Return to Scenario ListShow Learning Points most relevant to Phase 1:

Pupil abnormality

Clinical Discipline(s)/Organ System(s)
Ophthalmology, General Practice
Progress Test Topic(s)
A 72yr female longsighted teacher presents with a 2 day history of headache and blurred vision. She reports the pain starting in the evening while watching TV and subsequently worsening with right eye blurring, nausea and vomiting. On examination she has a hazy right cornea and mid-dilated pupil that has minimal reaction to light.
Progress Test-Type Questions:   Question 1 | Question 2 | Question 3
Applied Science for Medicine 
   - Anatomy of the iris including sphincter and dilator muscles
   - Sympathetic and parasympathetic nerve supply of the pupil
   - Structures of the irido-corneal angle (the anterior chamber angle)
   - Cerebrovascular anatomy in relation to cranial nerve III
   - Physiology of the accommodative reflex (triad)
   - Pharmacology of topical and systemic drugs that affect the pupil
Clinical and Communication Skills 
   - Elicit a relevant ocular and systemic history from a patient with anisocoria (unequal size pupils)
   - Examination of anisocoria and pupil responses; examination of cranial nerves
   - Differential diagnosis of anisocoria
   - Interpret pharmacological tests for pupil abnormalities
   - Interpret relevant imaging studies (X-ray, CT, MRI)
   - Determine the location of the lesion in Horner's syndrome
   - Management of Horner's syndrome
   - Management of cranial nerve III palsy with pupil involvement
   - Management of acute angle closure glaucoma (mid-dilated pupil)
Personal and Professional Skills 
   - Liaison with GP and other specialties
   - Ability to deliver life-changing news and empathise with a patient with cancer
Hauora Māori 
   - Ability to cater to differential health literacy needs of Māori patients and whānau
Population Health 
   - Service provision in the health service: criteria for urgent referral, prioritisation of medical imaging
   - Epidemiology of lung cancer
Conditions to be considered relating to this scenario
physiological anisocoria (physiological difference in pupil size), anterior uveitis/posterior synechiae, traumatic mydriasis, mid-dilated pupil in acute angle closure glaucoma
Less common but 'important not to miss'
Horners syndrome, Holmes-Adie pupil, acute cranial nerve III palsy with pupil involvement, acute angle closure glaucoma
cranial nerve III palsy in herpes zoster ophthalmicus, Argyll Robertson pupil in syphilis