 Delve a little bit deeper not have to spend too much time on the basics and spend a little more time on the cases Well, I just want to make a plug for the BCSC So I've gone I for the last couple years. I've volunteered for the American Board of Ophthalmology So I write narrow ophthalmology questions for the board exam and occasionally they asked me to write OCAP questions When I write an OCAP question like as I'm like they have like this online thing where you like put in the stem and put in the correct answer and the Distractors and then at the bottom. I have to put the exact page in the BCSC Where you can find that answer so in other words every question that I write for the OCAP exam has to come right out of the BCSC so There are some parts of the BCSC that are terrific that are some that are less terrific But if you want to do well on the OCAP It's it's in there somewhere every question on the OCAP comes directly out of that book Doesn't come from any other source so I Just want to review the Anatomy really quick we'll talk about the pharmacology really quick and then talk about some exam techniques and then move on so the The pupillary sphincter Muscle is innervated by the Edinger Westfall nucleus up here in the midbrain and Those pupillary fibers those that afferent limb Runs through the oculomotor nerve Cradle nerve 3 it synapses in the ciliary ganglion which becomes important when you're talking about 80s pupil and then it runs through the short ciliary nerve and eventually ends up as a acetylcoin Neuromuscular junction at the pupillary sphincter very easy very straightforward pathway just two neurons The dilator muscle which is innervated by the sympathetic pathway has a much more convoluted Pathway it starts up, you know up here in the Thalamus somewhere runs through the hypothalamus through the midbrain all the way down your spinal cord to the very bottom of your the spinal cord in the Cervical spine and it synapses here at the ciliospinal center of budge, which is between C8 T1 and Then it sends a second-order neuron up over the top of the lung Into your neck where it hits the superior cervical ganglion it synapses again And then the third-order neuron runs right along the carotid artery Into the cavernous sinus where it hops briefly onto v1 And it also runs on six actually for a short period of time. So if you ever have a Horner's syndrome associated with Ipsilateral v1 numbness or a six nerve palsy. That's highly localizing And then it runs through the long ciliary nerve as an adrenergic receptor onto the dilator muscle so you've got the parasympathetic and sympathetic Renovation of the iris and this is this is bread-and-butter OCAP stuff So in terms of pharmacology, there are about five drops that you should know about Cocaine blocks Re-uptake of norepinephrine. We'll talk about that in a minute Aproclonidine, I always forget it's like an alpha-1. It's a weak alpha-1 agonist or something and Because cocaine is just so hard so much harder to get at your hands on it's becoming the more popular eye drop for confirming the Horner's syndrome You need to know about both of these Hydroxiamphetamine used to be used to localize our Horner's because it It causes release of norepinephrine at the neuromuscular junction But because it's no longer commercially available. It's kind of falling off of the tests It's still mentioned in the BCSE for historical reasons. I imagine one day it'll go away We sometimes use dilute and stronger concentrations of pylokarpene We use the dilute solution to confirm the presence of an 80s pupil and we use 1% if we think somebody might have a pharmacologic Medriasis so in other words like if you're trying to differentiate a Big pupil you're like I wonder if this could be like part of a third nerve palsy or could it be that they You know wearing a scopolamine patch, you know on their cruise and you got some of that in their eye Well, if you put 1% pylokarpene in that eye if it Constricts then you have to start thinking about a third nerve palsy But if it doesn't constrict then that rules out a third nerve palsy, right a big pupil from a third nerve palsy will react to 1% and Then then a lot from we're sometimes we sometimes use that if a pupil doesn't dilate well Like let's say that you know, we're worried about a small pupil like hoarders Or maybe you're worried that somebody put some you know, this would be uncommon, but got some sort of a Something a myotic in their eye you could you could use fennel effrin. So if it's a pharmacologic Thing fennel effrin's not gonna dilate the pupil like it does in clinic when we're dilating people for a dilated exam or if it's like Mechanically a small people because of syndicata or because it's been traumatized. It won't react to fennel effrin So if you have a pupil that's small from Pylokarpene will it dilate to fennel effrin? It depends on how strong the concentration is of the pylokarpene and and how long ago it was put in It can be confusing and that's why sometimes you have to wait a couple of days and look at the pupils again Whenever you're doing any pharmacologic testing you want to put the drops in both pupils Because then the normal pupil acts as a control. We just had a case the