Argyll Robertson Pupil

    • Anisocoria with small pupils that do not constrict to direct light but constrict normally to a near target (“light-near dissociation”)
    • Common cause: syphilis, especially tabetic variant
    • Location of the lesion is unresolved; some say dorsal midbrain, others say ciliary ganglion
    • Core clinical features
      • Anisocoria
      • Unilateral or bilateral miosis
      • Light-near dissociation
      • Tip: surprisingly, other ophthalmic manifestations of syphilis are not usually present!
    • Accompanying clinical features
      • Other neurologic manifestations of syphilis, especially sensory loss in the extremities
      • Positive non-treponemal (VDRL, RPR) syphilis serology in 50-75% and positive treponemal (FTA-ABS) syphilis serology in 96%
      • Trap: serum syphilis tests are not entirely specific for syphilis
      • Cerebrospinal lymphocytic pleiocytosis and elevated protein in 95%
      • Trap: elevated cerebrospinal white count and protein are not at all specific for syphilis
    • Miosis caused by cholinergic medication
    • Tonic (Adie) pupil
    • Traumatic, inflammatory, or dysplastic iridoplegia
    • Diagnose Argyll Robertson pupils only if there is other neurologic evidence of syphilis
    • Perform non-treponemal serology; if it is negative, perform serum FTA-ABS only if there are signs of tabes dorsalis
    • Tip: if you find tonicity, segmental palsy, or denervation supersensitivity, you must reject the diagnosis of Argyll Robertson pupil in favor of tonic (Adie) pupil
    • These pupil abnormalities will persist
    • They do not generate symptoms, but they often generate an incorrect diagnosis, embarrassing moments for patients, and unnecessary evaluations

    Pupil Disorders

    Anisocoria Overview Physiologic Anisocoria Horner Syndrome Tonic (Adie) Pupil Argyll Robertson Pupil Pharmacologic Mydriasis Episodic Mydriasis Iridoplegic Mydriasis Mydriasis of Third Nerve Palsy Tectal Pupils