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A 15-year-old girl with variable anisocoria
Digital Journal of Ophthalmology 2014
Volume 20, Number 1
January 12, 2014
DOI: 10.5693/djo.03.2013.10.001
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Robert L. Tomsak MD, PhD | Department of Ophthalmology, Kresge Eye Institute, Wayne State University
Michael J. Coleman, MD | Department of Ophthalmology, Kresge Eye Institute, Wayne State University
Diagnosis and Discussion
Further probing revealed that she suffered from hyperhidrosis and that she used topical glycopyrrolate cream, a direct acetylcholine receptor antagonist, on her palms and axilla before bed daily. Furthermore, she occasionally handled her contact lenses and lens case after using the glycopyrrolate ointment. She would subsequently put the contact lens in her eyes before school the next morning. She was educated about all pertinent issues and has not had subsequent pupillary or visual symptoms.

This case is remarkable in that the patient had variable and fluctuating pupillary dilation and accommodative failure. The initial hypersensitivity response to 0.125% pilocarpine was consistent with Adie’s tonic pupil but in the absence of other signs of this condition. Although we do not know the exact mechanism of the suprasensitivity response to 0.125% pilocarpine, it is tempting to consider that it was related to repeated, variable receptor blockade of the cholinergic receptor by glycopyrrolate.

Primary hyperhidrosis (axillary or palmar) is a disease of excessive sweating. Hyperhidrosis affects about 2.8% of the American population (7.8 million people), with axillary hyperhidrosis being the most prevalent manifestation.(9) The treatment options for hyperhidrosis include antiperspirants, oral or topical anticholinergics, and surgical or chemical (ie, botox injection) sympathecotomy.(10-13)

This case demonstrates the value of a careful history in dealing with patients with anisocoria and the need to ask specifically about hyperhidrosis and the use of glycopyrrolate whenever pharmacologic mydriasis is suspected.
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