Argyll Robertson pupil ICD-10 | A52.1, H58.0 ICD-9 | 094.89, 379.45 DiseasesDB | 33036 WikiDoc Resources for Argyll Robertson pupil Articles Most recent articles on Argyll Robertson pupil Most cited articles on Argyll Robertson pupil Review articles on Argyll Robertson pupil Articles on Argyll Robertson pupil in N Eng J Med, Lancet, BMJ Media Powerpoint slides on Argyll Robertson pupil Images of Argyll Robertson pupil Photos of Argyll Robertson pupil Podcasts & MP3s on Argyll Robertson pupil Videos on Argyll Robertson pupil Evidence Based Medicine Cochrane Collaboration on Argyll Robertson pupil Bandolier on Argyll Robertson pupil TRIP on Argyll Robertson pupil Clinical Trials Ongoing Trials on Argyll Robertson pupil at Clinical Trials.gov Trial results on Argyll Robertson pupil Clinical Trials on Argyll Robertson pupil at Google Guidelines / Policies / Govt US National Guidelines Clearinghouse on Argyll Robertson pupil NICE Guidance on Argyll Robertson pupil NHS PRODIGY Guidance FDA on Argyll Robertson pupil CDC on Argyll Robertson pupil Books Books on Argyll Robertson pupil News Argyll Robertson pupil in the news Be alerted to news on Argyll Robertson pupil News trends on Argyll Robertson pupil Commentary Blogs on Argyll Robertson pupil Definitions Definitions of Argyll Robertson pupil Patient Resources / Community Patient resources on Argyll Robertson pupil Discussion groups on Argyll Robertson pupil Patient Handouts on Argyll Robertson pupil Directions to Hospitals Treating Argyll Robertson pupil Risk calculators and risk factors for Argyll Robertson pupil Healthcare Provider Resources Symptoms of Argyll Robertson pupil Causes & Risk Factors for Argyll Robertson pupil Diagnostic studies for Argyll Robertson pupil Treatment of Argyll Robertson pupil Continuing Medical Education (CME) CME Programs on Argyll Robertson pupil International Argyll Robertson pupil en Espanol Argyll Robertson pupil en Francais Business Argyll Robertson pupil in the Marketplace Patents on Argyll Robertson pupil Experimental / Informatics List of terms related to Argyll Robertson pupil Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ## Overview[edit | edit source] Argyll Robertson pupils (“AR pupils”) are bilateral small pupils that constrict when the patient focuses on a near object (they “accommodate” with near vision), but do not constrict when exposed to bright light (they do not “react” to light). They were formerly known as "prostitute's pupils" because of their association with syphilis and because, like a prostitute, they “accommodate but do not react.”[1]). They are a highly specific sign of neurosyphilis. Pupils that “accommodate but do not react” are said to show light-near dissociation. A video of AR pupils and light-near dissociation is available at http://content.lib.utah.edu/u?/EHSL-Moran-Neuro-opth,60 AR pupils are extremely uncommon in the developed world. There is continued interest in the underlying pathophysiology, but the scarcity of cases makes ongoing research difficult. ## Historical Perspective[edit | edit source] The AR pupil was named after Douglas Moray Cooper Lamb Argyll Robertson, a Scottish ophthalmologist who noted the association with syphilis in 1869.[2] When serological tests for syphilis became available, patients with AR pupils usually tested positive for syphilis. The AR pupil became known as a reliable clinical sign of syphilis. In the early 20th century, Adie described a second type of pupil that could “accommodate but not react.” Adie’s tonic pupil is usually associated with a benign peripheral neuropathy (Adie syndrome), not with syphilis.