Unilateral pupillary mydriasis from nebulized ipratropium bromide: A false sign of brain herniation in the intensive care unit

Abstract

Although there are many causes of anisocoria in the intensive care setting, the development of unilateral mydriasis in patients with intracranial hemorrhage or tumor is a neurological emergency, as it may herald the onset of uncal herniation. We describe two patients with a hemiparesis from neurosurgical disorder who subsequently developed a fixed and dilated pupil. The pupillary abnormality was caused by nebulized ipratropium bromide in both cases, and resolved when the medication was discontinued. Nebulized ipratropium may leak from the mask into ipsilateral eye and cause mydriasis in patients with facial weakness. This benign cause of anisocoria in the intensive care setting is distinguished from uncal herniation by the laterality of neurologic findings, and lack of mental status change, ptosis, and extraocular movement impairment.

Dont Believe Your Eyes- Ipratropium Induced Mydriasis: A Case Report and Review of the Literature

“…The remainder of the cases did not report duration of the mydriasis. Most cases were attributed to an improperly fitting face mask either from facial weakness [1] or a faulty seal on the mask [3-5,8,10], which we believe was the case in our patient. Faulty nebulizer circuit [2,13], and mechanical contamination of the nebulizer with the eye [9] were also cited as a potential cause.…”

“…Ipratropium bromide has been known to cause unilateral mydriasis from topical administration secondary to a poorly fitting face mask allowing for medication to directly inoculate one eye [1,3-5,8-10] or broken nebulizer circuit [2]. This phenomenon has been more commonly reported in intensive care and pediatric patient populations, since maintaining proper fitting facemasks may be more challenging in these patients.…”

Dont Believe Your Eyes- Ipratropium Induced Mydriasis: A Case Report and Review of the Literature

“…The remainder of the cases did not report duration of the mydriasis. Most cases were attributed to an improperly fitting face mask either from facial weakness [1] or a faulty seal on the mask [3-5,8,10], which we believe was the case in our patient. Faulty nebulizer circuit [2,13], and mechanical contamination of the nebulizer with the eye [9] were also cited as a potential cause.…”

“…Ipratropium bromide has been known to cause unilateral mydriasis from topical administration secondary to a poorly fitting face mask allowing for medication to directly inoculate one eye [1,3-5,8-10] or broken nebulizer circuit [2]. This phenomenon has been more commonly reported in intensive care and pediatric patient populations, since maintaining proper fitting facemasks may be more challenging in these patients.…”

In-hospital unexpected cerebral herniation—New neurosurgical quality control standards: A case report

“…Ipratropium bromide administration via nebulizer masks may induce pharmacological mydriasis through ocular exposure, mimicking herniation-related pupillary changes. [ 20 ] Such iatrogenic artifacts risk precipitating misdiagnosis, potentially triggering unnecessary therapeutic interventions.…”

Unilateral mydriasis after video-assisted thoracic thymectomy: case report and review of literature

“…Один из механизмов кратковременного угне-тения парасимпатической иннервации зрачка -проникновение в регионарный кровоток мест-ного анестетика [23,40,50], непреднамеренное попадание в конъюнктивальную полость атро-пина [14,65], ипратропия бромида из-под маски небулайзера при параличе мимической мускула-туры [15,16,53,63,70], скополамина и гиосцина при манипуляциях с купирующим тошноту/рвоту пластырем [14,28,39,49,61,76,78], сока луноц-вета, индейского дурмана и бругмансии [5,29,58] и даже порошкообразных стимулирующих пище-вых добавок [46]. В отличие от перечисленных выше фарма-кологических средств, диффузия ботулотокси-на за пределы таргетной зоны при выполнении лечебных или косметических процедур приводит к многонедельному расширению зрачка.…”

Dont Believe Your Eyes- Ipratropium Induced Mydriasis: A Case Report and Review of the Literature

