Seminars in Ophthalmology
ISSN: 0882-0538 (Print) 1744-5205 (Online) Journal homepage: http://www.tandfonline.com/loi/isio20
Accidental Unilateral Mydriasis from Hyoscine Patch in a Care Provider Jia Ng & James Li Yim To cite this article: Jia Ng & James Li Yim (2014): Accidental Unilateral Mydriasis from Hyoscine Patch in a Care Provider, Seminars in Ophthalmology, DOI: 10.3109/08820538.2013.874484 To link to this article: http://dx.doi.org/10.3109/08820538.2013.874484
Published online: 24 Jan 2014.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isio20 Download by: [Shaoxing University]
Date: 05 November 2015, At: 12:46
Seminars in Ophthalmology, Early Online, 1–2, 2014 ! Informa Healthcare USA, Inc. ISSN: 0882-0538 print / 1744-5205 online DOI: 10.3109/08820538.2013.874484
C ASE REPORT
Accidental Unilateral Mydriasis from Hyoscine Patch in a Care Provider Jia Ng and James Li Yim
Downloaded by [Shaoxing University] at 12:46 05 November 2015
University Hospital Ayr, Ayr, South Ayrshire, United Kingdom
ABSTRACT The hyoscine patch is effective and is frequently used in motion sickness treatment. Not uncommonly, it is used to control excessive respiratory secretions in palliative patients. Patients, healthcare workers, and caregivers who administer these may experience a benign, although worrying, mydriasis should they inadvertently rub their eye after handling the patch. A 46-year-old staff nurse working in a stroke ward presented with suddenonset unilateral enlarged pupil. To rule out any intracranial pathology, the stroke team requested an urgent head computed tomography (CT) scan, which showed no abnormality. Upon ophthalmology review, nonreactive dilated left pupil was noted. Examination was otherwise unremarkable with no focal neurology findings. Following further history, she recalled applying a hyoscine patch to a patient in the morning. Two days later, her left pupil returned to normal size. This unique presentation of pharmacological mydriasis reinforces the importance of a detailed targeted history to avoid unnecessary investigations and anxiety, as well as the importance of informing patients, healthcare workers, and caregivers of this peculiar side-effect. Keywords: Anisocoria, anticholinergic, antimuscarinic, pupil dilatation, scopolamine
CASE PRESENTATION
history, she recalled having administered a hyoscine hydrobromide 1 mg/72 hours patch on a patient two hours prior to the incidence. Her pupil and vision gradually returned to normal 48 hours later.
A 46-year-old nurse, while working in a stroke ward, reported sudden blurring of her vision in the left eye associated with a fixed dilated pupil. She denied any headache and had no focal neurological symptoms. Due to the acuteness of her symptom, intracranial pathology was suspected by the medical team on the ward. An urgent cranial CT scan was carried out and showed no abnormalities, to her relief. She was then referred to the ophthalmology team for further assessment. Her uncorrected distance visual acuity was 6/36 corrected to 6/9 with pinhole left eye and 6/6 right eye. The left pupil was unreactive and dilated at 9 mm, while the right pupil was normal. Consensual reflex was preserved in the right eye. Oculomotility was full, there was no ptosis, and her other cranial nerves were intact. Her intraocular pressures and fundoscopy were normal. Upon further
DISCUSSION Acute onset unilateral mydriasis can be associated with serious intracranial causes and therefore warrants immediate, thorough examination. It is a neurosurgical emergency if the anisocoria is associated with signs and symptoms of third-nerve palsy (diplopia, ptosis) and with severe headache. In this case, had it been known that the patient handled a hysocine patch before the onset of symptoms, she would not have been subjected to unnecessary anxiety and irradiation. The hyoscine patch (Scopolamine) acts as a competitive antagonist to acetylcholine and other
Received 23 July 2013; accepted 8 December 2013; published online 21 January 2014 Correspondence: Jia Ng, E-mail: [email protected]
1
2
J. Ng and J. L. Yim
parasympathomimetic agents. In the eye, it acts on muscarinic receptors of sphincter pupillae, resulting in mydriasis. Anticholinergic agents in the form of nebulized Ipratropium1 and oral supplement powder mix containing stimulant 1,3 dimethylamylamine (DMMA)2 have also been reported to cause unilateral mydriasis when inadvertently contaminating the eye in the previous reports. DMMA is a common ingredient in concentrated pre-workout supplements.
