Chonic Pupil Dilation From Adie’s

Dr. Kisling Uncategorized 31 Comments

Eye Doctor Explains Constantly Dilated Pupils From Adie’s Tonic Pupil Syndrome

Occasionally parents or individuals will notice the eye pupils appear to be abnormally large and stay dilated all of the time. Patients may complain of sensitivity to light and occasionally have problems focusing and reading at near distances. This may occur in one or both eyes. About 3/4’s of the time it occurs in one eye only. While many reports indicate the occurrence age as in

Eye Pupil Exam for Adie's Tonic Pupils

Eye Pupils Examined For Adie's Eye Condition

the 20-to 40 year age bracket, most of the cases we have seen in our Fort Collins Optometry Clinic tend to be young girls in their early teens. The prevalence is seven to eight times higher in females than in males.

An Eye Exam by Your Ft Collins Optometrist is Essential to Rule Out Serious Vision Conditions

Diagnosis can be somewhat tricky. If only one eye is dilated the determination needs to be made by an eye care professional if one eye is dilated more than normal, or if the other eye is constricted making the other eye have the appearance of an abnormally enlarged eye pupil by comparison. This can occur in Horner’s Syndrome. While usually benign, a number of serious health condition may cause Horner’s Syndrome in the eyes. A tumor near the apex (top) of the lung is one of the problems you would not want to develop to an advanced stage when an eye exam and visit to your optometrist could help detect serious causes of Horner’s Syndrome at an early stage. To help your eye doctor diagnose Adies Pupillary problems, a prescription eye drop called Pilocarpine can be applied to the eye in a very diluted from. The loss of nerve stimulation causes the eye drug receptor sites to become hypersensitive and eyecare patients with Adie’s Tonic Eye Disorder will constrict to a concentration that has little effect on a normal eye.

Adie’s Tonic Pupil is a dysfunction of the parasympathetic nerve fibers. First a short explanation of the nervous system of the body. The central nervous system is composed of the brain and spinal cord. The peripheral nervous system is everything else, and has two parts, the autonomic system and the somatic system. The autonomic nervous system has two branches, the parasympathetic and the sympathetic. Combined, these generally control functions automatically, we don’t will our eyes to dilate (it can however be trained) or our heart to beat. The somatic nervous system is the part of the nervous system under our conscious control, that helps us move arms and legs when we want to go someplace, like to the optometrist office to find out why the eyes pupils are staying dilated all the time.

The parasympathetic nervous system controls functions in a manner usually opposite to the sympathetic system. The parasympathetic system is the opposite of the sympathetic fight or flight response when the body is in a state of arousal. Parasympathetic nerves increase tearing from the eyes, fluid secretions in the mouth, increase bladder and bowel function, move blood out to the surface layers of the body and digestive track. In comparison, the sympathetic nervous system moves blood away from the surface tissues and the digestive track, so the individual in a threatening environment can increase their chances of survival by protecting blood flow to vital organs.

The parasympathetic nerves also connect to the iris, the colored tissue that surrounds the black pupil. The iris determines the size of the pupil. The parasympathetic nerves act to constrict the pupil (by increasing the iris size leaving a smaller opening) when activated by sunlight. The sympathetic nerves act to dilate the eye pupil (decreasing the iris size by bunching it back toward the outer edges which exposes more open space thus enlarging the pupil). Just as a reminder, the pupil is a hole through the colored iris of the eye that allows light into the eye. Smaller pupils allow less light inside the eye which is important on sunny days. Dilated eye pupils allow more light inside the eye to help in dark environments and at night. When the parasympathetic nerves are compromised, the sympathetic nerves are unopposed in activating the iris muscle that draws the iris back and results in a larger pupil. Sometimes this problem extends past it’s base to the attached culinary body where a muscle functions to focus the eye for near vision. When this muscle contracts, it alters the shape of the lens inside the eye creating more curvature to allow focusing at close distances. If the damage to the parasympathetic nerves extends to the ciliary body, the ciliary body can’t contract normally and there will be an eye focusing problem that causes blurred vision when trying to read with symptoms of eyestrain and occasionally headaches. Other symptoms may include sensitivity to light due to the inability of the pupils of the eyes to constrict in bright light.

