Ipsilateral transient amaurosis, mydriasis and light reflex absence after subconjunctival local anesthesia with mepivacaine in three patients with refractory glaucoma - a case report.

BACKGROUND: The subconjunctival anesthesia with local anesthetics is considered as a low-risk procedure allowing ocular surgery without serious complications typical for retro- or parabulbar anesthesia, especially in patients with preexisting Optic Nerve damage. We report development of ipsilateral transient amaurosis accompanied with mydriasis and both, direct and consensual light response absence. CASE PRESENTATION: Three patients with advanced refractory glaucoma undergoing laser cyclophotocoagulation (CPC) for intraocular pressure lowering experienced these adverse effects just few minutes after subconjunctival injection of mepivacaine 2% solution (Scandicaine® 2%, without vasoconstrictor supplementation). The vision was completely recovered to usual values in up to 20 h after mepivacaine application. Extensive ophthalmological examination, including cranial magnetic resonance imaging (MRI), revealed no further ocular abnormalities, especially no vascular constriction or thrombotic signs as well as no retinal detachment. The oculomotor function remained intact. The blockade of ipsilateral ciliary ganglion parasympathetic fibers by mepivacaine may be the responsible mechanism. Systemic pathways as drug-drug interactions seem to be unlikely involved. Importantly, all three patients tolerated the same procedure previously or at a later date without any complication. Overall, our thoroughly elaborated risk management could not determine the causative factor explaining the observed ocular complications just in the current occasion and not at other time points. CONCLUSIONS: Doctors should be aware and patients should be informed about such rare complications after subconjunctival local anesthetics administration. Adequate risk management should insure patients' safety.

Anisocoria Secondary to Anticholinergic Mydriasis from Homeopathic Pink Eye Relief Drops.

A woman, aged 70 years, developed anisocoria after applying homeopathic eye drops (Similasan Pink Eye Relief) to her left eye. Her pupil was dilated for two weeks and did not respond to light or near stimuli for one week. Both 0.1% and 1% pilocarpine failed to constrict her left pupil, and magnetic resonance imaging of her brain did not reveal any abnormality. The eye drops she had used contain belladonna extracts which have a natural atropine component. This case demonstrates the importance, when evaluating a patient presenting with anisocoria, of knowing the chemical ingredients of the homeopathic eye drops, which often are not listed.

Effects of peribulbar anesthesia (sub-Tenon injection of a local anesthetic) on akinesia of extraocular muscles, mydriasis, and intraoperative and postoperative analgesia in dogs undergoing phacoemulsification.

OBJECTIVE: To evaluate the effects of peribulbar anesthesia (sub-Tenon injection of lidocaine hydrochloride) on akinesia of extraocular muscles, mydriasis, and intraoperative and postoperative analgesia in dogs undergoing phacoemulsification. ANIMALS: 14 Beagles with ophthalmically normal eyes. PROCEDURES: A blinded randomized controlled trial was performed. Dogs were anesthetized and assigned to 2 treatments: concurrent sub-Tenon injection of 2% lidocaine hydrochloride solution (2 mL) and IV injection of saline (0.9% NaCl) solution (0.02 mL/kg; lidocaine group [n = 7]) or concurrent sub-Tenon injection of saline solution (2 mL) and IV injection of 0.2 mg of atracurium/kg (0.02 mL/kg; control group [7]). Pupils were dilated by topical application of a combined tropicamide and phenylephrine ophthalmic solution. Ten minutes after the injections, pupil diameter was measured and phacoemulsification was performed. End-tidal isoflurane concentration was used to evaluate intraoperative pain. Subjective pain scores were recorded during the postoperative period. RESULTS: Akinesia was induced and maintained throughout the surgery in all eyes. Mean ± SD pupil diameter was significantly greater in the lidocaine group (13.7 ± 0.7 mm) than in the control group (12.2 ± 0.8 mm). Isoflurane requirements were significantly lower in the lidocaine group than the control group. However, postoperative pain scores were not significantly different between the groups. CONCLUSIONS AND CLINICAL RELEVANCE: Sub-Tenon injection of lidocaine was an effective method for inducing akinesia of extraocular muscles, mydriasis, and intraoperative analgesia for phacoemulsification in dogs. Therefore, this could be another option for surgical field exposure and pain management during phacoemulsification in dogs.

Amaurosis, ophthalmoplegia, ptosis, mydriasis and periorbital blanching following inferior alveolar nerve anaesthesia.

BACKGROUND: Ophthalmic complications following inferior alveolar nerve anaesthesia are rare. They include transient blindness (amaurosis), ophthalmoplegia, ptosis, mydriasis and diplopia. These events may occur following the intravascular administration of anaesthetic solution and are distressing to both patient and operator alike. CASE REPORT: We report the unusual case of a young patient who experienced amaurosis, total ophthalmoplegia, complete upper eyelid ptosis, mydriasis and periorbital blanching following inferior alveolar nerve anaesthesia. Similar but less profound signs were observed in the same patient on a subsequent occasion. This was following general anaesthesia, during which she had received local anaesthetic prior to mandibular wisdom tooth removal. CONCLUSIONS: Ophthalmic complications following inferior alveolar nerve anaesthesia are rare but distressing events. In particular, amaurosis is an extremely rare event and usually heralds a more sinister pathology such as stroke. Clinicians should be aware of these complications to minimise anxiety and reassure their patients appropriately.

Mydriasis induced by sub-Tenon's ropivacaine injection in patients undergoing strabismus surgery.

