Dilute pilocarpine test for diagnosis of Adie's tonic pupil

We have compared the diagnostic ability of different concentrations of 0.125% and 0.0625% dilute pilocarpine for detecting denervation supersensitivity in unilateral Adie's tonic pupil. This retrospective, observational, case-control study involved 117 subjects, consisting of 56 patients with unilateral Adie's tonic pupil and 61 controls with other causes of unilateral dilated pupils. Subjects underwent the dilute pilocarpine test with one of the two concentrations, 0.125% or 0.0625%. Pupillary light reflex was recorded with a dynamic pupillometer at baseline and at 30-40 min after instilling one of the two concentrations of dilute pilocarpine. Diagnostic accuracy of two different concentrations of the dilute pilocarpine test, 0.125% group versus 0.0625% group, were compared by area under the receiver operating characteristic curve (AUC). Diagnostic ability of the dilute pilocarpine test for detecting denervation supersensitivity in unilateral Adie's tonic pupil was significantly better in the 0.0625% group than in the 0.125% group (AUC = 0.954 vs. 0.840, respectively, P = 0.047). In the 0.0625% group, the change in maximal pupil diameter of ≥ 0.5 mm after topical pilocarpine instillation showed 100% sensitivity and 82.8% specificity for detecting Adie's tonic pupil. This study confirmed that pupillary constriction with 0.0625% pilocarpine is better than 0.125% pilocarpine for detecting denervation supersensitivity in Adie's tonic pupil. Digital pupillometry is a reliable method for assessing denervation supersensitivity in Adie's tonic pupil.

Idiopathic Unilateral Hyperhidrosis with Holmes-Adie Syndrome: Case Report

Hyperhidrosis is a disease that is characterized by excessive sweating due to hyperactivation of eccrine sweat glands. It may be localized or generalized form. Holmes-Adie syndrome is an idiopathic disease with unilateral pupil dilatation and loss of deep tendon reflexes. We present a 37-year-old female patient diagnosed with unilateral hyperhidrosis coincident with Holmes-Adie syndrome because of this unusual presentation.

The Holmes-Adie plus syndrome

A clinical syndrome of tonic pupil associated with tendon areflexia was first described by Holmes and Adie; autonomic neuropathy and peripheral neuropathy can be associated. The postulated mechanism of areflexia in Holmes-Adie syndrome is a synaptic disorder of the spinal reflex pathways. We report a case of a Holmes-Adie syndrome variant with hitherto unreported cranial neuropathy. A 41 year old woman developed insidious onset of sensory symptoms related to her left trigeminal and chorda tympani nerves over a few months. Physical examination showed generalised tendon areflexia and a left sided Adie's pupil. Imaging did not reveal any structural abnormality. Electrophysiological studies demonstrated an absent blink reflex on stimulating the left supraorbital and infraorbital nerves. These findings were suggestive of a dysfunction affecting the brain stem reflex arc. The pathophysiological process of Holmes-Adie syndrome may be more widespread than previously thought.

Neurophysiological evaluation of areflexia in Holmes-Adie syndrome

PURPOSE

To evaluate ankle areflexia in Holmes-Adie syndrome (HAS).

PATIENTS AND METHODS

Hoffmann (H) and Tendon (T) soleus reflexes, tonic vibration reflex (TVR), and polysynaptic extension reflex of soleus muscle (PERS) were evaluated in eight patients with idiopathic HAS. Motor (MNCV) and sensory (SNCV) nerve conduction velocities, compound motor-action potential (CMAP), and sensory action potential (SAP) were also determined in upper and lower limbs.

RESULTS

Soleus T reflex was obtained in one out of eight patients, and H-reflex was found in none of the patients. TVR was recorded in four out of eight patients, and PERS in all of the patients. MNCV, SNCV, CMAP and SAP showed normal values in all patients. In six out of the eight patients a late response following the tibial nerve stimulation showed constant latency, amplitude and morphology, with no recovery cycle or vibration inhibition.