other day where It's either dr. I think this doctor see your doctor crumb one of them had what looked like for sure a Horner syndrome And they put cocaine in both eyes and neither pupil dilated So they knew that the cocaine was bad and they knew they had to start over and then you always want it You never want to like sit there with your little Pupil card before and after drops trying to figure out how much anisocorrhea is there is you really need to take some photographs and really and measure carefully so just briefly about the Pharmacology of cocaine So there's always at the solicit now. We're talking about that neuromuscular junction Between the third order neuron and the dilator muscle that had your allergic receptor So this is a big picture of that now. So here's the third order neuron Here's the dilator muscle that has little, you know, norepinephrine receptors on it and There's always a basal release of norepinephrine and that norepinephrine is always being sucked out of the neuromuscular junction This just the reason that our bodies do this is to make that Receptor just much more quick to respond works faster There's always this little basal release of norepinephrine and then always this little bit of reuptake So when the nerve fires like all of a sudden a lot of norepinephrine is able to come out and actually Cause the dilator muscle to respond If you put cocaine on that neuromuscular junction as an eyedrop The reuptake of norepinephrine is blocked and so that little basal release of norepinephrine That's constantly going on all of a sudden a lot of cocaine I'm sorry, norepinephrine builds up in the junction and these receptors get activated in the dilator dilator muscle contracts to open up the people So here's an example of somebody with a orner syndrome They've got a small pupil on the left and a little bit of ptosis Remember the ptosis that's that you associate with orner syndrome. It's just a millimeter or two It's not like a down like a full-out ptosis like you see in the third nerve palsy It's just a couple of millimeters because it's only the Mueller's muscle. That's not working when the meter is still working Okay, so then they put in some cocaine eyedrops and then 30 40 minutes later The normal right pupil has dilated as it should because of this action But the left pupil hasn't moved So there's much more anise coria after Cocaine than there was before cocaine and the cutoff is a millimeter for a positive orner syndrome If there's more than one millimeter of anise coria after cocaine, that's a positive cocaine And this person has any I think this is a ganglion aroma of their chest so the The second quarter neuron the one that you use associate with a panko's tumor is being blocked by By this tumor or it's been damaged by this tumor Which brings up another point a horny syndrome by itself is not important like it doesn't affect your vision Cosmetically, it's only a little bit of ptosis your pupils a little bit small So what like it really doesn't affect your eye or your vision the thing that's important about the horny syndrome is it's a sign of potentially a sign of something bad That's why they make such a big fuss about it. I'm going to talk really briefly about the pharmacologic action of hydroxy amphetamine and So this is an eyedrop that we sometimes use to localize a horny syndrome to tell if it's a third or a second order Horners so the Pharmacology of hydroxy amphetamine is to cause the release of norepinephrine into the Neuromuscular junction it doesn't depend on that slow basal release of norepinephrine to work like cocaine does so when you so This is the normal junction. There's nothing happening And we're looking at that same neuromuscular junction between the third order Sympathetic neuron and the dilator muscle of the pupil when you dump on hydroxy amphetamine if this neuron is alive at all Then all the norepinephrine at the synapse will be dumped out into the neuromuscular junction and will cause the dilator muscle To contract so nor in a normal pupil. It will dilate to hydroxy amphetamine Okay, so here's another patient with a left-sided horners They've got a smallish pupil on the left and again a little bit of ptosis not a lot Yeah, I forgot this is kind of an important point So this was our previous case we were doing cocaine testing in the patient with a ganglion neuroma of the thorax Notice it not only is the upper lid a little bit tautic But the lower lid is up just a little bit compared to the right one So the palpibral fissures a little bit smaller and and that's because there are some sympathetically innervated Muscle fibers in the lower lid retractors, which become important when you're doing extra business surgery To avoid them So you'll sometimes have what we call upside-down tautosis, which means the lower lid will sometimes be up a little bit Okay, that didn't happen in this Well, maybe they're not not in this particular case, you know, I'd say the eyes are pretty symmetric I don't really see a lot of upside-down tautosis, but definitely some tautosis of the upper lid Then they put on hydroxyamphetamine and both pupils dilate that tells you that This third-order neuron is working so that there is not a problem at