Your Eye Doctor Can Help You With Treatment

Once it has been determined your eye condition is Adie’s Tonic Pupil (also known as Holmes-Adie’s Syndrome or Ross Syndrome when there is an alteration in sweating), several treatments are recommended. Sunglasses need to be worn outdoors even when photophobia (light sensitivity) is not a symptom. A larger pupil allows more ultraviolet light and blue light to enter the eyes and can increase the risk over a lifetime for developing macular degeneration and cataracts. This is especially important to eye doctors in areas like fort collins and Northern Colorado where the number of sunny days and light reflected off of snow greatly increases UV exposure. Prescription eyeglass lenses may be needed to help with near vision. This is normally not a progressive condition and the pupils may even become smaller with time, even though the lack of response to light will continue. Occasionally, prescription eyedrops have been used to decrease the dilation of the eyes pupil.

How Does Your Optometrist Determine The Cause of the Constantly Dilated Pupils?

Well that’s why they call Eye Doctors Offices Practices. Like a lot of other eye diseases and conditions we just don’t know yet. The very definition of Adie’s Tonic Pupil is an idiopathic tonic pupil (idiopathic is a nice word diverting the attention away from the fact that we have no idea). Rightfully so, idiopathic sounds like the Eye Doctor has an idiot disorder themselves! Even after numerous years as a Ft Collins Optometrist, the rapid expansion of knowledge serves more and more to show me how little we really know about eye diseases and disorders.

There is a significant incidence of Adie’s Tonic Pupils that occur shortly after a viral or bacterial infection of the body. Most colloquial eyecare provider reports indicate a viral infection. Somehow an infection is causing inflammation that damages the parasympathetic nerves connecting to the iris muscle. Since migraine headaches occur at a much higher frequency in females than males, and also after puberty, one can only speculate there could be some kind of correlation with changes in hormonal levels. Migraine headaches also frequently damage neurons and cause small losses of peripheral vision that are not noticed by the eyecare patient. Migraine headaches may create a disruption of blood flow or some other mechanism that acts in conjunction with an infection in the body to damage the Pupillary eye response. Twenty percent of Adies Eye Syndrome occur in both eyes. Other symptoms that can occur are increased and decreased areas of sweating and the loss of deep tendon reflexes (When your Doctor whacks your knee and the involuntary kick is lost). It may be found to have multiple different causes in the future.

Some known cases are of Adie’s eye disorder include complications of retinal detachment surgery involving a sclera buckle, other types of eye surgery, eye trauma, diabetes, Herpes Zoster infections (the chicken pox virus), syphilis, some dental, surgery, Guillain–Barré syndrome which rarely is caused by vaccinations, and some internal organ problems. While I have not seen any documented cases, I suspect that viral infections like West Nile Virus which has been so prevalent in Northern Colorado probably result in an occasional case of Adie’s eye disorder. Most  viral infections remain latent in the body after they are resolved, and viral infections like Herpes Simplex sit dormant in the ciliary ganglion (where the parasympathetic nerves for the eye aggregate together) until some form of stress causes the virus to follow the nerves back to the lips causing cold sores or to the herpes eye ulcers. Any virus laying dormant in the ciliary ganglion could possibly be reactivated by stressors like infections in the body and damage the parasympathetic nerves. Most of the time, we just don’t know what causes the Pupillary disorder and can only speculate.

Glaucoma and Adie’s Tonic Dilated Pupils

Little research is available on Adie’s Tonic Pupil and Glaucoma. Because the iris tissue is typically bunched up by Adie’s pupil eye disease it could result in blocking the drainage of eye fluid leading to a rapid increase in the eye pressure. This could result in an uncommon form of the eye disease called angle closure glaucoma. Theoretically, the effect of the parasympathetic nerve dysfunction on the ciliary body should result in an increase in eye pressure. I am not aware of any studies that substantiate this. In past years the drug Pilocarpine was frequently used to treat glaucoma by stimulating the parasympathetic system and increasing the outflow of the fluid inside the eye (resulting in intraocular eye pressure reduction). The effect of the Adie’s Tonic Pupil on glaucoma remains unknown, but probably is significant only in rare cases.

Perhaps the most important thing to learn about this eye condition is that it does not progress or cause blindness and vision loss. You can lead a normal, healthy life after appropriate diagnosis and treatment by your optometrist.

