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Anisocoria

Enlargement of one pupil; Pupils of different size; Eyes/pupils different size

 

Anisocoria is unequal pupil size. The pupil is the black part in the center of the eye. It gets larger in dim light and smaller in bright light.

Considerations

 

Slight differences in pupil sizes are found in up to 1 in 5 healthy people. Most often, the diameter difference is less than 0.5 mm, but it can be up to 1 mm (0.05 inch).

Babies born with different sized pupils may not have any underlying disorder. If other family members also have similar pupils, then the pupil size difference could be genetic and is nothing to worry about.

Also, for unknown reasons, pupils may temporarily differ in size. If there are no other symptoms and if the pupils return to normal, then it is nothing to worry about.

Unequal pupil sizes of more than 1 mm that develop later in life and do NOT return to equal size may be a sign of an eye, brain, blood vessel, or nerve disease.

 

Causes

 

The use of eye drops is a common cause of a harmless change in pupil size. Other medicines that get in the eyes, including medicine from asthma inhalers, can change pupil size.

Other causes of unequal pupil sizes may include:

  • Aneurysm
  • Bleeding inside the skull caused by head injury
  • Brain tumor or abscess
  • Excess pressure in one eye caused by glaucoma
  • Increased intracranial pressure, because of brain swelling, intracranial hemorrhage, acute stroke, or intracranial tumor
  • Infection of membranes around the brain ( meningitis or encephalitis )
  • Migraine headache
  • Seizure (pupil size difference may remain long after seizure is over)
  • Tumor, mass, or lymph node in the upper chest or lymph node causing pressure on a nerve may cause decreased sweating , a small pupil, or drooping eyelid all on the affected side (Horner syndrome)
  • Diabetic occulomotor nerve palsy

 

Home Care

 

Treatment depends on the cause of the unequal pupil size. You should see a health care provider if you have sudden changes that result in unequal pupil size.

 

When to Contact a Medical Professional

 

Contact a provider if you have persistent, unexplained, or sudden changes in pupil size. The new development of different-sized pupils may be a sign of a very serious condition.

If you have differing pupil size after an eye or head injury, get medical help immediately.

Always seek immediate medical attention if differing pupil size occurs along with:

  • Blurred vision
  • Double vision
  • Eye sensitivity to light
  • Fever
  • Headache
  • Loss of vision
  • Nausea or vomiting
  • Eye pain
  • Stiff neck

 

What to Expect at Your Office Visit

 

Your provider will perform a physical exam and ask questions about your symptoms and medical history, including:

  • Is this new for you or have your pupils ever been different sizes before? When did it start?
  • Do you have other vision problems such as blurred vision, double vision, or light sensitivity?
  • Do you have any loss of vision?
  • Do you have eye pain?
  • Do you have other symptoms such as headache, nausea, vomiting, fever, or stiff neck?

Tests that may be done include:

  • Blood studies such as CBC and blood differential
  • Cerebrospinal fluid studies ( lumbar puncture )
  • CT scan of the head
  • EEG
  • Head MRI scan
  • Tonometry (if glaucoma is suspected)
  • X-rays of the neck

Treatment depends on the cause of the problem.

 

 

Open References

References

Baloh RW, Jen J. Neuro-ophthalmology. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine . 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 424.

Dhume KU, Paul KE. Incidence of pupillary involvement, course of anisocoria and ophthalmoplegia in diabetic oculomotor nerve palsy. Indian J Ophtalmol . 2013:61(1):13-7. PMID: 23275215 www.ncbi.nlm.nih.gov/pubmed/23275215 .

Rucker JC. Pupillary and eyelid abnormalities. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds. Bradley's Neurology in Clinical Practice . 6th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 16.

 
  • Normal pupil

    Normal pupil - illustration

    The pupils of an individual are usually very symmetrical in appearance. In certain instances the pupils may vary in size. Occasionally, differing pupil size is inherited and there is no underlying disorder. Varying pupil size may also be due to infection, tumors, disease or trauma.

    Normal pupil

    illustration

    • Normal pupil

      Normal pupil - illustration

      The pupils of an individual are usually very symmetrical in appearance. In certain instances the pupils may vary in size. Occasionally, differing pupil size is inherited and there is no underlying disorder. Varying pupil size may also be due to infection, tumors, disease or trauma.

      Normal pupil

      illustration

     

    Review Date: 6/1/2015

    Reviewed By: Daniel Kantor, MD, Kantor Neurology, Coconut Creek, FL and Immediate Past President of the Florida Society of Neurology (FSN). Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.

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