Pharmacological Dilated Pupil

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Identifier pharmacological_dilated_pupil
Title Pharmacological Dilated Pupil
Creator Andrew G. Lee, MD; Saira E. Alex
Affiliation (AGL) Chairman, Department of Ophthalmology, The Methodist Hospital, Houston, Texas; Professor of Ophthalmology, Weill Cornell Medicine, New York City, New York; (SEA) Class of 2022, Baylor College of Medicine, Houston, Texas
Subject Pupil; Dilation; Adie; Pilocarpine
Description Summary I. Pharmacologic dilation of the pupils a. Defined as a large pupil dilated on the order of 10 or 11 millimeters. b. If the other eye is uninvolved, the condition is normal. II. When light is shone on the pharmacologically dilated pupil, the pupil won't do anything a. If the light is shone on the normal pupil, there will be constriction. III. Test the near reaction of the pupils. a. If the pupil is pharmacologically blocked, it won't react to either the near test or to light, it will just stay dilated. IV. Make sure it's not a third nerve palsy. a. If there's no ptosis and no motility deficit, it is not a third nerve palsy. V. Test this dilated pupil with pilocarpine. a. If it is an Adie's tonic pupil, use one quarter percent pilocarpine or 1/10 percent pilocarpine. i. If the pilocarpine low dose is negative, then use the full-strength pilocarpine of 1%. ii. If at both pilocarpine 1/10 percent and pilocarpine 1% failed to constrict his pupil, that is evidence that this pupil is pharmacologically blocked. VI. Other agents that cause pupil dilation in isolation a. Atropine agents b. Nurses: after administering inhalers c. Post-surgery patients and cruise participants: scopolamine patches d. Accidental exposures. VII. Summary: a. A pharmacologically dilated pupil is big and does not respond to light/ near test b. Rule out a third nerve palsy by identifying lack of ptosis and no movement deficit. c. Rule out Adie's tonic pupil in the acute phase by doing a 1/10 percent pilocarpine followed by a full-strength pilocarpine 1%. i. If it doesn't constrict to anything, be assured that this is a pharmacologically dilated pupil. d. Ask the patient about scopolamine use, atropine use, or inadvertent exposure e. Two things that could dilate the pupil in the garden: belladonna alkaloids and Jimsonweed f. Reassure patients that the condition will resolve over time.
Transcript So today, we're going to be talking about pharmacologic dilation of the pupils, and what that produces is usually a very large pupil like on the order of 10 or 11 millimeters. And if the other eye is uninvolved it'll be normal. So, this anisocoria is going to be greater in the light. And it's going to be greater in the light because when we shine the light on the pharmacologically dilated pupil it won't do anything versus if we shine the light on the normal pupil with a little constraint. So, when we have an anisocoria with a very large pupil and anisocoria greater in light and a pupil that's fixed like this we want to test the near reaction next. And if it's pharmacologically blocked it won't react to either near or to light, it'll just stay dilated like that. And so, if we have a light reaction that's poor or nil and the near reaction that's poor or nil and we want to see if this is pharmacologically dilated, we can test this pupil and see if it's blocked. But first you have to make sure it's not a third nerve palsy and that's easy to do because the patient's motility will not be affected if it's pharmacologically dilated and that would be straight and there can't be any ptosis. So, if there's no ptosis and no motility deficit and it's just an isolated dilated pupil. The way to test this pupil is to put pilocarpine in there. So pilocarpine is going to bind to the receptors, and if it is a Adie's tonic pupil we want to use one quarter percent pilocarpine or 1/10 percent pilocarpine, some low strength of pilocarpine, to constrict the pupil if it's demonstrating super sensitivity from a Adie's tonic pupil from up-regulation of the receptors. If the pilocarpine low dose is negative, then we want to go to the full-strength pilocarpine of 1% and at both pilocarpine 1/10 percent and pilocarpine 1% failed to constrict his pupil that is pretty good evidence that this is pharmacologically blocked. The most common things that would block a pupil and make your pupil big in isolation are the use of some type of atropine agent so that means for a nurse who might be exposed to Atrovent the inhaler and it gets in our hand because she's giving the dosage to the patient, or scopolamine patch that's used after surgeries to reduce nausea-they put it behind their ear and the patient might touch it by accident or they're using it on a cruise to reduce their nausea for the cruise. You know the malls and clinics of course we have to deal with all the drops and exposure either on purpose or accidentally to the dilating drops. So, the main things about a pharmacologically dilated pupil that you need to know are its dilated, it's big, it doesn't respond to light or near if it's completely blocked. Make sure it's not a third inner palsy eliminate that by saying there's no ptosis and no movement deficit. Make sure it's not an Adie's tonic pupil in the acute phase by doing a 1/10 percent pilocarpine followed by a full-strength pilocarpine 1%. If it doesn't constrict to anything the light the near the low dose and the full strength pilo, you can be pretty assured that this is a pharmacologically dilated pupil. And it'll probably wear off. You need to ask about scopolamine, atropine, and exposure inadvertently to two things that could dilate the pupil in the garden, that's things like the belladonna alkaloids Jimsonweed. Gardeners sometimes get exposed to these things while they're working on their plants, and the main thing is reassurance it'll just go away over time.
Date 2019-10
Language eng
Format video/mp4
Type Image/MovingImage
Collection Neuro-Ophthalmology Virtual Education Library: Andrew G. Lee Collection: https://novel.utah.edu/Lee/
Publisher North American Neuro-Ophthalmology Society
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah
Rights Management Copyright 2019. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
ARK ark:/87278/s6b6199t
Setname ehsl_novel_lee
ID 1469320
Reference URL https://collections.lib.utah.edu/ark:/87278/s6b6199t
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