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Competing Interests: The authors report no conflicts of interest.

Significance: Objective pupillometry with standardized light intensities allows a comprehensive assessment of the relative afferent pupillary defect in patients with unilateral neuro-ophthalmic pathology., Purpose: This study aimed to determine the impact of varying light intensities on the grade of relative afferent pupillary defect in unilateral neuro-ophthalmic pathology vis-à-vis healthy controls., Methods: Monocular pupillary light reflexes of 20 controls (14 to 50 years) and 31 cases (12 to 72 years) with clinically diagnosed relative afferent pupillary defect were measured thrice using 1-second-long light pulses, followed by 3 seconds of darkness, at eight light intensities (6.4 to 1200 lux) using objective pupillometry. The relative afferent pupillary defect was quantified as the ratio of the percentage change in the direct light reflexes of the left and right eyes. Its change with light intensity was described using standard exponential fits., Results: The median (25th to 75th interquartile range) defect score of 54.8% cases decreased from baseline values of 1.58 (1.25 to 1.87) for right eye pathology and 0.45 (0.39 to 0.55) for left eye pathology to saturation values of 1.18 (1.05 to 1.31) and 0.98 (0.95 to 1.06), respectively, at light intensities between 56.9 and 300.5 lux. Like controls (1.01 [1.00 to 1.06]), the defect scores of the remaining 45.2% cases were constant with light intensity at 1.23 (1.18 to 1.46) and 0.87 (0.86 to 0.89) for right and left eye pathologies, respectively., Conclusions: Relative afferent pupillary defects may decrease with test light intensity in a significant proportion of patients with unilateral neuro-ophthalmic pathology. This highlights the importance of objective pupillometry with standardization light intensities for clinical assessment of afferent pupillary defects., Competing Interests: Conflict of Interest Disclosure: None of the authors have reported a financial conflict of interest., (Copyright © 2023 American Academy of Optometry.)

Abstract: This study aims to identify predictive factors associated with surgical intervention and the visual outcome of orbital cellulitis and to evaluate the treatment outcomes.A retrospective study involving 66 patients (68 eyes; 64 unilateral and 2 bilateral) diagnosed with bacterial orbital cellulitis was conducted between November 2005 and May 2019.The mean (± standard deviation) age was 42.1 (± 25.8) years (range: 15 days-86 years). Sinusitis was the most frequent predisposing factor, occurring in 25 patients (37.9%), followed by skin infection in 10 patients (15.2%), and acute dacryocystitis in 9 patients (13.6%). Subperiosteal abscesses were found in 24 eyes and orbital abscesses in 19 eyes. Surgical drainage was performed in 31 eyes. Regarding the abscess volume for surgical drainage, a cut-off of 1514 mm3 showed 71% sensitivity and 80% specificity. There was significant improvement in visual acuity (VA) and decrease in proptosis after treatment (for both, P ≤ .001). Only pre-treatment VA ≤20/200 was a significant predictor for post-treatment VA of 20/50 or worse (adjusted odds ratio: 12.0, P = .003). The presence of a relative afferent pupillary defect was the main predictor of post-treatment VA of 20/200 or worse (adjusted odds ratio: 19.0, P = .003).The most common predisposing factor for orbital cellulitis in this study was sinusitis. VA and proptosis significantly improved after treatment. We found that the abscess volume was strongly predictive of surgical intervention. Pre-treatment poor VA and the presence of relative afferent pupillary defect can predict the worst visual outcome. Hence, early detection of optic nerve dysfunction and prompt treatment could improve the visual prognosis., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Despite automated pupillometry's (AP) improved detection of relative afferent pupillary defects (RAPDs) compared with the Swinging Flashlight Test (SFT), AP remains uncommon in clinical practice. This study examined barriers to routine use of AP in evaluation of acute vision loss., Methods: (1) Ophthalmologists and optometrists' perceptions of AP were captured via electronic survey. (2) Ophthalmologists were presented with clinical vignettes to assess their use of AP in clinical decision-making. (3) Patients presenting with decreased vision to an ophthalmology urgent care clinic underwent manual SFT and AP screening to evaluate ophthalmologists' perceptions of the device., Results: Surveys indicated that clinicians were "neutral" to "somewhat likely" to use AP. In clinical vignettes, more physicians proceeded with workup for optic nerve pathology when presented with an RAPD by AP than SFT (77% vs 26%, P = 0.003). When SFT and AP results were discordant, more physicians proceeded with workup for optic nerve disease when AP was positive and SFT was negative than vice versa (61% vs 18%, P = 0.008). In the clinical study of 21 patients, 50% of RAPDs detected by AP were not detected by SFT, although ophthalmologists rated AP's usefulness as only "neutral" to "somewhat useful.", Conclusion: Clinicians value pupillary examination and trust AP over SFT; however, widespread adoption and perceived value of AP may depend on its impact on clinical outcomes. Within a comprehensive diagnostic device, AP may be an important tool, but is not necessary to screen for optic nerve disease or evaluate acute vision loss., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by North American Neuro-Ophthalmology Society.)

