Adie’s tonic pupil
Adie’s tonic pupil is a dilated, poorly reacting pupil caused by damage to the ciliary ganglion or the short ciliary nerves, which supply the iris sphincter and the ciliary muscle.1 Patients are usually healthy young adults, more often women, who notice that one pupil is large or that near focus is poor in one eye.1,2
The pupil is initially large, reacts poorly to light, and redilates slowly after constricting for a near target, which is why the pupil is called tonic.1 Fibers bound for the ciliary muscle outnumber those bound for the sphincter by 30 to 1. As the injured ganglion regrows axons, accommodative fibers reach the sphincter, and the pupil comes to constrict at near but not to light.1,2 Light-near dissociation therefore marks a chronic, reinnervated Adie’s pupil rather than an acute one.2
Adie syndrome, also called Holmes Adie syndrome, is a tonic pupil combined with absent deep tendon reflexes.1 Most cases are unilateral, and the fellow pupil becomes involved in about 10% of cases, months or years later. After 1 or 2 months, a tonic pupil may become miotic and smaller than the fellow pupil.1
More detail
Dilute pilocarpine 0.125% constricts a tonic pupil, because the denervated sphincter is hypersensitive to cholinergic drugs.1 The slit lamp shows sectoral paralysis of the sphincter, vermiform movements of the iris and loss of the pupillary ruff. Accommodative insufficiency and depressed corneal sensation may accompany the pupil signs.1 Accommodation shares the tonic behavior, so patients often have trouble refocusing from near to far.1,2
Sources (4)
- Liu, Volpe and Galetta, Neuro-Ophthalmology: Diagnosis and Management, ch. 13
- Adler's Physiology of the Eye, ch. 25
- American Academy of Ophthalmology (2020) What Is Adie's Pupil? Available at: https://www.aao.org/eye-health/diseases/what-is-adies-pupil (Accessed: 4 May 2024).
- EyeWiki (2024) Adie Pupil. Available at: https://eyewiki.aao.org/Adie_Pupil (Accessed: 4 May 2024).
Reviewed October 2026