Pupillary Disorders Including Anisocoria. If you have anisocoria, it means your pupils are not the same size . Neither of the above agents is any value in the localization of the lesion in the sympathetic chain. (See also Overview of the Autonomic Nervous System.) Cranial MRI, cervical magnetic resonance angiography, and chest radiograph were all normal. Testing is usually unnecessary but is indicated for clinically suspected disorders. Vision Center is funded by our readers. Cholinergic medications can cause miosis of the pupil through activation of the sphincter pupillae. The affected pupil demonstrates a response with poor constriction to light but significantly better to accommodation; this is referred to as light near dissociation. There are four main types of anisocoria: Simple anisocoria. Examples of conditions that can result in pathologic anisocoria include: Many people do not realize that their pupils vary in size. We may earn commissions if you purchase something via one of our links. However, it can be linked to eye trauma such as trauma from complicated. In this condition, the larger pupil fails to constrict to the extent of the other pupil. (See also Overview of the Autonomic Nervous System.) Indian J Ophthalmol. (7) Cranial nerve III palsy will also manifest with upper eyelid ptosis and external ophthalmoplegia. concussion. Use for phrases Can you have a corneal topography scan with an opaque cornea? Because anisocoria can be caused by such a wide range of conditions, theres no one surefire way to prevent it. Anisocoria can be caused by lots of conditions. Pelak, S.L. On examination, there was no blepharoptosis, no facial anhidrosis, eye movements were full, and cranial nerve (CN) function was normal. The third-order neurons (postganglionic fibers) travel with the internal carotid artery (ICA) through the cavernous sinus and then along the abducens nerve. What is Anisocoria (Unequal Pupil Sizes)? Other important aspects of the physical exam include assessing visual acuity at both distance and near. Anisocoria may be present for a number of reasons. 'Orthopedic Surgeon'. There may be an underlying neurological condition that requires immediate medical attention. Obrero, Davao City, and a brand-new one in Iloilo at the 2nd floor of the Festive Walk Mall, Iloilo City and . The swinging flashlight test should be performed to assess for a relative afferent pupillary defect. An asymptomatic 65-year-old patient with no prior ocular surgery but a history of hypertension, hyperlipidemia, and hypothyroidism was noted to have a left miotic pupil during a routine ophthalmic examination. However, a crucial difference between these 2 disorders is the intact pupillary light reflex in a Horner pupil and lightnear dissociation in an Adie tonic pupil. The first question facing the ophthalmologist is to ascertain if anisocoria is present or not. This can be caused by uveitis, angle-closure glaucoma, or other inflammatory conditions. sometimes with prolonged suction, the iris sphincter can be deprived of blood flow and be damaged. The difference in pupil size in physiologic anisocoria remains stable over time and is not a concern for an underlying medical condition. PMC This gave the injured eye a much darker appearance. That makes it easier to spot problems. Dr. Moosa of Excel Laser Vision Institute has performed tens of thousands of LASIK eye surgeries and is considered one of the leading laser eye experts in Southern California. This inhibits the signal to the sphincter pupillae, causing unopposed dilation of the pupil on the affected side. Schallhorn SC, Farjo AA, Huang D, Boxer Wachler BS, Trattler WB, Tanzer DJ, Majmudar PA, Sugar A; American Academy of Ophthalmology. If the anisocoria is physiologic, the difference in pupil sizes should remain equal in dim and bright lights. However, patients should be educated that if they developa sudden severe headache, blood in sputum, or a sudden blurring of vision with an associated anisocoria, they should be seen by a medical specialist as soon as possible. [3], Mydriasis is activated by the sympathetic pathway. Causes of Anisocoria Greater in Dim Light. In my opinion anisocoria after LASIK is due to cuttining corneal nerves, which causes pupilary abnormaties due to reflex, as in case of keratitis following myosis. Your role and/or occupation, e.g. The firstorder neuron arises from the posterolateral hypothalamus and synapses at the C8-T2 level in the intermediolateral column of the spinal cord, also called the ciliospinal center of Budge. In the acute phase, both the light reflex and near response are severely impaired, but the near response improves over several months due to aberrant regeneration. Classic clinical findings are unilateral miosis, ptosis, and anhydrosis, which may be present in any combination and also be incomplete and difficult to ascertain. Villarrubia A, Palacn E, Bains R, Gersol J. Cornea. Additionally, some autonomic ganglion pathology may manifest as anisocoria. Common causes read more , subarachnoid hemorrhage Subarachnoid Hemorrhage (SAH) Subarachnoid hemorrhage is sudden bleeding into the subarachnoid space. The differential of conditions causing anisocoria may be divided into three sub-categories, depending upon whether the anisocoria increases in dim light, in bright light, or remains equal in both lighting conditions. It's similar to the way you might see swelling in your body referred to as edema. Symptoms and signs include diplopia, ptosis, and paresis of eye adduction and of upward and downward gaze read more ). No pharmacologic testing was performed. 