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Holmes-Adie pupil

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The Holmes-Adie pupil is large and irregular.

Pupillary constriction:

  • to light is slow and incomplete
  • to accomodation is relatively normal
  • once the pupil has constricted it remains small for an abnormally long time (tonic pupil)

The Holmes-Adie pupil is considered a variation of normal but is rarely the result of a lesion in the efferent parasympathetic pathway.

The Holmes-Adie syndrome is the association of a Holmes-Adie pupil with absent deep tendon jerks.

Clinical features include:

  • unilateral in 80% of cases
  • dilated pupil in early stages
  • decreased consensual and direct light reflex
  • tonic pupil: pupil slowly constricts in bright light
  • decreased accommodation reflex
  • decreased tendon reflexes
  • hypersensitivity to G pilocarpine solution (0.12%)
  • patients are often young women
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