Good lightreactionin both eyesMore anisocoriain darknessthan in lightMore anisocoriain light thanin darknessPoor lightreactionin one eyeIs there moreanisocoria in darknessor in light?Look for‘‘dilation lag’’of the smaller pupilCompletelyimmobileSector palsyof irissphincterSphincteris notsupersensitiveSphincterissupersensitiveIristransilluminatespupil margintornTest for cholinergicsupersensitivity withMecholyl 2.5% orpilocarpine 0.1%Test foranticholinergicblockade withpilocarpine 1%Adie’s tonic pupilHorner syndromeSimple anisocoriaSmaller pupildilates‘‘Dilation lag’’of smallerpupilImpairedlight reactionbut no sector palsyof iris sphincter ordistortion of stromaNeither pupildilatesNo dilation lagIris damageThird-nerve palsy‘‘Atropinic’’mydriasisdue toeye-dropsPostganglionicHornerPreganglionic orcentral HornerNo dilationDilationPupil fails to constrictPupil constrictsCheck light reactionExamine irissphincter at slit lampApraclonidinetest1%Hydroxyamphetaminetest
Figure 13-11. A schematic approach for sorting out the nature of anisocoria. (Adapted by permission from Thompson and Pilley.)
Chapter  13    Disorders of Ocular Movement and Pupillary Function
Deafness, Dizziness, and
Disorders of Equilibrium
Sounds alert us to danger; spoken words are the universal means of communication; music is one of our most exalted aesthetic pleasures. The loss of hearing excludes the individual from many important external stimuli, and adjustment to this deprivation imposes profound challenge. Vestibular function ensures one’s ability to stand steadily, stabilize eye position during head movement, and move about gracefully. Hence, an understanding of the functions of the eighth cranial nerves and their derangements by disease is as much the concern of the neurologist as the otologist. Generally, the association of vertigo and deafness signifies a disease of the end organs for hearing and vestibular function, or of the eighth nerve. The precise locus of the disease is determined by tests of labyrinthine and auditory function, described further on, and by findings on neurologic examination and imaging studies that implicate the primary and secondary connections of the eighth cranial nerve.
The vestibulocochlear, or eighth, cranial nerve has two separate components: the cochlear nerve, which subserves hearing, and the vestibular nerve, which is concerned with equilibrium (balance) and orientation of the body and eyes to the surrounding world. The acoustic division has its cell bodies in the spiral ganglion of the cochlea. This ganglion is composed of bipolar cells, the peripheral processes of which convey auditory impulses from the specialized neuroepithelium of the inner ear, the spiral organ of Corti. This is the end organ of hearing, wherein sound is transduced into nerve impulses. It consists of approximately 15,000 neuroepithelial (hair) cells that rest on the basilar membrane, which extends along the entire 2.5 turns of the cochlea. Projecting from the inner surface of each hair cell are approximately 60 very fine filaments, or stereocilia, which are embedded in the tectorial membrane, a gelatinous structure overlying the organ of Corti (Fig. 14-1). Sound causes the basilar membrane to vibrate; upward displacement of the basilar membrane bends the relatively fixed stereocilia and provides a stimulus adequate for activating the hair cells. The stimulus is then transmitted to the sensory fibers of the cochlear nerve, which emanate from the base of each hair cell.