'Royal Free Hospital'. In other cases, anisocoria can occur due to an underlying health condition, like a stroke. The second question to answer is which pupil is the defective one. Slit-lamp examination revealed poor temporal and inferior segmental iris sphincter movement. Most people can see clearly immediately after surgery, and any soreness or redness should be gone in about a week. StatPearls Publishing, Treasure Island (FL). If my pupil isnt dilating fully, does that mean that there is still some left over inflammation or something like that? Your ophthalmologist will also check your eyes with a slit-lamp microscope. This is a muscle located in the colored part of the eye called the iris. After numbing the eye and giving medicine to relax you, the surgeon extracts the cataract by making an opening (incision) in the outer layer of the lens, in a structure called the capsular bag that holds the lens in place. 8600 Rockville Pike An injury or lesion in either pathway may result in changes in pupil size. The link you have selected will take you to a third-party website. The main complication of anisocoria is not the difference in pupil size but the complications of the underlying condition itself. When this happened, my pupil wouldnt dilate much in that eye and I was rushed to get examined, where the doctor told me I just have a lot of inflammation and prescribed me some drops for a few weeks, which seemed to reverse the damage. In fact, one out of five people have pupils that are normally different sizes. From the Departments of Ophthalmology (E.W., S.A.M., J.J.C., M.T.B.) Thats why you should talk to your provider as soon as you notice any changes in your eyes or vision. However, anisocoria can also result from a trauma, such as a blow to the head, medication use, or an underlying. [19]Lastly, iatrogenic trauma from ophthalmic surgery can cause an irregular pupil, and an ophthalmic surgical history should be obtained whenever assessing anisocoria. The diagnostic approach first involves a careful ophthalmological examination. Anisocoria means the presence of difference in the size of the right and left pupils. Submissions should not have more than 5 authors. The most common eye drop is pilocarpine, which has historically been used to treat glaucoma. Payne WN, Blair K, Barrett MJ. Physiologic (present in about 20% of people): The difference between pupil sizes in physiologic anisocoria is typically about 1 mm. After graduation, he decided to live abroad in Spain. Experts estimate that around 15% of people experience anisocoria at some point in their lives. It naturally changes size without you noticing or controlling it. (See also Overview of the Autonomic Nervous System.) (8) Pupil may react to 1%2% pilocarpine if the muscarinic blocking activity of the offending agent is wearing off. The city you live in also makes a difference.      Laser vision correction is subject to complications. If a third nerve palsy is causing anisocoria, imaging is recommended to rule out a compressive lesion, especially an aneurysm, which can be acutely fatal. (1) Size of the pupils indicated is only a representative measure and does not indicate the absolute pupil size for a patient seen clinically. Clipboard, Search History, and several other advanced features are temporarily unavailable. Horner syndrome results when the cervical read more , 3rd cranial nerve palsy Third Cranial (Oculomotor) Nerve Disorders Third cranial nerve disorders can impair ocular motility, pupillary function, or both. Pilocarpine will not be effective in causing this pupil to constrict. A third nerve palsy can be differentiated from other causes if the oculomotor component is affected. Anisocoria can be caused by lots of conditions. [12] If Horner syndrome is causing the anisocoria and a carotid artery dissection or aneurysm could be the cause, imaging is recommended. The pupils dilate (widen) when illumination levels are low to let more light into the eye. o [ pediatric abdominal pain ] ), Mayo Clinic College of Medicine, Rochester, MN. It is a sign of an abnormality in the efferent pathway. Some issues like migraines or reactions to medications will resolve themselves on their own. While the condition is common, the causes may or may not be benign. This can help them figure out which pupil is abnormal. The anisocoria was noted to