Holmes-Adie Pupil, Holmes-Adie Syndrome

Holmes-Adie Pupil, Holmes-Adie Syndrome

The Holmes-Adie, or tonic, pupil is an enlarged pupil which, in a darkened environment, is unresponsive to a phasic light stimulus, but may respond slowly to a tonic light stimulus. Reaction to accommodation is preserved (partial iridoplegia), hence this is one of the causes of light-near pupillary dissociation (q.v.). A Holmes-Adie pupil is usually unilateral, and hence a cause of anisocoria.
Holmes-Adie pupil may be associated with other neurological features (Holmes-Adie syndrome). These include loss of lower limb tendon reflexes (especially ankle jerks); impaired corneal sensation; chronic cough; and localized or generalized anhidrosis, sometimes with hyperhidrosis (Ross’s syndrome). Holmes-Adie syndrome is much commoner in women than men.
Pathophysiologically Holmes-Adie pupil results from a peripheral lesion of the parasympathetic autonomic nervous system and shows denervation supersensitivity, constricting with application of dilute (0.2%) pilocarpine (cf. pseudo-Argyll Robertson pupil).

References

Kawasaki A. Approach to the patient with abnormal pupils. In: Biller J (ed.). Practical neurology (2nd edition). Philadelphia: Lippincott Williams & Wilkins, 2002: 135-146
Martinelli P. Holmes-Adie syndrome. Lancet 2000; 356: 1760-1761 Pearce JMS. The Holmes-Adie tonic pupil and Hughlings Jackson. In: Pearce JMS. Fragments of neurological history. London: Imperial College Press, 2003: 249-251

Cross References

Anhidrosis; Anisocoria; Hyperhidrosis; Light-near pupillary dissociation; Pseudo-argyll robertson pupil