In Adie's tonic pupil, the dilated pupil shows which characteristic response to pharmacological testing?

• A Constricts with 1% pilocarpine but not 0.1% pilocarpine
• B Constricts with dilute (0.1%) pilocarpine due to denervation supersensitivity ✓
• C Dilates paradoxically with pilocarpine due to sphincter fibrosis
• D No response to either concentration of pilocarpine

Explanation

Adie's tonic pupil results from postganglionic parasympathetic denervation of the ciliary ganglion. The denervated iris sphincter develops denervation supersensitivity to cholinergic agents. Dilute pilocarpine 0.1% (which does not constrict a normal or pharmacologically dilated pupil significantly) causes prompt constriction of the Adie's pupil, confirming denervation supersensitivity. A normal pupil requires 1% pilocarpine for constriction. This pharmacological test distinguishes Adie's pupil from pharmacological mydriasis (no response to dilute pilocarpine).

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

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