- Email: [email protected]
Epiphora after Irradiation of Medial Eyelid Tumors
804
A M E R I C A N JOURNAL O F O P H T H A L M O L O G Y
In this patient, the unilateral mydriasis and cycloplegia suggested finger-to-eye contamination with scopolamine as the cause. The patient had no known contact with plants, cosmetics, perfumes, or medicines associated with pupillary dilatation except for the scopolamine. The relative inability of 1% pilocarpine to constrict the affected pupil confirmed the diagnosis of pharmacologic mydriasis. Transderm-V is a flexible disk 1 . 5 cm in diameter and 0 . 2 mm thick. It consists of a drug reservoir separated from the skin by a microporous rate-controlling membrane, an adhesive that provides contact between the membrane and the skin, and a backing layer of polyester film. The disk is placed against the postauricular skin and delivers 0 . 5 mg of scopolamine into the systemic circulation during a threeday period. Oral, parenteral, and topical administration of scopolamine are known to cause mydriasis and cycloplegia and blurred vision has been reported after transdermal use of scopolamine. Chiaramonte recently reported unilateral mydriasis on the side where transdermal scopolamine had been placed, but did not describe any cycloplegic effects or any test for pharmacologic mydriasis. Because life-threatening intracranial disease may be associated with a fixed dilated pupil, physicians and patients should be aware that transdermal scopolamine, an increasingly popular drug, may cause this condition. 2
3
4
6
DAVID D . VERDIER, M . D . JOHN S. KENNERDELL, M . D .
Pittsburgh,
Pennsylvania
REFERENCES 1. Transdermal scopolamine for motion sickness. Med. Lett. Drugs Ther. 23:89, 1981. 2. Thompson, H. S., Newsome, D. A., and Loewenfeld, I. E.: The fixed dilated pupil. Sudden iridoplegia or mydriatic drops? A simple diagnostic test. Arch. Ophthalmol. 86:21, 1971. 3. Weiner, N.: Atropine, scopolamine, and related antimuscàrinic drugs. In Oilman, A. C , Good-
JUNE, 1982
man, L. S., and Gilman, A. (eds.): The Pharmacologic Basis of Therapeutics, 6th ed. New York, Macmillan, 1980, p. 123. 4. Price, N. M., Schmitt, L. G., McGuire, J . , Shaw, J. E., and Trogough, G.: Transdermal scopolamine in the prevention of motion sickness at sea. Clin. Pharmaeol. Ther. 29:414, 1981. 5. Chiaramonte, J. S.: Cycloplegia from transdermal scopolamine. N. Engl. J. Med. 306:174, 1982.
Epiphora After Irradiation of Medial Eyelid Tumors Editor: In their article, "Epiphora after irradiation of medial eyelid tumors" (Am. J . Ophthalmol. 9 2 : 8 4 2 , 1 9 8 1 ) , N. B. Call and R. A. N. Welham referred to a problem that is also germane to the southern hemisphere. In this area the incidence of eyelid cancer is high and radiotherapists refer cases to their ophthalmologic colleagues shortly after treatment. One interesting phenomenon sometimes noted at this early stage can occasionally be reversed with medical therapy. In these cases, everting the lower punctum with a cotton-wool applicator and examining it under magnification discloses intense edema of the proximal portion of the canaliculus. The lumen is occluded and the swollen tissue may even protrude into the punctum, becoming obvious even on a cursory examination with the biomicroscope. Many small superficial hemorrhages can accompany this condition. These patients respond to intensive topical corticosteroid therapy, given for several weeks, and complete resolution of epiphora can occur. Amelioration of symptoms does not occur in patients without this appearance. In view of these features, early referral to the ophthalmologist and close scrutiny of the punctum may make surgery unnecessary. FRANK P. ENGLISH, F . R . C . S .
Brisbane,
Australia
A M E R I C A N JOURNAL O F O P H T H A L M O L O G Y
In this patient, the unilateral mydriasis and cycloplegia suggested finger-to-eye contamination with scopolamine as the cause. The patient had no known contact with plants, cosmetics, perfumes, or medicines associated with pupillary dilatation except for the scopolamine. The relative inability of 1% pilocarpine to constrict the affected pupil confirmed the diagnosis of pharmacologic mydriasis. Transderm-V is a flexible disk 1 . 5 cm in diameter and 0 . 2 mm thick. It consists of a drug reservoir separated from the skin by a microporous rate-controlling membrane, an adhesive that provides contact between the membrane and the skin, and a backing layer of polyester film. The disk is placed against the postauricular skin and delivers 0 . 5 mg of scopolamine into the systemic circulation during a threeday period. Oral, parenteral, and topical administration of scopolamine are known to cause mydriasis and cycloplegia and blurred vision has been reported after transdermal use of scopolamine. Chiaramonte recently reported unilateral mydriasis on the side where transdermal scopolamine had been placed, but did not describe any cycloplegic effects or any test for pharmacologic mydriasis. Because life-threatening intracranial disease may be associated with a fixed dilated pupil, physicians and patients should be aware that transdermal scopolamine, an increasingly popular drug, may cause this condition. 2
3
4
6
DAVID D . VERDIER, M . D . JOHN S. KENNERDELL, M . D .
Pittsburgh,
Pennsylvania
REFERENCES 1. Transdermal scopolamine for motion sickness. Med. Lett. Drugs Ther. 23:89, 1981. 2. Thompson, H. S., Newsome, D. A., and Loewenfeld, I. E.: The fixed dilated pupil. Sudden iridoplegia or mydriatic drops? A simple diagnostic test. Arch. Ophthalmol. 86:21, 1971. 3. Weiner, N.: Atropine, scopolamine, and related antimuscàrinic drugs. In Oilman, A. C , Good-
JUNE, 1982
man, L. S., and Gilman, A. (eds.): The Pharmacologic Basis of Therapeutics, 6th ed. New York, Macmillan, 1980, p. 123. 4. Price, N. M., Schmitt, L. G., McGuire, J . , Shaw, J. E., and Trogough, G.: Transdermal scopolamine in the prevention of motion sickness at sea. Clin. Pharmaeol. Ther. 29:414, 1981. 5. Chiaramonte, J. S.: Cycloplegia from transdermal scopolamine. N. Engl. J. Med. 306:174, 1982.
Epiphora After Irradiation of Medial Eyelid Tumors Editor: In their article, "Epiphora after irradiation of medial eyelid tumors" (Am. J . Ophthalmol. 9 2 : 8 4 2 , 1 9 8 1 ) , N. B. Call and R. A. N. Welham referred to a problem that is also germane to the southern hemisphere. In this area the incidence of eyelid cancer is high and radiotherapists refer cases to their ophthalmologic colleagues shortly after treatment. One interesting phenomenon sometimes noted at this early stage can occasionally be reversed with medical therapy. In these cases, everting the lower punctum with a cotton-wool applicator and examining it under magnification discloses intense edema of the proximal portion of the canaliculus. The lumen is occluded and the swollen tissue may even protrude into the punctum, becoming obvious even on a cursory examination with the biomicroscope. Many small superficial hemorrhages can accompany this condition. These patients respond to intensive topical corticosteroid therapy, given for several weeks, and complete resolution of epiphora can occur. Amelioration of symptoms does not occur in patients without this appearance. In view of these features, early referral to the ophthalmologist and close scrutiny of the punctum may make surgery unnecessary. FRANK P. ENGLISH, F . R . C . S .
Brisbane,
Australia