be greater in the dark and was interpreted as a left Horner pupil. In physiologic anisocoria, the difference in pupil size may also be equal in light and dark. No comments have been published for this article. After instilling 1-2 drops of 4-10% solution (painful for several minutes), postdrop anisocoria of . In pharmacologic anisocoria cases, stopping the administration of the causative pharmacologic agent should address the issue. This allows them to see how your pupils respond to light. For instance, you can be born with it or develop it later in life. First-order neurons, which originate in the hypothalamus, may be affected by the hypothalamic, brain stem, cervical cord lesions, or other causes. Adies tonic pupil. Contributed by Steve Bhimji, MS, MD, PhD, Anisocoria (unequal pupils). . The FDA . Anisocoria due to medication will resolve over time. Although he is famous for his music, he is also known for having particularly unique eyes. The anisocoria in both a Horner pupil and many chronic Adie tonic pupils is more pronounced in the dark. A referral to a neuro-ophthalmologist, ophthalmologist, or neurologist may be warranted in cases that do not resolve. Diagnosis is radiological with computed tomogram (CT) or magnetic resonance imaging (MRI). This activity examines when anisocoria should be considered on differential diagnosis and how to evaluate it properly and highlights the role of the interprofessional team in caring for patients with this condition. You may require emergency intervention to address the cause of the eye condition. Pilocarpine (a medication used to reduce eye pressure) can also be used to constrict the pupil. The information provided on VisionCenter.org should not be used in place of actual information provided by a doctor or a specialist. Several conditions that cause damage to the nerves in the brain or spinal cord can result in anisocoria. Horner pupil has negligible noradrenaline at the synaptic cleft. Getting a history of cycloplegic medication use is the best way to make this diagnosis. Symptoms of acute angle closure are severe ocular pain read more ). Please confirm that you are a health care professional. Ocular structures are inspected by using a slit lamp or other magnification to identify structural abnormalities and ptosis. Submitted comments are subject to editing and editor review prior to posting. Learn more about the Merck Manuals and our commitment to Global Medical Knowledge. What eye drops do you recommend following LASIK? On the other hand, critical anisocoria has several causes, several of which are medical issues. 2011 Mar;37(3):574-81. doi: 10.1016/j.jcrs.2010.11.025. Eye trauma, surgery, or inflammatory conditions like uveitis (inflammation of the middle tissue layer of the eye) are just some examples that could lead to mechanical anisocoria. National Library of Medicine In the third case, the patient's exotropia resolved after mild refractive overcorrection. inflammation of your optic nerve. Anisocoria greater in the light indicates the large pupil is the abnormal pupil due to poor pupillary constriction. Some people are born with pupils of different sizes, known as anisocoria. It has been theorized that an Adie tonic pupil becomes miotic over time due to an increase in reinnervated fibers to the iris sphincter muscle and tonic contraction from accommodative fibers.4 Infrequently (<2%), an acute Adie tonic pupil may present with a miotic pupil, which has been termed primary miotic Adie tonic pupil.5 In both a chronic Adie and primary miotic Adie tonic pupil, there will be lightnear dissociation with sectoral iris muscle palsy. Neuroimaging of the entire oculosympathetic system from the hypothalamus to the lower cervicalupper thoracic spinal cord including the cervical internal carotid artery is recommended, although only 20% of cases will have abnormal neuroimaging findings.3. The most common cause of spontaneous bleeding is a ruptured aneurysm. Your organization or institution (if applicable), e.g. bleeding in your skull. A CTA or MRA of the head and neck should be performed.[13]. Wavefront-guided LASIK for the correction of primary myopia and astigmatism a report by the American Academy of Ophthalmology. In this case, the underlying conditionneeds to be treated. Pharmacological testing of anisocoria. Strabismus following implantable anterior intraocular lens surgery. