I would agree with the Harvey's differential diagnosis. More than likely
this is physiologic which was brought to the caretakers attention by the
The pupillo-constrictor fibres carried by the III CN are on the outermost
aspect of the nerve bundle. So any compressive pathology ( as opposed to an
intrinsic pathology like demyelination or vasculopathy or direct orbital
trauma) will cause early an consistent mydriasis before the EOM are
affected. Unless there is uncal herniation from raised ICP it is hard to
imagine this occurring in an asymptomatic patient.
I would also add to the list of organic possibilities an "afferent pupillary
defect" following blunt orbital trauma due to a retinal detachment or
vitreous hemorrhage. Testing visual acuity would sort this out.
Another possibility is the prior use of mydriatics/miotics for pre-existing
ocular conditions. Lastly, I once had a case similar to yours but the
patient had a lac close to the eye on the cheek. While the resident was
suturing, inadvertently some of lidocaine with EPI had sprayed the patient's
eyes. You can imagine the aftermath. Frantic call from the nurse 20 minutes
later that on her neuro checks one pupil was "blown"..... The resident came
running wanting to urgently intubate this awake alert child who was just
worn out after all the screaming during the suturing!!! My diagnosis:
"Iatrogenic Inadvertent Anisocoria" Is there a CPT code for this ????
Hope this helps
Jay Pershad, M.D.
"We care for wee folks"
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