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Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1487--1488

Adie's Tonic Pupil: An Uncommon Ophthalmological Emergency

Amit S Nene1, Onkar H Pirdankar2, Smitesh Shah1, Pushpanjali Badole1, Sonal Shah1,  
1 Department of Ophthalmology, Isha Netralaya, Karnik Road, Kalyan West, Maharashtra, India
2 Department of Clinical Research, Isha Netralaya, Karnik Road, Kalyan West, Maharashtra, India

Correspondence Address:
Onkar H Pirdankar
Department of Clinical Research, Isha Netralaya, Karnik Road, Kalyan West, Maharashtra

How to cite this article:
Nene AS, Pirdankar OH, Shah S, Badole P, Shah S. Adie's Tonic Pupil: An Uncommon Ophthalmological Emergency.Neurol India 2021;69:1487-1488

How to cite this URL:
Nene AS, Pirdankar OH, Shah S, Badole P, Shah S. Adie's Tonic Pupil: An Uncommon Ophthalmological Emergency. Neurol India [serial online] 2021 [cited 2022 Jan 20 ];69:1487-1488
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Full Text

A 22-year-old female presented to the emergency department with complaints in the near vision for three months following viral fever. Her visual acuity for distance was 20/20 while for near in the right and left eye were N8 and N6, respectively. The pupil in the right eye was fixed mid-dilated 6 mm with poor contraction during accommodation [Figure 1]. Retinal evaluation was normal [Figure 2]. A provisional diagnosis of the right eye Adie's tonic pupil was made and was confirmed with a dilute (0.125%) pilocarpine test [Figure 3]. Moreover, perimetry, MRI brain, routine blood investigations, and vasculitis profile were found to be normal.{Figure 1}{Figure 2}{Figure 3}


In 1932, Adie described a syndrome in young women having unilateral fixed dilated pupil, nonreacting and unresponsive to light, and associated with absent or markedly reduced deep tendon reflexes.[1] A prevalence of 2/1000 cases have been reported, with a mean age of onset in the third decade and commonly unilateral.[2] It results from parasympathetic denervation at the level of the ciliary ganglion characterized by a large regular pupil with decreased response to light but preserved or enhanced constriction to accommodation, segmental iris constriction, vermiform movements of the pupillary border, and hypersensitivity to 0.125% pilocarpine.[3] It may be associated with autonomic dysfunction such as cough, sweating, orthostatic hypotension, hyperhidrosis, impaired cardiovascular reflexes, and diarrhea.[4] Miotics and reading glasses for near vision can be prescribed to reduce symptoms. Usually an improvement in accommodation can be achieved by partial regeneration of the damaged neurons. In conclusion, Holmes-Adie syndrome is a rare entity in clinical practice and warrants a detailed evaluation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


1Adie WJ. Tonic pupils and absent tendon reflexes: A benign disorder sui generis; Its complete and incomplete forms. Brain 1932;55:98-113.
2Thompson HS. Adie's syndrome: Some new observations. Trans Am Ophthalmol Soc 1977;75:587-626.
3Moeller JJ, Maxner CE. The dilated pupil: An update. Curr Neurol Neurosci Rep 2007;7:417-22.
4Kimber J, Mitchell D, Mathias CJ. Chronic cough in the Holmes-Adie syndrome: Association in five cases with autonomic dysfunction. J Neurol Neurosurg Psychiatry 1998;65:583-6.