least between the superior Cervical ganglion and the eye that that that pathway is is working It's either the first or the second-order neuron that's broken causing this horners syndrome And in this case, this is a very similar tumor. I Can't I think I wrote myself a note about what this is. Oh Yeah, this is a this is metastatic breast cancer with infiltration of the pleura By metastatic breast cancer, and that's a damage to the second-order neuron Causing a second-order horners syndrome. So again the horners by itself not important sign of something else bad That's important and that's in general another principle about O caps is that if you if you're like reading your BC SC and you See something that is associated with a systemic disease that man write that down because that's another thing that's strongly emphasized is Systemic diseases with the albumic manifestations. So systemic disease of the albumic manifestation It's important So if you have somebody that's coming in with That's complaining about anisocorrhea or oftentimes sent to you by another physician Because of anisocorrhea, you want to know if they've had any previous surgery or trauma Not only to the eyes or the orbit, but also like maybe to the neck sometimes insertion of a central line, you know up here near the Subclavian give you a horners syndrome. So anything that's happened around the outer neck Old photos are super helpful because sometimes people Don't notice that they have some anisocorrhea somebody pointed out to him either a co-worker or a friend or a Family member or a doctor, you know, like a maybe a primary care doctor and then they're like, oh shit When did that you know happen? And so sometimes it's been there for years and like if it's like let's say they have something that sort of looks Like a horners, but it's been there for ten years. Who cares like it? Don't worry about it So old photos can be super helpful and then any history of previous intraocular inflammation like somebody that's had a Herpetic uveitis or anything like that that can damage the dilator and the sphincter muscle and cause some anisocorrhea You want to measure the pupils and you know just figuring out which pupil is abnormal is actually a little bit more challenging than it would seem I know DR went over this in his video But you just want to measure the pupils and dim a length illumination and bright light You want to look at their near response and of course y'all just as part of your normal exam You look for an APD and then the next thing that I do after I measure somebody's pupils in clinic is I put them behind the Slipknot microscope because you can see sphincter palsies You can see trans illumination defects from previous either like from pigment dispersion syndrome Which is a cause of anisocorrhea previous Inflammation, you know sometimes leaves some trans illumination defects maybe a rough cataract surgery You know where there was like floppy iris syndrome and the dilator muscle got boogered up You know during the cataract surgery those will show up as trans illumination defects You can look for other rare stuff like an ice syndrome or something like that that could cause the pupils to be a different size So when you measure pupils in the dark What I do is I take a Finhoff trans illuminator and I sort of shine it up I have I have a I have my lamp at the ready Up here, but it's turned off currently in this picture I use my trans illuminator and shine light sort of up the patient's nose Just to get a little bit of light in the end of the eyes so that I can see what I'm doing in the dark Then you flip that light on and you can see the pupils constrict and then you can flip it back Off and you know watch them dialy Look for a dilation lag This is funny that so this this is Stan Thompson He's a retired neuro ophthalmologist where I trained at Iowa and he always found that using muddy as a near target was a much more effective Like just say looking at my look at my finger look at the tip of my pen or whatever And you can see that her pupils really yeah, wow great near response So at the slit lamp you want to make sure the dilator and sphincter muscles are working look for segmental palsy's and look for idiopathic stuff like syniquia Figma dispersion syndrome eye syndrome. Oh, if somebody has congenital anterior second just genesis This would be a Canis acoria anything that boogers up the iris the dilator the sphincter So you want to make sure that all four there's four iris muscles two in each eye So you want to make sure they're all working if the people won't dilate then something's wrong with the dilator muscle Or its innervation if the people won't constrict and something's wrong with the sphincter muscle or its innervation if you just kind of think Of it logically like that. It kind of helps sometimes makes it easier Okay, so if you have an anise acoria that's greatest in the light that tells you that it's the big pupil that's not working and So the major differential would be You just shout them out The other thing that I wrote down was angle closure Hopefully you'd be able to figure that out without Doing a lot of pharmacologic testing Okay, so yeah, those are the big ones third nerve and eighties. Oh