Downloaded by [Shaoxing University] at 12:46 05 November 2015
HYOSCINE-INDUCED MYDRIASIS Transdermal Hyoscine Hydrobromide 1.5 mg/72 hours (Scopoderm TTS) is an antimuscarinic agent normally applied to the post-auricular area. This is most commonly used in management of motion sickness, nausea, and vomiting. Antimuscarinic agents have potent mydriatic effects. They compete with acetylcholine for muscarinic receptors at the sphincter muscle of the iris, leading to pupil dilatation. Unilateral mydriasis secondary to direct contamination in a hyoscine patch user has been reported in the past.3–5 In all three cases, an MRI or CT scan had been scheduled to investigate the mydriasis.3–5 The scan was cancelled in two cases, as one patient recalled coming into contact with a hyoscine patch4 and another patient refused being investigated.5 Mydriasis caused by hyoscine normally resolved spontaneously within 24–72 hours.3,4 Central anticholinergic syndrome due to topical scopolamine has been reported in a case of bilateral mydriasis.6 In all these cases, the patient using the hysocine patch contaminated his own eye, unlike this case, where the nurse applying the patch contaminated her own eye.
CONCLUSION Physicians should be aware of accidental ocular contamination with anticholinergic agents in isolated unilateral mydriasis. Any contact with anticholinergic agents should be established to avoid needless anxiety, costly investigations, and unnecessary irradiation. Patients, and especially caregivers, should be warned of a dilated pupil as a possible side-effect should there be any accidental direct ocular contamination or cross-contamination.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Krovvidi HP, Thillaivasan A. A benign cause for a unilateral dilated pupil in a critical care patient. Eur J Anaesthesiol 2008;25:692–693. 2. McDermott AJ. Unilateral mydriasis potentially associated with contact with a supplement powder mix. Mil Med 2012;177(3):359–360. 3. Lin YC. Anisocoria from transdermal scopolamine. Paediatr Anaesth 2001;1:626–627. 4. Vasselon P, Weiner L, Rossi-Pujo F, et al. Unilateral mydriasis due to scopolamine patch. Int J Clin Pharm 2011;33:737–739. 5. Hannon B, Jennings V, Twomey M, O’Reilly M. Transdermal hyoscine induced unilateral mydriasis. BMJ Case Reports 2012;10.1136/bcr.08.2011.4697 (accessed on June 28, 2013). 6. Repe´sse´ X, Geeraerts T, Pottecher J, et al. Coma with bilateral mydriasis after use of transdermal scopolamine in ICU. Ann Fr Anesth Reanim 2007;26:1070–1072.
Seminars in Ophthalmology
ISSN: 0882-0538 (Print) 1744-5205 (Online) Journal homepage: http://www.tandfonline.com/loi/isio20
Accidental Unilateral Mydriasis from Hyoscine Patch in a Care Provider Jia Ng & James Li Yim To cite this article: Jia Ng & James Li Yim (2014): Accidental Unilateral Mydriasis from Hyoscine Patch in a Care Provider, Seminars in Ophthalmology, DOI: 10.3109/08820538.2013.874484 To link to this article: http://dx.doi.org/10.3109/08820538.2013.874484
Published online: 24 Jan 2014.
Submit your article to this journal
Article views: 30
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isio20 Download by: [Shaoxing University]
Date: 05 November 2015, At: 12:46
Seminars in Ophthalmology, Early Online, 1–2, 2014 ! Informa Healthcare USA, Inc. ISSN: 0882-0538 print / 1744-5205 online DOI: 10.3109/08820538.2013.874484
C ASE REPORT
Accidental Unilateral Mydriasis from Hyoscine Patch in a Care Provider Jia Ng and James Li Yim
Downloaded by [Shaoxing University] at 12:46 05 November 2015
University Hospital Ayr, Ayr, South Ayrshire, United Kingdom
ABSTRACT The hyoscine patch is effective and is frequently used in motion sickness treatment. Not uncommonly, it is used to control excessive respiratory secretions in palliative patients. Patients, healthcare workers, and caregivers who administer these may experience a benign, although worrying, mydriasis should they inadvertently rub their eye after handling the patch. A 46-year-old staff nurse working in a stroke ward presented with suddenonset unilateral enlarged pupil. To rule out any intracranial pathology, the stroke team requested an urgent head computed tomography (CT) scan, which showed no abnormality. Upon ophthalmology review, nonreactive dilated left pupil was noted. Examination was otherwise unremarkable with no focal neurology findings. Following further history, she recalled applying a hyoscine patch to a patient in the morning. Two days later, her left pupil returned to normal size. This unique presentation of pharmacological mydriasis reinforces the importance of a detailed targeted history to avoid unnecessary investigations and anxiety, as well as the importance of informing patients, healthcare workers, and caregivers of this peculiar side-effect. Keywords: Anisocoria, anticholinergic, antimuscarinic, pupil dilatation, scopolamine
CASE PRESENTATION
history, she recalled having administered a hyoscine hydrobromide 1 mg/72 hours patch on a patient two hours prior to the incidence. Her pupil and vision gradually returned to normal 48 hours later.
