1. The use of automated photo-analysis of pupil size in different levels of ambient illumination to aid diagnosis of Horner syndrome Simon Barnard PhD FCOptom FAAO FEAOO DipClinOptom DipCLP DipTh(IP) Department of Optometry & Visual Science, Hadassah Academic College, Jerusalem Paper presented by Menachem Salasnik BSc(Hons) MCOptom CIDC

2. Disclosure Dr Simon Barnard is a Director & Chief Medical Officer of IRISS Medical Technologies a partner company of Volk Optical

3. Hand held device that captures and fully automates the analysis and display of diagnostic eye data including pupil size Automated Photo-Ophthalmic Device

4. How accurate is the device ? Accuracy of corneal diameter (“white to white”)  < 1.0% of structure being measured compared to a range of topographers ( Oculus, Nidek, Zeiss and Medmont) Rosen C, Ramdass S, Norman C, Buckingham R (2015), BCLA conference, UK

5. The distribution of anisocoria in a group of unelected patients attending a primary care optometry practice Barnard S, Yashiv Y, Maor R, Levit A, Johnson E (2015) 31 st Annual Pupil Colloquium, Oxford Purpose To analyse the distribution of anisocoria amplitude of a cohort of patients attending a primary care optometry practice for an eye examination using a hand held automated photo-ophthalmic device

6. Method Data were captured from 143 consecutive patients aged between 2 and 91 years attending a London optometry practice for an eye examination Patients were unselected in terms of abnormal eye conditions The ambient lighting conditions during the capture sessions were the same for every patient

7. Results Average anisocoria for this population was 0.17mm with a standard deviation of 0.15mm 10% had at least 0.40mm and 4% had at least 0.50mm with the largest anisocoria being 0.70mm.

8. The findings of this study are broadly in line with previously published findings (Hashemi et al (2009) If 0.40mm is taken as the clinical cut off to define anisocoria, a further 21% had a difference that is just below the threshold Hashemi H, Khabazkhoob M, Mehravaran S, Mohammad K, Foutouhi H (2009) Distribution of photopic pupil diameter in the Tehran eye study. Curr Eye Res. May;34(5):378-85.

9. Conclusions In this study, 10% of the study population showed anisocoria of at least 0.40mm The patients in this population appeared to present as entirely normal and are presumed to have had no neurological issues that might affect pupil size

10. Over a 12 month period in primary care optometry practice in London 4 cases Horner in babies and young children 1 acquired adult Horner secondary to neck surgery In all cases, the difference in size of anisocoria under two ambient light levels in the practice was documented Horner cases

11. Horner Case #1 Congenital Horner syndrome 5 month-old infant Mother concerned by left pupil appearing larger in room light More noticeable over last two or three months Emergency C-section + forceps

12. Anisocoria 0.22 mm Light level 80 (bright ) Total relative ptosis OD MRD1 + MRD2 = 0.87mm Bright ambient light level 80

13. Light level 66 (dim ) Anisocoria 1.04 mm Total relative ptosis OD MRD1 + MRD2 = 0.61mm Bright ambient light level 67

14. Horner Case # 2 Acquired Horner secondary to neck surgery 59 year-old female presented 1 week following neck surgery worried about lid appearance RE 30 Anisocoria 0.27 mm at light index 85

15. Anisocoria 0.37 mm at light index 67 Barnard S et al (2014) Automated documentation, using Volk Eye Check, of acquired Horner's syndrome following surgical anterior cervical decompression, AAO, Denver, USA

16. Conclusion Automated photo-analysis of pupil size can detect changes in the amount of anisocoria in two lighting levels

17. Thank you and best wishes from London simon.barnard@irissmedical.com