trauma Another common cause something that's had a blunt trauma to the eye I don't know why but I think that sphincter muscle is more easily damaged So generally something that's had an eye trauma if it's going to damage the Pupil it's usually a big people and I square that's greatest in the dark That means the dilator muscle of a small pupil is broken. So of course, that's a Horner syndrome Diabetics so can sometimes have a small pupil. It doesn't dilate very well, but usually that's symmetric Somebody that's using a Brimodendine like like say somebody's just using Brimodendine and one eye for their Unilateral glaucoma that'll make a smallish people sometimes an 80s pupil Which usually starts out as a big poorly reactive pupil over like five to ten years Sometimes become a small Poorly reactive people so that sometimes will give you anise acoria that's greatest in the dark But you should be able to take that person right to the slit lamp Look find those segmental palsies and you're done If you have an awake Angulatory patient and they've got a big pupil and everybody's like you know pooping in their pants about a third nerve palsy There's got to be an associated motility deficit Okay, so if you've got some of the big pupil and their lid is good and their motility is good They don't have to plop yet It's it's got to be something like benign episodic medrisis or an 80s or pharmacologic You can just just cross that off your list and if you and if you're worried like I said you can take a drop of pilot carpeen and if and and my bet is that the pilot carpeen is not going to do anything Always remember look for aberrant re-innovation of the pupils So sometimes if if you if you have somebody with a compressive third nerve palsy You can again you can watch them at the slit lamp when they look right left up and down and if you see like the Classic one is that when somebody looks toward their nose when they add up to their eye The pupil constricts if you see that Then you you know that there might be a Compressive lesion of the third nerve palsy that's caused the aberrant re-innovation of the pupil now some of them Fibers that were supposed to go to the medial rectus muscle have been misdirected to the sphincter Dr. Covered 80s pupil in his lecture. It's like this is completely unimportant Except that you don't want to confuse it with something else and so that's why we talk about it You don't want to mix it up with a third nerve palsy and start getting MRIs and stuff like that So and it's pretty common. So because it's common and because you you want to not Go down the pathway of thinking it's something more Worrisome that's why it's it's so strongly emphasized The colonergic super sensitivity takes a few days to occur So if you see somebody with an acute 80s, which is pretty uncommon to see that in clinic They might not react to dilute by the carpet And the effect you have to wait like 45 to 60 minutes to see the full effect So you have to put in the dilute by the carpet in both eyes and send the patient off to do something for Okay, so now I want to Show you so this is in the novel collection The neuro ophthalmology virtual education library, and we're gonna skip ahead a little bit It contracts but pretty slowly the rest of the people is pretty quiet see that That's fairly did everybody see that so when they turn the lights on Like this part of a sphincter constricted you could see like the iris stroma sort of streaming in toward each itself The whole rest of the people did nothing Lights off Sector palsy extending pretty much from 130 to 2 o'clock all the way around the people to about 6 to 7 o'clock Lights off See is the iris folding in around two to three o'clock And maybe four o'clock those are active segments that are contracting although not normally, but the rest of the iris is pretty quiet There's a good one. I think it shows up very well here Focus so In that's that's something just like if you just Google novel and OVL Sphincter palsy 80s pupil like this URL will pop right up Okay, so that if you see that like nothing else does that like if you see that at the slam You're done. You could do the pharmacologic testing if you want to But like I wouldn't or I don't anymore Unless I have like a bunch of residents with me. I'll sometimes do it for fun You know just as a demo, but if you see those sphincter palsies, that's pathic mnemonic Dorsal mid-range and drums gonna have other Signs or symptoms with it. They're gonna have eyelid retraction. They're gonna have a light near dissociation just like an 80s They're gonna have usually an upgaze deficit and they're gonna have Convergence retraction I stacked so yeah, if you see those other things then yeah, obviously actually never I Don't know if you get segmental denervation like I've never taken a parenotes patient And looked at them closely at the slit lamp. They for sure have a light near dissociation They're near responses stronger than their light response, but I don't think they have segmental palsies like this You usually you might have some sec my experience is that like the whole thing doesn't work And again, you're gonna have that history of trauma Looks like this But like I'm trying to think like when