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• W2896962164 abstract "Anisocoria is a relatively common condition that is characterized by unequal pupil size and affects up to 20% of the normal population.1Lam B.L. Thompson H.S. Corbett J.J. The prevalence of simple anisocoria.Am J Ophthalmol. 1987; 104: 69-73Abstract Full Text PDF PubMed Scopus (91) Google Scholar As causes of anisocoria range from benign conditions such as physiologic anisocoria to life-threatening emergencies such as a carotid artery dissection or third nerve palsy, careful clinical evaluation is essential for establishing a diagnosis and management plan. We present a case of acute onset anisocoria where the diagnosis was established based on a careful medical history, clinical presentation, and pharmacological testing. A systemic approach to the diagnosis of anisocoria is then presented. A 69-year-old woman presented with a dilated left pupil (Fig.1) which was noticed the previous day by a family member. She complained of trouble focusing on near objects and photophobia. She denied a history of trauma, pain, ptosis, diplopia, and other focal neurological deficits. Best corrected visual acuity was 20/30 in each eye. Intraocular pressures were 13 and 14mm Hg in the right and left eye respectively. Right pupil constricted from 5mm in the dark to 3mm in the light; left pupil measured 8mm in the dark and only minimally constricted to 7.5mm with light. There was no reverse relative afferent pupillary defect. Right pupil constricted to 3mm at near but the size of the left pupil did not change on near testing. Anterior segment examination was normal with no signs of sectoral iris paresis or intraocular inflammation. There was no ptosis and extraocular movements were full in each eye. Fundus examination was within normal limits in each eye. Dilute pilocarpine (0.125%) was instilled in each eye and resulted in no change in pupil size in either eye. Pilocarpine 1% was then instilled, resulting in constriction of the right pupil to 1mm but no change in the size of the left pupil. The patient was questioned regarding possible instillation of any pharmacological drops or coming into contact with any topical medications which she denied. Observation was recommended at that point. The patient was re-assessed 3days later. Now both pupils were measuring 5mm in the dark constricting to 3mm with light (Fig.2). The patient was further questioned in detail regarding any possible interaction with cholinergic agents. She recalled that she had been gardening prior to presentation. When asked about what plants she has in her garden, she recalled pruning a plant in her garden which she knew as “upside-down flower.” A Google search revealed this to be a plant species known as Brugmansia versicolor (Fig.3).Fig.3Angel’s trumpet flowers.View Large Image Figure ViewerDownload Hi-res image Download (PPT) This is a species of plant in the Solanaceae family, commonly known as angel’s trumpet or upside-down flower, due to their distinguishing characteristic of large drooping flowers which hang upside-down. Brugmansia versicolor is poisonous if ingested in large quantities as it contains alkaloids, including atropine, scopolamine, and hyoscyamine. Symptoms of toxicity can include hallucinations, dry mouth, muscle weakness, increased blood pressure and heart rate, fever, dilated pupils, confusion and paralysis.2Griffin W.J. Lin G.D. Chemotaxonomy and geographical distribution of tropane alkaloids.Phytochemistry. 2000; 53: 623-637Crossref PubMed Scopus (203) Google Scholar The diagnosis of pharmacologic dilation was made and the patient was discharged in good health with no further follow-up required. The assessment and management of anisocoria is challenging for many clinicians given the breadth and potential morbidity of the underlying diagnosis. However, a systematic approach to history and special testing will help one arrive at a correct diagnosis quickly in most cases, avoiding the need for costly and invasive investigations. A careful history of the onset and chronicity of the anisocoria is useful in determining the underlying etiology. Old photographs are helpful for this purpose. Chronic anisocoria with no associated symptoms points to a benign process, such as physiologic anisocoria. Abrupt onset, with associated neurological symptoms is more worrisome. Presence of headache, ptosis, diplopia, numbness, weakness, or ataxia warrant evaluation for more life-threatening causes including trauma, intracranial mass, aneurysm, or carotid dissection. A complete ophthalmic history including pharmacological history is also important. Previous surgeries, uveitis, and eye trauma must be questioned. A history of microvascular disease, cancer, head and neck surgery, or demyelinating disease may also point to a specific etiology. A review of topical medications and exposures can indicate less common causes of anisocoria, such as in our case. Physical examination will further localize the cause of anisocoria. Ocular adnexa should be surveyed for clinical associations of anisocoria. Ptosis and ocular misalignment would suggest an oculomotor nerve palsy. The presence of proptosis can point to an underlying orbital process. Pupillary assessment is critical in the evaluation of anisocoria. The