Comments 31

  1. Melanie Teegarden

    Hi, my 17-year-old daughter was recently diagnosed with Adie’s syndrome. She has some concerns about whether or not this is correct, though. For one thing, it happened to both eyes simultaneously. The second issue is that two weeks after diagnosis, they continue to fluctuate wildly, from almost-normal some days/hours to almost no visible iris at all on other days or at other random times. The optometrist did not test for deep tendon reflex issues, but the eye drop test was pretty obviously a positive. In addition, she has been treated for diaphoresis (excessive sweating) for over a year prior to the eye symptoms appearing. I feel pretty sure it is Adie’s, but because her eyes are still fluctuating back and forth, she is doubtful. Is there anything else that could be going on with this? What sorts of tests should we consider getting done? Not really sure what to do from here other than investing in an awesome wardrobe of cool sunglasses for my girl.

  2. Post

    The fluctuation should settle down if it is Adie’s. Over the course of years the pupils may actually end up being small but still tonic (not constricting very well to light) Bilateral Adies’s is less common but does occur (about 20% of the cases). There is a condition called episodic isolated mydriasis that results in episodes of wide variations in pupil size but bilateral cases are rare. With the proper testing positive it should be Adie’s. If you want a second opinion I would request a referral to a neurologist or neuro-ophthalmologist. They might want to have a CAT scan or MRI to rule out anything else, but other conditions usually have obvious other signs.

  3. Jackie

    Thank You for going into such detail regarding this pupil dilation disorder. I have two eye doctors currently. I have had an eye issue for three and a half weeks now and finally decided to go ahead and check the internet for any helpful information. I am a very healthy 35 year old female and developed what the doctors think is a herpetic eye. However, I am only showing symptoms of severe inflammation of the iris as well as high white blood cell count in fluid of the eye, and a dilated pupil all occuring in the left eye. My family has not history of eye problems or any autoimmune disorders. I am on an antiviral pill now for four days as well as Pred Forte every two hours. I am not noticeing any improvement. I am a little frustrated and thought that I would just (as you say) speak my mind. Maybe there are other cases out there with the same symptoms that could help me or at the very least let somone out there know that they are not alone!

  4. Post

    Hi Jackie,

    Google herpetic ciliary ganglion pupil dilation, or herpes infections ciliary ganglion pupil dilation, or adie’s herpes ciliary ganglion pupils, and variations of these. You will find a lot of company there. The parasympathetic nerves that constricts the pupil form a connection relay type point there. Herpes Viruses reside in the ciliary ganglion and when they become active travel to the eye, lips, or face along the same nerve pathway when they become active. The damage can occur in the ciliary ganglion. You probably have damage in the ciliary ganglion causing the pupil disorder and the virus has probably traveled down the nerve to the eye and is causing a corneal ulcer or to the iris and connecting ciliary body. (so you have two different things going on from the virus). The infection results in cells in the anterior chamber (fluid in the eye from the lens to the cornea on the front of the eye. You are not alone and there are plenty of other people with the same problems.
    Presumably this is from the HSV-1 virus or the herpes simplex virus. Almost everyone carries this virus but a low percentage of carriers will have it create problems with their eyes. Since it has occurred there you should talk to your doctor about the possibility of preventative treatment. It is indicated in certain types of cases and reduces re-occurrence by about a third.

    Good Luck and and you are not alone. You should be able to find a chat group online.

  5. Nicole

    I was just unofficially diagnosed by the opthlamologist with Adie’s Tonic Pupil. It started about a month ago and hasn’t changed since. I already had a catscan and MRI done to check for any of the more serious causes of anisocoria (extensive family history of retinal detachment, brain aneurysm, brain cancer and brain tumors). I get to take the images from those to the optical neurologist in a couple of days to see if he can find anything on there that might be of a concern.

    Thank you for the interesting article, it helps a lot.

  6. Post

    Hi Nicole,

    Thanks for your comment. It is good to have a benign outcome but a real pain to go through all of the testing to rule out everything else. If only we had easier and faster ways to do it!

    Best Wishes

  7. Post

    Hi Nicole,

    Thanks for your comment. Fortunately Adie’s is a nuisance but not a serious health issue. It is such a pain to have all of that testing to rule everything else out!