CONCLUSION

In this study, the neurophysiological spinal reflex circuitry evaluations support the view that HAS ankles areflexia is due to a selective impairement of monosynaptic connections of Ia afferents. A normal nuclear excitability is suggested by polysynaptic activation of the soleus motor nucleus.

Chronic cough in the Holmes-Adie syndrome: association in five cases with autonomic dysfunction

The Holmes-Adie syndrome consists of unilateral or bilateral tonic pupils with near light dissociation and tendon areflexia. It is associated with autonomic disturbances affecting sudomotor and vasomotor function. Five such patients are reported on who also had a troublesome chronic dry cough, which was of unknown aetiology and was resistant to a range of treatments. The cough may be related to involvement of afferent or efferent pathways in the vagus. Chronic cough may be an accompaniment in the Holmes-Adie syndrome, like other forms of autonomic dysfunction.

Comparison of cholinergic supersensitivity in third nerve palsy and Adie's syndrome

OBJECTIVE

To determine whether the degree of cholinergic supersensitivity of the pupil differs in patients with preganglionic injury of the oculomotor nerve (third nerve palsy) compared with patients with postganglionic injury (Adie's pupil).

METHODS

In this retrospective study, the authors first identified 11 patients with oculomotor nerve palsy and 11 patients with unilateral Adie's pupil who demonstrated supersensitive pupillary responses using dilute pilocarpine. The same methods for testing supersensitivity of the iris sphincter, and for defining its presence, had been used in both groups of patients. Pupil diameters of the affected and unaffected fellow eye were measured directly from self-developing photographs obtained before and 30 minutes after pilocarpine 0.1% was applied to both eyes. The amount of absolute constriction of the affected pupil, as well as the net constriction of the affected pupil (i.e., the amount of pilocarpine-induced constriction of the unaffected pupil subtracted from the amount of pilocarpine-induced constriction of the affected pupil), was compared between the two groups of patients using the Mann-Whitney test.

RESULTS

No significant differences were identified in any of the comparisons.

CONCLUSIONS

The degree of cholinergic supersensitivity of the iris sphincter appears to be similar regardless of whether the site of injury along the parasympathetic pathway of the oculomotor nerve is preganglionic or postganglionic.

Asymptomatic autonomic and sweat dysfunction in patients with Adie's syndrome

A study was conducted to determine by using noninvasive tests whether autonomic dysfunction occurs in patients with Adie's syndrome. Eighteen consecutive patients with Aide's syndrome prospectively underwent a standardized battery of five noninvasive tests of autonomic function, including three that predominantly reflected parasympathetic function and two that predominantly reflected sympathetic function. Eight of these patients additionally underwent thermoregulatory sweat testing. Of the 18 patients 10 (56%) had no abnormal autonomic test results, 5 (28%) had one abnormal result, 2 (11%) had two abnormal results, and 1 (6%) had three abnormal results. None of the patients had more than three abnormal results. Tests that predominantly reflected parasympathetic function produced abnormal results more frequently than those that predominantly reflected sympathetic function. Three of eight (38%) patients who underwent thermoregulatory sweat testing showed abnormal patterns of sweating. Although abnormal autonomic and sweat functions are not uncommon in patients with Aide's syndrome, the abnormalities are mild and are generally unassociated with symptoms of dysautonomia. Such abnormalities have little clinical significance but may be important from a nosologic point of view.

Segmental denervation and reinnervation of the iris sphincter as shown by infrared videographic transillumination

OBJECTIVE

This study aimed to analyze the denervation and reinnervation history of individual segments of the iris sphincter in patients with Adie's syndrome.

DESIGN

The irises of these patients were retroilluminated by shining an infrared-rich light through the lower eyelid and sclera and viewing the transilluminated iris from the front with an infrared-sensitive video camera. The irises of the same group of patients also were videotaped through a slit-lamp camera using routine frontal illumination. Both of these techniques also were used to examine a series of normal subjects.

PARTICIPANTS

A total of 61 patients with Adie's syndrome or Adie's-like denervation of the iris sphincter (from surgery, trauma, or radiation) and 10 normal subjects were studied.

