with tertiary neurosyphilis.

Articles of Interest

Argyll Robertson pupils

A reflex iridoplegia characterized by small, irregular, unequal pupils, with near-light dissociation; absence of a miotic reaction to both direct and consensual light with preservation of the accommodation reflex. Classically associated with neurosyphilis. Rare since the advent of penicillin. Most often found on Medical school exams… Other causes of reflex iridoplegia include Holmes-Adie syndrome, Parinaud syndrome, diabetic neuropathy, brain injury, thiamine deficiency, and mitral regurgitation.

Argyll-Robertson Pupil Syndrome

The pathophysiology of the Argyll-Robertson Pupil Syndrome is unknown; the most widely accepted theory suggests a lesion at the posterior aspect of the Edinger-Westphal nucleus, where the efferent pupillary fibres travel. The fibres associated with the accommodation reflex are located more anteriorly and are thus unaffected.

Basicmedical Key

History of multiple sclerosis, sarcoidosis or syphilis... The pupils are small and irregular, Light reflex is absent, Accommodation reflex is intact, There may be depigmentation of the iris, Bilateral ptosis and marked overcompensation by frontalis muscle (in tabes doralis).

Mnemonic Monday: Argyll-Robinson Pupil

The term “Argyll-Robinson Pupil” refers to a specific defect as a consequence of tertiary syphilis. However, any lesion resulting in a present accommodation reflex and absent pupillary reflex can be referred to under the more general term “light-near dissociation”. These include Adie’s tonic pupil and Parinaud Syndrome – and since the advent of penicillin, they are much more common in the Western world than Argyll-Robinson pupil.

Significance of the Argyll Robertson pupil in clinical medicine

The Argyll Robertson pupil, a miotic pupil that fails to react to direct light, has been described for more than a century. Originally associated with tabes dorsalis, the sign has now been found in a number of conditions with lesions in the area of the nucleus of Edinger-Westphal. Magnetic resonance imaging studies have localized the lesion in patients with sarcoidosis and multiple sclerosis. With the declining incidence of neurosyphilis, the sign is increasingly likely to indicate another cause, although an assiduous search for lues should also be undertaken.

The Argyll Robertson pupil

Resolving the issue about the location of the syphilitic lesion that produces the AR pupil will depend on careful examination of patients with techniques designed to disclose segmental palsy of the iris.

Resources

EyeWiki

Argyll Robertson (AR) pupils, are characterized by small and irregular pupils that have little to no constriction to light but constricts briskly to near targets (light-near dissociation). The affected pupils initially appear small, and are irregular, but as opposed to the tonic pupil do not maintain increased tone to near targets. The pupils are noticeably able to accommodate to near targets, with subsequent normal and brisk redilation to far.

StatPearls

Argyll Robertson pupils describe the physical exam findings associated with advanced stages of syphilis. Characterized by bilateral small pupils that fail to constrict in response to bright light but exhibit constriction during near vision tasks, Argyll Robertson pupils are a diagnostic marker for tertiary syphilis.