Anisocoria is frequently encountered in the ophthalmology clinic and often a source of anxiety for the patient. Obtaining a detailed history and proceeding with a thorough ophthalmic examination are essential steps in establishing the correct diagnosis. The most common causes of anisocoria greater in dim light are HS and physiologic anisocoria, and the most common causes of anisocoria greater in bright light are tonic (Adie) pupil, TNP, pharmacologic mydriasis and damage to the iris sphincter muscle. A stepwise approach to the examination should help the clinician establish the most likely cause of a patient's anisocoria and pharmacologic testing, when indicated, can help confirming the diagnosis.
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