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. This has reduced my pain significantly, but as soon as I skip a day of alrex my eyes/head/nerves begin hurting again. If the large pupil constricts, the cause is probably Adie tonic pupil; if the large pupil does not constrict, the cause is probably drugs or structural (eg, traumatic, surgical) damage to the iris. Appropriate imaging, including Magnetic Resonance Imaging (MRI) head, neck, chest, and abdomen, should be carried out for timely detection and appropriate management. To measure the pupil, a small ruler may be used. Its role is to let light come into the eye so you can see. You should describe and report any symptoms or signs present during anisocoria to a healthcare professional. These signs could indicate a serious medical issue and need to be evaluated. All rights reserved. Magnetic resonance angiogram (MRA) has a threshold of 3 to 5mm and may indicate other pathologies. The pupil that has this condition does not react to light. Advertising on our site helps support our mission. It is a benign condition that is also known as Adies pupil, tonic pupil, or Adies syndrome and usually causes one pupil to be significantly bigger than the other. Open mobile navigation NVISION Centers Call Book now for $1000 Off + 0% financing for 24 months*** NVISION Centers Surgeons If you carefully take a look at your eyes in a mirror, you might notice that one of your pupils is significantly bigger than the other. Int Ophthalmol. The examination will also let your specialist compare pupils in size, shape, position, symmetry, and reactivity in both light and dark settings. Anisocoria can result from a variety of things. Its role is to let light come into the eye so you can see. If you need professional and caring corrective eye surgery advice, call Excel Laser Vision Institute at + (818) 907-8606 today. An irregular pupil after intraocular surgery has a higher likelihood of remaining permanent. Web page addresses and e-mail addresses turn into links automatically. Is this something that will progressively get worse, or will it eventually resolve? Worse near visual acuity in the eye with a larger pupil is more likely to indicate pharmacologic dilation from a cycloplegic medication. Visit your provider or go to the emergency room if you notice one of your pupils is suddenly larger than the other. Anisocoria (Different Size Pupils in Children) Unequal Size Pupils We often see new young patients to evaluate one pupil being larger than the other. Clinical features include ipsilateral miosis, ptosis, anhidrosis, enophthalmos, and loss of ciliospinal reflex. ), which permits others to distribute the work, provided that the article is not altered or used commercially. Small pupils may be caused by opiates, clonidine, organophosphates, pilocarpine, and prostaglandins. As mentioned before, anisocoria can be broken down into three categories: As with many medical conditions, the first approach should be to get a good history from the patient, family, friends, and medical records. Anisocoria has a variety of causes, many of which are benign. An initial step in the evaluation of anisocoria is assessing the pupillary light reflex. An inhibition of constriction of the pupil on one side - the pathological pupil remains larger than the other pupil (pupil is dilated), and this difference is more pronounced in light conditions, An inhibition of dilatation of the pupil on one side - the pathological pupil remains smaller than the other pupil (pupil is constricted), and this difference is more pronounced in dark conditions, Difference pupil sizes that in which the difference remains the same in light and dark condition - the anisocoria is more likely to be physiologic with neither pupil having pathology. , U.S. National Library of Medicine, 21 Apr. NOTE: The first author must also be the corresponding author of the comment. Would you like email updates of new search results? In general, anisocoria that is greater in the dark indicates disruption of the oculosympathetic pathway (i.e., Horner pupil), resulting in a miotic pupil that dilates slowly (i.e., dilation lag) following removal of light stimulus. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. Outline the treatment and management options available for anisocoria. Physiologic anisocoria and Adie tonic pupil simply require observation and proper documentation of the condition to prevent unnecessary medical workup in the future potentially. The affected pupil also does not react to light. Horner pupil with post-ganglionic lesion will not dilate. We do not control or have responsibility for the content of any third-party site. A 65-year-old woman with a chronic miotic Adie pupil. sharing sensitive information, make sure youre on a federal If you experience something more serious like an aneurysm or stroke, your life might be changed permanently. Twenty percent of the general population has slight anisocoria that does not signal anything abnormal. London, UK: JP Medical Publishers Ltd; 2014. In the neurological examination, your specialist will look for lesions and neurological deficits in sensory, motor, and deep tendon reflex pathways. Important etiologies of anisocoria include third nerve palsy, Adie pupil, pharmacologic mydriasis, pharmacologic miosis, traumatic mydriasis, physiologic anisocoria, and Horner syndrome. Of note, caution should be applied to the interpretation of the dilute pilocarpine test due to its limited specificity. Accessibility (See also Overview of the Autonomic Nervous System.) Some eye