Mydriasis: Difference between revisions

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__NOTOC__
__NOTOC__
{{SI}}
{{SI}}
{{CMG}}
{{CMG}} {{AE}} {{LRO}}
 
{{SK}} Pupillary dilation; dilated pupil
==Overview==
==Overview==
'''Mydriasis''' is an excessive dilation of the [[pupil]] due to [[disease]], [[Physical trauma|trauma]] or [[Psychoactive drug|drug]]s. Normally, the pupil dilates in the dark and constricts in the light. A mydriatic pupil will remain excessively large, even in a bright environment.  Sometimes colloquially referred to as a "[[blown pupil]]."
'''Mydriasis''' is an excessive dilation of the [[pupil]] due to [[disease]], [[Physical trauma|trauma]] or [[Psychoactive drug|drug]]s. Normally, the pupil dilates in the dark and constricts in the light. A mydriatic pupil will remain excessively large, even in a bright environment.  Sometimes colloquially referred to as a "[[blown pupil]]."
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The mechanism of mydriasis depends on the agent being used. It usually involves either a disruption of the [[parasympathetic nerve]] supply to the eye (which causes contraction of the pupil), or over activity of the [[sympathetic nervous system]] (SNS).
The mechanism of mydriasis depends on the agent being used. It usually involves either a disruption of the [[parasympathetic nerve]] supply to the eye (which causes contraction of the pupil), or over activity of the [[sympathetic nervous system]] (SNS).
==Causes==


==Causes==
===Common Causes===
===Common Causes===
===Non Pathological===
*[[Adregenic agents]]
Mydriasis can be congenital.
*[[Amphetamines]]
 
*[[Antihistamines]]
===Pathological===
*[[Antipsychotic agents]]
The [[parasympathetic]] nervous supply which causes constriction of the pupil, or [[miosis]], is supplied by [[cranial nerve]] III, the [[oculomotor nerve]]. Damage to this nerve typically manifests itself as mydriasis, because the [[sympathetic]] supply to the pupil which causes mydriasis remains unaffected, and therefore unopposed.
*[[Apraclonidine]]
 
*[[Atropine]]
===Traumatic===
*[[Chlorpheniramine]]
 
*[[Chlorpromazine]]
In cases of [[head injury]] or [[eye injury|orbit trauma (eye injury)]], the [[Iris sphincter muscle|iris sphincter]] (the muscle responsible for closing the pupil) or the nerves controlling it can be damaged, reducing or eliminating [[reactivity]] to light.
*[[Cinnarizine]]
*[[Cocaine]]
*[[Cyclopentolate]]
*[[Diphenhydramine]]
*[[Dipivefrin]]
*[[Disopyramide]]
*[[Dopram injection]]
*[[Doxapram hydrochloride]]
*[[Hallucinogens]]
*[[Hexamethonium]]
*[[Hydroxyzine]]
*[[Lachesine]]
*[[Levomepromazine]]
*[[Lysergic acid diethylamide]]
*[[Mdma]]
*[[Mescaline]]
*[[Naphazoline]]
*[[Noradrenaline]]
*[[Opiate]]
*[[Oxcarbazepine]]
*[[Perazine]]
*[[Phenelzine]]
*[[Phenylephrine]]
*[[Pipothiazine]]
*[[Pizotifen]]
*[[Prochlorperazine]]
*[[Psychedelic mushrooms]]
*[[Sibutramine]]
*[[Systemic anticholinergics]]
*[[Tetrahydrozoline]]
*[[Tricyclic antidepressants]]
*[[Tropicamide]]


