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 Table of Contents  
CLINICAL QUIZ
Year : 2015  |  Volume : 16  |  Issue : 1  |  Page : 42-43

Clinical quiz


Department of Ophthalmology, University of Alexandria, Alexandria, Egypt

Date of Submission02-Dec-2014
Date of Acceptance10-Jan-2015
Date of Web Publication29-May-2015

Correspondence Address:
MD Amgad M Dowidar
Department of Ophthalmology, University of Alexandria, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-9173.157791

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Keywords: anisocorea, blurred vision, unilateral mydriasis


How to cite this article:
Dowidar AM. Clinical quiz. Delta J Ophthalmol 2015;16:42-3

How to cite this URL:
Dowidar AM. Clinical quiz. Delta J Ophthalmol [serial online] 2015 [cited 2017 Dec 11];16:42-3. Available from: http://www.djo.eg.net/text.asp?2015/16/1/42/157791


  History Top


A 15-year-old girl presented with a 4-month history of variable anisocoria and fluctuating blurred vision. Past medical history was significant for migraines, which were well controlled with amlotriptan. She denied a history of trauma, use of topical medications, or worsening or change in her headaches. She also denied having visual phenomenon associated with her previous headaches.


  Examination Top


On 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 5-3 mm with direct pupillary light reflex and 5-2.5 mm to near stimulus. Her near point of convergence was ∼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 with other pictures of her on similar days. There is also subtle anisocoria greater in the right eye than in the left; either pupil could be involved during symptomatic episodes.
Figure 1: Photographs demonstrating the variable anisocoria. (a) Bilateral mydriasis on a sunny day. (b) Right-sided mydriasis. (c) Left-sided mydriasis.

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  Treatment Top


We 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 re-examined 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.



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  References Top

1.
Tamburin S, Turri G, Kuhdari P, Fiaschi A, Manganotti P. Unilateral fixed mydriasis: an uncommon presentation of temporal lobe epilepsy. J Neurol 2012; 259:355-357.  Back to cited text no. 1
[PUBMED]    
2.
Jacobson DM. Benign episodic unilateral mydriasis: clinical characteristics. Ophthalmology 1995; 102:1623-1627.  Back to cited text no. 2
    
3.
Evans RW, Jacobson DM. Transient anisocoria in a migraineur. Headache 2003; 43:416-418.  Back to cited text no. 3
[PUBMED]    
4.
Camkurt MA, Ay D, Akkucuk H, Ozcan H, Kunt MM. Pharmacologic unilateral mydriasis due to nebulized ipratropium bromide. Am J Emerg Med 2011; 29:576.e5-576.e6.  Back to cited text no. 4
    
5.
Panting KJ, Alkali AS, Newman WD, Sharpe GR. Dilated pupils caused by topical glycopyrrolate for hyperhidrosis. Br J Dermatol 2008; 158:187-188.  Back to cited text no. 5
[PUBMED]    
6.
Polomský M, Smereck J. Unilateral mydriasis due to hemorrhoidal ointment. J Emerg Med 2012; 43:e11-e15.  Back to cited text no. 6
    
7.
Wilhelm H, Wilhelm B, Schiefer U. Mydriasis caused by plant contact [in German]. Fortschr Ophthalm 1991; 88:588-591.  Back to cited text no. 7
    
8.
Rubinfeld RS, Currie JN. Accidental mydriasis form blue nightshade 'lipstick' J Clin Neuroophthalmol 1987; 7:34-37.  Back to cited text no. 8
    
9.
Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 2004; 51:241-248.  Back to cited text no. 9
    
10.
Eisenach JH, Atkinson JL, Fealey RD. Hyperhidrosis: evolving therapies for a well-established phenomenon. Mayo Clin Proc 2005; 80:657-666.  Back to cited text no. 10
    
11.
Izadi S, Choudhary A, Newman W. Mydriasis and accommodative failure from exposure to topical glycopyrrolate used in hyperhidrosis. J Neuroophthalmol 2006; 26:232-233.  Back to cited text no. 11
[PUBMED]    
12.
Collin J, Whatling P. Treating hyperhidrosis. Surgery and botulinum toxin are treatments of choice in severe cases. BMJ 2000; 320:1221-1222.  Back to cited text no. 12
[PUBMED]    
13.
Vergilis-Kalner IJ. Same-patient prospective comparison of botox versus dysport for the treatment of primary axillary hyperhidrosis and review of literature. J Drugs Dermatol 2011; 10:1013-1015.  Back to cited text no. 13
    


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