Uneven pupils are a sign most consistent with which condition?

• A. Pseudotumor cerebri.
• B. Conjunctival injection.
• C. Normal pupil size.
• D. Increased intracranial pressure.

Answer: (D)

Unequal pupils signal a possible cranial nerve III impairment from rising intracranial pressure, which can occur when the brain is under pressure and may herniate. As ICP increases, the uncal portion of the temporal lobe can press on the third nerve, causing the pupil on the affected side to dilate and respond poorly to light. This neurologic sign points to a serious intracranial process rather than a local eye issue or a normal pupil, making increased intracranial pressure the best match. Pseudotumor cerebri is a cause of raised ICP, but the key clue here is the anisocoria due to nerve compression.