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Fixed Dilated Pupil Resulting from Transdermal Scopolamine
VOL. 93, NO. 6
CORRESPONDENCE
quent and intense palinopsia and visual allesthesia when his diphenylhydantoin dosage was less than optimal. His visual disturbances were much less frequent and his electroencephalogram became normal when the dosage of his medication was increased and the diphenylhydantoin level became therapeutic. We suspect that our patient's palinopsia probably resulted from seizure activity in areas of the cortex made irritable by ischemic damage. Spread of seizure discharges to the opposite hemisphere may have resulted in the palinoptic allesthesia. Patients with these complaints may be thought to have nonorganic disease. We stress that these disorders should not be called functional until seizure activity and ischemia of the parieto-occipital region have been ruled out. PATRICIA A. E R E T T O , M . D . FREDERICK S. SCHOEN, M . D . GREGORY B . KROHEL, M . D . DOUGLAS P E C H E T T E , B . A .
Albany, New York REFERENCES 1. Bender, M. B., Feldman, M., and Sobine, A. J.: Palinopsia. Brain 91:321, 1968. 2. Bender, M. B.: Neuro-ophthalmology. In Baker, A. B., and Baker, L. H. (eds): Clinical Neurology. New York, Harper & Row, 1977, vol. 1, pp. 37 and 38. 3. Jacobs, L.: Visual allesthesia. Neurology 30:1059, 1980. 4. Bowen, S. F.: Visual disorientation in allesthesia and palinopsia. J.A.M.A. 239:56, 1978. 5. Kinsbourne, M., and Warrington, E . K.: A study of visual perseveration. J. Neurol. Neurosurg. Psychiatry 16:468, 1963.
803
blue irides, awoke with blurred vision and a nonpainful, mildly dilated pupil in the right eye. An examination 24 hours later showed that her right pupil was fixed and dilated. Her corrected visual acuity was R . E . : 6/6 (20/20) and J3 ( J l with a +2.50 bifocal) and L . E . : 6/6 (20/20) and J l . The right pupil did not constrict but the left pupil reacted normally to direct and consensual light (Table). Extraocular movements, confrontation visual fields, and optic disks were normal and no neurologic abnormalities were noted. The patient was referred here three weeks later. She recalled that 72 hours before the onset of mydriasis and blurred vision, she had applied a scopolaminecontaining disk behind her right ear. She had removed the disk four hours after her symptoms began, and her symptoms gradually resolved during the next eight days. She also reported that her left pupil had always been slightly larger than the right. On examination her corrected visual acuity in each eye was 6/4.5—1 (20/15 - 1 ) and J 1 + . No afferent pupillary defect was present and both pupils were briskly reactive to light and near stimuli (Table). Applanation tonometry values were 16 mm Hg in each eye. Color vision, extraocular movements, and visual fields by Goldmann perimetry were normal, as were the results of slit-lamp examination of the anterior segments and direct and indirect ophthalmoscopy. TABLE PUPILLARY MEASUREMENTS
Fixed Dilated Pupil Resulting from Transdermal Scopolamine Editor: Transdermal scopolamine (TransdermV) has been recently introduced as a treatment for motion sickness. One of our patients who used transdermal scopolamine developed cycloplegia and a fixed dilated pupil. The patient, a 34-year-old woman with 1
Condition At 1st examination In darkness In light In light after 1% pilocarpine At 2nd examination In darkness In light
Pupillary Diameter (mm) R. E. L. E. 6.0 5.5
5.5 4.5
5.5
3.0
5.0 2.0
6.0 2.0
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
CORRESPONDENCE
quent and intense palinopsia and visual allesthesia when his diphenylhydantoin dosage was less than optimal. His visual disturbances were much less frequent and his electroencephalogram became normal when the dosage of his medication was increased and the diphenylhydantoin level became therapeutic. We suspect that our patient's palinopsia probably resulted from seizure activity in areas of the cortex made irritable by ischemic damage. Spread of seizure discharges to the opposite hemisphere may have resulted in the palinoptic allesthesia. Patients with these complaints may be thought to have nonorganic disease. We stress that these disorders should not be called functional until seizure activity and ischemia of the parieto-occipital region have been ruled out. PATRICIA A. E R E T T O , M . D . FREDERICK S. SCHOEN, M . D . GREGORY B . KROHEL, M . D . DOUGLAS P E C H E T T E , B . A .
Albany, New York REFERENCES 1. Bender, M. B., Feldman, M., and Sobine, A. J.: Palinopsia. Brain 91:321, 1968. 2. Bender, M. B.: Neuro-ophthalmology. In Baker, A. B., and Baker, L. H. (eds): Clinical Neurology. New York, Harper & Row, 1977, vol. 1, pp. 37 and 38. 3. Jacobs, L.: Visual allesthesia. Neurology 30:1059, 1980. 4. Bowen, S. F.: Visual disorientation in allesthesia and palinopsia. J.A.M.A. 239:56, 1978. 5. Kinsbourne, M., and Warrington, E . K.: A study of visual perseveration. J. Neurol. Neurosurg. Psychiatry 16:468, 1963.
803
blue irides, awoke with blurred vision and a nonpainful, mildly dilated pupil in the right eye. An examination 24 hours later showed that her right pupil was fixed and dilated. Her corrected visual acuity was R . E . : 6/6 (20/20) and J3 ( J l with a +2.50 bifocal) and L . E . : 6/6 (20/20) and J l . The right pupil did not constrict but the left pupil reacted normally to direct and consensual light (Table). Extraocular movements, confrontation visual fields, and optic disks were normal and no neurologic abnormalities were noted. The patient was referred here three weeks later. She recalled that 72 hours before the onset of mydriasis and blurred vision, she had applied a scopolaminecontaining disk behind her right ear. She had removed the disk four hours after her symptoms began, and her symptoms gradually resolved during the next eight days. She also reported that her left pupil had always been slightly larger than the right. On examination her corrected visual acuity in each eye was 6/4.5—1 (20/15 - 1 ) and J 1 + . No afferent pupillary defect was present and both pupils were briskly reactive to light and near stimuli (Table). Applanation tonometry values were 16 mm Hg in each eye. Color vision, extraocular movements, and visual fields by Goldmann perimetry were normal, as were the results of slit-lamp examination of the anterior segments and direct and indirect ophthalmoscopy. TABLE PUPILLARY MEASUREMENTS
Fixed Dilated Pupil Resulting from Transdermal Scopolamine Editor: Transdermal scopolamine (TransdermV) has been recently introduced as a treatment for motion sickness. One of our patients who used transdermal scopolamine developed cycloplegia and a fixed dilated pupil. The patient, a 34-year-old woman with 1
Condition At 1st examination In darkness In light In light after 1% pilocarpine At 2nd examination In darkness In light
Pupillary Diameter (mm) R. E. L. E. 6.0 5.5
5.5 4.5
5.5
3.0
5.0 2.0
6.0 2.0
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