medications such as pilocarpine eye drops which are used to treat glaucoma can make the pupil of the treated eye smaller than the other pupil. HHS Vulnerability Disclosure, Help It is possible to experience anisocoria either on a permanent basis or just temporarily. Most patients after LASIK or IntraLase, which are the older, cutting procedures, develop at least some degree of dry eyes, because when you cut the corneal flap, you cut the corneal nerves, which is the cause of dry eyes. Epub 2008 Jul 9. Anyone can have pupils that differ in size with no problems. Some are temporary, but some can be life-threatening. Last reviewed by a Cleveland Clinic medical professional on 02/16/2022. Tell your healthcare provider about any changes in your eyes or vision. In most cases, these instances of anisocoria where one pupil is bigger than the other by less than 1.0 mm with no probable cause are referred to as simple anisocoria, benign anisocoria or physiologic anisocoria. Pathologic . It is important to communicate this finding with other healthcare providers so that the appropriate intervention can take place. In cases of longstanding iris inflammation, prostaglandin release may cause pupillary miosis and formation of posterior iris synechiae preventing normal pupillary dilation best seen with the slit-lamp. Anisocoria itself is unlikely to cause significant complications, although some do exist. What does it mean when one pupil dilates and Should I be seen by a doctor if one pupil Can the iris of one eye be larger than the other. In the mirror, the pupil of the eye appears as a black circle in the middle of the iris (the colored part of the eye). If you develop anisocoria, you may also experience symptoms. Inverse ptosis (upside-down ptosis), a condition where the lower eyelid elevates due to underlying denervated tarsal muscle, may also be seen. Comparison of visual results between laser-assisted subepithelial keratectomy and epipolis laser in situ keratomileusis to correct myopia and myopic astigmatism. Although the classical clinical features are sufficient to diagnose Horner syndrome, several pharmacological tests are available to confirm a case of suspected Horner syndrome, as summarised in Table 2. The left pupil responds poorly to light but briskly to near stimulation. If you have no other symptoms and your provider rules out any serious underlying conditions you probably wont need any treatment. The eye would also be abducted and depressed, also known as "down and out." FDA May Issue Warnings About LASIK Surgery. [8]Special attention should be paid to assessing extraocular motility, which tests cranial nerves III, IV, and VI. The pupil is large and more commonly occurs in young women. Galetta, R.I. Grossman et al.Neurology, September 01, 1999, Erin C. Conrad, Imran Jivraj, Randy Kardon et al.Neurology, December 08, 2017, Erika Horta, Andrew McKeon, Vanda A. Lennon et al.Neurology, May 02, 2012, Randy H. Kardon et al.Neurology, March 01, 1998, DOI: https://doi.org/10.1212/WNL.0000000000011221, Flow Diagram for the Evaluation of Anisocoria, Unequal pupils: a flow chart for sorting out the anisocorias, The yield of diagnostic imaging in patients with isolated Horner syndrome, Disorders of pupillary function, accommodation, and lacrimation, Walsh and Hoyt Clinical Neuro-Ophthalmology, The Pupil: Anatomy, Physiology, and Clinical Applications, Pseudo-Argyll Robertson pupils with absent tendon reflexes: a benign disorder simulating tabes dorsalis, Partial iridoplegia with symptoms of other diseases of the nervous system, Segmental denervation and reinnervation of the iris sphincter as shown by infrared videographic transillumination, Pupillary responses to dilute pilocarpine in preganglionic 3rd nerve disorders, Evidence for preganglionic pupillary involvement in superficial siderosis, Unilateral periodic pupillary constriction causing alternating anisocoria, Reversible Paraneoplastic Tonic Pupil with PCA-Tr IgG and Hodgkin Lymphoma, Neurology: Neuroimmunology & Neuroinflammation. there are drops that can decrease pupil size. If you think you have anisocoria, you should speak with your ophthalmologist or healthcare professional. The clinical findings were consistent with a longstanding or chronic Adie tonic pupil and no further intervention was required. All rights reserved. This article highlights the neurological as well as the ophthalmological aspects of this condition. Injuries and trauma to your head, eyes or the arteries that supply blood to them. a colored contact with a smaller pupil, an artificial iris, orpurse string suture can be attempted. His commitment to writing fact-driven, health-related content stems from the belief that such type of information can empower all individuals to take action and improve their health today. An eye doctor will be able to rule out any life-threatening conditions and perform a diagnosis. While you cannot prevent anisocoria due to a stroke, you could minimize the risk of suffering