Pediatric emergency medicine trisk 0618 0618
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is always the more sluggish pupil that is abnormal. Often, the more sluggish pupil
will be a unilaterally dilated pupil. If both pupils are symmetric in their baseline
positions, an abnormally sluggish pupil may indicate the presence of a serious
retinal or optic nerve problem that is impairing the ability of the affected eye to
perceive the light source equally. Testing visual acuity is essential under these
circumstances. A Marcus Gunn pupil (also known as afferent pupillary defect
[APD]) occurs when there is unequal perception of light between the two eyes,
usually due to a unilateral or asymmetric optic neuropathy, which could be due to
trauma, tumor (e.g., glioma in neurofibromatosis type 1), genetic optic
neuropathies (e.g., Leber hereditary optic neuropathy), demyelinating disease, or
inflammation of the optic nerve (papillitis). The reader is referred elsewhere for
details of the “swinging flashlight test” used to evaluate for a Marcus Gunn pupil.
The pupil should not be pharmacologically manipulated in the ED if there is a
concern about a pupil abnormality. Rather, direct referral to an ophthalmologist is
appropriate so the pupils may be observed unaltered.
Suggested Readings and Key References
American Academy of Pediatrics, Section on Ophthalmology, American
Association for Pediatric Ophthalmology And Strabismus, et al. Red reflex
examination in neonates, infants, and children. Pediatrics 2008;122:1401–
1404.
Biousse V, Newman NJ. Neuro-Ophthalmology Illustrated . Stuttgart, Germany:
Thieme Verlag; 2009.
Brodsky MC, Baker RS, Hamed LM. Pediatric Neuro-Ophthalmology . 3rd ed.
New York: Springer; 2016.
Cahill JA, Ross J. Eye on children: acute work-up for pediatric Horner’s
syndrome. Case presentation and review of the literature. J Emerg Med
2015;48:58–62.
Chapter 8 Pediatrics. In: Bagheri N, Wajda BN, eds. Wills Eye Manual: Office
and Emergency Room Diagnosis and Treatment of Eye Disease . 7th ed.
Philadelphia, PA: Wolters Kluwer; 2017:177–203.
Hamed LM. Associated neurologic and ophthalmologic findings in congenital
oculomotor nerve palsy. Ophthalmology 1991;98:708–714.
Jeffery AR, Ellis FJ, Repka MX, et al. Pediatric Horner syndrome. J AAPOS
1998;2:159–167.
Miller NR. Solitary oculomotor nerve palsy in childhood. Am J Ophthalmol
1977;83:106–111.