===Drugs===
===Causes by Organ System===
[[Atropine]] blocks [[muscarinic acetylcholine receptor]]s. [[Acetylcholine|Acetylcholine (ACh)]] is the [[neurotransmitter]] of the [[parasympathetic nervous system]] and blocking its action means the pupil cannot constrict.
{|style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" |'''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | No underlying causes
|-
|bgcolor="LightSteelBlue"| '''Chemical/Poisoning'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| [[Adregenic agents]],  [[Amphetamines]],  [[Antihistamines]],  [[Antipsychotic agents]],  [[Apraclonidine]],  [[Atropine]],  [[Chlorpheniramine]],  [[Chlorpromazine]],  [[Cinnarizine]],  [[Cocaine]],  [[Cyclopentolate]],  [[Diphenhydramine]],  [[Dipivefrin]],  [[Disopyramide]],  [[Dopram injection]],  [[Doxapram hydrochloride]],  [[Hallucinogens]],  [[Hexamethonium]],  [[Hydroxyzine]],  [[Lachesine]],  [[Levomepromazine]],  [[Lysergic acid diethylamide]],  [[Mdma]],  [[Mescaline]],  [[Naphazoline]],  [[Noradrenaline]],  [[Opiate]],  [[Oxcarbazepine]],  [[Perazine]],  [[Phenelzine]],  [[Phenylephrine]],  [[Pipothiazine]],  [[Pizotifen]],  [[Prochlorperazine]],  [[Psychedelic mushrooms]],  [[Sibutramine]],  [[Systemic anticholinergics]],  [[Tetrahydrozoline]],  [[Tricyclic antidepressants]],  [[Tropicamide]]
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal/Orthopedic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| [[3rd cranial nerve disorder]],  [[Adie's tonic pupil]],  [[Autonomic seizure]],  [[Brain death]],  [[Cerebral oedema]],  [[Coma]],  [[Raised intracranial pressure]],  [[Seizures]],  [[Serotonin syndrome]],  [[Third nerve palsy]],  [[Weber syndrome]]
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional/Metabolic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Ophthalmologic'''
|bgcolor="Beige"| [[Acute closed angle glaucoma]],  [[Adie's tonic pupil]],  [[Benign episodic mydriasis]],  [[Pourfour du petit syndrome]]
|-
|-bgcolor="LightSteelBlue"
| '''Overdose/Toxicity'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Renal/Electrolyte'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Rheumatology/Immunology/Allergy'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| [[Coma]], [[Trauma]]
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| No underlying causes
|-
|}


[[Cocaine]] inhibits the reuptake of [[noradrenaline]] ([[norepinephrine]]) within a nerve [[synapse]]. When a [[solution]] of cocaine is dropped into the eye, noradrenaline is no longer reabsorbed by [[neuron]]s, and its levels increase. Noradrenaline, the [[neurotransmitter]] for the SNS, causes dilation of the pupil. Mydriasis is used as a [[diagnostic test]] for [[Horner's Syndrome]], in which it is initiated using a similar mechanism, though cocaine is not usually used in this procedure. Many other drugs such as [[amphetamine]]s and [[psychedelic drug]]s ([[LSD]], [[psychedelic mushrooms]], [[mescaline]], and [[MDMA]]) are also known to cause mydriasis. <!-- Are they known to cause mydriasis using this mechanism? If not, why are they in this paragraph? Considering the distinctiveness of their effects on the body, as compared to those of cocaine, I would strongly suggest this is misplaced. -->
===Causes in Alphabetical Order===
 
===Causes in Alphabetical Order===
[[Opiate]] withdrawal can cause dilated pupils in some people. <ref>[http://www.nd.gov.hk/chapter_4b2_eng.pdf]</ref>
{{columns-list|
 
*[[3rd cranial nerve disorder]]
[[Antihistamine]]s and [[tricyclic antidepressant]]s may cause mydriasis.
*[[Acute closed angle glaucoma]]
 
===Mydriatic Drops===
 
A '''mydriatic''' is an agent which induces [[dilation]] of the [[pupil]]. Drugs such as [[tropicamide]] are used in [[medicine]] to permit examination of the [[retina]] and other deep structures of the eye, and also to reduce painful [[ciliary muscle]] [[muscle spasm|spasm]] (see [[cycloplegia]]). One effect of administration of a mydriatic is intolerance to bright light.
 
