Alternative names: Enlargement of one pupil; Pupils of different size; Eyes/pupils different size
Anisocoria is unequal pupil size. The pupil is the black part in the centre of the eye. It gets larger in dim light and smaller in bright light.
Slight differences in pupil sizes are found in up to one in five healthy people. Most often, the diameter difference is less than half a millimetre, but it can be up to one millimetre.
Babies born with different sized pupils may not have any underlying disorder. If other family members also have similar pupils, then the pupil size difference could be genetic and is nothing to worry about.
Also, for unknown reasons, pupils may temporarily differ in size. If there are no other symptoms and if the pupils return to normal, then it is nothing to worry about.
Unequal pupil sizes of more than one millimetre that develop later in life and do NOT return to equal size may be a sign of an eye, brain, blood vessel or nerve disease.
The use of eye drops is a common cause of a harmless change in pupil size. Other medicines that get in the eyes, including medicine from asthma inhalers, can change pupil size.
Other causes of unequal pupil sizes may include:
- Aneurysm in the brain
- Bleeding inside the skull caused by head injury
- Brain tumuor or abscess (such as, pontine lesions)
- Excess pressure in one eye caused by glaucoma
- Increased intracranial pressure, because of brain swelling, intracranial hemorrhage, acute stroke or intracranial tumour
- Infection of membranes around the brain (meningitis or encephalitis)
- Migraine headache
- Seizure (pupil size difference may remain long after seizure is over)
- Tumour, mass or lymph node in the upper chest or lymph node causing pressure on a nerve may cause decreased sweating, a small pupil or drooping eyelid all on the affected side (Horner syndrome)
- Diabetic oculomotor nerve palsy
- Prior eye surgery for cataracts
Treatment depends on the cause of the unequal pupil size. You should see a health care provider if you have sudden changes that result in unequal pupil size.
When to Contact a Medical Professional
Contact a provider if you have persistent, unexplained or sudden changes in pupil size. If there is any recent change in pupil size, it may be a sign of a very serious condition.
If you have differing pupil size after an eye or head injury, get medical help immediately.
Always seek immediate medical attention if differing pupil size occurs along with:
- Blurred vision
- Double vision
- Eye sensitivity to light
- Loss of vision
- Nausea or vomiting
- Eye pain
- Stiff neck
What to Expect at Your Office Visit
Your provider will perform a physical exam and ask questions about your symptoms and medical history, including:
- Is this new for you or have your pupils ever been different sizes before? When did it start?
- Do you have other vision problems such as blurred vision, double vision or light sensitivity?
- Do you have any loss of vision?
- Do you have eye pain?
- Do you have other symptoms such as headache, nausea, vomiting, fever or stiff neck?
Tests that may be done include:
- Blood studies such as CBC and blood differential
- Cerebrospinal fluid studies (lumbar puncture)
- CT scan of the head
- Head MRI scan
- Tonometry (if glaucoma is suspected)
- X-rays of the neck
Treatment depends on the cause of the problem.
Baloh RW, Jen JC. Neuro-ophthalmology. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 396.
Cheng KP. Ophthalmology. In: Zitelli, BJ, McIntire SC, Nowalk AJ, eds. Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis. 7th ed. Philadelphia, PA: Elsevier; 2018:chap 20.
Thurtell MJ, Rucker JC. Pupillary and eyelid abnormalities. In: Daroff RB, Jankovic J, Mazziotta JC, Pomeroy SL, eds. Bradley’s Neurology in Clinical Practice. 7th ed. Philadelphia, PA: Elsevier; 2016:chap 18.