“…The remainder of the cases did not report duration of the mydriasis. Most cases were attributed to an improperly fitting face mask either from facial weakness [1] or a faulty seal on the mask [3-5,8,10], which we believe was the case in our patient. Faulty nebulizer circuit [2,13], and mechanical contamination of the nebulizer with the eye [9] were also cited as a potential cause.…”

“…Ipratropium bromide has been known to cause unilateral mydriasis from topical administration secondary to a poorly fitting face mask allowing for medication to directly inoculate one eye [1,3-5,8-10] or broken nebulizer circuit [2]. This phenomenon has been more commonly reported in intensive care and pediatric patient populations, since maintaining proper fitting facemasks may be more challenging in these patients.…”

In-hospital unexpected cerebral herniation—New neurosurgical quality control standards: A case report

“…Ipratropium bromide administration via nebulizer masks may induce pharmacological mydriasis through ocular exposure, mimicking herniation-related pupillary changes. [ 20 ] Such iatrogenic artifacts risk precipitating misdiagnosis, potentially triggering unnecessary therapeutic interventions.…”

Unilateral mydriasis after video-assisted thoracic thymectomy: case report and review of literature

“…Один из механизмов кратковременного угне-тения парасимпатической иннервации зрачка -проникновение в регионарный кровоток мест-ного анестетика [23,40,50], непреднамеренное попадание в конъюнктивальную полость атро-пина [14,65], ипратропия бромида из-под маски небулайзера при параличе мимической мускула-туры [15,16,53,63,70], скополамина и гиосцина при манипуляциях с купирующим тошноту/рвоту пластырем [14,28,39,49,61,76,78], сока луноц-вета, индейского дурмана и бругмансии [5,29,58] и даже порошкообразных стимулирующих пище-вых добавок [46]. В отличие от перечисленных выше фарма-кологических средств, диффузия ботулотокси-на за пределы таргетной зоны при выполнении лечебных или косметических процедур приводит к многонедельному расширению зрачка.…”

Dont Believe Your Eyes- Ipratropium Induced Mydriasis: A Case Report and Review of the Literature

“…The remainder of the cases did not report duration of the mydriasis. Most cases were attributed to an improperly fitting face mask either from facial weakness [1] or a faulty seal on the mask [3-5,8,10], which we believe was the case in our patient. Faulty nebulizer circuit [2,13], and mechanical contamination of the nebulizer with the eye [9] were also cited as a potential cause.…”

“…Ipratropium bromide has been known to cause unilateral mydriasis from topical administration secondary to a poorly fitting face mask allowing for medication to directly inoculate one eye [1,3-5,8-10] or broken nebulizer circuit [2]. This phenomenon has been more commonly reported in intensive care and pediatric patient populations, since maintaining proper fitting facemasks may be more challenging in these patients.…”

In-hospital unexpected cerebral herniation—New neurosurgical quality control standards: A case report

“…Ipratropium bromide administration via nebulizer masks may induce pharmacological mydriasis through ocular exposure, mimicking herniation-related pupillary changes. [ 20 ] Such iatrogenic artifacts risk precipitating misdiagnosis, potentially triggering unnecessary therapeutic interventions.…”

Unilateral mydriasis after video-assisted thoracic thymectomy: case report and review of literature

“…Один из механизмов кратковременного угне-тения парасимпатической иннервации зрачка -проникновение в регионарный кровоток мест-ного анестетика [23,40,50], непреднамеренное попадание в конъюнктивальную полость атро-пина [14,65], ипратропия бромида из-под маски небулайзера при параличе мимической мускула-туры [15,16,53,63,70], скополамина и гиосцина при манипуляциях с купирующим тошноту/рвоту пластырем [14,28,39,49,61,76,78], сока луноц-вета, индейского дурмана и бругмансии [5,29,58] и даже порошкообразных стимулирующих пище-вых добавок [46]. В отличие от перечисленных выше фарма-кологических средств, диффузия ботулотокси-на за пределы таргетной зоны при выполнении лечебных или косметических процедур приводит к многонедельному расширению зрачка.…”