===Physiological Response Indicating Interest===
 
[[Pupillary response]] may also indicate interest in the subject of attention or sexual stimulation.<ref>{{Citation
  | last1 = Hess  | first1 = Eckhard H.
  | last2 = Polt | first2 = James M.
  | title = Pupil Size as Related to Interest Value of Visual Stimuli
  | journal = Science
  | volume = 132
  | issue = 3423
  | pages = 349
  | date = 5 August 1960
  | year = 1960
  | doi = 10.1126/science.132.3423.349 }}</ref>
===Causes in Alphabetical Order<ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref><ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>===
 
*[[Acute Closed Angle glaucoma]]
*[[Adie's tonic pupil]]
*[[Adie's tonic pupil]]
*Adregenic agents
*[[Adregenic agents]]
*[[Amphetamines]]
*[[Antihistamines]]
*[[Antipsychotic agents]]
*[[Apraclonidine]]
*[[Atropine]]
*[[Autonomic seizure]]
*[[Benign episodic mydriasis]]
*[[Benign episodic mydriasis]]
*[[Brain death]]
*[[Cerebral oedema]]
*[[Chlorpheniramine]]
*[[Chlorpromazine]]
*[[Cinnarizine]]
*[[Cocaine]]
*[[Coma]]
*[[Coma]]
*[[Congenital mydriasis]]
*[[Congenital mydriasis]]
*Drug withdrawal
*[[Cyclopentolate]]
*[[Diphenhydramine]]
*[[Dipivefrin]]
*[[Disopyramide]]
*[[Dopram injection]]
*[[Doxapram hydrochloride]]
*[[Hallucinogens]]
*[[Hallucinogens]]
*[[Seizure]]s
*[[Hexamethonium]]
*[[Hydroxyzine]]
*[[Lachesine]]
*[[Levomepromazine]]
*[[Lysergic acid diethylamide]]
*[[Mdma]]
*[[Mescaline]]
*[[Naphazoline]]
*[[Noradrenaline]]
*[[Opiate]]
*[[Oxcarbazepine]]
*[[Perazine]]
*[[Phenelzine]]
*[[Phenylephrine]]
*[[Pipothiazine]]
*[[Pizotifen]]
*[[Pourfour du petit syndrome]]
*[[Prochlorperazine]]
*[[Psychedelic mushrooms]]
*[[Raised intracranial pressure]]
*[[Seizures]]
*[[Serotonin syndrome]]
*[[Serotonin syndrome]]
*Systemic [[anticholinergics]]
*[[Sibutramine]]
*[[Systemic anticholinergics]]
*[[Tetrahydrozoline]]
*[[Third nerve palsy]]
*[[Third nerve palsy]]
*[[Trauma]]
*[[Trauma]]
*[[Tricyclic antidepressants]]
*[[Tropicamide]]
*[[Weber syndrome]]
}}
==Diagnostic Findings==
==Diagnostic Findings==
<gallery>
Image:Dilated_pupil.gk.jpg|Pupil dilated using [[anaesthetic]] and muscle relaxant
Image:Eye dilate.gif|Pupillary response
</gallery>
=== History and Symptoms ===  
=== History and Symptoms ===  
*Complete history with special attention to:
*Complete history with special attention to:
:*neurologic
:*Neurologic
:*Ophthalmologic
:*Ophthalmologic
:*Otolaryngologic  
:*Otolaryngologic  
=== Physical Examination ===  
=== Physical Examination ===  
=== Eyes ===
=== Eyes ===
<gallery>
Image:Dilated_pupil.gk.jpg|Pupil dilated using [[anaesthetic]] and muscle relaxant
Image:Eye dilate.gif|Pupillary response
</gallery>
*Pupil size (light & dark)
*Pupil size (light & dark)
*Pupil response to light and convergence
*Pupil response to light and convergence
*Lid position
*Lid position
===MRI===  
===MRI===  
*MRI to check for [[third cranial nerve palsy]]
*MRI to check for [[third cranial nerve palsy]]
==Treatment==
==Treatment==
===Medical Therapy===  
===Medical Therapy===  
*[[Adie's pupil]] - Pilcarpine .125% BID-QID  
*[[Adie's pupil]] - Pilcarpine .125% BID-QID  
*Migraines - pain meds, antidepressants, anticonvulsants, beta blockers, calcium channel blockers
*Migraines - pain meds, antidepressants, anticonvulsants, beta blockers, calcium channel blockers
===Primary Prevention===  
===Primary Prevention===  
*Remove causative medication
*Remove causative medication
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==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{Eye pathology}}
{{SIB}}


