An Overview of Adie's Pupil

Close up of a person's eye

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Adie’s pupil (also referred to as Holmes-Adie syndrome, Adie’s tonic pupil or Adie syndrome) is a neurological disorder that affects the pupil of the eye and the autonomic nervous system. Patients with Adie's pupil are predominantly females between the ages of 20 and 40.


People with Adie's pupil usually develop several distinct symptoms. The pupil of the affected eye first appears larger or more dilated than the normal eye and reacts abnormally to light. Initially, the pupil reacts slowly or irregularly during close tasks such as reading because the eye begins to lose its close-range focusing power. After extended near focusing or accommodation, the involved pupil may actually become tonic, remaining constricted long after discontinuing accommodative effort. Occasionally, the iris becomes depigmented, losing most or all of its color. Deep tendon reflexes, such as the classic hammer-to-knee reflex, may also be diminished in those patients that have systemic dysautonomia. Blurred vision, especially at close range, is another common symptom of the disorder, as well as excessive sweating.


The exact cause of Adie's pupil is unknown. There are many potential causes, including a type of bacterial or viral infection that damages the nerves, but often Adie's pupil is idiopathic, meaning it has no known cause.


Your eye doctor will ask you several questions to determine when your pupil size difference or blurry vision became noticeable. Your doctor will most likely conduct a comprehensive eye examination. This will include shining a very bright light into your eyes to test your pupil reactions. Your doctor may also instill special diagnostic eye drops to assess the location in the nerve pathway that problems may be occurring. You may or may not be referred to a neuro-ophthalmologist for more testing.


Standard treatment for Adie's pupil usually includes prescribing a bifocal or reading glasses to help with near focusing issues. A drug called pilocarpine is sometimes prescribed to reduce the pupil size in people dealing with night driving glare or light sensitivity. Brimonidine, a glaucoma drug, has also been used to reduce pupil size. Excessive sweating can be treated with a surgical procedure called thoracic sympathectomy. Unfortunately, loss of deep tendon reflexes tends to be permanent.


About 50% of people with Adie's pupil recover fully within 2 years. In some people, the affected pupil becomes smaller than the normal pupil, and in others, the near pupillary response never fully recovers.


Though Adie’s pupil is not a life-threatening disease, it can be debilitating. Adie's pupil causes premature loss of near-focusing power similar to presbyopia, a condition that occurs around the age of 40. As a result, it can be difficult for a younger patient because one eye focuses just fine and the other does not. Some people may complain of extreme light sensitivity. Others may have a difficult time with night vision or driving at night. Some people with the disorder find that the excessive sweating causes quality of life issues.

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Article Sources

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  1. Sarao MS, Sharma S. Adie Syndrome. [Updated 2019 Nov 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.

  2. Sinharoy U, Chakraborty D, Saha S, Mukherjee J. Isolated dilated pupil: Is it adies pupil? Archives of Medicine and Health Sciences. 2016;4(2):233. doi:10.4103/2321-4848.196211

Additional Reading

  • Slmovits, Thomas L and Ronald Burde. Neuro-ophthalmology. Year Book Europe Ltd, 1994.