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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.
FigureRight festooned pupil in the shape of a star due to multiple posterior synechiae.
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.
The uniqueness of this case was the symmetrical appearance of the pupillary defect. This finding can be misinterpreted as sequelae of acute stroke, leading to unnecessary neuroimaging.
References
Kaiser P
Friedman N
Pineda R
Iris and pupils.
The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. Saunders Elsevier,
4th ed. New York2014: 257-263 (4th ed)
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