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SECO 2023: Neuro nuggets with Dr Lee


Andy Lee, MD, gives highlights from his SECO special session, "Neuro nuggets."

Andy Lee, MD, caught up with Optometry Times® to chat about his 2023 SECO special session, "Neuro Nuggets!" The special session was held during the meeting's 100 year celebration, in Atlanta, Georgia.

Editor's note: This transcript has been edited for clarity.


Hi, my name is Andy Lee, and I'm a neuro ophthalmologist from Houston, Texas. I'm happy to be here at SECO and tell you a little bit about what we talked about in our session, which is about the pupil.

And basically pupil has two features: an afferent side, which is the sensory side. And we detect that with a relative afferent pupillary defect (RAPD), and the efferent side, which is the motor side.

The motor side has two components: the parasympathetics and the sympathetics. They're part of the automatic autonomic nervous system, and one basically makes your pupil small, and one makes your pupil big.

And so any unexplained relative afferent pupillary defect demands assessment, and that usually means imaging to make sure it's not a tumor. And if you have any doubts, you should just refer that to your local friendly neuro-ophthalmologist in your area.

On the efferent side, it's much more dangerous because there are things that can kill or blind the person. And so we need to be able to recognize, triage, and refer the emergent conditions that cause different size pupils also known as anisocoria.

If it's a big pupil, that's the problem, and you have a big ptosis, the thing we're worried about is aneurysm from third nerve palsy. And if we don't detect that aneurysm, it'll rupture and the patient will die, usually within the first 30 days.

If it's a small ptosis and a small pupil, we are worried about the Horner syndrome. And in that case, we're worried about cancer in the chest —that's Pancoast tumor—or a dissection a tear in the internal carotid artery.

Both of these conditions are potentially life threatening. And so the key in differentiating part of the history for both the afferent side and the efferent side is acute and painful.

An acute painful RAPB demands immediate assessment, and acute and painful little pupil with little ptosis is a big problem. And an acute and painful big pupil with a big ptosis is a bigger problem: that's an aneurysm.

And so if you just knew those things you knew most of what we covered today at SECO.

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