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Adie's Tonic Pupil, a patient's perspective

I’ve got Adie’s tonic pupil, also known as Adie’s syndrome, Holmes-Adie syndrome, or Adie’s pupil … again. A hallmark characteristic of Adie’s is a pupil that is dilated larger than normal. The good news is that Adie’s, in the grand scheme, is not a big deal. Going through it can be a bit scary though, and consulting the internets about one pupil being bigger than the other with blurry vision yields things like aneurism and stroke. No mention of Adie’s. So I’m writing this post to add a patient’s perspective on Adie’s in hopes that those that need to find it do.

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 Tonic Pupil? Loosen Up

Often, practitioners are alarmed by acute isolated dilated pupils. This need not be the case. While isolated acute pupillary dilation can be alarming at first, it is almost always the result of a more benign process. The main concern with this finding is to ensure it is not in association with a third nerve palsy. That is why clinicians must review and understand the various clinical features of these other benign disorders to save the patient from undergoing various unnecessary testing and anxiety.

 “Tonic” but not “Adie” Pupils

Tonic pupils react poorly to light but constrict during viewing of a near stimulus. Adie's name is typically used in association with tonic pupils, but a review of Adie's articles reveals that he described the syndrome of tonic pupils and absent reflexes and not the pupillary abnormality per se. Therefore, it would be more appropriate to refer to a tonic pupil as simply a “tonic pupil” and leave Adie's name for the syndrome.

Articles of Interest

Adie syndrome

Holmes-Adie syndrome (aka Adie syndrome) affects the autonomic nervous system. Patients present with the pupil of one eye being larger and only slowly constricts in bright light (tonic pupil). There is also absence of deep tendon reflexes, usually the Achilles tendon.

Adie’s Tonic Pupil

A tonic pupil results from parasympathetic denervation at the level of the ciliary ganglion. It is characterized by a large, regular pupil with decreased response to light but preserved or enhanced constriction to accommodation, segmental iris constriction, vermiform movements of the pupillary border, and hypersensitivity to pharmacologic constricting agents.

Holmes-Adie syndrome

Holmes-Adie syndrome (HAS) is a neurological disorder affecting the pupil of the eye and the autonomic nervous system. It is characterized by one eye with a pupil that is larger than normal and constricts slowly in bright light (tonic pupil), along with the absence of deep tendon reflexes, usually in the Achilles tendon.

Tonic Pupil (Adie Syndrome)

Adie syndrome is a relatively rare condition affecting 5 in every 100,000 people, most often young adults aged 25-45.

What Is Adie's Pupil?

No one knows for sure what causes Adie’s pupil. Most doctors think it’s caused by a viral or bacterial infection that damages the nerves that control the pupil. Some think it may be caused by autoimmune disease, when the body’s immune system attacks its own healthy tissues, like the nerves that operate the pupil.

Resources

Adie syndrome

Adie syndrome, also known as the Holmes-Adie syndrome, is a neurological disorder of unknown etiology comprising unilateral or bilateral tonically dilated pupils with light-near dissociation and tendon areflexia., is a neurological disorder of unknown etiology comprising unilateral or bilateral tonically dilated pupils with light-near dissociation and tendon areflexia.

Eyecare Trust

Adie's pupil, sometimes called the Holmes-Adie syndrome, is an unusual neurologic disorder in which the ability of the pupil to constrict is impaired, usually in one eye (although the second eye has a tendency to become involved eventually, usually at a later time, in about 20-30% of cases). It is generally associated with loss of some reflexes, such as the knee-jerk. It occurs mainly in middle age, and more commonly in women than in men. The cause is unknown, but it is thought to be a form of neuropathy, in which the nerves that control the pupils and the reflexes selectively degenerate.