Unilateral mydriasis from ipratropium in transplant patients

Anisocoria after scopolamine transdermal patch contamination: A case report

RATIONALE

We report a case of anisocoria that occurred after contamination with a scopolamine transdermal patch, and introduce a diagnostic approach for anisocoria patients.

PATIENT CONCERNS

A 35-year-old woman with no past ophthalmologic history presented to the ophthalmology department complaining of a dilated pupil in the right eye. Corrected visual acuities was 20/20 in both eyes, and the intraocular pressures were 20 and 18 mm Hg in the right and left eye, respectively. The anterior chambers in both eyes were unremarkable on slit-lamp examination. The pupil size was 5.0 mm in the right eye and 2.0 mm in the left eye, and the extraocular muscles of both eyes were intact.

DIAGNOSIS

The patient neither did present with facial anhidrosis nor did she present with ptosis. Furthermore, as we did not observe dilatation lag in the smaller pupil, we applied 1% apraclonidine in the left eye in order to rule out Horner syndrome and did not observe dilatation of the pupil. We then applied 0.125% and 1% pilocarpine to exclude oculomotor nerve palsy; however, it could not be ruled out as constriction of pupil to 3.1 mm in the right eye was observed after applying 1% pilocarpine. Moreover, upon further investigation, we discovered that the patient had a scopolamine transdermal patch applied for 2 days prior to the clinic visit.

INTERVENTIONS

Artificial tears were administered and the patient was observed and monitored.

OUTCOMES

The pupil size in the right eye gradually decreased to 4.5 mm on the second day of observation and to 3.6 mm on the fourth day of observation.

LESSONS

A detailed history of the use of medications such as scopolamine patches in patients with unilateral dilated pupils without vision loss is of utmost importance. We report the exclusion of important diseases using pilocarpine and apraclonidine hydrochloride. It was confirmed that improvement naturally occurs over time.

"Don't Believe Your Eyes" Ipratropium Induced Mydriasis: A Case Report and Review of the Literature

Unilateral fixed mydriasis can be an ominous sign; however in many cases, it is benign and represents pharmacologic mediated action on the iris dilator or sphincter. Differentiation between pharmacologic mediated anisocoria and physiologic anisocoria can be challenging but may save on costly imaging. An 83 year-old woman was admitted with critical limb ischemia and subsequently developed respiratory failure treated with positive pressure ventilation and ipratropium nebulizers. She was noted to have left unilateral mydriasis without other neurologic deficits. Brain magnetic resonance imaging with MR angiography showed no evidence for a mass lesion or posterior communicating artery aneurysm. Her anisocoria self-resolved within 36 hours after nebulizer treatments were stopped. Ipratropium bromide is one of the most common medications used in the hospital setting and should be consider as a possible etiology when examining patients with unilateral mydriasis in the absence of other neurologic findings.

Unilateral pupillary mydriasis from nebulized ipratropium bromide: A false sign of brain herniation in the intensive care unit

Although there are many causes of anisocoria in the intensive care setting, the development of unilateral mydriasis in patients with intracranial hemorrhage or tumor is a neurological emergency, as it may herald the onset of uncal herniation. We describe two patients with a hemiparesis from neurosurgical disorder who subsequently developed a fixed and dilated pupil. The pupillary abnormality was caused by nebulized ipratropium bromide in both cases, and resolved when the medication was discontinued. Nebulized ipratropium may leak from the mask into ipsilateral eye and cause mydriasis in patients with facial weakness. This benign cause of anisocoria in the intensive care setting is distinguished from uncal herniation by the laterality of neurologic findings, and lack of mental status change, ptosis, and extraocular movement impairment.

Unilateral mydriasis secondary to ipratropium bromide in a critically ill patient

Unilateral dilated pupil in a critical patient under sedation is an important clinical sign that requires prompt evaluation. An exhaustive assessment must be performed, including neurological examination and imaging tests, and pharmacological causes must be ruled out. We describe a case of unilateral fixed dilated pupil secondary to the administration of a nebulized cholinergic antagonist, ipratropium bromide, in an unconscious patient.

The dilated pupil: an update

The dilated pupil can present a significant challenge to the clinician. Although in most cases a complete history and physical examination is sufficient to make an accurate diagnosis, selected patients will require further investigation, including pharmacologic testing and neuroimaging. This review outlines the physiology, clinical features, and diagnostic approach to the most important causes of the dilated pupil. Particular attention is given to recent publications on this topic.