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Título

Prolonged unilateral mydriasis secondary to chronic ipratropium bromide nebulization in the outpatient setting: Case report

RESUMO

Case presentation: A 42-year-old female was evaluated at our Neurology service due to blurred vision and dilated pupil in the right eye for three years. There were no pain, diplopia, nor other associated symptoms. Visual complaints and pupil diameter both fluctuated throughout the months, without correlation to any factors. She had hypertension, pre-diabetes, and asthma. Her current medications were losartan and inhalatory combination of formoterol and budesonide, the latter started last month. She had been using salbutamol and ipratropium bromide nebulization since childhood; five years ago, frequency increased to 8-hourly courses every day. She had suspended its use two weeks before consultation, as asthmatic symptoms were improving, and subsequently perceived a discrete pupillary reduction. At examination, there was right mydriasis with absent direct and consensual photomotor reflex (Figure 1). Visual acuity, visual field, direct ophthalmoscopy, and extrinsic ocular motricity were unremarkable, as well as the remaining neurological examination. She had been evaluated by several physicians, and submitted to ophthalmological tests, laboratory work-up, and neuroimaging studies (i.e., computed tomography and magnetic resonance imaging with angiography), without any findings. Ipratropium suspension was reinforced.
Discussion: Some reports have established the relationship between unilateral mydriasis and nebulized ipratropium bromide in intensive care patients. It acts topically in the pupillary sphincter muscle by blocking cholinergic stimulation. Ill-fitting face masks, especially in patients with facial asymmetries, are attributed as the major cause for unilateral presentation. Inadequate self-medication and chronic misuse of face masks could explain this finding in the outpatient setting. Physical examination, complementary work-up, and follow-up are essential for differential diagnosis, especially with Adie’s pupil. Pilocarpine test is also helpful. In most reports, exposure is short and recovery fast after suspension. As the patient had five years of continuous exposure, a longer time to resolution could be expected.
Final considerations: The present report stresses the importance of an extensive review of patient history, especially in an already over investigated patient. As far as we know, this is the first case in which chronic exposure to ipratropium bromide in the outpatient setting caused a prolonged unilateral mydriasis.

Palavras Chave

Mydriasis; ipratropium; ambulatory care