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Show Title: A Case Series of Mydriasis from an Anticholinergic Antiperspirant Authors: Aileen Antonio MD1, Inna Bondira DO2, Cameron Holicki DO2, Christopher Glisson DO1, Tatiana Deveney MD3, Lina Nagia DO2 Trinity Health Saint Mary’s, Hauenstein Neurosciences, Grand Rapids, MI Michigan State University, Department of Neurology and Ophthalmology, East Lansing, MI 3 University of Michigan, Department of Ophthalmology, Ann Arbor, MI 1 2 Take home points: • Pharmacologic etiology should be considered when the degree of mydriasis is worse in bright light conditions, especially when there are no associated extraocular and lid abnormalities or iris synechiae. • Pharmacologic eyedrop tests may be helpful in diagnosing the underlying cause of anisocoria • Taking a careful history and examination may save a patient from unnecessary testing and anxiety. • When taking the history, clinicians must work toward establishing an effective therapeutic relationship with the patient and family by demonstrating sensitivity to issues related to body image and self-esteem. Introduction: Causes of anisocoria span a wide range, from benign to life threatening, making it a common indication for Neuro-Ophthalmology referrals. One such cause is related to pharmacologic mydriasis due to direct or systemic exposure. We present a case series of four patients with different presentations of pharmacologic mydriasis due to a new anticholinergic medication. The diagnosis was hindered by the fact that some patients hesitated to disclose their medical history of axillary hyperhidrosis and their use of a prescription cloth wipe intended for its use. Body: Case 1: A 14-year-old female started using contact lens a month prior to consultation. Two days later, she started having episodes of variable anisocoria and bilateral pupillary dilation that lasted several days. She did not have any other associated symptoms, except for slight photophobia. There was no history of trauma. She did not disclose any other medical history or medication use. Vision was 20/20 bilaterally (OU) at distance and near. Ocular motility was full and there was no ptosis. Her pupils were nonreactive to light at 8.5 mm. Slit lamp and fundus exams were normal. Pharmacologic testing with 1% pilocarpine eyedrops did not elicit a pupillary response to light or near stimulus. Case 2: A 16-year-old female presented to the neuro-ophthalmology clinic after a single episode of a dilated left pupil and blurred vision lasting approximately 48 hours three months prior to her visit. She thought her symptoms were related to a new pair of contact lenses and had since worn her glasses without further recurrence. She denied any associated symptoms, trauma, medical history, or medication use. She has been using contact lens since age 11. The patient presented a phone photograph illustrating a mydriatic right pupil. Vision was 20/20 OU at distance and near. Ocular motility was full, and pupils were isocoric, round, and reactive to light and accommodation. There was no relative afferent pupillary defect (RAPD). Examination of the anterior and posterior segments was normal. Case 3: A 38-year-old female was seen in the neuro-ophthalmology clinic for three episodes of blurred vision accompanied by a dilated, nonreactive left or right pupil. Episodes began one month prior to the appointment, each one approximately two weeks apart and lasting one to two days. The patient provided photographs demonstrating the variable nature of her anisocoria (Figure 1A and 1B). She was a contact lens user and did not have any other significant medical issues. Vision was 20/20 OU at distance and near. Ocular motility was full, pupils were isocoric, round, and reactive to light and accommodation without an RAPD. Slit lamp and fundus examinations were normal. Case 4: A 20-year-old female presented to the emergency department with photosensitivity and a larger left pupil, which she noted in the mirror earlier the same day. There were no other visual or systemic symptoms, trauma, substance or medication use, or significant ocular or medical history. The ophthalmology service was consulted. Her visual acuity was 20/20 OU at near. Her pupils measured 5 mm to 3 mm with direct pupillary light reflex in the right eye and 9 mm to 8 mm in the left eye. No RAPD was noted. Ocular motility was full without any ptosis. Slit lamp and dilated fundus exam were normal. Computed tomography angiography (CTA) of the head and neck was normal. Further history revealed that the first three patients had a diagnosis of primary axillary hyperhidrosis, for which they had been prescribed a newly Food and Drug Administration (FDA)-approved topical glycopyrronium cloth wipe, Qbrexza™, an anticholinergic agent that targets peripheral