MAIN OUTCOME MEASURES

Slit-lamp examination results of the segmental movement of the iris were compared to the infrared transillumination pattern of the iris sphincter before and during the light reflex, before and during the near-vision reaction, before and during eye movement, and before and after the application of dilute pilocarpine and 1% pilocarpine.

RESULTS

Whenever an iris sphincter segment contracted, it also became denser by using these techniques. Reinnervated iris segments failed to contract to light but did contract and became denser with a near effort or with eye movement. Segments supersensitive to pilocarpine became denser than adjacent segments without supersensitivity, but atrophic-appearing segments looked translucent and thin, failing to become denser, even with 1% pilocarpine.

CONCLUSIONS

The innervational history and current status of each clock-hour segment of the iris sphincter can be determined using this technique of videographic infrared transillumination, and the progression and pattern of iris denervation and reinnervation can be determined in patients with Adie's pupil. A miotic Adie's pupil that is "tonic," even in darkness, was found to be associated with a dense pattern of infrared transillumination in sphincter segments, which the authors interpret as being associated with a rich reinnervation from accommodative fibers. Segments that become densely reinnervated appear to lose their cholinergic supersensitivity.

Analysis of accommodation function with ultrasonography

The aim of this study was to present a new method that uses ultrasonography to analyse accommodation function, and to do a preliminary investigation of its possible use in clinical practice. Using the method of continuous ultrasonographic biometry, changes in lens thickness were measured during accommodation. From these measurements response latency and duration were determined. Normal values for latency and duration were obtained by measuring 20 healthy subjects of different ages. Measurements were also performed on three patients with different accommodation disorders: diabetes, Adie's syndrome and third nerve palsy. Normal response latency is 394 ms (+/-46 SD) and independent of are. Normal response duration increases with age from an average 306 ms at 15 years-of-age to an average 954 ms at 55 years-of-age. Normal latency as well as duration appear to have a large interindividual variability. The diabetic patient had a delayed latency but a normal response duration. The patient with Adie's syndrome had a delayed latency and prolonged duration. The patient with third nerve palsy had a normal latency and duration. We conclude that ultrasonographically determine latency and duration give additional information on accommodation function that is more complete and objective than maximum accommodative amplitude alone. The results in our patients suggest that, in selected cases, this information may aid in the diagnosis and management of patient's complaints.

Adie's tonic pupil secondary to migraine

A 46-year-old woman observed transient unilateral mydriasis during a classic migraine attack. One week later she experienced a similar episode after which anisocoria was persistent. Subsequent examination showed the clinical and pharmacologic features of a postganglionic parasympathetic paresis (Adie's tonic pupil). This case confirms the hypothesis that transient mydriasis accompanying migraine is due to interruption of parasympathetic innervation rather than sympathetic overactivity.

Cardiovascular and sweating dysfunction in patients with Holmes-Adie syndrome

A cross-sectional study is reported in which 53 patients with Holmes-Adie syndrome have been subjected to a battery of tests of autonomic nervous function referable to the cardiovascular system, to two objective tests of sweating function, and to subjective assessment of sweating by application of quinizarin powder followed by body heating. The majority of patients were consecutive referrals; none was selected because of clinical indications of autonomic dysfunction. Eighty three per cent of these patients had at least one, 57% at least two, and 40% at least three objective test abnormalities, as defined by values lying outside 95 percentiles of healthy subjects who were matched for age and subjected to the same tests. In the context of multiple testing, the probability of finding outside values was such that a minimum of 3 was required to define abnormality. On this basis 40% of patients were found to have significant evidence of autonomic dysfunction. The most frequent abnormalities were impaired digital vasoconstriction to cold (23%), a reduced heart rate response to the Valsalva manoeuvre (17%), and excessive variability in sweating between test sites (in one of the tests, 43%) which is consistent with patchy loss. Abnormal quinizarin test appearances were seen in 10 patients and in a further five patients the appearances were thought to be suggestive of abnormality. Though assessment of the results of this test are subjective, the observations are consistent with the findings obtained from the objective tests which were applied. Cardiovascular and sweating abnormality did not concur significantly and only the former was found to increase progressively with known duration of the pupillotonia. It is concluded that Holmes-Adie syndrome is commonly accompanied by progressive mild but widespread autonomic involvement but rarely is this symptomatic. If symptoms suggestive of autonomic neuropathy are found in a patient with tonic pupils, a careful search for some other generalised disorder is recommended.

