Neuro Exam

last updated: July 22, 2016

Dilated pupil (mydriasis) (blown pupil)

  • brain swelling / bleeding that has progressed to compression of CN III (usually from cerebral herniation) - unopposed sympathetic stimulation

Drugs

  • drugs will dilate the pupils but they will still react to light

  • anticholinergic drugs:

    • atropine

    • scopolamine

    • cyclopentolate

    • tropicamide

  • alpha1-agonists: phenylephrine.

Oculomotor nerve palsy (3rd cranial nerve)

  • parasympathetic nerves are in the superficial parts of the nerve, so tend to be more vulnerable to compressive lesions and spared by vascular lesions (e.g. diabetes mellitus).

  • If an acute third nerve palsy is accompanied by pupillary mydriasis an aneurysm arising from the posterior communicating artery must be excluded

Others:

  • Holmes-Adie pupil (tonic phase)

  • post-traumatic iridocyclitis (e.g. direct facial trauma)

  • acute closed-angle glaucoma

  • physiologicalanisocoria

  • ocular prosthesis – the normal pupil may be relatively constricted due to ambient light.

Constricted pupil (miosis)

Anisocoria 

  • one pupil being more dilated than the other

Fundoscopic Exam

Normal Anatomy

  • optic disk

  • optic cup

  • retinal artery/vein

  • macula

  • fovea

Pathology

  • papilledema: optic disk swelling

    • hemorrages​

    • exudate

    • narrow vessels

    • edema of the optic disk

  • glaucoma

  • optic neuritis

  • macular degeneration

  • cataracts

... but I would more especially commend the clinician who, in acute diseases, by which the bulk of mankind are cutoff, conducts the treatment better than others.
 
Hippocrates, 400 BC