Pupillary size and equality

Anisocoria indicates an inequality in pupil size between the right and left pupils.

Light reflex = direct/indirect Horner's syndrome: see Horner's syndrome Ciliospinal reflex: see CN and Coma Pinpoint pupils:

May be a sign of opioid intoxication or a structural lesion of the pons (pontine hemorrhage).


Foodborne: Cranial nerve duction appears first, then dilated fixed pupils (not always present)

Reflex iridioplegia:

Argyll Robertson pupils

Optic nerve lesions: (swinging flashlight test) - MS Adie tonic pupils

Unilateral dilatation: Raised intracranial pressure

Chadwick D (1993) The cranial nerves and special senses. In: Walton J (ed) Brain's diseases References of the nervous system. Oxford University Press, Oxford, pp 76-126 Shintani RS, Tsuruoka S, Shiigai T (2000) Carotid cavernous fistula with brainstem congestion mimicking tumor on MRI. Neurology 55: 1229-1931

Multiple and combined oculomotor nerve palsies

Venous Congestion Mri Cns

Fig. 17. Optomotor nerves and relation to vessels and brainstem: 1 Trigeminal ganglion, 2 Trochlear nerve, 3 Abducens nerve, 4 Oculomotor nerve, 5 Optic nerve, 6 Internal carotid artery

Oculomotor NerveClivustumor

Fig. 18. Orbital metastasis: A Atypical optomotor function; B Exophthalmos, best seen from above; C CT scan of orbital metastases

Site of lesion


Associated findings


Subarachnoid space

Cavernous sinus


Infarction Leigh syndrome Tumor

Wernicke's disease

Aneurysm Clivus tumor

Meningeal carcinomatosis






Herpes zoster Infection Mucormycosis Mucocele Nasopharyngeal Carcinoma Pituitary apoplexy Tolosa Hunt syndrome Tumor: meningeoma

Thyroid eye disease

Orbital cellulitis




Associated brainstem signs

Other cranial nerve palsies

Ophthalmic division of trigeminal nerve involved, orbital swelling pain



Cranial arteritis Miller Fisher syndrome Diabetes Toxic

Pain, polymyalgia



Differential diagnosis: orbital muscle disease including thyroid disease, MG, rare ocular myopathies


Garcia-Rivera CA, Zhou D, Allahyari P, et al (2001) Miller Fisher syndrome: MRI findings. Neurology 57: 1755-1769


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