Unilateral Mydriasis Due to Hemorrhoidal Ointment

Polomsky, Matej; Smereck, Janet

doi:10.1016/j.jemermed.2009.05.018

Cited by 17 publications

(4 citation statements)

References 36 publications

(43 reference statements)

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“…In addition, anisocoria has been reported in the emergency room with unintended eye contact after use of a hemorrhoidal cream (Polomsky & Smereck, 2012). Anisocoria has also been reported with selective serotonin-reuptake inhibitors (Barrett, 1994;Falavigna, Kleber, Teles, & Molossi, 2010) and diphenhydramine (Delaney, 1980).…”

Section: Anisocoriamentioning

confidence: 99%

Anisocoria and an Array of Neurologic Symptoms in an Adult With Ewing Sarcoma

Laroche¹

2017

JADPRO

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Ms. M, a 50-year-old female, reported a progressive 2-year history of sacral pain that became severe in the 2 to 3 months prior to her diagnosis of Ewing sarcoma (ES) and was initially evaluated by her gynecologist. Her presenting symptoms included urinary retention and impaired bowel function. Evaluation via magnetic resonance imaging (MRI) revealed a 6-cm sacral mass consistent with a chordoma. Biopsy of the lesion led to the diagnosis of a high-grade small round blue cell tumor. High Ki67 index and CD-99 positivity supported a diagnosis of ES (Machado et al., 2009; Rocchi et al., 2010). The patient required urgent hospitalization for pain control, and repeat imaging demonstrated a 4-cm increase in the size of the sacral mass in the 1-month scan interval. Repeat biopsy was performed quickly, and chemotherapy was begun urgently when this biopsy revealed an EWSR1 translocation, confirming the diagnosis of ES (Machado et al., 2009). No disease was found outside of the pelvis on imaging, and her ES was staged as grade 3, cT2b,Nx,Mx. For Ms. M, medical oncology recommended curative-intent chemotherapy with dose-dense CAV-IE (cyclophosphamide, doxorubicin [Adriamycin], vincristine, ifosfamide, and etoposide). The CAV-IE regimen alternates between CAV and IE every 14 days for 14 planned cycles, requiring growth factor support (Bacci et al., 2007; Jain & Kapoor, 2010; Womer et al., 2012). On day 4 of her first cycle of CAV chemotherapy treatment, Ms. M was noted to have some fine-motor tremors and dysmetria (inability to properly direct or limit motions), which were attributed to rapid upward titration of gabapentin for pain. Ms. M also had worsening of her initial symptoms of sacral nerve compression during the initial hospital admission, requiring self-catheterization to urinate and digital stimulation to enable bowel movements. Radiation oncology was consulted. The goal of radiation therapy was definitive local control, with the hope of preserving and possibly improving bowel and bladder function.

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Section: Anisocoriamentioning

confidence: 99%

Anisocoria and an Array of Neurologic Symptoms in an Adult With Ewing Sarcoma

Laroche¹

2017

JADPRO

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“…Once this has been ruled out, Adie's tonic pupil must be considered. Other causes of mydriasis and accommodative failure include temporal lobe epilepsy, 1 migraine, 2,3 use of topical and systemic medications, [4][5][6] or exposure to plant toxins. 7,8 …”

Section: Differential Diagnosismentioning

confidence: 99%

A 15-year-old girl with variable anisocoria

Coleman¹,

Tomsak²

2014

Digit J Ophthalmol

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HistoryA 15-year-old young woman presented with a 4-month history of variable anisocoria and fluctuating blurred vision. Past medical history was significant for migraines, which were well controlled by amlotriptan. She denied a history of trauma, use of topical medications, or a worsening or change in her headaches. She also denied having visual phenomenon associated with her previous headaches. ExaminationOn examination, her uncorrected near visual acuity was J1+ and her best-corrected visual acuity was 20/20 at distance and J1+ at near. Her glasses measured −4.50 +0.50 × 98 in the right eye and −4.75 D in the left eye. Ocular motility was full, and the pupils were equal, round, and reactive to light and accommodation. Her pupils measured 5 mm to 3 mm with direct pupillary light reflex and 5 mm to 2.5 mm to near stimulus. Her near point of convergence was approximately 4 cm from the nose, and her accommodative amplitude was assumed normal given her ease of accommodation and excellent near visual acuity through her full myopic correction. Slit-lamp examination demonstrated normal pupils without iris atrophy, sectoral palsy of the iris sphincter, or vermiform movements.The patient provided several photographs that illustrate fluctuating symptoms. Figure 1 shows inappropriate dilation on a bright sunny day compared to other pictures of her on similar days; there is also subtle anisocoria greater in the right eye than in the left and either pupil could be involved during symptomatic episodes. TreatmentWe elected to proceed with pharmacologic testing with 0.125% pilocarpine. This demonstrated bilateral pupillary constriction suggestive of cholinergic receptor suprasensitivity in both eyes. She was diagnosed with a variant of Adie's tonic pupil in each eye, and she was reassured.Three weeks later she was reexamined because of a worsening of her symptoms. On follow-up examination, her pupils were 8 mm and nonreactive to light, accommodation, or 1% pilocarpine. Distance visual acuity was 20/20 with correction and near acuity was J7 with correction and J2 without correction. Differential DiagnosisEvaluation of unilateral mydriasis can be a diagnostic dilemma and could be a medical emergency in the set-

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“…She was found to be using a hemorrhoidal cream to decrease puffiness around her eyes. The cream contained phenylephrine 0.25% [15].…”

Section: Medications That May Affect the Pupilmentioning

confidence: 99%