I've taken somebody with a traumatic medriosis at the slit lamp It seems to me like the whole thing is just like dead in the water It's not segmental like this because it's the re-intervention that like in a traumatic big pupil It's because the sphincter muscle has been physically damaged Whereas the sec segmental Constriction that you see in an 80s syndrome is because of re-intervation The nerve got damaged and then it re-intervated so the pathophysiologies And so I don't think you would see this If you see the fixed dilated people pharmacologically dilated pupils are that comes up with some regularity I don't see a lot of like cocaine users get it in their eye, but Sometimes ENT, you know, I know definitely once when I was a resident I was seeing the trauma patient on call that was Like on a ventilator like they were asleep and the nurses got freaked out because they had a dilated pupil and it took me like Most of that night to figure out that ENT had been there right before me and it shot some cocaine up their nose So they could look at their sinuses So that that can happen epinephrine, ventilathrin You know anybody that like works in a pharmacy, you know, you want to per a nurse anything like that You want to definitely ask them about what they've been what eight drugs they've been handling Skopalamine is another common one. Oh a new one that I just learned about in the last couple years is glycoperellate. So glycoperellate is a I want to say it's a parasympatholic and some people use it for Hyperhydrosis It's like a topical cream. They can I think they rubbed on their hands. I don't know if they put in their armpits, maybe Anyway, you get that in your eye and that'll dilate your pupil, too But far and away like in not in my neuroclinic, but in my general clinic, but most common reason The most common diagnosis that I make when somebody comes in with a chief complaint of anisocorrhea is benign metriosis This is a very common thing It's more common in patients with migraine. It's it's it's unilateral It looks freaky patients are usually asymptomatic It's usually pointed out to them by a friend co-worker family member They're like what the hell's wrong with your eye and they look in their mirror and they're like, oh my god If you're lucky, they take a picture of it But they take a selfie because when they come to see you their pupils should be absolutely normal No anisocorrhea normal light reaction normal dilation Traumatic metriosis again makes a fixed dilate pupil and citerosis very uncommon these days, but You know every now and then somebody gets a foreign body in their eye that gets not diagnosed After a while they start getting not only a retinopathy, but also a big poorly wrapped There's this thing called tadpole pupil that might be a variant of benign episodic metriosis Which is way less common, but it's sort of like a segmental Mental benign metriosis, and I just have a quick picture of it Here's a patient coming in, you know complaint vanisocorrhea at the time they present their pupils are totally normal But they took this selfie and so here's the patient clinic You know they've got normal symmetric pupils and here's the selfie and so this just turns out turns out That's kind of like a typical benign episodic metriosis You know their motility is normal their eyelid is normal They don't have any double vision during the spell, right? It's all it is is a big pupil Isolated vision with that little tiny bit, but you but because they've got both eyes open They're usually not you know, let's say I have amylobe ears, and they're not This one's from novel So this so this is like a second so some people think that benign episodic Andriosis is the dilator muscle on one eye just gets activated somehow So if you have a segmental activation you can get this funny kind of tadpole shape to the people and again having a selfie is super Super helpful in my experience. This is way this is like 20 times less common than just benign episodic So if you if you think somebody might have got something in it you're off there I 2% is kind of that kind of hurts. I would just use 1% So a pharmacologically dilated pupil will not constrict or my constrict just a little bit There's somebody like got scopalm in their eye or like a pyrrolate or something like that Again like how much they got in their eye and how long ago they got it in their eyes going to depend On how much constriction you get from public But remember to test both eyes Don't forget about physiologic anisecoria DR talked about that as lecture Order syndrome DR talked about a lot in this lecture the one thing I do want to show you is an example of dilation lag you know this is on the novel website Next example will be showing the dilation lag typical of a order center the lights are now turned So this is an infrared camera. So that's why you can see what's going on in the dark They they use some prisms on the Video camera so both eyes are right next to each other It's just a lot easier to see what's happening that way But that's why the video looks funny But the right eye is over here and the left eye is over there Just like if you're facing the patient and they've just like you're taking out their mid-face To put