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Show Journal of Neuro- Ophthalmology 20( 2): 100- 101, 2000. © 2000 Lippincott Williams & Wilkins, Inc., Philadelphia Anisocoria Associated With the Medical Treatment of Irritable Bowel Syndrome Jonathan D. Nussdorf, MD, and Eric L. Berman, MD A case of anisocoria associated with oral pharmacologic treatment of irritable bowel syndrome is reported. A 26- year- old woman developed sudden onset of anisocoria and compromised accommodation that lasted 2 days after the use of oral scopolamine methylbromide for treatment of irritable bowel syndrome. The anisocoria and compromised accommodation occurred after contamination of the ocular surface after administration of scopolamine methylbromide and resolved within 1 week without further contamination. Oral preparations used for the pharmacologic treatment of irritable bowel syndrome can cause anisocoria due to anticholinergic pharmacologic blockade of the iris sphincter muscle. Key Words: Anisocoria- Anticholinergic agent- Irritable bowel. CASE REPORT A 26- year- old woman generally in good health noted a dilated pupil and blurred vision OS while applying makeup on the morning of the examination. She stated this was her first episode of blurred vision, and she had never noticed a dilated pupil in the past. Ocular history was significant for dry eyes, for which she had undergone silicone plug placement. She was taking birth-control pills, loratadine, and scopolamine methylbromide, an anticholinergic for the management of irritable bowel syndrome, which she started 1 month before presentation. She denied trauma to the head or ocular region, headache, diplopia, or orbital pain. Corrected visual acuity was 20/ 20 OD and 20/ 25 + 1 OS, with normal near vision OU. Motility was full and symmetric without diplopia or ptosis. There was no relative afferent pupillary defect, and the anisocoria was greater in light than dark, with the left pupil reacting from 8 to 7 mm and the right pupil reacting from 7 mm to 5lA mm. The pupils responded briskly to light and accommodation. Results of the slit- lamp examination were unremarkable, and there was no vermiform iris movement. Results of a fun- Manuscript received December 14, 1999; accepted March 3, 2000. From the Department of Ophthalmology ( JDN), Ochsner Clinic, New Orleans, Louisiana; and the Department of Neuro- ophthalmology & Oculoplastics ( ELB), The Eye Consultants and Manatee Eye Clinic, Sarasota, Florida. Address correspondence to Jonathan D. Nussdorf, MD, Ochsner Clinic, Department of Ophthalmology, Glaucoma Service, 1514 Jefferson Highway, New Orleans, LA 70121. dus examination were normal, and there were sharp optic nerve heads. The anisocoria persisted after two doses of pilocarpine 0.1% instilled OU. The differential diagnosis of anisocoria in this patient included 1) newly recognized physiologic anisocoria, 2) Adie tonic pupil, or 3) pharmacologic blockade. The patient was contacted 2 days after her initial examination, and she reported that the symptoms of blurred vision for near tasks and anisocoria had resolved. Upon further questioning, the patient recounted the events that led to her presentation. The night before, she went through her usual routine of washing her face, removing eye makeup, and breaking a tablet of scopolamine methylbromide ( 20 mg) before taking her nightly dose. She recalled that she took the medication before removing her eye makeup. Results of an ocular examination conducted 1 week after the initial presentation were unremarkable, and there was full resolution of anisocoria. The patient was instructed to thoroughly clean her hands immediately after taking the nightly dose of scopolamine methylbromide. She has not had a recurrent episode of anisocoria or blurred vision over a 2- year period since instituting strict hand washing after the breaking of the scopolamine methylbromide tablet. DISCUSSION We believe this case of anisocoria was due to inadvertent inoculation of the ocular surface with anticholinergic residue from manually splitting the scopolamine methylbromide tablet, which resulted in pharmacologic TABLE 1. Antispasmodic anticholinergic medications used in the treatment of irritable bowel syndrome and bladder spasms Brand name Anticholinergic agent Arco- Lase Plus, urised Atropine sulfate, Hyoscyamine sulfate Bentyl Dicyclomine hydrochloride Ditropan Oxybutynin chloride Donnatal Atropine sulfate, hyoscyamine sulfate, scopolamine hydrobromide Kutrase, Levsin Hyoscyamine sulfate Pamine Scopolamine methylbromide Robinul Glycopyrrolate 100 ANISOCORIA ASSOCIATED WITH IRRITABLE BOWEL SYNDROME 101 blockade of the iris and ciliary body. We found this presentation of an oral medication causing unilateral pupil dysfunction surprising, and we want to call attention to this possibility when evaluating anisocoria. In this particular patient, the presence of punctal plugs may have added to the effectiveness of inoculation by increasing the contact time of the medication with the ocular surface. Inadvertent installation of anticholinergic medications can result in pharmacologic blockade and anisocoria and previously has been reported with scopolamine patches for treatment of motion sickness and with inadvertent administration of eye drops ( 1,2). The medical treatment for irritable bowel syndrome often includes the use of agents that have anticholinergic properties ( 3). Table 1 lists the most common medications that possess anticholinergic activity because they contain natural belladonna and synthetics alkaloids, including atropine sulfate, hyoscyamine sulfate, and scopolamine hydrobro-mide ( 4). It is important for the ophthalmologist to be familiar with these medications and to look for them in the workup of an otherwise unexplained fixed and dilated pupil. REFERENCES 1. Thompson SH, Newsome DA, Loewenfeld IE. The fixed dilated pupil: sudden iridoplegia or mydriatic drops? A simple diagnostic test. Arch Ophthalmol 1971; 86: 21- 7. 2. Slamovits TL, Glaser JS. The pupils and accommodation. In: Gla-ser JS, Sergott RC, Linberg JV, eds. Duane's clinical ophthalmology. Vol. 2. Philadelphia: Lippincott, Williams & Wilkins, 1998: 1- 28. 3. Dalton CB, Drossman DA. Diagnosis and treatment of irritable bowel syndrome. Am Fam Physician 1997; 55: 875- 80. 4. Arky R. Physician's desk reference. 53rd ed. Montvale, NJ: Medical Economics Company, 1999. / Neuro- Ophthalmol, Vol. 20, No. 2, 2000 |
