Adie’s tonic pupil

The clinical eponym for ciliary neuropathy or ganglionopathy. Importantly, this condition produces a supersensitivity to direct cholinergic agonists via denervation effects! Weak (dilute) pilocarpine (a direct cholinergic agonist) will causes pupillary constriction in an Adie's tonic pupil because it is super sensitive to even weak pilocarpine. Whereas in other conditions, there will be no response, meaning the pupil remains dilated. To further assess for the presence of an Adie’s tonic pupil, instill weak (0.1%) pilocarpine (a direct-acting cholinergic agonist), which will produce pupillary constriction in an Adie’s tonic pupil. If the larger pupil doesn’t react to light, near accommodation, or weak pilocarpine, instill concentrated (1%) pilocarpine. If the pupil reacts to 1% pilocarpine, an oculomotor palsy or iris abnormality is possible. If the larger pupil doesn’t react to 1% pilocarpine, a pharmacologic blockade from a parasympatholytic agent is possible.