About Arif Khan, <B>MD</B> Expertise I am an assistant professor of ophthalmology at the Mount Sinai Medical
Center in New York City. I practice all aspects of ophthalmology (medical
and surgical treatment of the eye) in both children and adults, but I have
subspeciality training and interest in pediatric ophthalmology and
strabismus.
Expert: Arif Khan, <B>MD</B> Date: 10/23/2004 Subject: physiologic anisocoria vs. Horner's Syndrome
Question Hello,
My 5 1/2 mo. old daughter has a smaller left pupil that is more obvious in dim light. We noticed it when she was about 2 mos. old and are not sure if it was there since birth. She does not appear to have any noticeable ptosis or anhydrosis and her face can flush on both sides. She does not show heterochromia at this time.
We have seen now three ophthalmologists for her. While gross measurements taken at the first who was not a pediatric specialist and without photos showed around a 2 mm difference in the pupils in dim vs. negligible difference in bright light. She is farsighted slightly more than usual for her age and has mild astigmatism. This ophthalmologist suggested we see a pediatric ophthalmologist.
The second one was the pediatric ophthalmologist and he read the first report and then suggested just a head MRI w/o contrast. We decided to see a pediatric neurologist before proceeding with this.
The pediatric neurologist suggested another pediatric ophthalmologist who did cocaine eye drop testing to check for Horner's syndrome. He took before and after pictures but the results were inconclusive as the suspect pupil (L) dilated but not enough to call the problem just anisocoria for sure. The difference in dim light before cocaine was 0.8 mm and after was 0.7 mm. He did admit, however, that the pictures were not exact and as they were taken on a struggling infant the angles were slightly different and the pictures were not digital so the measurements were not 100% reliable.
All physicians suspect that this is a benign anisocoria but since they are not sure we are now scheduled for MRI w/ and w/o contrast of head and soft tissues of neck and chest on Friday Oct. 29. We are also having a urinary VMA and HVA checked for neuroblastoma.
The questions I have are:
1) Is there any reliable way on an infant to definitively tell if this problem is anisocoria vs. a Horner's syndrome?
2) Can dilatation lag be measured to diagnose this on an infant?
3) I have heard of using a pupilometer with infrared light. Would this work and if so who does this testing?
4) Would the types of ordered MRIs be the best to find any problem causing a Horner's syndrome and be the safest diagnostic options?
This has been a frustrating experience as resources on the Internet suggest that it is easy to tell between the two conditions but we cannot so far.
Thank you very much for your time.
Amber B
Answer 1) Is there any reliable way on an infant to definitively tell if this problem is anisocoria vs. a Horner's syndrome?
...In real life situations are not always as clear as in the books. From what you describe, it sounds like physiological anisocorian. The only definite way to tell that it is definitely Horner's syndrome is if all the tell-tale signs were present (such as ptosis and other things you alluded to).
2) Can dilatation lag be measured to diagnose this on an infant?
..."Dilation lag" can sometimes be helpful, but it is difficult to see this finding even in cooperative adults. Therefore, it is not of much practical use in an infant.
3) I have heard of using a pupilometer with infrared light. Would this work and if so who does this testing?
...This again would not be of much practical use in an infant.
4) Would the types of ordered MRIs be the best to find any problem causing a Horner's syndrome and be the safest diagnostic options?
The testing you are having is probably more than necessary; however, it will rule-out the worrisome causes for Horner's syndrome. If you are having these tests, it really doesn't matter whether or not true Horner's syndrome is present because the importance of recognizing Horner's syndrome is so the tests you are having can be peformed. There are no safer diagnostic options for the information that will be gained from the tests.