[3] When penicillin became widely available in the 1940s, the prevalence of AR pupils (which develop only after decades of untreated infection) decreased dramatically. AR pupils are now quite rare. A patient whose pupil “accommodates but does not react” almost always has a tonic pupil, not an AR pupil. In the 1950s, Loewenfeld[4] distinguished between the two types of pupils by carefully observing the exact way in which the pupils constrict with near vision. The near response in AR pupils is brisk and immediate. The near response in tonic pupils is slow and prolonged. ## Pathophysiology[edit | edit source] The two different types of near response are caused by different underlying disease processes. Adie's pupil is caused by damage to peripheral pathways to the pupil (parasympathetic neurons in the ciliary ganglion that cause pupillary constriction to bright light and with near vision). The AR pupil is thought to be caused by damage to central pathways for pupillary constriction. Specifically, the AR pupil is thought to be caused by selective damage to pathways from the retina to the Edinger-Westphal nucleus. These light-sensitive pathways allow the pupil to constrict to bright light. The accommodation pathways – pathways to the Edinger-Westphal nucleus that cause the pupils to constrict with near vision – are thought to be spared because of their more ventral course in the brainstem. The exact relationship between syphilis and the two types of pupils (AR pupils and tonic pupils) is not known at the present time. The older literature on AR pupils did not report the details of pupillary constriction (brisk vs. tonic) that are necessary to distinguish AR pupils from tonic pupils. Tonic pupils can occur in neurosyphilis.[5] It is not known whether neurosyphilis itself (infection by Treponema pallidum) can cause tonic pupils, or whether tonic pupils in syphilis simply reflect a coexisting peripheral neuropathy. Thompson and Kardon (2006)[6] summarize the present view: The evidence supports a midbrain cause of the AR pupil, provided one follows Loewenfeld’s definition of the AR pupil as small pupils that react very poorly to light and yet seem to retain a normal pupillary near response that is definitely not tonic. To settle the question of whether the AR pupil is of central or peripheral origin, it will be necessary to perform iris transillumination (or a magnified slit-lamp examination) in a substantial number of patients who have a pupillary light-near dissociation (with and without tonicity of the near reaction), perhaps in many parts of the world. ## Parinaud's syndrome[edit | edit source] A third cause of light-near dissociation is Parinaud syndrome, also called dorsal midbrain syndrome. This uncommon syndrome involves vertical gaze palsy associated with pupils that “accommodate but do not react.”[7] The causes of Parinaud syndrome include brain tumors (pinealomas), multiple sclerosis and brainstem infarction. Due to the lack of detail in the older literature and the scarcity of AR pupils at the present time, it is not known whether syphilis can cause Parinaud syndrome. It is not known whether AR pupils are any different from the pupils seen in other dorsal midbrain lesions. ## Related Chapters[edit | edit source] * Syphilis * Parinaud's syndrome ## References[edit | edit source] 1. ↑ http://www.fpnotebook.com/EYE89.htm 2. ↑ http://www.whonamedit.com/doctor.cfm/260.html 3. ↑ Kawasaki A. Physiology, assessment, and disorders of the pupil. Curr Opin Ophthalmol 10(6):394-400, 1999 4. ↑ Thompson HS, Kardon RH. Irene E. Loewenfeld, PhD Physiologist of the Pupil. J Neuroophthalmol 26(2):139-148, 2006 5. ↑ Fletcher WA, Sharpe JA (1986). "Tonic pupils in neurosyphilis". Neurology. 36 (2): 188–92. PMID 3945389. 6. ↑ Thompson HS, Kardon RH (2006). "The Argyll Robertson pupil". Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society. 26 (2): 134–8. doi:10.1097/01.wno.0000222971.09745.91. PMID 16845316. 7. ↑ http://content.lib.utah.edu/u?