Unilateral loss of facial flushing and sweating with contralateral anhidrosis: harlequin syndrome or Adie's syndrome?

A 45-year-old woman presented with a 10 year history of asymmetrical facial flushing and sweating after exertion or in hot weather. During these episodes the right side of her face remained dry and white, while the left side normally flushed. Sweating was impaired on the left side in the limbs and trunk. She also had areflexia in the lower limbs and slow pupillary reactions to light and darkness, as seen in Adie's syndrome. The topography of the sweating disorder suggested that the lesion involved the sympathetic pathways at the level of spinal cord. The relationship with the harlequin syndrome and related disorders is discussed.

Neuro-ophthalmology

The anatomy, neurophysiology, semiology, and pathology of the pupillary reflexes are reviewed. Recent advances in the demonstration of midbrain pathways projecting to and from the Edinger-Westphal (EW) nucleus are discussed. Observations of the pupillary diameter and reflexes in premature infants can be helpful in the diagnosis of neurological disorders. A relative afferent pupillary defect (RAPD) without visual disturbances can be suggestive of midbrain lesions. Automated pupil perimetry is proposed as an objective method for the evaluation of the visual field. Tonic pupil, the pupil in diabetics, and blue-cone monochromatism are also discussed.

[Ross syndrome: Adie syndrome with disorders of sweat and body temperature regulation]

In 1958 Ross described a triade consisting of tonic pupils, hyporeflexia and sudomotor denervation. Etiology and pathogenesis are unknown. 14 cases of Ross' syndrome have been mentioned in the literature up to now. Three additional cases are demonstrated.

Autonomic function in Holmes Adie syndrome

Autonomic function was studied in a group of 11 patients with Holmes Adie Syndrome. Autonomic function was assessed by the measurement of cardiovascular reflexes. Heart rate responses to respiration, valsalva manoeuvre and standing were studied. The change in systolic blood pressure on moving from the lying to the standing position was measured. Abnormalities of parasympathetic function were found in three patients, compared with matched controls. Autonomic dysfunction in Holmes Adie Syndrome may be more widespread than previously suspected.

Loss of facial sweating and flushing in Holmes-Adie syndrome

We investigated pupillary responses to parasympathetic (pilocarpine) and sympathetic agents (tyramine, cocaine, and phenylephrine) in a 51-year-old woman with tonic pupils, loss of muscle stretch reflexes in the limbs, and hemifacial loss of sweating and flushing (Ross' syndrome). A smaller pupillary response to tyramine and cocaine eyedrops on the symptomatic side indicated that outflow was disrupted in the postganglionic section of the ocular sympathetic pathway. A greater response to phenylephrine eyedrops on this side was consistent with denervation supersensitivity to adrenergic agents. Loss of thermoregulatory sweating and flushing and emotional blushing in the forehead, cheek, and chin indicated that sympathetic disruption was proximal to the bifurcation of the common carotid artery, probably in the superior cervical ganglion. A similar degenerative process may be responsible for loss of muscle stretch reflexes, tonic pupils, and other autonomic disturbances in Ross' syndrome.

Accommodative fluctuations in Adie's syndrome

Recent reports suggest that the higher frequency components (around 2 Hz) of accommodative fluctuations may arise from the accommodative 'plant' and may have no role in the control of the accommodation system. The dynamic responses of accommodation in two cases with Adie's syndrome were recorded. The results showed that the velocity of accommodative responses was reduced, and the accommodative fluctuations in the higher frequency components were completely diminished. It can be concluded that the origin of fast fluctuations is not located at a more peripheral site than the lesion of tonic accommodation. Since the possible lesion exists at the ciliary ganglion, the origin of the fast oscillation may not be the accommodative 'plant', but the neural one.

