It may be accompanied by spastic shaking or jerking that can be mistaken for seizures. Argyll Robertson pupils are usually unilateral and due to syphilis or rarely, diabetes mellitus.Ī pontine stroke or hemorrhage is often a cause of bilateral miosis accompanied by a sudden loss of consciousness. Some of them will not include unconsciousness such as Horner’s syndrome, chronic lesions to the rostral midbrain from MS, Lyme disease, chronic alcoholism, etc. There are numerous lesions that can lead to miosis. All of these substances have cholinergic effects and will likely have SLUDGEM symptoms such as increased sweating, bronchial secretions, diarrhea, GI distress, vomiting, salivation, and tearing.
Certain poisonous mushrooms and nicotine poisoning can present with similar symptoms. Nerve agents (sarin, VX) and organophosphate insecticides can cause miosis. There are numerous Alzheimer’s medications such as tacrine and donezepil and cholinesterase inhibitor medications used to treat myasthenia gravis which can also cause tiny pupils. Other medications such as phenothiazine, lomotil (diphenoxylate), clonidine, barbiturates, clozapine, eye drops, GHB, antipsychotics such as olanzapine (Zyprexa), and valproate, can also cause miosis. But the narcotic overdose requiring naloxone will also cause altered mental status/unconsciousness and respiratory depression requiring ventilatory assistance. This is especially true in an overdose situation. From morphine to heroin and Fentanyl to Percocet and codeine, these medications can cause the pupils to be smaller than 2mm. The most commonly remembered cause of miosis is opiate use. A patient in bright sunlight, with pupils that are 7mm could be considered too large for the situation. This means that in the correct setting, the pupils measure less than 2mm or larger than 7mm. Dilated pupils (mydriasis) are more than 7mm. They should be equal and move briskly.Ĭonstricted pupils (miosis) are less than 2mm. Normal pupils are between 2-5 mm in bright light and 4-8 mm in the dark. You should shine the light from below the face while they are looking at an object behind you.
The ideal way to measure pupil size is in dim lighting and using a bright light. If you search the internet, you can find numerous mnemonics that may help (“CPR ON SLIME” is even one!). Today, we will mention a few causes of miosis or pinpoint pupils.
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