    Best Wishes

  8. himan

    Hi, i am 24 years old guy ,from india.I appreciate your discussions on Adie’s Pupil and glaucoma.
    Last year in the month of march 11, i discovered that one of my eye has a tonic pupil,At that point of time ,i was quite shocked to see difference in size of my pupils.But it had never created so much problems for me.
    I was able to see with both of my eyes properly .But this year when i got placed as a software engineer,i have to sit for hours facing monitor.These long duration of work hours has brought a lot of changes to my eyes.My eye other than tonic pupil one gives a lot of pain from morning itself when i start my work.
    Can anyone explain why is this happening to my eyes?
    I have recently seen on websites that “alphagan p” is a solution for glaucome or ocular hypertension,
    Is ocular hypertension same as tonic pupil…….
    plz guide my anyone about this disease n possible treatment or relaxation for eyes.


  9. Post

    Hi Himan,

    You can have a tonic pupil with a focusing spasm for near. If you are alternating between your eyes trying to find a common focal plane on the computer you could suffer eyestrain and it might seem to occur in the non tonic eye. The difference in pupil sizes also can be problematic. The larger pupil will allow more optical imperfections (aberrations) into one eye and this could disrupt the way your eyes are working together. The difference in pupil size allows different amounts of light in each eye with slightly different images and that can also present subtle challenges to the brain in making the two images into one visual entity in the brain.
    Computers are not the normal visual world we are built to see. With back-lighting, flat planes of vision, and various ways of utilizing light (LED, Plasma) they all challenge our visual system. Near work also reduces your blink rate and drys the eyes out, sometimes one eye is much more symptomatic than the other. There can be eyestrain from the lowered cues to depth on computers, the sustained low focusing required, and/or eyes drying out. Even the height of most computer screens is a problem since most reading has been done traditionally down closer to our laps. When you elevate a computer screen at eye level the eyes are held open wider and dry out faster.

    Alphangan (brimonidine) is a drug used to treat glaucoma or pre-glaucoma by lowering the eye pressure. It also has a nice little side effect of decreasing the pupil size and sometimes is useful in treating Adie’s Tonic Pupil. You probably should try testing and treating for a possible dry eye first to rule this out. The next step would be trying to see if the way the eyes worked together was a problem with binocular testing. Finally you could test if the focusing, or accommodative function was the true cause of your problems. If this ends up being the problem, a low multifocal contact lens on one eye might be the treatment you need. The symptoms of Adie’s do tend to lessen over 1-2 years so it may improve on its own. One other thing to check is the general lighting of your work area. Contrast between the screen and background around it should not exceed a 3:1 ratio-so its not a good idea to have a computer by a bright window. Also overhead lighting can create glare and resultant eyestrain.

    All of this means there is not an easy answer, and like a lot of things you will just have to as they say “eat an elephant one leg at a time”. Well, at least they say that here, probably not so much where there really are elephants:)

    I would start on the easiest thing first which happens to be dry eyes and go from there until you find relief. Just make sure you find a doc to work with who can go through this type of process.

    Best Wishes (And Give It Some Time)

  10. Post

    Hi Jody,

    It’s a good question, unfortunately I don’t have a good answer. In the early days of LASIK, many of the problems reported were found in patients with larger pupil sizes at night. The pupils naturally dilate at night to allow more light in. Sadly, the eye is not a perfect optical system, and the larger it gets the more optical aberations or imperfections are allowed in. LASIK does create some aberrations but the so called wavefront guided procedures help lessen this issue.

    The amount of correction required may play a larger role in symptoms of reduced nighttime vision, halos and glare. The combination of a higher prescription and Adies could be a potential problem. A good LASIK Center should be able to give an idea of what to expect. Unfortunately, there is no sure deal. Occasionally someone with smaller pupils and a low prescription will end up with larger problems at night. Some things can’t be predicted, the healing response of the corneal tissue can vary individually. Your best bet is to get a couple of opinions including one by someone without a vested interest in LASIK. That can be a little tough to find today.

    Best Wishes

  11. cristelle

    I was diagnosed with this disease a few years ago and was given the special eye drop which did minimise my pupil, however this chanfed the colour of my eye and looked even worse. Now a few years later, I feel as if it is getting worse as I can sometimes feel a pressure build up in my eye and this hurts…is this something else then? Do I need to be worried?

