Neuro-Ophthalmic
Adie Pupil
Also known as: adie pupil, tonic pupil, light near dissociation pupil, sector palsy pupil, young unilateral large pupil
Filed as: Routine
Source-cited from the record's own evidence list. Clinical content programme led by Dr Ankit Mathur, PhD, Grad Cert Ocu Thera, B.S. Optom. How the clinical content is governed
Clinical decision support only
Overview
A tonic pupil caused by damage to the ciliary ganglion or the short posterior ciliary nerves, usually idiopathic and most often in a younger adult. The affected pupil is the larger one, responds poorly to light, and constricts slowly and sustainedly to a near target, typically without ptosis or double vision. The clinical task is separating it from the other causes of a large pupil, which differ sharply in urgency.
Recognition
Symptoms: what patients report
- Usually incidental anisocoria or blur at near.
- Often younger patient.
- Typically no diplopia and no ptosis.
- Light sensitivity or difficulty adapting to the dark, from the poorly reacting larger pupil.
Signs: what the examination shows
- Unilateral large pupil.
- Poor light response.
- Tonic near response.
- Sector palsy of the iris sphincter may be visible.
- Reduced or absent deep tendon reflexes are common (Holmes–Adie syndrome) and support the pattern.
What OptoGuide™ covers for adie pupil
- Pattern reasoning: what this combination of findings points to, and its differentiators
- Don't-miss risks and escalation triggers
- Management tiers with linked New Zealand therapeutics
- Referral urgency, specialty, and letter drafting
Sources
- Adie Pupil — EyeWiki
- The Neuro-Ophthalmology Survival Guide (Pane, Miller & Burdon) — standard reference text
- The Eye in Neurological Disease. Miller NR, Newman NJ. Lancet (London, England). 2004 Dec 4-10;364(9450):2045-54.
- Dilute pilocarpine test for diagnosis of Adie’s tonic pupil. Yoo YJ, Hwang JM, Yang HK. Scientific Reports. 2021;11(1):10089.
- Adie's Pupil: A Diagnostic Challenge for the Physician. Xu SY, Song MM, Li L, Li CX. Medical Science Monitor : International Medical Journal of Experimental and Clinical Research. 2022;28:e934657.
- Optometry Australia — A Diagnostic Guide to Posterior Eye Disease, Chairside Reference Pack (Centre for Eye Health), Version 2.0, 2026: Pupil Disorders
- Adie's syndrome: some new observations. Thompson HS. Trans Am Ophthalmol Soc. 1977;75:587-626.
Standard texts: Kanski's Clinical Ophthalmology: A Systematic Approach, Oxford Handbook of Ophthalmology, Oxford American Handbook of Ophthalmology, Signs in Ophthalmology: Causes & Differential Diagnosis.