Bilateral Horner's syndrome: detection and occurrence
a Diabetes Day Centre,
Guy's and St Thomas' Hospital Trust, London, UK, b Department of Neuro-Ophthalmology, National
Hospital for Neurology and Neurosurgery, London, UK
Correspondence to: Professor S E Smith, Department of Neuro-Ophthalmology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
Received 2 April 1998 and in revised form 23 July 1998;
Accepted 10 August 1998
OBJECTIVE
To develop a
method for the detection of bilateral Horner's syndrome in patients
with bilateral interruption of the cervical sympathetic pathway or
widespread autonomic neuropathy.
METHODSDarkness
pupil diameters and redilatation times during light reflexes have been
recorded with infrared TV pupillometry in 65 healthy subjects, 47 patients with unilateral Horner's syndrome, and 20 patients with
bilateral Horner's syndrome. The aetiologies of the last group were
diabetic autonomic neuropathy (three cases), amyloidosis (four), pure
autonomic failure (PAF) (four), dopamine-
-hydroxylase deficiency
(two), and one case each of hereditary sensory and autonomic neuropathy
(HSAN) type III, carcinomatous sympathetic neuropathy, familial
dysautonomia, multiple system atrophy, Anderson-Fabry disease, and
anterior spinal artery thrombosis at C5,6 and one had had bilateral
cervical sympathectomies.
RESULTSDarkness
diameters on the affected side were below normal in 12 patients with
unilateral Horner's syndrome, the measurement yielding only 26%
sensitivity for detection of the condition. By contrast, the time taken
to reach three quarter recovery in the light reflex (T3/4)
was abnormally prolonged (redilatation lag) in 33 of the same eyes. The
measurement yielded 70% sensitivity and 95% specificity for detection
of the condition. In 20 cases, diagnosed on clinical grounds as having
bilateral Horner's syndrome of various aetiologies, pupil diameters
were abnormally small on both sides in five and on one side in three
patients. Fourteen of these patients had significant redilatation lag
in both eyes, five patients in one eye, and one patient had it in
neither eye. Measurement of redilatation lag was therefore a more
sensitive diagnostic test than pupil diameter in both unilateral and
bilateral Horner's syndrome.
CONCLUSIONSProvided
that the pupils are not tonic, bilateral Horner's syndrome can be
diagnosed on the basis of redilatation lag. It occurs clinically in
some generalised autonomic neuropathies and with interruption of the
local sympathetic nerve supplies to the two eyes.
© 1999 by Journal of Neurology, Neurosurgery, and Psychiatry
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