Title : Holmes adie tonic syndrome- A diagnostic challenge
Abstract:
A 22-year-old gentleman presented with a history of blurry vision and light sensitivity in both eyes. He had difficulty reading for the past two months. He denied any history of hyperhidrosis or anhidrosis. Clinical examination revealed that the basal diameter of both pupils was larger, with an absent reaction to light. The near vision reaction showed extended latency and slow contraction speed. A slit lamp examination revealed bilateral, irregular, oval-shaped pupils. Pupillography performed with the instillation of diluted (0.0625%) pilocarpine solution resulted in more than 50% constriction of both pupils. Achilles tendon and knee reflexes were absent bilaterally. A starch iodine test revealed normal sweating, excluding Adie's pupil associated with partial dysautonomia such as Ross and Harlequin syndromes. He was evaluated for infectious, autoimmune, and paraneoplastic causes, all of which returned normal results. Contrast-enhanced MRI of the brain and spine was normal. A contrast-enhanced computed tomography (CECT) scan of the chest, abdomen, and pelvis to search for any tumors was also normal. Laboratory tests, including cerebrospinal fluid examination with venereal disease research laboratory test (VDRL) for Neurosyphillis, peripheral nerve conduction, and autonomic function assessments, were normal. He was diagnosed with idiopathic Holmes-Adie syndrome, highlighting the involvement of both eyes in a male, which is uncommon, and the need for comprehensive neurological and ophthalmological investigation to rule out secondary causes.
