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Symptoms ⬇

Usually asymptomatic.

Signs ⬆ ⬇

Critical

Small, irregular pupils that exhibit “light-near” dissociation (react poorly or not at all to light but constrict normally during accommodation/convergence). By definition, vision must be intact.

Other

The pupils dilate poorly in darkness. Always bilateral, although may be asymmetric.

Differential Diagnosis ⬆ ⬇

Differential Diagnosis of “Light-Near” Dissociation

Etiology ⬆ ⬇

  • Tertiary syphilis.

Work Up ⬆ ⬇

Workup
  1. Test the pupillary reaction to light and convergence: To test the reaction to convergence, patients are asked to look first at a distant target and then at their own finger, which the examiner holds in front of them and slowly brings in toward their face.
  2. Slit lamp examination: Look for interstitial keratitis (see 4.17, INTERSTITIAL KERATITIS).
  3. Dilated fundus examination: Search for chorioretinitis, papillitis, and uveitis.
  4. Fluorescent treponemal antibody absorption (FTA-ABS) or treponemal-specific assay (e.g., microhemagglutination assay–Treponema pallidum [MHA-TP]) and rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test.
  5. If the diagnosis of syphilis is established, lumbar puncture (LP) may be indicated. See 12.12, SYPHILIS, for specific indications.

Treatment ⬆ ⬇

  1. Treatment is based on the presence of active disease and previous appropriate treatment.
  2. See 12.12, SYPHILIS, for treatment indications and specific antibiotic therapy.

Follow Up ⬆

Pupillary findings alone are not an emergency. Diagnostic workup and determination of syphilitic activity should be undertaken within a few days.