In bilateral miosis the differential diagnosis includes a number of medications-most notably opioids, phenothiazines, sedatives, and clonidine-as well as pontine stroke, neurosyphilis, and complications of diabetes. If so, the differential diagnosis includes unilateral use of pilocarpine eye drops, unilateral iris pathology, and Horner’s syndrome, which has its own extensive list of causes ( see page shot in Figure 2, above please click to enlarge). In unilateral miosis, one first has to confirm that the small pupil is indeed the abnormal one. The differential can be further narrowed based on whether miosis is unilateral or bilateral. When the onset is acute, stroke should always be one of the top considerations, especially when other neurologic symptoms or signs are present. Discussion Miosis, like many physical exam findings, can have many causes. In this patient’s case, parapontine stroke was the diagnosis. Given the sudden onset, lack of new medications, and the patient’s risk factors, a pontine stroke should be at the top of the differential diagnoses considered. The differential diagnosis for bilateral miosis includes syphilis, diabetes, pontine stroke, and medication or insecticide toxicity. Please click below for answers and discussion.Īnswers 1. What is the most likely cause in this case? What is the differential diagnosis of bilateral miosis?Ģ. The neurologic exam is notable for mild ataxia. Results of the chest and abdominal exam are both normal. She also has a mild disconjugate gaze, with the right eye deviated slightly to the right (see facial image in Figure 1, above right please click to enlarge). The head and neck exam is notable for bilaterally small pupils, which are both ~1.5 mm in both dim and full light (non-reactive). She denies use of any alcohol, pain medications, or sedatives.Įxam: Her vital signs are all within normal limits except for her blood pressure, which is 171/99 mmHg. She takes only metoprolol and ranitidine, neither of which is new. She also describes imbalance, generalized weakness, and double vision. History: A 74-year-old female with a history of hypertension and GERD presents to the ED with dizziness that came on suddenly about 6 hours ago.
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