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Table of Contents    
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1487-1488

Adie's Tonic Pupil: An Uncommon Ophthalmological Emergency

1 Department of Ophthalmology, Isha Netralaya, Karnik Road, Kalyan West, Maharashtra, India
2 Department of Clinical Research, Isha Netralaya, Karnik Road, Kalyan West, Maharashtra, India

Date of Web Publication30-Oct-2021

Correspondence Address:
Onkar H Pirdankar
Department of Clinical Research, Isha Netralaya, Karnik Road, Kalyan West, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.329525

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How to cite this article:
Nene AS, Pirdankar OH, Shah S, Badole P, Shah S. Adie's Tonic Pupil: An Uncommon Ophthalmological Emergency. Neurol India 2021;69:1487-8

How to cite this URL:
Nene AS, Pirdankar OH, Shah S, Badole P, Shah S. Adie's Tonic Pupil: An Uncommon Ophthalmological Emergency. Neurol India [serial online] 2021 [cited 2021 Dec 3];69:1487-8. Available from:

A 22-year-old female presented to the emergency department with complaints in the near vision for three months following viral fever. Her visual acuity for distance was 20/20 while for near in the right and left eye were N8 and N6, respectively. The pupil in the right eye was fixed mid-dilated 6 mm with poor contraction during accommodation [Figure 1]. Retinal evaluation was normal [Figure 2]. A provisional diagnosis of the right eye Adie's tonic pupil was made and was confirmed with a dilute (0.125%) pilocarpine test [Figure 3]. Moreover, perimetry, MRI brain, routine blood investigations, and vasculitis profile were found to be normal.
Figure 1: Fixed dilated pupil in the right eye (6 mm) whereas normal, round, regular, and reacting to light pupil in the left eye (3 mm)

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Figure 2: Normal fundus in both eyes with healthy disc and no focal neurological deficit except for diminished deep tendon reflexes

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Figure 3: Significant constriction of the pupil observed in the right eye after instillation of dilute pilocarpine (0.125%) whereas no changes were seen in the left eye

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  Discussion Top

In 1932, Adie described a syndrome in young women having unilateral fixed dilated pupil, nonreacting and unresponsive to light, and associated with absent or markedly reduced deep tendon reflexes.[1] A prevalence of 2/1000 cases have been reported, with a mean age of onset in the third decade and commonly unilateral.[2] It results from parasympathetic denervation at the level of the ciliary ganglion characterized by a large regular pupil with decreased response to light but preserved or enhanced constriction to accommodation, segmental iris constriction, vermiform movements of the pupillary border, and hypersensitivity to 0.125% pilocarpine.[3] It may be associated with autonomic dysfunction such as cough, sweating, orthostatic hypotension, hyperhidrosis, impaired cardiovascular reflexes, and diarrhea.[4] Miotics and reading glasses for near vision can be prescribed to reduce symptoms. Usually an improvement in accommodation can be achieved by partial regeneration of the damaged neurons. In conclusion, Holmes-Adie syndrome is a rare entity in clinical practice and warrants a detailed evaluation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Adie WJ. Tonic pupils and absent tendon reflexes: A benign disorder sui generis; Its complete and incomplete forms. Brain 1932;55:98-113.  Back to cited text no. 1
Thompson HS. Adie's syndrome: Some new observations. Trans Am Ophthalmol Soc 1977;75:587-626.  Back to cited text no. 2
Moeller JJ, Maxner CE. The dilated pupil: An update. Curr Neurol Neurosci Rep 2007;7:417-22.  Back to cited text no. 3
Kimber J, Mitchell D, Mathias CJ. Chronic cough in the Holmes-Adie syndrome: Association in five cases with autonomic dysfunction. J Neurol Neurosurg Psychiatry 1998;65:583-6.  Back to cited text no. 4


  [Figure 1], [Figure 2], [Figure 3]


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