A 46-year-old nurse, while working in a stroke ward, reported sudden blurring of her vision in the left eye associated with a fixed dilated pupil. She denied any headache and had no focal neurological symptoms. Due to the acuteness of her symptom, intracranial pathology was suspected by the medical team on the ward. An urgent cranial CT scan was carried out and showed no abnormalities, to her relief. She was then referred to the ophthalmology team for further assessment. Her uncorrected distance visual acuity was 6/36 corrected to 6/9 with pinhole left eye and 6/6 right eye. The left pupil was unreactive and dilated at 9 mm, while the right pupil was normal. Consensual reflex was preserved in the right eye. Oculomotility was full, there was no ptosis, and her other cranial nerves were intact. Her intraocular pressures and fundoscopy were normal. Upon further
DISCUSSION Acute onset unilateral mydriasis can be associated with serious intracranial causes and therefore warrants immediate, thorough examination. It is a neurosurgical emergency if the anisocoria is associated with signs and symptoms of third-nerve palsy (diplopia, ptosis) and with severe headache. In this case, had it been known that the patient handled a hysocine patch before the onset of symptoms, she would not have been subjected to unnecessary anxiety and irradiation. The hyoscine patch (Scopolamine) acts as a competitive antagonist to acetylcholine and other
Received 23 July 2013; accepted 8 December 2013; published online 21 January 2014 Correspondence: Jia Ng, E-mail: [email protected]
1
2
J. Ng and J. L. Yim
parasympathomimetic agents. In the eye, it acts on muscarinic receptors of sphincter pupillae, resulting in mydriasis. Anticholinergic agents in the form of nebulized Ipratropium1 and oral supplement powder mix containing stimulant 1,3 dimethylamylamine (DMMA)2 have also been reported to cause unilateral mydriasis when inadvertently contaminating the eye in the previous reports. DMMA is a common ingredient in concentrated pre-workout supplements.
Downloaded by [Shaoxing University] at 12:46 05 November 2015
HYOSCINE-INDUCED MYDRIASIS Transdermal Hyoscine Hydrobromide 1.5 mg/72 hours (Scopoderm TTS) is an antimuscarinic agent normally applied to the post-auricular area. This is most commonly used in management of motion sickness, nausea, and vomiting. Antimuscarinic agents have potent mydriatic effects. They compete with acetylcholine for muscarinic receptors at the sphincter muscle of the iris, leading to pupil dilatation. Unilateral mydriasis secondary to direct contamination in a hyoscine patch user has been reported in the past.3–5 In all three cases, an MRI or CT scan had been scheduled to investigate the mydriasis.3–5 The scan was cancelled in two cases, as one patient recalled coming into contact with a hyoscine patch4 and another patient refused being investigated.5 Mydriasis caused by hyoscine normally resolved spontaneously within 24–72 hours.3,4 Central anticholinergic syndrome due to topical scopolamine has been reported in a case of bilateral mydriasis.6 In all these cases, the patient using the hysocine patch contaminated his own eye, unlike this case, where the nurse applying the patch contaminated her own eye.
CONCLUSION Physicians should be aware of accidental ocular contamination with anticholinergic agents in isolated unilateral mydriasis. Any contact with anticholinergic agents should be established to avoid needless anxiety, costly investigations, and unnecessary irradiation. Patients, and especially caregivers, should be warned of a dilated pupil as a possible side-effect should there be any accidental direct ocular contamination or cross-contamination.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Krovvidi HP, Thillaivasan A. A benign cause for a unilateral dilated pupil in a critical care patient. Eur J Anaesthesiol 2008;25:692–693. 2. McDermott AJ. Unilateral mydriasis potentially associated with contact with a supplement powder mix. Mil Med 2012;177(3):359–360. 3. Lin YC. Anisocoria from transdermal scopolamine. Paediatr Anaesth 2001;1:626–627. 4. Vasselon P, Weiner L, Rossi-Pujo F, et al. Unilateral mydriasis due to scopolamine patch. Int J Clin Pharm 2011;33:737–739. 5. Hannon B, Jennings V, Twomey M, O’Reilly M. Transdermal hyoscine induced unilateral mydriasis. BMJ Case Reports 2012;10.1136/bcr.08.2011.4697 (accessed on June 28, 2013). 6. Repe´sse´ X, Geeraerts T, Pottecher J, et al. Coma with bilateral mydriasis after use of transdermal scopolamine in ICU. Ann Fr Anesth Reanim 2007;26:1070–1072.
Seminars in Ophthalmology