[[Category:Ophthalmology]]
[[Category:Ophthalmology]]
[[Category:Medical signs]]
[[Category:Signs and symptoms]]
[[Category:Signs and symptoms]]
[[Category:Physical examination]]
[[Category:Physical examination]]
[[da:Mydriasis]]
[[de:Mydriasis]]
[[es:Midriasis]]
[[fr:Mydriase]]
[[it:Midriasi]]
[[ja:散瞳]]
[[pl:Mydriasis]]
[[pt:Midríase]]
[[sv:Mydriasis]]
{{WH}}
{{WS}}

Latest revision as of 22:04, 10 January 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Luke Rusowicz-Orazem, B.S.

Synonyms and keywords: Pupillary dilation; dilated pupil

Overview

Mydriasis is an excessive dilation of the pupil due to disease, trauma or drugs. Normally, the pupil dilates in the dark and constricts in the light. A mydriatic pupil will remain excessively large, even in a bright environment. Sometimes colloquially referred to as a "blown pupil."

The opposite, constriction of the pupil, is called miosis.

Pathophysiology

There are two types of muscle that control the size of the iris: circular muscle and radial muscle. The former is innervated by the parasympathetic nervous system, the latter by the sympathetic nervous system. Sympathetic stimulation of α1 adrenergic receptors causes the contraction of the radial muscle, and subsequent dilation of the pupil. Conversely, parasympathetic stimulation cause contraction of the circular muscle and constriction of the iris.

The mechanism of mydriasis depends on the agent being used. It usually involves either a disruption of the parasympathetic nerve supply to the eye (which causes contraction of the pupil), or over activity of the sympathetic nervous system (SNS).

Causes

Common Causes

Causes by Organ System

Cardiovascular No underlying causes
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Adregenic agents, Amphetamines, Antihistamines, Antipsychotic agents, Apraclonidine, Atropine, Chlorpheniramine, Chlorpromazine, Cinnarizine, Cocaine, Cyclopentolate, Diphenhydramine, Dipivefrin, Disopyramide, Dopram injection, Doxapram hydrochloride, Hallucinogens, Hexamethonium, Hydroxyzine, Lachesine, Levomepromazine, Lysergic acid diethylamide, Mdma, Mescaline, Naphazoline, Noradrenaline, Opiate, Oxcarbazepine, Perazine, Phenelzine, Phenylephrine, Pipothiazine, Pizotifen, Prochlorperazine, Psychedelic mushrooms, Sibutramine, Systemic anticholinergics, Tetrahydrozoline, Tricyclic antidepressants, Tropicamide
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease No underlying causes
Musculoskeletal/Orthopedic No underlying causes
Neurologic 3rd cranial nerve disorder, Adie's tonic pupil, Autonomic seizure, Brain death, Cerebral oedema, Coma, Raised intracranial pressure, Seizures, Serotonin syndrome, Third nerve palsy, Weber syndrome
Nutritional/Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Ophthalmologic Acute closed angle glaucoma, Adie's tonic pupil, Benign episodic mydriasis, Pourfour du petit syndrome
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal/Electrolyte No underlying causes
Rheumatology/Immunology/Allergy No underlying causes
Sexual No underlying causes
Trauma Coma, Trauma
Urologic No underlying causes
Miscellaneous No underlying causes

Causes in Alphabetical Order

Causes in Alphabetical Order

Diagnostic Findings

History and Symptoms

  • Complete history with special attention to:
  • Neurologic
  • Ophthalmologic
  • Otolaryngologic

Physical Examination

Eyes

  • Pupil size (light & dark)
  • Pupil response to light and convergence
  • Lid position

MRI

Treatment

Medical Therapy

  • Adie's pupil - Pilcarpine .125% BID-QID
  • Migraines - pain meds, antidepressants, anticonvulsants, beta blockers, calcium channel blockers

Primary Prevention

  • Remove causative medication
  • Sunglasses to decrease light sensitivity

Related Chapters


References