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The man in black with headache, photophobia and fixed pupils
  1. Marcel M M Bulder1,
  2. Jan van Gijn2
  1. 1Resident in Neurology and PhD Student, Department of Neurology, University Medical Centre Utrecht, Utrecht, The Netherlands
  2. 2Emeritus Professor of Neurology, University Medical Centre Utrecht, Utrecht, The Netherlands
  1. Correspondence to Dr M M M Bulder, Department of Neurology, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands; m.m.m.bulder{at}

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Bilaterally fixed pupils suggest different associations in different circumstances. With a drowsy patient in the accident and emergency department it is transtentorial herniation and the need for a neurosurgeon that springs to mind, but the possibilities are more diverse in patients with normal vision who patiently wait their turn in the outpatient department. A nurse who tampered with atropine? A gardener or a child that played in the garden? A pinealoma? Neurosyphilis? Cocaine? Or what?

The story

A 41-year-old man was referred to our outpatient clinic by an ophthalmologist. His symptoms had started 1 month earlier with an itchy, burning sensation in both eyes. Initially he did not pay much attention, mainly because he could see normally and his partner could not see anything wrong with his eyes. Two weeks later he developed a slowly worsening headache behind the eyes, worse when looking into bright light. Because he found that shade and dim light improved his headache, he started wearing sunglasses during the day (figure). He visited his general practitioner who found dilated and unreactive pupils.

Ophthalmological assessment confirmed bilateral dilated pupils (6–8 mm), unreactive to light. Pilocarpine 0.125% did not constrict the pupils, but pilocarpine 1% did. As the ophthalmologist could not find an explanation for the fixed pupils, the patient was referred to our department.

His headache and photophobia were by then stable. He did not report double vision, slurred speech, difficulty swallowing, weakness, sensory deficits or gait disturbance. In 1988 (22 years beforehand) he had been treated for Hodgkin's lymphoma stage IIIA with chemotherapy and splenectomy, and he had remained in complete remission. Three months …

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  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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