Horner syndrome: clinical perspectives

Figures & data

Figure 1 Right Horner syndrome in a 65-year-old man. Note right-sided upper lid ptosis, right miosis, and “upside-down” ptosis (ie, elevation) of right lower lid.

Figure 2 Drawing showing the anatomy of the oculosympathetic pathway.

Notes: Sympathetic fibers in the posterolateral hypothalamus pass through the lateral brain stem and to the ciliospinal center of Budge and Waller in the intermediolateral gray column of the spinal cord at C8–T1. Preganglionic sympathetic neurons exit from the ciliospinal center of Budge and Waller and pass across the pulmonary apex and ascend up the carotid sheath to the superior cervical ganglion. The postganglionic sympathetic neurons originate in the superior cervical ganglion and travel up the wall of the internal carotid artery. Once the fibers reach the cavernous sinus, they travel with the abducens nerve before joining the ophthalmic division of the trigeminal nerve and entering the orbit with its nasociliary branch. From here, they divide into two long ciliary nerves to reach the iris dilator muscle. Copyright © 1978 Wolters Kluwer. Reproduced with permission from. Glaser JS, editor. Neuro-ophthalmology. 1st ed. Hagerstown MD, USA: Harper & Row; 1978.¹³³
Abbreviations: a, artery; n, nerve.

Figure 3 (A) Cadaver dissection showing oculosympathetic fibers (S) attaching (lower arrow) to the abducens nerve (VI) within the cavernous sinus. After running with the nerve for a short distance, they separate from the nerve (upper arrow) and join with the first division of the trigeminal nerve (V₁) to enter the orbit.

Notes: II, optic nerve; III, oculomotor nerve; V, trigeminal ganglion. Copyright © 1978 Wiley-Liss, Inc. Adapted with permission from Parkinson D, Johnston J, Chaudhuri A. Sympathetic connections to the fifth and sixth cranial nerves. Anat Rec. Wiley Publishers. 1978;191:221–226.⁴⁹ (B) Artist’s drawing showing that the post-ganglionic oculosympathetic fibers briefly travel with the abducens nerve (VI) before joining the ophthalmic division (V₁) of the trigeminal nerve. Thereafter, the sympathetic fibers enter the orbit with its nasociliary branch. Copyright © 2005, Lippincott Williams. Adapted with permission from Kardon R. Anatomy and physiology of the autonomic nervous system. In: Miller NR, Biousse V, Kerrison JB, editors. Walsh and Hoyt’s Clinical Neuro-Ophthalmology. 6th ed. Baltimore, MD, USA: Lippincott-Williams & Wilkins; 2005.¹³⁴
Abbreviations: ON, optic nerve; ICA, internal carotid artery.

Figure 4 Infant with right Horner syndrome, demonstrating ipsilateral upper lid ptosis, “upside-down” ptosis of the lower lid, and anisocoria, with the right pupil smaller than the left. Both pupils reacted briskly to light stimulation.

Figure 5 Cocaine Testing for Horner Syndrome.

Notes: (A) Right Horner syndrome in a 72-year-old man. Note right ptosis and anisocoria with the smaller pupil on the right side. Both pupils reacted briskly to light stimulation. (B) After topical administration of 10% cocaine drops in both eyes, there is marked dilation of the left pupil but the right pupil dilates only very slightly. This response indicates that the patient has a right Horner syndrome.

Figure 6 Apraclonidine Testing for Horner Syndrome.

Notes: (A) Left Horner syndrome in a 25-year-old man. Note left ptosis and anisocoria with the smaller pupil on the left. Both pupils reacted briskly to light stimulation. (B) Forty-five minutes after topical instillation of 1% apraclonidine in both eyes, there is reversal of anisocoria, with the right pupil now smaller than the left. Note also improvement in the left-sided ptosis.

GlaserJSNeuro-ophthalmology1st edHagerstown MD, USAHarper & Row1978

 Google Scholar

ParkinsonDJohnstonJChaudhuriASympathetic connections of the fifth and sixth cranial nervesAnat Rec1978191221226666018

 PubMedGoogle Scholar

KardonRAnatomy and physiology of the autonomic nervous systemMillerNRBiousseVKerrisonJBWalsh and Hoyt’s Clinical Neuro-Ophthalmology6th edBaltimore, MD, USALippincott-Williams & Wilkins2005649714

 Google Scholar