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Uneven Pupils upon waking in the morning (resolves)
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Uneven Pupils upon waking in the morning (resolves)

Hello,

I am trying to get to the bottom of an ongoing issue I am encountering each morning.  When I first wake up each morning, my left pupil is almost always slightly larger than the right (approximately 10-15% larger).  It seems to dilate and and shrink when exposed to/removed from a light source, however it does not seem to constrict as efficiently as the right when I use a flashlight in a dark room.

Peculiarly enough, the issue seems to resolve itself within a couple hours of being awake and moving around/walking etc.  On rare occasions, the larger pupil will return in either eye in the afternoon, but it is rare and never lasts long.

I have been Dx with a migrainal (a non-headache type) condition which has caused some dizziness (more of a detached, spacey feeling).  Only other thing to note is that I had sudden onset of many dark and light floaters 2 months ago.  I saw a neuro-opthomalogist and a neuro-otologist/ENT and radiologist.  Ete Dr said I was fine, and the ENT said I have hyper nervous system tendencies which are migraine in nature.

I am on some anxiety and anti-depressant meds (Buspirone, Imipramine, and Clonazepam).

I was unable to reproduce the unequal pupils in the opth's office exam (of course, right?)  :)

Does this at all sound like something normal or should I be concerned of something like Marcus Gunn Pupil (Afferent Pupillary Defect)?  Any information you can tell me would be of much help!
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Avatar_dr_f_tn
Hi,
How are you? Anisocoria or unequal pupil size may be due to genetic or underlying medical conditions. If there are no other symptoms present and if the pupils return to normal, then there is nothing to worry about. Other causes of unequal pupil sizes may include: aneurysm, bleeding inside the skull caused by head injury or abscess, excess pressure in one eye caused by glaucoma, infection, migraine headache, seizure (pupil size difference may remain long after seizure is over) and even tumor or mass. Treatment depends on the cause of the unequal pupil size. If it persists, further evaluation may need to be done. Take care and best regards.
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Avatar_m_tn
Hello - thank you.  I am doing well other than a little bit if nervousness about this condition.  :)

I am trying to perform the swinging flash light test on myself and though difficult to see completely, I can see that my left pupil does not seem to respond to the light as efficiently as the does the right.  What should I look for with using lights on and off my eyes?
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Avatar_dr_f_tn
Hi,
The pupillary light reflex is a reflex that controls the diameter of the pupil when a light falls on the retina of the eye. Greater intensity of light causes the pupil to become smaller and allows less light in.While lower intensity light causes the pupil to become larger and allows more light in. If it persists, I recommend that you check with your eye doctor for proper evaluation and to ease any worry. Warm regards.
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Avatar_m_tn
Will do - thank you.  I have a follow up in about a month or so with a neuro-opth.  He did check my eyes once already and said there were no signs of problems.  I just have a hard time reproducing this effect other than in the mornings upon first waking.  I was unable to produce the symptom in my first visit.  My only other symptom is a slight off-balance feeling which i tend to have 24/7.

Regards,
DrumD8on
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Avatar_dr_f_tn
Were you able to check with an ENT specifically with this off-balance feeling? If your previous ENT's hyper nervous system tendencies which are migraine in nature, is a bit vague, you may also try to have a second opinion on this.  What tests were done? Some conditions like anemia may also be the cause. Take care.
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Avatar_m_tn
Yes, thanks.  I did see an ENT and neuro-otologist along with the audiologist's barrage of tests.  I assume they found nothing inner ear as they noted nothing.  The hyper NS Dx seemed a bit fishy to me as well.  I do follow up with him in a cpl weeks as well so I will be asking.  The meds he gave me (an anti-depressant and panic disorder meds haven't really altered the feeling yet - though I have only been on them for 3 days now). My sort of "dizziness" is quite mild, but very annoying - almost a disconnected, spacey feeling. It was originally preceded by very brief, rare bouts of vertigo and a middle ear infection, however that is gone and the vertigo type spells never seem to occur now, just the constant off balance feeling 24/7.

I also notice faint crackling or rustling sounds in my left ear in the morning if I use muscles to move my ears and close my eyes tightly, and a feeling of fluid behind the ear after I do things like Yoga and my body temp rises a bit when I roll over to my right side at the end of the session.  I even get an occasional myclonus effect in the left ear when certain sounds are going on in bed.  It triggers a low and slight rumble - even over background noise with the TV on etc.  My wife was lightly snoring one morning and I had the rumble echoing her snoring.  This rumbling has only happened on 2 or 3 occasions. I am wondering if there is some issue with eustachian tube on my left side along with the pansinus disease they found on MRI.  This still doesn't explain my pupils, but then again, as I write this, they have resolved to equal sizes and light responses.  It is really strange it only happens in the morning!

