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JAMA Clinical Challenge
June 20, 2019

Dilated Pupil in a Patient With Hyperhidrosis

Author Affiliations
  • 1Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 2Division of Neurology, Department of Ophthalmology and Vision Sciences, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 3Kensington and Vision Research Center, Toronto, Ontario, Canada
  • 4Department of Ophthalmology, St Michael’s Hospital, Toronto Western Hospital, Toronto, Ontario, Canada
JAMA. 2019;322(3):264-265. doi:10.1001/jama.2019.8589

A 39-year-old woman presented to the emergency department after she noticed that her left pupil was dilated when looking in the mirror earlier in the day. She had a medical history of hypertension and palmar and axillary hyperhidrosis. She denied double vision, ptosis, headache, and weakness. On examination, she appeared well and her blood pressure was 128/78 mm Hg; heart rate, 76/min; and respiratory rate, 13/min. Visual acuity was 20/20 in both eyes, there was no ptosis, and extraocular movements were full. Pupillary examination revealed anisocoria that was more pronounced in bright lighting conditions (Figure). The right pupil measured 6 mm in the dark and 3 mm in the light, whereas the left pupil measured 9 mm in the dark and 8 mm in the light. The left pupil was poorly reactive to light and to a near target. Slitlamp examination revealed normal-appearing anterior chambers without any signs of intraocular inflammation. Cranial nerve function was otherwise normal. The remainder of the neurologic examination revealed normal muscle tone, strength, reflexes, and gait.