On the cause of hyporeflexia in the Holmes-Adie syndrome

Electrophysiologic studies were carried out on 11 patients with Holmes-Adie syndrome, 8 of whom had reduced or absent ankle jerks. Conduction velocities and evoked nerve and muscle compound action potentials in the peroneal, posterior tibial, and sural nerves were normal. The H reflex was absent (or virtually absent) in the patients with depressed reflexes. The amplitude of the composite Ia EPSP in single soleus motoneurons was estimated from changes in firing probability of voluntarily activated soleus motor units in response to stimulation of low threshold afferents in the tibial nerve. These amplitudes were used to test the afferent side of the reflex pathway. Composite group Ia EPSPs in Holmes-Aide patients with hyporeflexia were smaller than normal or absent, indicating that the areflexia in the Holmes-Aide syndrome is due to loss of large spindle afferents or reduced effectiveness of their monosynaptic connections to motoneurons.

Adie's syndrome as a cause of amblyopia

Adie's syndrome comprises a tonic pupil, which may be associated with impairment of accommodation, in the presence of diminished or absent deep tendon reflexes. We report a case of a 4-year-old boy with Adie's syndrome in which latent hypermetropia was made manifest by accommodative paresis and resulted in reversible amblyopia.

Dilute solutions of phenylephrine and pilocarpine in the diagnosis of disordered autonomic innervation of the iris. Observations in normal subjects, and in the syndromes of Horner and Holmes-Adie

A standardized method of testing irideal sensitivity to 1% phenylephrine and 0.05% pilocarpine is described, and a quantitative basis for pupillary neurotransmitter "supersensitivity" established. In a normal 20-year-old subject the pupillary diameter increases in bright light by no more than 2.1 mm 1 h after ocular application of phenylephrine; this figure should be adjusted for age since "phenylephrine sensitivity" of the iris increases by 0.23 mm per decade. The pupillary diameter, when measured in darkness, has normally decreased by less than or equal to 1.4 mm within 30 min of administration of pilocarpine. Differences in drug-induced diameter alterations between pairs of pupils should not normally exceed 0.7 mm for phenylephrine or 0.4 mm for pilocarpine. Seventy one percent of sympathetically denervated or decentralized (Horner's) pupils and 41% of parasympathetically denervated ("tonic") pupils are abnormally responsive or "supersensitive" to dilute solutions of phenylephrine and pilocarpine respectively. Supersensitivity to these agents is therefore a useful but not invariable diagnostic feature of disturbed irideal innervation.

Adie's syndrome: a medical treatment for symptomatic patients

A symptomatic patient with Adie's syndrome is described as successfully managed with pilocarpine 0.125% applied topically to the involved eye three times daily. This is the first report of such a patient responding to direct parasympathomimetic therapy. Alternate approaches to the therapy of Adie's syndrome are mentioned. An approach to the management of Adie's syndrome is proposed.

[A case of bilateral tonic pupil (Holmes-Adie syndrome)]

The authors present a case of bilateral tonic pupil and discuss clinical and physiopathological aspects of this syndrome. They discuss some elements necessary for the understanding of the etiopathogenesis of the disease.

Methacholine pupillary responses in third nerve palsy and Adie's syndrome

In order to examine the clinical usefulness of methacholine in assessing the site of ocular parasympathetic lesions, pupillary responses in man were measured in postganglionic (Adie's syndrome) and preganglionic third nerve lesions involving the pupil and in controls. From previous work with methacholine it might have been expected that greater constriction would occur in the postganglionic lesions but similar responses were found in both. Corneal hypoxia due to ptosis appeared unlikely to affect corneal permeability significantly and it is probable that these results reflect an increase responsiveness of the iris at, or distal to, the site of muscarinic acetylcholine receptors. Pupils contralateral to third nerve palsy, when tested on a separate occasion, also constricted by an amount approximately proportional to that of the clinically abnormal pupil. The possibilities that this may result in some way from reduction in total retinal illumination, or from retrograde changes in preganglionic pupilloconstrictor neurons affecting contralateral pupilloconstrictor neurons via central pathways, are discussed. It is concluded that supersensitivity to methacholine, tested carefully in the manner described, is a useful guide to the presence of parasympathetic denervation or decentralization, but that it is not reliable in distinguishing between the two sites.

