Anisocoria? No Sweat! A Case Series of Anticholinergic Mydriasis (4570)

Objective: We present three cases of pharmacologic anisocoria caused by inadvertent ocular exposure to a product marketed for axillary hyperhidrosis. Background: Causes of anisocoria range from benign to life-threatening, making it a common reason for urgent Neuro-Ophthalmology referrals. The pathways controlling pupillary size and reactivity are complex and affected by lesions along this pathway or by systemic or topical agents. Design/Methods: Case series and review of literature. Results: A 15-year-old female had transient episodes of anisocoria and bilateral pupillary dilation. On exam, both pupils were mydriatic to 8.5 mm and nonreactive to light, without response to 1% pilocarpine eyedrops. A 16-year-old female, referred for Adie tonic pupil, experienced a single episode of blurred vision, photophobia, and a dilated left pupil that lasted two days. She believed her symptoms were related to new contact lenses and had since worn her glasses without further recurrence. A 38-year-old female noted three episodes of blurred vision accompanied by a dilated, nonreactive left pupil, lasting one to two days. Patient-provided photos showed a 4-mm right pupil and a fixed 7-mm left pupil. The rest of the exam for all three patients was normal. All three patients failed to list any medications that could explain their symptoms. Further questioning revealed the recent addition of an antiperspirant cloth wipe. Glycopyrronium (Qbrexza) cloth is an anticholinergic drug that received FDA approval in June 2018 for topical use to treat primary axillary hyperhidrosis. Conclusions: Mydriasis is a well-known side-effect of anticholinergic agents. This is one of the first case reports of pharmacologic anisocoria due to a new topical product intended for primary axillary hyperhidrosis. As more pharmacologic agents are incorporated into commercial beauty and hygiene products, clinicians should be mindful of this benign etiology to alleviate patient and physician worry and reduce unnecessary testing. Disclosure: Dr. Potekhina has nothing to disclose. Dr. Holicki has nothing to disclose. Dr. Nagia has nothing to disclose. Dr. Antonio has received personal compensation in an editorial capacity for Cochrane Clinical Answers. Dr. Glisson has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Alexion.