Argyll Robertson Pupil

Argyll Robertson Pupil Definition

Argyll Robertson Pupil (ARP), also called AR Pupils, refers to small bilateral pupils that constrict when a person tries to focus on a near object but do not constrict when the eyes are exposed to light of bright intensity [1]. They react to accommodation but show no response to light.

Argyll Robertson Pupil History

ARP has been named after Argyll Robertson (1837-1909), a British Ophthalmologist [2]. In the late 19th and early 20th century, the typical signs of AR pupils indicated tertiary syphilis up to 99% of the time. Most patients were found to be involved in flesh trade. Due to this reason, the disorder was given the queer name of “Whore’s eye” or “Prostitute’s eye.”

AR pupils develop only after long periods of untreated syphilis infection.

Argyll Robertson Pupil Epidemiology

This is a rare disease and occurs only sometimes in advanced cases of syphilis and other neurological disorders [3]. As it is associated with syphilis in most cases, it is uncommon in developing countries.

Argyll Robertson Pupil Symptoms

AR Pupils are usually characterized by [4]:

  • Absence of light reflex
  • Small, irregular pupils
  • Prompt accomodation reflex
  • Possibly unequal size of the pupils
  • Slowly dilating pupils with mydriatics

The pupils are usually irregular and unequal if syphilis is the cause. Depigmentation, atrophy and loss of ciliospinal reflex are other noted problems.

It usually affects both eyes (bilateral).

What Causes Argyll Robertson Pupil?

Syphilis, a common venereal disorder caused due to the treponema pallidum spirochete, is the most common cause. Alcoholism and diabetes are other possible causes.

ARP was originally linked with tabes dorsalis [5]. The sign has now been detected in various disorders with lesions in the region of the nucleus of Edinger-Westphal. MRI studies have localized the lesion in multiple sclerosis and sarcoidosis sufferers.

Argyll Robertson Pupil Risk Factors

Syphilis sufferers have the highest susceptibility to ARP. Pseudo Argyll Robertson pupil is seen in patients of pseudotabes diabetica, pseudotabes pituitaria and third cranial nerve misdirection.

Argyll Robertson Pupil Diagnosis

A slit-lamp examination is conducted to detect signs of iris atrophy [6]. Other signs that help confirm diagnosis involves:

  • Stamping gait
  • Positive Romberg’s test
  • Charcot’s joint with hyperextensibility of joint
  • Loss of joint and vibration sense to posterior column damage

Argyll Robertson Pupil Differential Diagnosis

Differential diagnoses (ddx) should aim at finding out whether the underlying cause is syphilis or some other disorder like [7]:

  • Horner’s syndrome
  • Diabetes mellitus
  • Encephalitis
  • Dorsal mid-brain syndrome (DMS)
  • Sarcoidosis
  • Iritis
  • Lyme disease
  • Chronic Adie’s tonic pupil

Argyll Robertson Pupil Treatment

Syphilis is the primary cause of ARP and hence, should be treated immediately. Intravenous administration of Penicillin is the best method to cure almost all stages of syphilis. A 2-4 week course of Tetracsycline or Doxycycline can be used as an alternative medicine [8]. People with features of ARP should consult a healthcare professional on an immediate basis.

Argyll Robertson Pupil Prognosis

Most sufferers do well after treatment. The outcome is poorest for patients who suffer permanent nerve or cardiac damage. Life expectancy is poor due to inability to reverse these symptoms of such advanced disease.

Argyll Robertson Pupil Complications

In the later stages of ARP, following administration of treatment, patients often suffer from a problem known as the JarischHerxheimer reaction. It results from the destruction of millions of infectious organisms by antibiotic therapy. Sufferers experience:

  • Fever
  • Chills
  • Sweating
  • Headache

Argyll Robertson Pupil Prevention

There are no specific prevention guidelines for ARP as yet. However, practicing safe sex is supposed to be helpful in avoiding syphilis – the main underlying cause of ARP.

Argyll Robertson Pupil ICD9 Code

The ICD9 Codes for this condition are 094.89 and 379.45.


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