  12. Post

    Hi Cristelle,

    Did the drops dilate your pupils or make them smaller? There are rare reports of dilating drops being used after penetrating keratoplasty for keratoconus resulting in something called “Urrets-Zavalia syndrome.” Patients who have pigment dispersion syndrome that have this surgery can develop restrictions to the blood flow of the iris (which could end up changing the color of the iris from loss of pigment; and also lead to a pupil that is more or less fixed in the same position.

    There are possible cases reported of this occurring in patients with pigment dispersion syndrome after routine dilation.

    In either case there would presumably be an elevation in eye pressure from the pigment that typically ends up where the fluid drains out of the eye interfering with adequate drainage rates.

    If this is the case a drop to constrict the pupils and keep them from chaffing and releasing pigment could be helpful. If you are truly taking this type of drop already then I am not sure what is going on. You could let me know which drop it was, that might help answer your question better!

    Best Wishes!

  13. Maria

    I was diagnosed with Adie’s Tonic Pupil a year ago and have suffered from pretty intense pain in the tonic pupil eye. Every eye dr. and neurologist I have seen does not know the cause or a way to treat the pain. Is eye pain a cause of Adie’s and is there any way to treat it?

  14. Post

    Hi Maria,

    Pain could be from nerve damage but more likely from the increased light entering the dilated pupil. Ask your Doc about the possibility of using a low dose of pilocarpine (unusually low does since it is probably hypersensitive at this point) in the affected eye.

    Best Wishes

  15. Post

    Hi Patti,

    Astigmatism could cause small variations in the size of the pupils but it would occur in both eyes. With some forms of astigmatism, light ends up with two focal points, one in front of the retina and one behins it. Essentially people can be farsighted in one plane and nearsighted in another at the same time. The brain can direct the eyes back and forth between the different focal points trying to find a clear image. This results in pupil dilation (and constriction) since focusing automatically alters pupil size. I have never seen this but it certainly could happen. The result would not be a constant pupil dilation but more like a minor variation in size alternating fairly rapidly over time.

    Best Wishes

  16. Rick Everroad

    This is for Dr. Kisling. I am a 47 year old white male with Adies Pupil in both eyes. Contracted it in England while on active duty in the Air Force in the 90’s. I recently had an eye exam at the VA and was told I may Macular Degeneration. Is there research out there of the two being linked?


    Rick Everroad

  17. Post
    Dr. Kisling

    Hi Rick,

    As far as I know there is no known connection. Over time, the pupil dilation from Adies might allow a little more ultraviolet and blue light to enter into the eye which potentially has some effect on macular degeneration. I don’t believe it is enough to make a significant difference. You should be wearing UV and blue light protective sun-wear when out of doors irregardless.

    Best Wishes!

  18. Bob Mikulak

    I believe I have Adie’s (little old Adie’s) but have not found a doctor who can diagnose me yet. I was told by a optometrist that I need to see a neuro-optometrist. I have read that optometrists can diagnose this. Not sure if I should try a neuro-optometrist or see if a different optometrist would do the testing.

  19. Post
    Dr. Kisling

    Hi Bob,

    I would suggest that you ask around for a referral then call the office to see if they are comfortable diagnosing Adie’s. They should tell you. Most optometrists should be able to diagnose it. You really should not have to see a specialist.

    Best Wishes!

  20. Faisal

    Hi dr.

    I was diagnosed with Adie’s tonic pupil back in 2008. Since then i have had no or very less issues with my eyes. Although i was not wearing the glasses which were prescribed (far sightedness since 2006). I started using them in 2014 (irregular basis but more often). Now, since the past few days I have started having severe issues while reading on closeby things like mobiles, brochures etc.

    I was diagnosed with ATP in my right eye. Now, the closeby objects appear pretty large (which makes it easier for me to read) with my eight eye. This is with glasses or without glasses. Whereas my left eye, is giving me severe issues when i try and and read small fonts without glasses (which was fine a few days back) and even when i wear glasses, the usual font gets really optometrist is not prescribing me bifocal lenses for my right eye (which in my opinion should help me) as he says that I am not suffering from near sightedness.

    I am today going to another optometrist to check if I can have a better solution.

