<prompt> Homer syndrome is characterized by all EXCEPTMiosisPtosisAnhidrosisExophthalmos  <response>: D. i.e. Exophthalmos 356 - Khurana 4thHORNERS SYNDROME - Oculosympathetic palsyClinical features Mild ptosis usually 1- 2 mm as a result of weakness of mullermuscles Slight elevation of the inferior eyelid as a result of weakness of inferior tarsal muscle narrowed palpebral fissure Miosis - resulting from unopposed action of the sphincter pupillae with resultant anisocoria which is accentuated in dim light. Since the Homer pupil will not dilate like its fellow Normal reactions to light and near Reduced ipsilateral sweating Anhidrosis but only if the lesion is below the superior cervical ganglion because the fibres supplying the skin of the face run along the external carotid artery Slight enophthalmos due to loss of tone of muller muscle Hypochromic - heterochromia irides of different colour- Homer is lighter may be seen if the lesion is congenital or long standing The pupil is slow to dilate Less important sign include - hyperactive accommodation, ocular hypotony and conjunctival hyperaemia Hirschbergs test is used for squint Jones test is used to detect - Nasolacrimal duct block Swinging flash light test is used to examine pupilCauses of Horners Syndrome 806 -Kansi 6th1. Centralfirst order neuron2. Pre- ganglionicsecond order neuron4. Post ganglionicthird order neuron Brainstem disease tumour, vascular demyelination Syringomyelia Lateral medullary Wallenberg syndrome Spinal cord tumour Diabetic autonomic neuropathy Pancoast tumour Carotid and aortic aneurysm and dissection Neck lesions glands trauma. Post surgical Cluster headache ICA dissection Nasopharyngeal tumour Otitis media Cavernous sinus mass 