/EHSL-Moran-Neuro-opth,55 * v * t * e * Diseases of the human eye (H00–H59 * 360–379) Adnexa | Eyelid| | Inflammation| * Stye * Chalazion * Blepharitis | * Entropion * Ectropion * Lagophthalmos * Blepharochalasis * Ptosis * Blepharophimosis * Xanthelasma Eyelash| * Trichiasis * Madarosis Lacrimal apparatus| * Dacryoadenitis * Epiphora * Dacryocystitis * Xerophthalmia Orbit| * Exophthalmos * Enophthalmos * Orbital cellulitis * Orbital lymphoma * Periorbital cellulitis Conjunctiva| * Conjunctivitis * allergic * Pterygium * Pinguecula * Subconjunctival hemorrhage Globe | Fibrous tunic| | Sclera| * Scleritis * Episcleritis | Cornea| * Keratitis * herpetic * acanthamoebic * fungal * Corneal ulcer * Photokeratitis * Thygeson's superficial punctate keratopathy * Corneal dystrophy * Fuchs' * Meesmann * Corneal ectasia * Keratoconus * Pellucid marginal degeneration * Keratoglobus * Terrien's marginal degeneration * Post-LASIK ectasia * Keratoconjunctivitis * sicca * Corneal neovascularization * Kayser–Fleischer ring * Haab's striae * Arcus senilis * Band keratopathy Vascular tunic| * Iris * Ciliary body * Uveitis * Intermediate uveitis * Hyphema * Rubeosis iridis * Persistent pupillary membrane * Iridodialysis * Synechia | Choroid| * Choroideremia * Choroiditis * Chorioretinitis Lens| * Cataract * Congenital cataract * Childhood cataract * Aphakia * Ectopia lentis Retina| * Retinitis * Chorioretinitis * Cytomegalovirus retinitis * Retinal detachment * Retinoschisis * Ocular ischemic syndrome / Central retinal vein occlusion * Central retinal artery occlusion * Branch retinal artery occlusion * Retinopathy * diabetic * hypertensive * Purtscher's * of prematurity * Bietti's crystalline dystrophy * Coats' disease * Macular degeneration * Retinitis pigmentosa * Retinal haemorrhage * Central serous retinopathy * Macular edema * Epiretinal membrane (Macular pucker) * Vitelliform macular dystrophy * Leber's congenital amaurosis * Birdshot chorioretinopathy Other| * Glaucoma / Ocular hypertension / Primary juvenile glaucoma * Floater * Leber's hereditary optic neuropathy * Red eye * Globe rupture * Keratomycosis * Phthisis bulbi * Persistent fetal vasculature / Persistent hyperplastic primary vitreous * Persistent tunica vasculosa lentis * Familial exudative vitreoretinopathy Pathways | Optic nerve Optic disc| * Optic neuritis * optic papillitis * Papilledema * Foster Kennedy syndrome * Optic atrophy * Optic disc drusen Optic neuropathy| * Ischemic * anterior (AION) * posterior (PION) * Kjer's * Leber's hereditary * Toxic and nutritional Strabismus Extraocular muscles Binocular vision Accommodation| | Paralytic strabismus| * Ophthalmoparesis * Chronic progressive external ophthalmoplegia * Kearns–Sayre syndrome palsies| * Oculomotor (III) * Fourth-nerve (IV) * Sixth-nerve (VI) Other strabismus| * Esotropia / Exotropia * Hypertropia * Heterophoria * Esophoria * Exophoria * Cyclotropia * Brown's syndrome * Duane syndrome Other binocular| * Conjugate gaze palsy * Convergence insufficiency * Internuclear ophthalmoplegia * One and a half syndrome Refraction| * Refractive error * Hyperopia * Myopia * Astigmatism * Anisometropia / Aniseikonia * Presbyopia Vision disorders Blindness| * Amblyopia * Leber's congenital amaurosis * Diplopia * Scotoma * Color blindness * Achromatopsia * Dichromacy * Monochromacy * Nyctalopia * Oguchi disease * Blindness / Vision loss / Visual impairment Anopsia| * Hemianopsia * binasal * bitemporal * homonymous * Quadrantanopia subjective| * Asthenopia * Hemeralopia * Photophobia * Scintillating scotoma Pupil| * Anisocoria * Argyll Robertson pupil * Marcus Gunn pupil * Adie syndrome * Miosis * Mydriasis * Cycloplegia * Parinaud's syndrome Other| * Nystagmus * Childhood blindness Infections * Trachoma * Onchocerciasis de:Argyll-Robertson-Zeichen it:Segno di Argyll-Robertson no:Argyll Robertsons pupill Template:WH Template:WS *[v]: View this template *[t]: Discuss this template *[e]: Edit this template