Episode 28: Anisocoria
The sun rises over the San Joaquin Valley, California, today is September 18, 2020.
Welcome to our “student-only” episode. Out of all the social determinants of health, the USPSTF recommends screening for intimate partner violence and for child maltreatment[1]. Today, we would like to dedicate a few minutes to intimate partner violence (IPV) in women.
Screening for IPV is a USPSTF grade B recommendation, which means you should offer this service to your patients. Women of reproductive age should be screened for IPV and receive ongoing support services, if screening is positive. There are several tools you can use to screen. For example, HARK (Humiliation, Afraid, Rape, Kick); HITS (Hurt, Insult, Threaten, Scream); and WAST (Woman Abuse Screening Tool)[2].
Briefly, the WAST has two questions, which can be followed by 6 additional questions (just like when you do PHQ2 and PHQ9). The first two questions are:
1. In general, how would you describe your relationship? (No tension, Some tension, A lot of tension)
2. Do you and your partner work out arguments with... (No difficulty, Some difficulty, Great difficulty?).
It is POSITIVE if patient answers "a lot of tension" and "great difficulty", then you can continue with the rest of the questions which is part 2, until completing 8 questions in total. The screen is positive based on your clinical judgement, no positive score threshold is established.
In California, health practitioners are required to report to law enforcement if they provide medical services to a patient with a physical injury due to firearm, or assaultive/abusive conduct within two working days[3]. Make sure you review your local regulations about mandatory reporting in your area.
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This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971.
“The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.” ― William Arthur Ward.
Did you know the word doctor comes from the Latin root docere which means teacher? I was very surprised by that etymology. So, as doctors, we are teachers. What kind of teacher do you want to be as a doctor? A teacher who tells, explains, or demonstrates? It takes a lot of practice and effort, I bet, but your patients will thank you if you become a teacher who inspires them. Today, you will listen to our medical students. This is the first episode that is 100% made by medical students. Today our doctor students become our teachers. First, let’s listen to Li Liang, then Hugh and Meredith.
Anisocoria: Unequal Pupils
As a continuation on the theme of anisocoria, we will wrap up. Hopefully with something wise, but more than anything the point of this is just to stir your mind and say, “Yeah…the cobwebs are lifting.” Yes, Halloween is coming. Is it the eye? Or is it the brain? Or is it in the blood vessel?
It has been said by multiple somebodies some time ago, “the eyes are the windows into the soul” or rather into the hidden chambers of what’s inside the big watermelon we have atop of our gravity defying bodies.
I learn best by stories and people, so if you’ll indulge me. Think of a musician, a rather famous rock star who The Rolling Stones called “The Greatest Rock Star ever.” Maybe this clip might help. https://youtu.be/J-_30HA7rec.
That was just David Bowie. I never knew this but conveniently he will highlight our topic for both anisocoria and heterochromia. As a quick reminder, heterochromia is asymmetric iris coloration, when hereditary, is a phenotypic expression of 2 different iris variegation. When someone young presents with heterochromia it can be associated with congenital syndromes, but in the case of David Bowie[4], it was acquired from injury. This also clues us into his story about anisocoria, which he was not born with.
In fact, it was over a love for a girl when he was an invincible teenager. Turns out most love stories have a villain, and his happened to be his best friend at the time, who also loved the same girl. What’s two teenage boys filled with testosterone to do about this? Dueling in a “fight of passion,” Bowie was sucker punched in his left eye, added a fingernail scratch, and even after surgery and prompt care, he “wears the badge of love on his eye.” His abnormal pupil is the big pupil! So, it isn’t the small one as you may think.
What is anisocoria?
Unequal pupil size, specifically by at least 0.4mm. The difficulty is determining what caused it. Therefore, the goal in primary care is to quickly identify the emergent/urgent causes from the ones that have time to do further workup.
Anisocoria doesn’t really sound benign when educating a patient about this. But in fact, physiologic anisocoria happens often. Some people may even have anisocoria daily. Prevalence is in the range of 15 – 30% for the general population.
How do you test and tell which one is abnormal if it’s not always the small one?
Normal pupillary reflex: symmetric pupils in both light and dark.
Abnormal pupillary reflex: If a small pupil fails to dilate in the dark, it is abnormal, which means the sympathetic nervous system is affected. If a large pupil does not constrict in response to light, then the parasympathetic nervous system is affected.
Look at the pupils in 4 steps to identify the abnormal pupil.
-1st when greeting and interviewing your patient in ambient light
-2nd during your physical exam via a light source for direct and consensual with the Light Reflex
-3rd followed up with the Near Reflex
-4th as well as confirmatory, turn off the lights and observe for abnormal constriction or dilation in your suspected eye.
When is anisocoria something to worry about?
Anisocoria may actually be physiologic and most commonly benign, but when it happens suddenly or without apparent reason, this is when we worry it may be life threatening. Patient factors will help the most to sort this out. When evaluating someone for the first time, and you’re doing their cranial nerve exam, You notice pupil asymmetry! But now what? Well, first ask the patient. As William Osler has once said, “Listen to your patient; he is telling you the diagnosis.” It’s very important to do medication reconciliation at each visit since some medications can induce anisocoria. COPD or asthma medications can potentially trigger anisocoria.
Horner’s syndrome is unilateral ptosis, anhidrosis - the inability to sweat, and mydriasis. This is a syndrome from many etiologies, so Horner’s syndrome itself is not the main cause and needs immediate workup.
Comprehensive evaluation requires appropriate tools and best left to specialists who are well trained in the field, mostly neurologists. However, it is very important that we recognize the signs and symptoms of anisocoria so as to make proper referrals or guidance towards the emergency department when seeing a new patient for the first time.
When do you send a patient the ED?
