Pupillary Reflexes and Pathologies

A 52-year-old man presents with acute onset of severe eye pain, blurred vision, and a fixed, mid-dilated pupil. Anterior chamber examination shows corneal edema and elevated intraocular pressure (68 mmHg). Gonioscopy reveals angle closure. What is the drug of choice for immediate management of the acute attack?

A 28-year-old woman presents with progressive bilateral pupillary constriction over 6 months, with preserved light and accommodation reflexes. She reports no vision loss or ocular pain. Slit-lamp examination reveals no iris atrophy, transillumination defects, or anterior chamber inflammation. Systemic examination is unremarkable. Which investigation is most appropriate to evaluate the underlying cause of this bilateral pupillary miosis?

A 58-year-old man presents to the ophthalmology clinic with a 3-day history of right eye pain and blurred vision. On examination, the right pupil is mid-dilated (5 mm) and fixed to light, while the left pupil reacts normally. Extraocular movements are intact. Visual acuity is 6/9 in both eyes. Slit-lamp examination reveals ciliary injection and keratic precipitates. Intraocular pressure is 42 mmHg in the right eye. What is the most likely explanation for the pupillary finding?

A 32-year-old woman presents with a 2-week history of progressive blurred vision in the left eye and left-sided headache. On examination, the left pupil is 4 mm and reacts sluggishly to light, while the right pupil is 2 mm and reacts briskly. The left eye shows a relative afferent pupillary defect (RAPD). Visual acuity is 6/18 in the left eye and 6/6 in the right eye. Fundoscopy reveals left optic disc swelling. MRI brain shows a 2 cm lesion in the left optic nerve. What is the mechanism of the RAPD in this patient?

In a patient with acute Horner syndrome, which of the following pupillary findings would be expected?