    The focusing is very slow in my ATP diagnosed eye but is still bearable. The left eye does react to light but I feel that it is slower than usual (as it takes a second to settle). This might be a problem due to which i have started facing difficulties while reading. I cant say that I didnt had this focus issue when I was earlier diagnosed as even then I was facing severe focusing issues due to which I stopped wearing glasses. One more reason now, can be that my ATP is fixed rather than changing slowly (in the past). But wont it affect my focusing as well?.

    I know that there is no treatment to ATP. All I want is to be able to read and look at screens as I work 24 7 with them.

  21. Julie

    Hi there,

    I was recently given a preliminary diagnosis of Adie’s syndrome by my optometrist. I am a female between 20-30 years of age, since March my left pupil has regularly constricted much more dramatically than my right causing a slightly blurred vision, a loss of night vision and some discomfort/pain. I also have regular ‘light headedness’ when standing from a sitting position and a loss of knee jerk reflexes. The pupil does not always misbehave, I have some good days without any symptoms and others where the pupil mismatch is very noticeable to my family/friends/coworkers. My optometrist tested my eye with diluted drops of some kind which made him feel comfortable in diagnosing Adie’s, however he recommended I see an ophthalmologist to confirm the diagnosis.

    I unfortunately was having a good day when I went to meet the ophthalmologist. He ran the usual tests and did a brief eye exam. He then informed me that my tests were all negative, my left pupil is naturally 2mm smaller than my right and nothing appeared out of order. His diagnosis was that I hadn’t been blinking properly and suffered from dry eyes. I showed him pictures of my pupils on a bad day but he dismissed them. My optometrist and I both disagree with his diagnosis. However, I can’t help but wonder if dry eyes can cause such symptoms? Is it common for your pupils to dilate differently if one eye is drier than the other? I am worried that my symptoms could be related to a different medical issue if it isn’t Adie’s.


  22. Post
    Dr. Kisling

    Hi Julie,

    Ipresume your right eye is the Adies pupil. I am not aware of any association between a dilated pupil on one side and dry eyes. Some medication might cause a dilated pupil in both eyes and a dry eye but not in one. You might want to get a better explanation or a third opinion. Sounds like the original doc was probably correct.

    Best Wishes!

  23. Post
    Dr. Kisling

    Hi Faisal,

    Bilateral Adie’s happens but usually it is in one eye. You might want to be looking for other causes, especially if your left eye is a little slower to react to light. There could be something else going on. I do think bifocals might help with the near work.

    Best WIshes!

  24. Bob


    First I want to say how informative this site it! I had a retinal detachment surgery on my left eye 11 days ago. I was informed everything went well, which I had not discomfort. Leaving the office after post surgery check up I was given three bottles of medication. Atropine (Dilator), Gentamycin (Steroid) , and Pred Forte (Inflammatory). I have followed instructions faithfully on administering these medications. After 7 days follow up the Doctor advised my eye was looking very good and that I can discontinue using the first two medications and only continue using Pred Forte. My left eye is still dilated 11 ays after surgery. Should I be concerned or is this to early after surgery.

    Best Regards,

  25. Post
  26. June


    I was recently diagnosed with Adie’s pupil and there is no known reason that I got it. Is it possible it was caused by an infection or virus I didn’t know I had? There was one day a few weeks before I noticed it that the affected eye was very watery but stopped after a few hours. Or could it be caused by stress in our lives that causes a reaction?


  27. Post
    Dr. Kisling

    Hi June,

    Yes it is very possible that you had a viral or bacterial infection that you were not aware of. The most common cause of Adie’s is damage to the place where the nerves for pupil constriction relay in the ciliary ganglion due to an infection. Stress is not a typical cause for Adie’s. There is a condition called Benign Episodic Unilateral Mydriasis where on pupil dilated form time to time that could be correlated with stress.

    Best Wishes!

  28. June

    Hi Dr. Kisling,

    Is it normal to feel a slight pain in or around the affected Adie’s eye every now and then?


  29. Jody

    Hi Dr. Kisling, thanks for this website! I have a permanently dilated pupil from a former tumor that compressed my 3rd cranial nerve. I tried 1% pilocarpine and the brow/headache was terrible. I then tried .1% Alphgan P but that had zero impact on the pupil. Does the pilocarpine side effects ever get better? Do you think a higher dose of Alphgan P could constrict the pupil?

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