Background: Visual acuity has been a significant outcome measure in clinical trials for patients suffering from neuro-ophthalmological diseases and multiple sclerosis; however, there are limited data on the comparison of various testing strategies in pediatric patients with these disorders. Clinical trials using vision as an outcome could include a variety of tools to assess the acuity, including 2-m and 4-m standardized retroilluminated charts., Methods: We investigated the difference in Early Treatment Diabetic Retinopathy Study (ETDRS) scores obtained using 2-m and 4-m charts, as well as the impact of optic neuritis, use of vision correction, age, and gender on visual acuity data from 71 patients with pediatric neuroimmunological conditions in a cross-sectional study., Results: We determine that the ETDRS letter scores obtained using 4-m charts are on average 3.43 points less (P = 0.0034) when testing monocular ETDRS letter scores and on average 4.14 points less (P = 0.0008) when testing binocular ETDRS letter scores, relative to that obtained using the 2-m charts. However, we find that when performing monocular testing, optic neuritis in the eye being tested did not result in a statistically significant difference between 2-m and 4-m ETDRS letter scores., Conclusions: Although visual acuity charts are formatted by the distance, there are significant differences in the number of letters correctly identified between 2-m and 4-m charts. Although the differences may not impact the clinical acuity, research protocols should consider these differences before collapsing data across disparate studies., Competing Interests: P. V. Sguigna has received grant support from the NMSS and PSTP. Morgan McCreary has nothing to declare. A. T. Waldman has received grant support from the NIH (K23NS069806), NMSS, and the United Leukodystrophy Foundation. She has received additional support for investigator-initiated research from Biogen Idec and Ionis Pharmaceuticals. She has received honoraria from UpToDate and consulting fees from Optum Inc. B. M. Greenberg has received grant support from the NIH, NMSS, Transverse Myelitis Association, PCORI, Guthy-Jackson Charitable Foundation, Chugai, MedImmune, MedDay, and Genentech. He has received consulting fees from Alexion, Novartis, EMD Serono, and Celgene. He is an unpaid board member of the Transverse Myelitis Association. The remaining authors report no conflicts of interest., (Copyright © 2020 by North American Neuro-Ophthalmology Society.)

Abstract: A 42-year-old Algerian man presented for binocular oblique diplopia, hypersomnolence with drop attacks, bilateral hearing loss, and thoracic pain. He had a right thalamomesencephalic hemorrhage due to an underlying cavernous malformation treated with subtotal surgical resection. On neuro-ophthalmic examination, the patient had a left relative afferent pupillary defect and a right oculosympathetic efferent pupillary defect (i.e., Horner syndrome) in addition to other thalamomesencephalic eye and neurologic signs (right fourth nerve palsy, hearing loss, hemiparesis, and thalamic pain). Clinicians should recognize the localizing value of this unique constellation of mesencephalic afferent and efferent pupillary defects., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by North American Neuro-Ophthalmology Society.)

Significance: This case highlights ocular ischemia after hemodialysis resulting in permanent vision loss. Fifteen percent of the U.S. population suffers from chronic kidney disease. Eye care providers should recommend risk factor modifications to their patients with end-stage renal disease before hemodialysis is started to prevent loss of vision., Purpose: The purpose of this study was to demonstrate a case of concurrent nonarteritic anterior ischemic optic neuropathy and central retinal artery occlusion in the setting of hemodialysis initiation., Case Report: A 68-year-old Irish man with end-stage renal disease undergoing dialysis presented, complaining of 3 weeks of progressive vision loss in his left eye. His medical history is complex and includes extensive cardiac disease, bilateral carotid stenosis, and peripheral vascular disease. His surgical history includes a right carotid endarterectomy, bilateral lower extremity amputations, and an aortic valve replacement. Clinical examination revealed light perception vision with an afferent pupillary defect in the left eye and count finger peripheral vision only in the superior temporal quadrant of his vision. The dilated fundus examination showed significant pallid disc edema and focal areas of retina whitening with attenuated peripapillary vasculature in the left eye. This edema was confirmed by optical coherence tomography and supported optic nerve and retinal infarction. A temporal artery biopsy confirmed no evidence of arteritis., Conclusions: Hemodynamic disruption during dialysis in patients with end-stage renal disease and overlying anemia can result in optic nerve and retinal infarction. Patients who are predisposed to nonarteritic anterior ischemic optic neuropathy or central retinal artery occlusion should be educated on this before starting dialysis to ensure careful blood pressure monitoring., Competing Interests: Conflict of Interest Disclosure: The author has reported no financial conflict of interest., (Copyright © 2021 American Academy of Optometry.)