the eyes together so you can watch them simultaneously, which is super helpful So you can see this person has a small pupil on the left. They have just a tiny bit of ptosis Maybe and you'll see that when they turn the lights off That the right people You know springs open goes and that's a normal pupil should be completely dilated within five seconds and the horners pupils are Like it dilates, which isn't super slow You can see the right pupil dilates quite fast relative to the left Normal people should dilate about five seconds Sympathetic defect the left eye you can see that it takes quite a bit longer for that pupil Another example lights on lights off notice how that right pupil springs to life and That left pupil just sort of lags behind Takes about 10 15 seconds to catch up. That's a nice way to document a horners syndrome Here it is lights around Now with the lights off See that right people just spring to life Slowly that left people will catch up. You can also document this by taking still photographs. For example darkness Take a photograph of five seconds and 15 seconds and compare the degree of anise acoria Okay, so this is a different patient Now the horners is on the right. You see they have small pupil a little bit of ptosis There's another example you see how that left people to sort of springs right up Right people takes a while to catch up lights back out Notice how the noise adds to the sympathetic life that accentuates the initial anise acoria That's something I'll sometimes do in clinic So I'll warn the patient ahead of time. Okay, when I turn the lights on I'm gonna yell at you And then that really drives the sympathetic system big even though they know that you're gonna do it And so a normal people will like really spring open very quickly and that and then the horners people just doesn't it just It just takes its sweet time lights back out. I'm just playing it over It's adds to the sympathetic drive and accentuates the initial anise acoria This is an example of apricot anidine testing. So this is somebody, you know like As a pretty good horners going on over there on the left very droopy lid Small pupil and they've been giving apricot anidine. You can use half percent. I'd prefer to use one percent and I think you wait like I want to say you have to wait like 45 minutes to get the full effect But you notice that the anise acoria is now reversed in the bottom photo So after apricot anidine now the right pupil is a small pupil and you notice it's come up, too Which is a nice again. You always want to take pictures But with the apricot anidine makes the lift come up and reverses the anise acoria. That's a positive apricot anidine test Oh, it's time to break up into groups Okay, so let's do two groups like how about like you Two sides of the table. Yeah, that's what I should have done. Yes Okay, the north we have team north What would you say? Fennel ephrin goes to yeah, that's a sympathetic right it mimics the Effect of a sympathetic. Okay team south. What does cocaine do? Watch where you uptake Okay team north hydroxy amphetamine Hey Causes release of norepinephrine neuromuscular junction pilot carpe team south Mimics the effect of a Like acetylcholine And then team north atropide The only one that's left is a parasympatholetic right it blocks the effect of acetylcholine Why does that should be dilate? Because there's always a basal release of acetylcholine at the sphincter muscle And so when you block that the So there's there's our neuromuscular junctions are all like this So there's always a little bit of acetylcholine being released at the dilator at the sphincter muscle There's always a little bit of norepinephrine being released at the dilator muscle and those things are in balance So that your pupil has a normal size if you block the effect of acetylcholine at the Sphincter neuromuscular junction and over time the norepinephrine takes over And the pupil dilates And it also of course eliminates the light reaction You know so if you shine a light in somebody's eye with atropine their third nerve fires But nothing happens because the acetylcholine has been blocked Okay team south Yeah, so a fresh 80s will not you know shouldn't A fresh 80s will react to pylokarpene, but it does not have the it has not developed the Supersensitivity So a fresh 80s, you know one that has not had time to develop that aberrant re-innovation Will still react to pylokarpene so This could so nothing so application pilot car because no so this could not be a fresh 80s. This would be false Team north True true. That's the big one team team south Correct a third nerve palsy will still react to pylokarpene because there's nothing wrong with the Sphincter There's nothing wrong with the neuromuscular junction at the Sphincter and Then where are we team north? Yeah traumatic medriasis the muscle is physically broken So you can pour on as much pylokarpene as you want that it's not gonna get straight. I will just do this one together So we can move on Okay, so So 80s pupils the classic Thing that's associated with the light near dissociation Parenthood syndrome as Marshall mentioned has a light near dissociation Physiologic anise aquaria should have the same light in