I appreciate your help!
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Avatar_dr_f_tn
It is indeed very interesting to note that only your left eye and ear are affected. However, issues with the eustachian tube may have shown up in the MRI. Although tinnitus or perception of sound within the ear is common, it can also result from a range of underlying causes from aging to side effect of certain medications. It is difficult to measure this using objective tests because of its subjectivity. Additional tests may need to be done to determine the possible cause.  Although it is odd to note of these symptoms in the morning, a careful investigation with the help of a journal wherein you can write the symptoms occurrences may help until your follow-up.  The effect of the medications may not be felt at this time but  after a few days more. Glad to be of help in some way and do keep us posted.
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Avatar_m_tn
I wondered about that showing up on the MRI as well.  I think they were initially looking to rule out things like tumors or lesions perhaps because my dizziness and some other strange symptoms, but instead found horrible pan sinus disease which appears to be chronic.  Unfortunately, the radiologist's report was extremely brief and gave very little details except for pan sinus disease as the Dx.  I did have swine flu late last year along with two upper respiratory episodes and occasional bouts with sinus drainage/infections a couple months before the dizziness which set in this Feb.

I have heard that MRI's can be notoriously inaccurate in showing true blockages and possibly distorting other things as inflammation in the sinus cavities, and that instead, a CT scan would be more ideal for determining this.  Do you know if this is true?  I am no expert, but I just remember reading that a couple times.

Glad you mentioned the journal too. I have been keeping a very detailed one for a couple weeks now.  I am hoping that between my neuro-opth and neuro-oto/ENT we can get to the bottom of this.

One of the very frustrating things is that many of my doctors, including my Primary Care Phys like to attribute all of this to stress and anxiety.  I know I certainly had some of that for a while when this all began, but it is really more of a question of what came first - the off-balance feeling or the anxiety.  I am relatively confident that the dizziness was first and then, naturally, I got worried when I read all the things it could be (MS, tumors, CNS problems, etc).

I am hoping the meds really help soon.  This is not making for a fun year so far.  :)

I really appreciate your help in taking time to respond.  It is nice to know there are people like yourself with such generosity to help others with questions and such.  It is much appreciated!
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Avatar_dr_f_tn
Hi,
How are you? A CT Scan provides good details about bony structures while MRI is indicated to visualize detailed internal structure and limited function of the body. It would really depend on the extent of the blockage, the reader's subjective evaluation, symptomatology and other factors as well in the decision to what diagnostic imaging modality is used. Wishing you all the best! Take care always.
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Avatar_m_tn
Thanks again,

I emailed my ENT/neuro-otologist last night and asked about the Eustachian tubes as a possibility since my most noticeable symptom is still the sounds in my left ear inthe morning. I also notice I can not ever seem to 'pop' them using the swimmer's technique by gently forcing air while pinching the nostrils.  The left side never pops and I only notice pressure changes in the right.  I may also push to have a CT scan with him or through my primary physician to check things further.

All in all, I seem to be doing much better the last couple days.  I tend to forget or not notice the off balance feeling.  I am wondering if this is my eyes/ears beginning to compensate or of the meds are just masking things.

This has certainly been a rollercoaster of symptoms that came on and left.  I have accpeted that I may never know, really, however I feel I should keep asking until I feel better about the Dx.

Thank you so much.

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Avatar_dr_f_tn
Hi,
It is good to know that you are feeling much better the past few days. The medications may be working well if you do not experience the off balance feeling now. While it is true that acceptance is the first step in the treatment.  But continue to be vigilant with your health. Work together with your doctors in finding the cause. Warm regards.
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Avatar_m_tn
I was just reading this thread about your unequal pupils.  I realize its a few years old and I hope your eyes are better.  I just wanted to mention that years ago I started taking prozac and I would get intermittent drastically unequal pupils followed by massive panic attacks.  The pupil problem went away a time after I stopped taking Prozac.  I dont currently take any SSRI.  So it could just be the medication you are on...
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Avatar_f_tn
Hi, I just read ur post, I don't know if anyone answered ur question because I didn't read all the answers here. However, different size pupils are associated with a head concussion. Also, Horner's syndrome is the pupils and the migraines. My dad had those floaters in his eyes, he has been diabetic for 26 years, and it seemed they would settle while sleeping, and rustle up more and more as the day progressed. He went to an eye specialist and they extracted the fluid from his eyes. They said it was from the blood vessels in his eye dying or hardening. My 2 month old had different sized pupils and I'm trying to get to te bottom of it. That how I stumped upon ur post...
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