A 67-year-old woman presented with acute loss of vision to no light perception (NLP), a right afferent pupillary defect, and anisocoria with a nonreactive and dilated pupil in the right eye. Fundus examination showed pallid optic disc edema and a central retinal artery occlusion (CRAO) in the right eye. A temporal artery biopsy showed giant cell arteritis (GCA). Orbital involvement in GCA has been reported previously. However the combination of an afferent and efferent pupillary defect, NLP vision, pallid disc edema, and a CRAO in an elderly patient is likely a unique clinical combination that should strongly suggest GCA. Clinicians should be aware of the myriad presentations of GCA, including orbital ischemia.

Purpose of Review: The goal of this article is to review the anatomy and physiology of pupillary function and then employ that information to develop a comprehensive framework for understanding and diagnosing pupillary disorders., Recent Findings: The contribution of rods and cones to the pupillary light reflex has long been known. A third photosensitive cell type, the intrinsically photosensitive retinal ganglion cell, has recently been discovered. This cell type employs melanopsin to mediate a portion of the pupillary light reflex independent of rods and cones (the postillumination pupillary response) and photic regulation of circadian rhythm., Summary: The autonomic nervous system regulates pupil size in response to stimuli. The parasympathetic nervous system causes miosis in response to light and near visual stimuli. These stimuli activate supranuclear pathways that project to the Edinger-Westphal nuclei. The sympathetic nervous system causes mydriasis in response to a variety of arousing factors, both physiologic (wakefulness) and pathologic (pain). Abnormalities of physiologic function cause disturbances of pupil size, shape, and response to stimuli. The clinical approach to pupillary abnormalities should focus on the clinical and pharmacologic assessment of the pupil's expected response to diverse stimuli.

Background: Radiation-induced optic neuropathy (RON) is a form of delayed radionecrosis of the anterior visual pathways, which develops within months to years after external cranial irradiation and causes severe and irreversible vision loss. Small series reports have adequately documented its clinical features, but imaging characteristics have been less completely described., Methods: We accrued cases from the University of Michigan Neuro-Ophthalmology Clinic files and from cases coded as "radiation optic neuropathy" at the University of Michigan Medical Center between 1994 and 2017. All patients had undergone 3D-conformal linear accelerator (photon) external beam radiation. We collected clinical details of vision loss, including the temporal relationship to radiation. A single neuroradiologist (E.A.L.) evaluated all available magnetic resonance imaging (MRI) studies, noting the presence of enhancement, expansion, or volume loss of the optic nerves or chiasm, corresponding T2 signal abnormalities, and the absence of demyelination or confounding compressive lesions., Results: Twelve patients (15 eyes) met inclusion criteria. Vision loss was usually monocular at outset, but both optic nerves were eventually involved in 3 (25%) patients. Although usually sudden in onset, vision loss often declined slowly over many months, frequently to finger counting, or worse without recovery. An afferent pupillary defect was always present at the time of presentation. Most affected optic discs were pale at the time of first visual symptoms, indicating that subclinical optic nerve damage had been present for several weeks. The latency from completion of radiation to onset of vision loss ranged from 7 to 48 months (average: 18 months). In 2 patients, radiation was delivered to the whole brain, rather than being limited to the anterior visual pathway. MRI typically displayed a discrete region of enhancement of the affected prechiasmatic optic nerve, often with expansion and high T2 signal in the enhancing segment. In 3 affected eyes, enhancement was apparent on imaging completed 3-6 weeks before the onset of vision loss. In one patient, segmental prechiasmatic enhancement became evident only on repeat MRI completed 7 months after vision loss. The duration of enhancement among 9 eyes with follow-up MRIs was at least 2 months, but in one case, enhancement was still present on a study performed 17 months after treatment., Conclusions: This study further delineates the profile of RON. Visual loss is often acute, profound, and monocular but may decline slowly after acute onset and later affect both optic nerves. High-resolution MRI of the optic nerves usually will display enhancement of a discrete segment of the intracranial prechiasmatic optic nerve, often with accompanying expansion and T2 hyperintensity. In some cases, these imaging features may precede vision loss. They may be subtle or appear after vision loss. Enhancement lingers for a wide interval, ranging in this study from 2 to at least 17 months. Recognition of these imaging characteristics assists in confirmation of the diagnosis of RON.