PURPOSE: To investigate the effects of sub-Tenon's capsule ropivacaine injection on pupillary diameter in strabismus surgery. METHODS: A total of 16 patients were randomly assigned to 2 groups. The ropivacaine group (R) received sub-Tenon's ropivacaine 1% (2.5-3 mL) injections. In the control group (C), general anesthesia was induced and a saline solution (2.5-3 mL) was injected in the sub-Tenon's capsule. Pupillary diameter was measured at baseline and 2 and 5 minutes from the injections. The effects of the injections were expressed as a ratio of final (5 minutes) versus basal diameter. RESULTS: A significant mydriasis occurred in the ropivacaine group when compared with the control group (Group R vs Group C ratio = 2.32, p < 0.0001) or with unoperated fellow eye (R vs unoperated eye ratio = 2.29, p < 0.0001). CONCLUSIONS: Ropivacaine in the sub-Tenon's capsule induces a mydriasis probably related to a pharmacological ciliary ganglion block.

[Mydriasis induced by splinter from belladonna bush]. / Mydriase pharmacologique par les alcaloïdes du bois d'atropa belladonna.

AIM: Pupillary dilatation with alcaloids from the Atropa belladonna plant have been used since antiquity. It is less known that the wood of the plant contains an even higher concentration of alkaloids than the ripe fruit. METHODS: Clinical case. RESULTS: A 32-year-old patient presented with a foreign body sensation after a splinter got in his eye while chopping wood of an Atropa belladonna bush in the underbrush. Ophthalmic examination showed a visual acuity of 0.9 s.c. (1.0 with pinhole) and a pupil in a fixed mydriasis without any visible rupture of the sphincter muscle. After a 3-day follow-up the pupil returned to normal size and visual acuity recovered to 1.25 s.c. CONCLUSION: The wood of the Atropa belladonna plant contains a very high concentration of alkaloids. A well-directed history may help to discover this less well-known cause of an accidental mydriasis.

Valerian overdose: a case report.

We present the first reported case of valerian (Valeriana officianalis) overdose. This herb is popular as a sedative but little is known about its toxic effects. The patient presented with mild symptoms, all of which resolved within 24 h. Valerian overdose, at approximately 20 times the recommended therapeutic dose, appears to be benign.

Unilateral mydriasis after induction of anaesthesia.

Unilateral mydriasis is a disturbing finding during anaesthesia and may indicate serious neurological injury. In addition, the assessment of abnormal neurological findings is limited during general anaesthesia, and therefore requires special consideration. I report finding a dilated right pupil (7 mm, nonreactive to light) after bronchoscopic tracheal intubation and induction of general anaesthesia in a frail, 74-yr-old woman with cervical subluxations and spinal cord impingement. The possible aetiology of the unilateral mydriasis includes the effects of anaesthetic agents, stellate ganglion block, impaired venous return from the head and neck, acute intracranial mass lesion or an haemorrhagic event, direct eye trauma, pre-existing medical or surgical conditions, and inadvertent direct deposition of alpha-adrenergic or anticholinergic agents in the eye. Consideration of these factors, the autonomic innervation of the eye, and an intraoperative "wake-up" test allowed satisfactory neurological assessment in this patient and surgery to proceed. Unilateral mydriasis, while unusual, may be seen during general anaesthesia and requires thorough knowledge of autonomic nerve pathways and pharmacology of the eye for correct diagnosis. In this case, mydriasis was considered to result from phenylephrine/lidocaine spray which was used to provide topical anaesthesia to the airway.

Atropine intoxication from the ingestion and smoking of jimson weed (Datura stramonium).

Anticholinergic effects occur due to jimson weed intoxication. The most common intoxication involves teenagers desiring mind-altering properties from the plant. We report 4 cases of jimson weed intoxication due to ingestion and inhalation (smoking) of jimson weed. Clinicians should be aware of the potential abuse of botanicals such as jimson weed.

Ocular toxicity in beagle dogs with lortalamine, a non tricyclic antidepressant compound.

During a preclinical safety evaluation study, an indication of ocular toxicity was noted in beagle dogs receiving orally (gelatin capsules) once a day, 7 days a week for, respectively, 7 and 91 days, 10 mg/kg/day of Lortalamine, a new non-tricyclic anti-depressant compound. Lortalamine treated dogs showed, progressively, bilateral mydriasis, conjunctivitis, epiphora, corneal oedema and corneal erosions from day 2 to day 7. Thereafter, even though treatment goes on, ocular lesions were progressively improved, and inflammation and swelling of both cornea slowly reversed, especially from day 8 to 30. These ocular changes were very similar to those reported with sympathomimetic agents. It was speculated that these lesions, following chronic oral administration of Lortalamine which induced high levels of the compound and its metabolite in the cornea, were related to an increased binding of norepinephrine to adrenergic receptors since the compound inhibits the re-uptake of the transmitter into the storing vesicles.

[Eye symptoms due to ginseng poisoning].

Ginseng has been used as a tonic for mind and body. A large number of pharmacological studies on ginseng have been done and the variety of effects were shown. In this paper 2 cases of ginseng poisoning has been reported the effects on both eyes were mydriasis and disturbance in accommodation, and the systemic symptoms included dizziness and semiconsciousness, which may be associated with hyperexitability of the sympathetic nerves (adrenergic nerves) due to overdose ginseng.

[Prolonged mydriasis caused by Lamaline]. / Mydriase prolongée à la Lamaline.

Atropine derivatives. The presence of atropine derivatives in numerous combined medicines is often ignored or reflected. A case report of prolonged bilateral non reactive mydriasis with "cycloplegia", linked with the utilisation of a therapeutic dose of Lameline suppositories raises the question of individual susceptibility, with particular ocular sensitivity. This urge one not to ignore the presence of these products and to respect the contraindications, even with minute doses.