your response That's something that distinguishes a physiologic anise aquaria from these other things Neurosophilus that is a really like I've never seen that cause small poorly reactive pupils but But it's still in the books and there's a lot of syphilis running around and so you still need to be aware of it That does cause a light near dissociation of those other pupils. Yeah, so the answer is B All these the all these other three things cause a light near dissociation. We'll do this one together Okay, so this person has a positive cocaine test because they've got more than one millimeter of anise aquaria cocaine, okay, so Team north why would you do a hydroxy amphetamine test? Good team south. Why would you do it? Team north, why would you do this? This is a hard one So the reason you do this is like you want to make sure that this isn't just like a small crappy pupil That's always been a small crappy pupil So if you put fennel effort in there and the pupil doesn't dilate all of a sudden you're not so worried about it about any out of corners It's because it just means their dilator muscles busted from some other cause Team Could be congenital it could be old So if you have a positive cocaine test, but it's been there for five years It's not a metastatic breast cancer. It's not a ganglion aroma It might have been a crowded dissection five years ago. You're not gonna do anything about that. So an old Horner's is You don't you really don't have to evaluate it Nobody'd fault you for getting an MRI, but I probably would oh Here's a great case. Okay, so really run your thinking caps. You're gonna work together in your little groups Okay, so here's some so this is a woman that's had variable anise acoria. She's She's when she comes in her pupils are normal. They're symmetric. They react to light. They dilate. She has no motility deficit. She has no Light near dissociation. She has no ptosis every her exam is normal. She does have migraines Here's some selfies that she took of herself so Here's one where it's a sunny day But both for pupils are big inappropriately Here's another Day where the right people's big the left people small and then here's another day where the right people's been Love people small is it lack of purely Yes Yeah So she comes in three weeks later for both pupils are gigantic not reacted to light and So you put in pylac harping and they don't move so somebody with benign episodic Madrasis first of all, that's usually unilateral matter of fact That's in the name benign episodic unilateral madrasis So if you have somebody that's got bilateral madrasis, that's sort of off the I'm sure it's possible But it's pretty much off the menu and in that case you really want to think more about pharmacologic I don't know if somebody has benign episodic madrasis and they come into your clinic while they're symptomatic I can't remember if their pupil will react or not It might react just very sluggishly So it'd be hard in clinic to differentiate it from a pharmacologic But if you've got somebody with both pupils are big and neither of them respond to Pylac harping You've got to be pharmacologic and in this case this patient was using like like a purely Okay, here's another one you think caps So I hear you guys already whispering about it, okay, so Team North what is the significance of the Small pupil and the droopy lid that the ER So there's a right-sided Horners, okay Team South does this go together that so the ER doc does just like gross Confrontation visual fields and there's a left hemianopia and they've got a right MCA stroke Does that hang together? Yeah. Yes, okay So the stroke is on the opposite side of the hemianopias that hangs together Patients with Left hemianopias are can sometimes have neglect Right, they don't realize that they have a left hemianopia and that's why he Still went out and drove his car Right because he didn't know and he really didn't know anything was wrong And also the only thing is weird about this case this guy's 44 like that's not your typical stroke patient I mean it happens, but it's not your typical patient. Okay, so then I'm sorry. I don't know your name Jeff Jeff so I heard you mumbling about a Dissection yeah, which is exactly right. So if you have a right-sided dissection That's gonna give you a right-sided Stroke because a crowd artery supplies the middle cerebral artery It's gonna give you a right-sided horners and If you have bad luck, you're gonna get a left So this is somebody who had a somehow dissected their right carotid artery. That's us. That is a thing That's a stroke thing in 44 year olds As opposed to like the usual smoking diabetes high blood pressure cholesterol Yeah, chiropractor could do it sure or a Wrestling with your grandkids on the on the floor Roller coaster rides Car accident, you know just like a bender bender with a whiplash injury, you know It doesn't depending on how which way you twist your neck It doesn't have to take a lot of force to dissect your carotid artery Especially if you've got something like fibromuscular dysplasia or some other, you know in a Weakness in the muscular part of your artery I do have two more cases, but it's late. So Let's get to where we need to be at 8 o'clock