Rhabdomyolysis is a condition in which striated muscle tissue breaks down rapidly and releases muscular cell constituents into extracellular fluid and the circulation. Renal symptoms, such as acute renal failure, are major complications of rhabdomyolysis. However, no previous report of rhabdomyolysis associated with orbital complication has been issued. Here, we report the first patient of rhabdomyolysis presenting as orbital apex syndrome. A 66-year-old man presented with right periorbital swelling with erythematous patches and conjunctival chemosis. In addition, swelling, redness, and vesicles were observed in both lower legs. He was found in a drunken state with the right side of his face pressed against a table. Ophthalmic examination showed right eye fixation in all directions and ischemic change of retina. Blood testing showed elevated muscle enzyme associated with muscle destruction. And computed tomography of the orbit showed swelling of right extraocular muscles and crowding of right orbital apex. Under a diagnosis of rhabdomyolysis-associated orbital apex syndrome and central retinal artery occlusion, intravenous steroid and antibiotics therapy with intraocular pressure-lowering topicals were begun. Clinical presentation, treatment course, and follow-up are discussed.

Purpose: The purpose is to report a patient with primary open-angle glaucoma that developed sudden painless unilateral vision loss, a sequential ophthalmoscopic appearance with features of both central retinal artery and later central retinal vein occlusion, and objective visual system dysfunction in the form of a relative afferent pupil defect, who spontaneously recovered vision along with complete resolution of the pupillary defect over several weeks., Case Report: A 50-year-old woman with a long-standing history of glaucoma presented with acute, painless vision loss in one eye, a pallid retina with a cherry red macula, diffuse retinal hemorrhages, and a relative afferent pupil defect. Spectral domain optical coherence tomography and fluorescein angiography were essentially normal with neither retinal edema nor retinal ischemia to account for the visual dysfunction. Over the course of 2 months, the patient regained vision and the relative afferent pupil defect, typically a permanent manifestation of retinal destruction, resolved., Conclusions: Not all retinal vaso-occlusive phenomena can be completely attributed to a central retinal vein or artery occlusion. In the patient presented, there was no objective diagnostic testing that revealed a cause for the patient's vision loss or relative afferent pupillary defect. This combined with the complete recovery of vision and resolution of the relative afferent pupillary defect underscores a lack of comprehensive understanding of retinal vaso-occlusive disease.

Purpose of Review: This article presents an overview of the common and various kinds of pupillary disorders that can be encountered in an outpatient setting., Recent Findings: The dorsal midbrain is a site where lesions may produce either an afferent or an efferent pupillary defect. The classic pupillary syndrome secondary to a dorsal midbrain lesion is bilateral light-near dissociation. Another recognized deficit is bilateral mydriasis. Recent reports have documented unilateral mydriasis, unilateral light-near dissociation, and a relative afferent pupillary defect without visual loss in association with lesions of the dorsal midbrain. These are rare syndromes., Summary: Careful history and examination can often identify and localize the pupillary disorder, as well as guide appropriate evaluation.

Purpose: To report a case series of pupil abnormalities consistent with features of Urrets-Zavalia syndrome (UZS) after Descemet stripping automated endothelial keratoplasty (DSAEK) for corneal edema secondary to corneal endothelial cell dysfunction., Methods: Retrospective chart analysis of subjects who developed UZS after DSAEK at the University of Texas Southwestern Medical Center., Results: We present a series of 7 eyes with features consistent with UZS, after undergoing DSAEK. Elevated intraocular pressures (IOP) were noted in the early postoperative period in all cases. Five of 7 had graft dislocation in the postoperative period and required rebubbling or repeat DSAEK to obtain a well-apposed graft. Patients were followed for 3 to 14 months and showed improvement in visual acuity and IOP, but fixed dilated pupils persisted., Conclusion: A fixed irregular or dilated pupil is a rare complication that can be associated with DSAEK surgery. Patients with an elevated IOP and complicated postoperative course seem to be at greater risk for developing iris ischemia and pupil abnormalities consistent with the diagnosis of UZS.