sweat glands (1). The fourth patient admitted to using her roommate’s prescription cloth earlier in the day. All four patients were educated about the potential for ocular exposure while using this product and reported complete resolution of pupillary and visual issues on follow-up. Figure 1 (Case 3): A: First episode, showing a mydriatic, nonreactive right pupil. B: Second episode two weeks later, showing a mydriatic nonreactive left pupil. Discussion: A careful and systematic examination is vital in differentiating innocuous versus life-threatening causes of anisocoria. First, the clinician must determine which of the pupils is abnormal. Anisocoria greater in light suggests that the mydriatic/larger pupil is abnormal, since the parasympathetic fiber is affected (1). One of the main concerns of the neurologist is a compressive pupil-involved oculomotor palsy that is usually caused by an aneurysm of the posterior communicating artery, which can be evaluated with neurovascular imaging with computerized tomography angiography (CTA) or magnetic resonance angiography (MRA) (2). In the absence of other findings, such as ptosis and extraocular muscle involvement, anisocoria is unlikely to be due to a pupil-involving third nerve palsy (1). Conversely, pharmacologic anisocoria is much more common in cases of mydriasis with an otherwise normal exam and can often be identified by failure of the pupils to constrict to 1% pilocarpine drops, as seen in Case 1 of our series. Well-known agents of pharmacologic mydriasis include the scopolamine patch, inhaled ipratropium, and plant toxins such as Jimson weed, and Angel’s trumpet (3-6). Although there have been case reports of anisocoria due to topical glycopyrronium preparations for hyperhidrosis (7-9), this is the first report of inadvertent ocular exposure to the prescription glycopyrronium cloth, Qbrexza™, in the neurologic literature. Glycopyrronium cloth (Qbrexza™) is a topical anticholinergic agent that competitively blocks acetylcholine receptors in peripheral sweat glands, thereby reducing sweat production (10). This product was approved by the FDA in June 2018 for patients ≥ 9 years old as an alternative treatment for primary axillary hyperhidrosis (10). The mydriatic effect of topical glycopyrrolate was first demonstrated in a 1996 study on rabbits, showing its potential as a quick and longlasting mydriatic agent (11). Similarly, the most common adverse events during clinical trials were mydriasis (6.8% vs 0% in placebo) and blurred vision (3.5 % vs 0 % in placebo) (10). Conclusion: Our case series illustrates a well-known mechanism of pharmacologic anisocoria via a less wellknown agent, glycopyrronium cloth (Qbrexza™). The clinical presentation can be quite variable and exam findings can be normal in the office or in the emergency room, making the diagnosis more elusive as clinicians have to rely on the patient’s reported history. As more pharmacologic agents are incorporated into commercial beauty and hygiene products, clinicians must obtain a careful medication history to include all modes of application. References (AMA): 1. Gross JR, McClelland CM, Lee MS. An approach to anisocoria. Curr Opin Ophthalmol. 2016;27(6):486‐492. doi:10.1097/ICU.0000000000000316 2. Elmalem VI, Hudgins PA, Bruce BB, Newman NJ, Biousse V. Underdiagnosis of posterior communicating artery aneurysm in noninvasive brain vascular studies. J Neuroophthalmol. 2011;31(2):103‐109. doi:10.1097/WNO.0b013e3181f8d985 3. Thiele EA, Riviello JJ. Scopolamine patch-induced unilateral mydriasis. Pediatrics. 1995;96(3 Pt 1):525. 4. Camkurt MA, Ay D, Akkucuk H, Ozcan H, Kunt MM. Pharmacologic unilateral mydriasis due to nebulized ipratropium bromide. Am J Emerg Med. 2011;29(5). doi:10.1016/j.ajem.2010.06.007 5. Thompson HS. Cornpicker's pupil: Jimson weed mydriasis. J Iowa Med Soc. 1971;61(8):475‐477. 6. Havelius U, Asman P. Accidental mydriasis from exposure to Angel's trumpet (Datura suaveolens). Acta Ophthalmol Scand. 2002;80(3):332‐335. doi:10.1034/j.16000420.2002.800319.x 7. Panting KJ, Alkali AS, Newman WD, Sharpe GR. Dilated pupils caused by topical glycopyrrolate for hyperhidrosis. Br J Dermatol. 2008;158(1):187‐188. doi:10.1111/j.1365-2133.2007.08261.x 8. Johnson C, Smereck J. Unilateral mydriasis due to a topical "anti-sweat" preparation. J Emerg Med. 2013;44(3):673‐674. doi:10.1016/j.jemermed.2012.09.021 9. Micieli R, Micieli JA. Dilated Pupil in a Patient With Hyperhidrosis. JAMA. 2019;322(3):264‐265. doi:10.1001/jama.2019.8589 10. Nwannunu CE, Limmer AL, Coleman K, et al. Glycopyrronium Tosylate (Qbrexza) for Hyperhidrosis. Skin Therapy Lett. 2019;24(2):1‐3. 11. Varssano D, Rothman S, Haas K, Lazar M. The mydriatic effect of topical glycopyrrolate. Graefes Arch Clin Exp Ophthalmol. 1996;234(3):205‐207. doi:10.1007/BF00462034 |
