J Korean Ophthalmol Soc.  2018 Jul;59(7):697-701. 10.3341/jkos.2018.59.7.697.

Treatment of Bilateral Tonic Pupil Associated with Syphilis

• Mun YS
• Yang HK
• Hwang JM

• KMID: 2416275
• DOI: http://doi.org/10.3341/jkos.2018.59.7.697

Abstract

PURPOSE
We report a case of a male with bilateral tonic pupils associated with syphilis, that partially improved after syphilis treatment.
CASE SUMMARY
A 27-year-old male presented with a 2-month history of near vision impairment. The right and left pupils were 5.5 mm and 6.5 mm in diameter, respectively, in the dark and 5.3 mm and 6.1 mm, respectively, in the light. Both pupils demonstrated light-near dissociation, slow constriction and redilation when looking at near, and constriction after instillation of 0.0625% pilocarpine. Serological tests were positive for syphilis, while cerebrospinal fluid testing was negative. Two months after treatment with intramuscular injection of benzathine penicillin G, his near vision subjectively improved and the right and left pupils were 5.9 mm and 6.4 mm, respectively, in the dark and 4.8 mm and 5.3 mm, respectively, in the light. The size of both pupils decreased and the pupillary light responses partially improved in both eyes.
CONCLUSIONS
Patients with bilateral tonic pupils should have serological tests for syphilis. Recovery of tonic pupils can be expected after early treatment with effective antibiotics.

Keyword

Syphilis; Tonic pupil

MeSH Terms

Adult
Anti-Bacterial Agents
Cerebrospinal Fluid
Constriction
Humans
Injections, Intramuscular
Male
Penicillin G Benzathine
Pilocarpine
Pupil
Serologic Tests
Syphilis*
Tonic Pupil*
Anti-Bacterial Agents
Penicillin G Benzathine
Pilocarpine

Figure

• 

  Figure 1 Pupil sizes before and after instillation of 0.0625% pilocarpine. (A) On initial examination, the minimal pupil sizes were 5.3 mm on the right and 6.1 mm on the left. (B) After instillation of 0.0625% pilocarpine, both pupils showed significant constriction, suggesting cholinergic denervation supersensitivity. (C) Results of digital pupillometry on initial examination showing decreased constriction (CON) to light. (D) Results of digital pupillometry after instillation of 0.0625% pilocarpine showing decreased pupil sizes in both eyes. MAX = maximum pupil diameter; MIN = minimum pupil diameter; CON = (MAX-MIN)/MAX; LAT = latency; ACV = average constriction velocity; MCV = maximum constriction velocity; ADV = average dilation velocity; T75 = time to reach 75% recovery.

• 

  Figure 2 Pupil sizes after treatment with benzathine penicillin G. (A) Two months after treatment with benzathine penicillin G, minimal pupil sizes decreased to 4.8 mm on the right and 5.3 mm on the left. (B) Results of digital pupillometer two months after treatment show partially improved pupillary light responses (CON, MCV, ACV) in both eyes. MAX = maximum pupil diameter; MIN = minimum pupil diameter; CON = (MAX-MIN)/MAX; LAT = latency; ACV = average constriction velocity; MCV = maximum constriction velocity; ADV = average dilation velocity; T75 = time to reach 75% recovery.

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