BLOWN PUPIL FULL

Upon detailed review of medications and the patient’s activity on the day of presentation, it is most likely that the mydriatic pupil was a side effect of the glycopyrronium 2.4% cloth he used on his face approximately 2.5 hours prior to noticing blurry vision. Patient had normal range of motion, tone, sensation, and strength in the upper and lower extremities with no rashes, lesions, swelling, or erythema noted.

Respiratory effort was normal with no apparent wheezing or shortness of breath. Upon further inspection of the left eye, the globe was intact and the conjunctiva were not injected, and no hyphema was noted. The left pupil was enlarged and unreactive to light ( Figure 1). The patient was alert, oriented, interactive and well-appearing. On physical exam, he was hypertensive with a blood pressure of 185/105, but in no apparent distress.

Integumentary: denies rashes, pigmentation, and dryness.

Psychiatric: denies depression, agitation, and anxiety.

Genitourinary: denies hematuria, dysuria, and incontinence.

Musculoskeletal: denies myalgias, joint pain, and joint stiffness.

Pulmonary: denies shortness of breath, cough, and wheezing.

Cardiovascular: denies chest pain, palpitations, and edema.

Gastrointestinal: denies nausea, vomiting, and diarrhea.

Ear, nose, throat: denies sore throat, rhinitis, tinnitus, and hearing loss.

Constitutional: denies weight loss/gain, fever, chills, fatigue.The patient takes fluticasone nasal inhalation (qd), omeprazole (qd), topical cloth glycopyrronium 2.4% applied to the forehead (PRN), botulinum toxin injections to his axilla (quarterly for the last 8 years). He denies any surgeries or relevant family history. The patient has a medical history significant for severe hyperhidrosis, GERD, and allergic rhinitis. He denies a history of prior similar episodes.

BLOWN PUPIL FULL

He reports full extraocular movements and denies eye pain, headache, stiff neck, nausea, vomiting, photophobia, seizure, use of blood-thinning medication, numbness, tingling, weakness, and dry mouth. He also denies any trauma during this time. He denies any atypical exposures while cleaning, including both new cleaning and gardening products. He reports thorough handwashing prior to and following medication application. Of note, he has a history of hyperhidrosis and reports applying a topical medicated wipe to his face just prior to engaging in his household chores. The patient states that he woke up that morning feeling normal and did not notice any pupillary abnormalities. Since onset, his symptoms have remained constant and his right eye is not affected. He reports that his symptoms started about 3 hours ago, following a morning of household chores. Kayla Penny, BS Joseph LaRochelle, PharmD, BCPPS, FCCP Deirdre Hooper, MD Haley Caire, BS and Kelsey Rooney, BS CASE PRESENTATIONĪ male in his 40s presented with complaints of an enlarged pupil and blurry vision in his left eye.

Employing the process of elimination to narrow down a broad differential, using the available evidence, can expedite the correct diagnosis while allowing the patient to remain in the urgent care. Urgent message: Ocular complaints for which there is no immediate, obvious explanation do not necessarily have to be referred to the emergency room or ophthalmology.

Blown pupil