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A 73-year-old woman with a past medical history of stroke, hypertension, and end-stage renal disease, on hemodialysis, presented to the Emergency Department for altered mental status and slurred speech. On physical examination, she had a right pupillary defect in a star-like pattern, with initial concern for a blown pupil (Figure), raising suspicion for acute stroke. Her initial blood pressure was 230/110 mm Hg, and neuroimaging was unremarkable for stroke. She was admitted for hypertensive emergency.
Posterior synechiae occurs when fibrous adhesions develop between the posterior portion of the iris and the anterior capsule of the lens, causing an irregular pupil.
The most common cause is anterior uveitis, while less common etiologies can include poorly controlled hypertension, as demonstrated in this case. Multiple synechiae leads to a festooned pupil. Further progression can lead to secondary angle-closure glaucoma.