first step is evaluation of pupillary size in light and dark conditions. Anisocoria being greater in the dark suggests a problem in the sympathetic pathway which will result in the abnormal pupil being unable to dilate, thus being smaller in the dark. Horner’s syndrome is the most important entity to diagnose in such cases, and testing with apraclonidine 0.5–1% is warranted. Apraclonidine is a strong alpha-2 adrenergic and weak alpha-1 adrenergic agonist. It will cause mild constriction of the normal pupil due to its strong alpha-2 activity and will cause dilation of the abnormal pupil, where denervation will result in hypersensitivity to alpha-1 stimulation. Therefore, apraclonidine causes reversal of the anisocoria in the presence of Horner’s syndrome. Denervation hypersensitivity takes 24–48hours to develop; therefore, in the acute phase false negatives may occur.3Freedman K.A. Brown S.M. Topical apraclonidine in the diagnosis of suspected Horner syndrome.J Neuroophthalmol. 2005; 25: 83-85Crossref PubMed Scopus (45) Google Scholar It is important to note that apraclonidine should not be used in children younger than 2years of age, as alpha-agonists carry a risk of respiratory depression in infants. Instead, 4% cocaine drops should be used for diagnosing Horner’s syndrome in this age demographic.4Watts P. Satterfield D. Lim M.K. Adverse effects of apraclonidine used in the diagnosis of Horner syndrome in infants.J AAPOS. 2007; 11: 282-283Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Cocaine inhibits the reuptake of norepinephrine in the post-synaptic space. After instillation of cocaine in each eye, the normal eye will dilate from the retention of norepinephrine in the synaptic space. However, in the eye with sympathetic dysfunction there is deficiency of norepinephrine in the synapse, and therefore the expected mydriasis will be absent. It should be noted that the cocaine test has fallen out of favor because of the difficulties in obtaining and storing the substance and because the results are often difficult to interpret.5Kardon R, Trobe J. Pupil disorders, is pharmacological testing necessary? NANOS 2010 Annual Meeting; February 27–March 3, 2016; Tucson, AZ. 〈www.nanosweb.org/files/Controversies.in.Neuro.Ophthalmology.pdf〉. AccessedGoogle Scholar Alternatively, anisocoria that is greater in light implies that the abnormal pupil is unable to constrict in response to light. This suggests a lesion in the parasympathetic pathway. The most important lesion to rule out in this scenario is an oculomotor nerve palsy. In patients with an oculomotor nerve palsy, impaired extraocular motility and variable degree of ptosis will be expected. It should be remembered that oculomotor nerve palsy cannot present with an isolated dilated pupil.5Kardon R, Trobe J. Pupil disorders, is pharmacological testing necessary? NANOS 2010 Annual Meeting; February 27–March 3, 2016; Tucson, AZ. 〈www.nanosweb.org/files/Controversies.in.Neuro.Ophthalmology.pdf〉. AccessedGoogle Scholar The next step in the diagnostic algorithm if the anisocoria is greater in the light is to look for the presence of Adie’s tonic pupil. Adie’s pupils are hypersensitive to dilute pilocarpine because of denervation hypersensitivity of parasympathetic receptors of the iris sphincter. Thus, instillation of dilute pilocarpine (0.125%) drop in each eye will result in the constriction of an Adie’s tonic pupil but will not affect a normal pupil.5Kardon R, Trobe J. Pupil disorders, is pharmacological testing necessary? NANOS 2010 Annual Meeting; February 27–March 3, 2016; Tucson, AZ. 〈www.nanosweb.org/files/Controversies.in.Neuro.Ophthalmology.pdf〉. AccessedGoogle Scholar, 6Bourgon P. Pilley F.J. Thompson H.S. Cholinergic supersensitivity of the iris sphincter in Adie’s tonic pupil.Am J Ophthal. 1978; 85: 373-377Abstract Full Text PDF PubMed Scopus (44) Google Scholar If there is no response to the dilute pilocarpine, full-strength pilocarpine (1–4%) can be instilled. Only a pupil that has been pharmacologically dilated will not respond to the instillation of full-strength pilocarpine Figure4. The algorithm for the work-up of anisocoria as described above, along with a thorough history, identified toxic pharmacological mydriasis as the cause of the dilated pupil in our case. Mydriasis from Brugmansia versicolor has been reported in the literature only three times.7Firestone D. Sloane C. Not your everyday anisocoria: angel’s trumpet ocular toxicity.J Emerg Med. 2007; 33: 21-24Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 8Van Der Donck I. Mulliez E. Blanckart J. Angel’s trumpet (Brugmansi arborea) and mydriasis in a child—a case report.Bull Soc Belge Ophthalmol. 2004; 292: 53-56PubMed Google Scholar, 9Andreola B. Piovan A. Da Dalt L. Filippini R. Cappeletti E. Unilateral mydriasis due to angel’s trumpet.Clin Toxicol. 2008; 46: 329-331Crossref PubMed Scopus (29) Google Scholar In each case, the diagnosis was made using the same diagnostic process provided above, avoiding costly, invasive, and unnecessary further investigations." @default.
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• W2896962164 title "Gardening and dilated pupils: an interesting case of anisocoria from Brugmansia versicolor" @default.
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