Acute Horner’s Syndrome as we’ve briefly mentioned before. It is a herald of something bad happening, has happened, or bound to happen…either way, you don’t want to be the last evaluating this patient and send the patient home. The most worrisome outcome is a carotid dissection, and one would hope there have been many others who have evaluated this patient before you see this as their primary provider.
Something else patients would not immediately complain about is something insidious with a slow compression that gives vision loss on CN III. Remember the peripheral nervous system travels on CN III to get to the eye. There would be like a mass effect caused by an aneurysm or tumor or distant metastases.
Why is that knowledge important for you and your patients?
You can detect conditions that need further evaluation in the ER, Neurology or by Ophthalmology. Consider a Neurology consult if not acute Horner’s Syndrome or Third Nerve Palsy or Tonic (Adie’s) Pupil. Consider an Ophthalmology consult if ocular trauma or mechanical causes being mechanical need workup or further pharmacological eye tests. Send to ED if you suspect stroke.
Where did that knowledge come from?
The main source was UpToDate, but from the perspective of a Family Medicine Practitioner, this was via the AAFP website. From the internal medicine standpoint, this was via Harrison’s or DynaMed, which is a branch from the American College of Physicians. Either approach assesses the patient before reaching the common pathway of consulting a specialist, most commonly a neurologist and/or ophthalmologist. As always, sources are attached for reference to take a look into anything deeper or for more information.
What happened to Davie Bowie’s girl and his bestie? It turns out she changed enemies into lifelong friends as well as artistic collaboration with George Underwood for those Davie Bowie fans out there.
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Speaking Medical: Presbyopia
by Hugh Alley, MS4
Presbyopia refers to age-related changes in accommodation, which is your eyes ability to adjust to seeing objects at different distances. In other words, this condition leads many people to use reading glasses. The word presbyopia, sounds like many other words in ophthalmology. It has, as a root, “opia”, the Greek word for eye. The prefix, “presby” is Greek for “old man”. So, if an ophthalmologist tells you that you have presbyopia, he’s calling you an old man!
The pathophysiology involves changes to the flexibility of the lens. To see objects nearby, the lens must be relaxed and rounded. As we age, the crystalline lens becomes less flexible. So, when the ciliary muscles relax, the lens stays in an oval shape, affecting the focal length of the eye and our ability to see objects clearly.
Fun fact: the age-related changes are predictable and the most clinically significant changes begin after age forty. In the United Kingdom, reading glasses are called “44’s”, the age most people begin wearing them.
This week, don’t forget the medical word presbyopia.
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Espanish Por Favor: Ojo
by Meredith Bell, MS4
This is your section Espanish Por Favor. Today's Spanish word is "ojo" (spelled O-J-O) which in English means "eye." The human “ojo” reacts to light and allows us to see. The “ojo” can differentiate between ten million colors, and as a whole, the eye is the fastest reacting muscle in the body. Because vision is so essential for the lives of many of us, your patients will come to clinic frequently for eye complaints. For example, a common complaint may be “Tengo el ojo rojo”, which means “my eye is red.” Having a red “ojo” can be a sign of an eye condition, but also may be a red flag of a systemic disease. You can continue learning about the ojo, but for now just remember the Spanish work of the week, ojo.
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Now we conclude our episode number 28 “Anisocoria”. If you are curious, go online and look at a picture of David Bowie and be reminded of anisocoria (unequal pupils). Anisocoria has a long list of differentials, including physiologic, traumatic or other neurologic and eye disorders. Presbyopia is a normal result of aging eyes that results in decreased accommodation of the lens of the eye. Presbyopia can happen as early as 40 years old. And to close this episode, we learned the word ojo (pronounced O-HO), which is Spanish for eye. For sure, the eye is a fascinating organ, and our medical students did a great job today. Good luck in your future careers!
Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Viraj Reddy, Allison Abad, Li Liang, Hugh Alley, and Meredith Bell. Audio edition: Suraj Amrutia. See you next week!
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References:
Krist, Alex H, MD, MPH, et al., “What Evidence Do We Need Before Recommending Routine Screening for Social Determinants of Health?” Am Fam Physician. 2019 May 15;99(10):602-605. https://www.aafp.org/afp/2019/0515/p602.html
WAST, pdf document, Woman Abuse in the Perinatal Period, Province of Ontario, Ontario Women's Directorate, http://womanabuse.webcanvas.ca/documents/wast.pdf
EVAWI, End Violence Against Women International, evawi.org, Mandatory Reporting of Domestic Violence and Sexual Assault Statutes, pdf file, http://www.evawintl.org/images/uploads/NDAA_Mandatory%20Reporting%20Compilation_2010.pdf
Basu, T. (2016, January 12th). The Story Behind David Bowie's Unusual Eyes. Retrieved from The Cut from the New York Magazine: https://www.thecut.com/2016/01/story-behind-david-bowies-unusual-eyes.html
American Association for Pediatric Ophthalmology and Strabimus. (2020, August 30). Anisocoria and Horner's Syndrome. Retrieved from American Association for Pediatric Ophthalmology and Strabimus: https://aapos.org/glossary/anisocoria-and-horners-syndrome
Horton MD, J. C. (2015). Disorders of the Eye. In D. L. Kasper MD, A. S. Fauci MD, S. L. Hauser MD, D. L. Longo MD, P. J. Jameson MD, & P. J. Loscalzo MD, Harrison's Principles of Internal Medicine (pp. 195 - 211). New York: McGraw Hill.
Sachin Kedar, M., Valerie Biousse, M., & Nancy J Newman, M. (2020, August 30). Approach to the patient with anisocoria. Retrieved from UpToDate: https://www.uptodate.com/contents/approach-to-the-patient-with-anisocoria?search=anisocoria&source=search_result&selectedTitle=1~39&usage_type=default&display_rank=1