a stroke by eating a well-balanced diet and staying active. Similar reports by several other neurologists were published around the same time, including observations by Gordon Holmes regarding the association of the myotonic pupil with other neurologic symptoms including weak or absent deep tendon reflexes and orthostatic hypotension (Holmes-Adie syndrome).7 Adie tonic pupil tends to affect young to middle-aged female patients, with an average age at onset of 32 years and an estimated prevalence of 0.02%. All types of medical providers may come across a patient with uneven pupils. Symptoms and signs include diplopia, ptosis, and paresis of eye adduction and of upward and downward gaze read more usually require brain MRI or CT and, with Horner syndrome, chest CT. Pupils dilate if 1/2 order neuron dysfunction is present. This also should be something that patient has had for a long time and has not acutely changed. Pupil size and quality of vision after LASIK. In cases of acute anisocoria with concern for a compressive third nerve palsy or Horner syndrome, the patient should be sent to the emergency department immediately for imaging. De Angelis A, Ricciardi L. Acute Anisocoria Related to Citalopram: A Case Report. Although anisocoria may result from numerous causes after general anesthesia, it is imperative to rapidly diagnose life-threatening intracranial hypertension. In each case, the visual outcome was excellent and no further intervention was necessary. Reproduced with permission from Bhatti MT, Schmalfus I. Handbook of Neuroimaging for the Ophthalmologist. 9.1 North America 9.2 Europe 9.3 Asia-Pacific 9.4 Latin America. [16]Horner syndrome can cause a miotic pupil, with the concerning conditions being a carotid artery dissection, which causes 2.5% of strokes, and a Pancoast lung tumor. When is Anisocoria Normal? 5 As in our case, that report suggested a decrease in anisocoria with time after refractive surgery. In the dark, the right pupil measured 5.5 mm and the left 4.0 mm. Patients with Horner syndrome Horner Syndrome Horner syndrome is ptosis, miosis, and anhidrosis due to dysfunction of cervical sympathetic output. The patient had no history of any iris or pupil size, shape, or reaction anomaly. If my pupil isn't dilating fully, does that mean that there is still some left over inflammation or something like that? Treatment of anisocoria itself is unnecessary. While this may not be available to all medical providers, an attempt at looking at both eyes closely should be made. Second-order neurons may be affected by the pathology of the lung, thyroid, sympathetic chain, and other causes. Symptoms may be the sign of a more severe health issue. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) The difference in pupil size will be less than or equal to 1 mm, and the condition may be intermittent, persistent, or self-resolving. A dilated pupil can be tested pharmacologically. Anisocoria is pronounced "an-eye-so-CORE-ee-ah". The two entities causing anisocoria that are the most significant to the clinician and require prompt and accurate diagnosis are TNP and Horner syndrome. Im just worried I have untreated inflammation inside the eye thats getting undetected during all of the exams.. Scan this QR code to download the app now. Our case highlights the importance of assessing the pupillary light reflex and careful visualization of the pupil movement in a patient with anisocoria. In the third case, the patient's exotropia resolved after mild refractive overcorrection. If you wear glasses or contact lenses, have your eyes examined regularly so your provider can adjust your prescription as often as necessary. Common signs and symptoms that a person is affected by Horners Syndrome are the following: Normally, pupils can dilate within five seconds when the lights in a room are dimmed. Also, it was not affected by the gender, age, or eye color of the participant. Lines and paragraphs break automatically. You might need imaging tests, including: You might also need blood tests or a lumbar puncture if your provider thinks you have an infection. (6) Lightnear pupil dissociation and segmental paresis of iris sphincter muscle (vermiform movement). TNP is an example of a large, abnormal pupil. Visit your provider or the emergency room as soon as you notice any irregularity in your pupils. Careers. International Society of Refractive Surgery. Your ophthalmologist will also check your eyes with a slit-lamp microscope. There are also near cards that have pupil sizes on them for comparison. Health professionals do not know exactly why people develop simple anisocoria. Brain disorders that are connected with anisocoria are strokes, hemorrhage (impromptu or because of head injury) and, very rare, some tumors or infections. Depending on observations recorded, your specialist should better understand what is causing the anisocoria. American Academy of Ophthalmology.
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