Tonic vibration reflex in Holmes-Adie syndrome: an electrophysiological study

The pathophysiological mechanisms underlying benign areflexia were studied in six patients with Holmes-Adie syndrome. No impairment of sensory conduction velocity of sural nerve was found. A normal tonic vibration reflex was obtained in all patients. H reflex was absent in five patients, but responses like F waves were recorded in three subjects. These findings suggest that muscle spindles are not affected and that spinal motoneurone excitability is normal.

[Adie's syndrome from a neurological standpoint (author's transl)]

The findings in 22 examinations of tonic pupils, 15 of which presented Adie's syndrome, are described. The neurological and chemical as well as liquor analyses are normal except for the well known tendon reflex anomalies. Neurophysiologically, in 7 of 10 examinations mild disruptions in the sensory nerve conduction velocity were observed. The literature of the last 10 years, where it is of interest from a neurological standpoint and where it relates to the site of damage or to the origin of the tendon reflex abnormalities in Adie's syndrome, is discussed. Adie's syndrome is interpreted as damage to the peripheral nervous system in a polyneuropathic form.

Ciliary muscle dysfunction in Adie's syndrome

Ciliary muscle function in patients with Adie's syndrome was studied retrospectively in 122 patients and prospectively in 17 patients. When a careful history was taken, two thirds of the patients had ciliary muscle-related symptoms. Most of the patients with Adie's syndrome had a moderate accomodative paresis, but there was a strong tendency for the ciliary muscle to recover with time. Many patients showed a tonicity of accommodation, especially those who had had the condition for several years. Astigmatism could be induced with accommodation in one third of patients. This may be related to segmental paralysis of the ciliary muscle. Seventy-three percent of the patients showed supersensitivity of the ciliary muscle in the involved eye, when both eyes were treated with a mixture of 0.25% pilocarpine hydrochloride and hydroxypropyl methylcellulose (Isopto Carpine). This may be a clinical aid in diagnosing Adie's syndrome. Two patients were found to have bilateral ciliary muscle dysfunction but only unilateral pupillary abnormalities. These two patients may have had a "pupil-sparing" Adie's syndrome.

Corneal sensation in Adie's syndrome

Using the Cochet-Bonnet esthesiometer, we evaluated the corneal sensation of 11 patients with unilateral Adie's tonic pupil. We eliminated six other patients with bilateral Adie's pupil or disease that lowered corneal sensation. An observed unfamiliar with each patient's condition tested 12 clock hour positions in the midperiphery in both eyes of all patients. We studied 30 normal subjects (60 eyes) in a similar fashion. Of those 11 patients with unilateral Adie's syndrome, ten had a regional decrease in corneal sensation. The 30 normal subjects examined did not exhibit any significant decrease in corneal sensation in any areas. Our study supports the concept that the lesion of Adie's tonic pupil is in the ciliary ganglion or short location where the innervation of the iris sphincter and corneal sensation are found together.

[Adie's syndrome]

The author has investigated patients suffering from disorders of the pupillary reflexes and of the tendon reflexes of the lower limbs which come under the heading of tonic pupil. Forty-five patients were followed up over a period of 15 years. The tendon reflexes of the lower limbs were recorded graphically and showed a very characteristic retardation of the second phase of the patellar reflex. The aetiopathogenesis of Adie's syndrome is discussed. The pathogenesis of Adie's syndrome has so far not been definitely established. We have merely tried to point out a few of the features which permit its early diagnosis and have drawn attention to the basic problem of the pathogenesis of certain neuro-muscular disorders on the basis of secondary considerations involved in this uncommon syndrome.

Flaccid paraplegia: a feature of spinal cord lesions in Holmes-Adie syndrome and tabes dorsalis

In a patient with Holmes-Adie syndrome, and in another with tabes dorsalis, a transverse cord lesion resulted in a severe, but flaccid paraplegia with absent tendon reflexes. Flexor spasms were severe in both patients, but spasticity was absent. The significance of these observations is discussed in relation to the functional and anatomical disorder in these two syndromes.