Isolated dilated pupil
BMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2021-069133 (Published 31 March 2022) Cite this as: BMJ 2022;376:e069133
- Iñigo Ruiz-Barrio, registrar1,
- Daniel Guisado-Alonso, consultant1,
- Victoria Bulnes-González, registrar2,
- Benedict T Green, research pharmacologist3
- 1Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- 2Department of Ophthalmology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- 3Department of Pharmacology, USA Poisonous Plant Research Lab, UT, USA
- Correspondence to: D Guisado-Alonso dguisado{at}santpau.cat
A woman in her 50s presented to the emergency department with blurred vision and pupil asymmetry for three hours, which had started while she was pruning plants in her garden. She had no headache, eye pain, or double vision. Corrected visual acuity in the right eye was 0.8 and in the left eye was 1.0. On examination, the right pupil was dilated (mydriasis) (fig 1), direct and consensual light reflexes were abolished, and there was loss of accommodation—all suggesting dysfunction of the ocular parasympathetic pathway. Eye movements, reflexes, and other neurological examination findings were normal. Her vital signs were normal, and an electrocardiogram was unremarkable.
(A) Dilated right pupil on arrival at hospital (patient looking to right.). (B) Brugmansia suaveolens (angel’s trumpet).
Pilocarpine (a muscarinic agonist) eye drops were instilled in both eyes to assess the parasympathetic pathway; first at concentrations of 0.125% and then 1%. The mydriasis was …
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