Background: Binocular infrared pupillometry allows an estimate of the relative afferent pupillary defect (RAPD), designated the pupillometric RAPD (pRAPD). We calibrated the pRAPD of a commercially available pupillometer against neutral density filters (NDFs) of known attenuation. The performance of the pupillometer using its own proprietary algorithm is assessed and compared to that of alternative algorithms., Methods: The pRAPDs of 50 healthy volunteers were measured with each of 4 filters of known attenuation: 0.0, 0.3, 0.6, and 0.9 log units, positioned unilaterally in the light stimulus pathway. The filter values were plotted against the pupillometer output, and the slope and intercept were used to determine a calibration factor. Corrected pRAPD results were used to assess physiological ranges of pRAPD. The sensitivity and specificity to 0.3 log unit differences between increasing filter densities using receiver operator characteristic (ROC) curves., Results: The calibrated physiological pRAPD ranged from 0 to 0.22 log units. The area under the ROC curve for detecting unilateral simulated pRAPD of 0.3 log units, the simulated disease progression from 0.3 to 0.6 log units, and a further progression from 0.6 to 0.9 log units by NDFs was 0.99 (95% confidence interval [CI], 0.95-1.00), 0.86 (95% CI, 0.78-0.92), and 0.79 (95% CI, 0.70-0.87), respectively. The optimum discrimination was for detecting a unilateral simulated pRAPD of 0.3 log units; sensitivity and specificity was 98% (95% CI, 88%-99%)., Conclusion: The commercially available pupillometer detects the RAPD induced by the NDFs with high sensitivity and specificity. The results suggest that it is best for detecting unilateral early disease but potentially useful for assessing progression of disease.

Leukocoria, meaning "white pupil," describes the clinical finding of a white pupillary reflex on examination. It may be discovered through an asymmetric red reflex using direct ophthalmoscopy, or it may be seen incidentally on flash photography. It results from an abnormality of the eyeball that interferes with the normal reflective process. We report a case of a 3-year-old boy who presents with leukocoria found to be caused by a retinoblastoma and discuss the differential diagnosis of this uncommon presentation to the pediatric emergency department.

Assessing pupil reactivity using the swinging flashlight technique in patients with miotic pupils or heavily pigmented irides can be difficult due to the reflection of the examination light off the cornea. We describe a modification of the standard method of detecting pupil reactivity in these difficult-to-see pupils. With the patient facing forward and eyes looking in maximal upgaze, fixed at distance, the examiner shines the light at the limbus in the straight ahead direction. Improved view of the pupil in upgaze results from reduction of the blink reflex and elimination of the Purkinje-1 image with minimal refractive distortion by the cornea. Optical calculations and multimedia demonstrations are provided to document these findings.

Background: Harlequin syndrome is a curious phenomenon in which one half of the face fails to flush during thermal or emotional stress as a result of damage to vasodilator sympathetic fibers. Anecdotal reports suggest that some of these patients have abnormal pupils. In this study we set out to systematically investigate autonomic pupil disturbances in an unselected cohort of patients with harlequin syndrome., Methods: A consecutive series of 39 patients with harlequin syndrome who were referred to a tertiary autonomic function laboratory underwent slit-lamp examinations, testing of deep tendon reflexes, infrared video pupillography and, where needed, additional pharmacologic pupillary testing. Results were compared with a meta-analysis of all previously reported cases of harlequin syndrome (n = 39) identified from a literature search., Results: In 65% of patients, no underlying causative medical disturbance could be identified. In 64% of patients, there were abnormal pupils, most commonly Horner syndrome, which was always present ipsilateral to the side of the face with impaired facial sweating and flushing. The lesion was postganglionic in 9 of 10 patients tested pharmacologically. Five (13%) patients had tonic pupils, most of whom also had tendon areflexia but no other neurologic findings, a pattern consistent with Holmes-Adie syndrome. In 2 of these patients, tonic and Horner pupils coexisted. Normal pupils were present in 36% of patients. These results are similar to those for the 39 previously reported patients with harlequin syndrome., Conclusions: The frequent coexistence of harlequin and Horner syndromes without other neurologic deficits suggests pathologic changes affecting the superior cervical ganglion. Because either syndrome may occur alone, damage is apparently selective. Among the patients with harlequin syndrome who also have tonic pupils and tendon areflexia (Holmes-Adie syndrome), we postulate a ganglionopathy affecting not merely the (sympathetic) superior cervical ganglion, but also the (parasympathetic) ciliary and dorsal root ganglia. Because we found that more than 10% of patients had an undisclosed mass lesion in the chest or neck or a generalized autonomic neuropathy, we recommend a targeted evaluation in selected patients with harlequin syndrome.

