Pupillary Light Reflex - Clinical Significance

Clinical Significance

In addition to controlling the amount of light that enters the eye, the pupillary light reflex provides a useful diagnostic tool. It allows for testing the integrity of the sensory and motor functions of the eye.

Under normal conditions, the pupils of both eyes respond identically to a light stimulus, regardless of which eye is being stimulated. Light entering one eye produces a constriction of the pupil of that eye, the direct response, as well as a constriction of the pupil of the unstimulated eye, the consensual response. Comparing these two responses in both eyes is helpful in locating a lesion.

For example, a direct response in the right pupil without a consensual response in the left pupil suggests a problem with the motor connection to the left pupil (perhaps as a result of damage to the oculomotor nerve or Edinger-Westphal nucleus of the brainstem). Lack of response to light stimulation of the right eye if both eyes respond normally to stimulation of the left eye indicates damage to the sensory input from the right eye (perhaps to the right retina or optic nerve).

Emergency room physicians routinely assess the pupillary reflex because it is useful for gauging brain stem function. Normally, pupils react (i.e. constrict) equally. Lack of the pupillary reflex or an abnormal pupillary reflex can be caused by optic nerve damage, oculomotor nerve damage, brain stem death and depressant drugs, such as barbiturates.

Normally, both pupils should constrict with light shone into either eye alone. On testing each reflex for each eye, several patterns are possible.

• Optic nerve damage on one side: (Example in parens.: Left optic nerve lesion)
  • The ipsilateral direct reflex is lost (Example: when the left eye is stimulated, neither pupil constricts, as no signals reach the brain from the left eye due to its damaged optic nerve)
  • The ipsilateral consensual reflex is INTACT (because light shone into the right eye can signal to the brain, causing constriction of both pupils via the normal oculomotor nerves)
  • The contralateral direct reflex is intact (because light shone into the right eye can signal to the brain, causing constriction of both pupils via the normal oculomotor nerves)
  • The contralateral consensual reflex is lost (because light shone into the eye on the damaged side cannot signal to the brain; therefore, despite the right eye's motor pathway (oculomotor nerve) being intact, no signals from the left eye are able to stimulate it due to the damage to the sensory pathway (optic nerve) of the left eye)

• Oculomotor nerve damage on one side: (Example in parens: Left oculomotor lesion)
  • The ipsilateral direct reflex is lost (Example: when the left eye is stimulated, only the right pupil constricts)
  • The ipsilateral consensual reflex is lost (Example: when the right eye is stimulated, only the right pupil constricts)
  • The contralateral direct reflex is intact (because light shone into both eyes can still signal to the brain, and the pupil on the undamaged side will still be able to constrict via its normal oculomotor nerve)
  • The contralateral consensual reflex is intact (because light shone into the left eye can still signal to the brain via the normal optic nerve, causing attempted constriction of both pupils; the contralateral pupil constricts via its normal oculomotor nerve, but the ipsilateral pupil is unable to constrict due to its damaged oculomotor nerve)