The Argyll Robertson (AR) pupil has been defined as a pupil that is small and constricts poorly to direct light but briskly when a target within reading distance is viewed ("light-near dissociation"). Most descriptions of the AR pupil do not mention segmental iris sphincter constriction, or slow, sustained constriction with a near vision effort. Such features are considered typical of the light-near dissociation of Adie syndrome and of neuropathic tonic pupils, where damage to the ciliary ganglion or ciliary nerves is believed to be the mechanism. Because the AR pupil lacks these features, it has been attributed to a dorsal midbrain lesion that interrupts the pupillary light reflex pathway but spares the more ventral pupillary near reflex pathway. However, lesions in this region have not been reliably demonstrated in syphilis. Resolving the issue about the location of the syphilitic lesion that produces the AR pupil will depend on careful examination of patients with techniques designed to disclose segmental palsy of the iris. If segmental iris sphincter palsy is found and the light-near dissociation has tonic features, one must conclude that the mechanism of the pupil disorder is a ciliary (peripheral) rather than a midbrain (central) denervation. Until better evidence settles the localization of the AR pupil, it is appropriate to screen patients with bilateral tonic pupils for syphilis.

The development of personal computer-based infrared video instruments has allowed pupillography to enter the clinical arena. Measuring pupil diameter for refractive surgery, distinguishing Horner syndrome from physiologic anisocoria, quantifying the relative afferent pupillary defect, and plotting visual fields by means of graded pupil constriction to focal light stimuli are recent applications in ophthalmology. Pupillography has also been used to determine sleepiness and autonomic effects of new pharmaceuticals.

Introduction: This report documents a case of an asymptomatic 34-year-old female who had right eye subtle temporal optic nerve pallor with absent clinically detectable relative afferent pupillary defect., Case Report: This presentation was secondary to a fusiform paraclinoid aneurysm resulting in lateral chiasmal syndrome. Visual fields demonstrated a nasal depression OD. Neuroimaging studies revealed the presence of a fusiform paraclinoid aneurysm compressing the right optic nerve and optic chiasm. The lesion was treated surgically without additional visual loss nor systemic and neurological complications., Conclusions: A clinically detectable relative afferent pupillary defect may be absent in unilateral optic nerve pallor and/or visual field loss and does not preclude the need to attempt to identify an underlying etiology. Neuroradiological examination of orbital and cranial structures is an imperative protocol in the appropriate management of this potential life- and vision-threatening condition.

Proper examination of the pupil provides an objective measure of the integrity of the pregeniculate afferent visual pathway and allows assessment of sympathetic and parasympathetic innervation to the eye. Infrared videography and pupillography are increasingly used to study the dynamic behavior of the pupil in common disorders, such as Horner's syndrome and tonic pupil.

Examination of the pupils is an essential component of both the neurologic and ocular evaluation of a child in the acute care setting. The manifestation of an afferent pupillary defect has significant clinical implications for diagnosis and management. Correctly assessing the pupils for an afferent defect is an important clinical skill for the pediatric emergency physician. An appreciation of the anatomy and understanding of the mechanisms involved in abnormal pupil responses, knowledge of the proper technique of the swinging flashlight test, and an awareness of potential pitfalls in performing this test will aid the physician in the detection of an afferent pupillary defect.

A rare case of optic leptomeningeal carcinomatosis secondary to a rectal adenocarcinoma is recorded. The presentation of rectal disease with blindness is unique. A diagnostic quartet of symptoms and signs of leptomeningeal infiltration of the optic nerve sheath is proposed and its value emphasized by the inability of further investigation to confirm the clinical diagnosis. The investigation and treatment of leptomeningeal carcinomatosis is reviewed.

I performed a pupillographic study of pupillary escape to determine its effectiveness in detecting optic nerve and retinal disease. Fourteen patients and 39 normal subjects were included in the study. Only one patient had abnormal pupillary escape, even though 13 patients had relative afferent pupillary defects. Testing for pupillary escape is not a reliable clinical technique.