Int J Clin Pharm (2011) 33:737–739 DOI 10.1007/s11096-011-9555-5
CASE REPORT
Unilateral mydriasis due to scopolamine patch Pauline Vasselon • Luisa Weiner • Fanny Rossi-Pujo Marie Socha • Patrick Peton • Isabelle May • Be´atrice Demore • Herve´ Javelot
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Received: 29 April 2011 / Accepted: 16 August 2011 / Published online: 26 August 2011 Springer Science+Business Media B.V. 2011
Abstract Case We report the case of a patient who presented with unilateral mydriasis after a scopolamine patch application. The specific clinical context (cancer) reported here may have led to the misinterpretation of the etiology of mydriasis. Conclusion Our case description warns against diagnostic mistakes related to this side effect and highlights the advantages of pilocarpine test in the differential diagnosis of unilateral mydriasis.
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Keywords Differential diagnosis Side effect Transdermal scopolamine patch Unilateral mydriasis
Scopolamine is effective and frequently used in motion sickness treatment [1]. However, its indications also include nausea, vomiting, dizziness, vertigo or drooling [2]. Scopolamine oral or parenteral administration is associated with frequent side effects and has a short duration of action [3], so a transdermal delivery system (Scopoderm) has been developed. Scopoderm is composed of a drug reservoir separated from the skin by a microporous ratecontrolling membrane and by an adhesive which keeps the membrane and the skin in contact. The disk, placed behind the ear, releases 1 mg of scopolamine into the systemic circulation during a three-day period [4]. Even though few systemic side effects are associated with this device, visual problems have been reported due to its direct contact with the eyes. Scopolamine has indeed cycloplegic and mydriatic action which can last up to a couple of weeks [5]. Mydriasis has already been observed following the use of a scopolamine patch in many clinical situations: motion sickness [4], nausea and vomiting [2] drooling [6], dizziness [7]. The most frequent symptom is a unilateral, fixed, dilated, and non-responsive pupil with a blurred vision [7], which usually concerns the ipsilateral eye compared with the application site. Patients contaminate themselves when they rub their eyes after manipulating the patch without washing their hands.
Impact statements •
Pilocarpine tests are useful in the differential diagnosis of unilateral mydriasis.
P. Vasselon M. Socha I. May B. Demore H. Javelot Service Pharmacie, CHU Nancy, Nancy, France L. Weiner Service de Psychiatrie II, CHU de Strasbourg, Strasbourg, France F. Rossi-Pujo Service d’Ophtalmologie, CHU Nancy, Nancy, France P. Peton Unite´ Hospitalie`re Se´curise´e Interre´gionale, Hoˆpital Brabois Adultes, CHU Nancy, Nancy, France H. Javelot (&) Faculte´ de Me´decine de Nancy, 9 Avenue de la Foreˆt de Haye, 54500 Vandoeuvre Le`s Nancy, France e-mail:
[email protected]
Non-detection of unilateral mydriasis may have significant pharmacoeconomic consequences, especially in the context of cancer.
Introduction
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Our case illustrates the problem of these relatively unknown and benign side effects which can have potentially important pharmacoeconomic consequences.
Case description M.S, a 34-year-old man, suffers from a nasopharyngeal carcinoma. He is treated with radiotherapy and chemotherapy. A patch of scopolamine (Scopoderm) was prescribed due to the drooling and emetic effects of his treatment. After a few weeks, M.S complained of blurred vision in his right eye. An ophthalmic consultation showed a unilaterally, dilated, non-responsive pupil. A cerebral metastasis was thus considered and an MRI was scheduled. However, a few moments later, M. S remembered having administrated the patch a few hours before the onset of symptoms and reported it to the nurse. The MRI was therefore deprogrammed. The mydriasis disappeared in 72 h and the vision got back to normal quickly.
Discussion Although several cases of ocular contamination caused by scopolamine have been reported in the literature [1–9], the diagnosis of unilateral mydriasis is still difficult to reach. Scopolamine patches are not usually considered by patients as a medicine, so they tend not to report it. Unilateral mydriasis symptoms may mimic intracranial disease symptoms and trigger the prescription of expensive medical examinations such as MRI [7, 8]. Our case report reflects the potentially serious pharmacoeconomic consequences of such side effects. When the etiology of the problem is not immediately identified, these include consultations with ophthalmologists, treatment for mydriasis, extension of the carcinoma in cancerology; the longer hospital stay and the negative impact on the patient’s morale (due to the carers’ uncertainties and possible mentions of a cancer relapse) may also lead to secondary prescriptions. Therefore, physicians should be aware of the possibility of a scopolamine contamination when they observe this kind of symptoms in patients. A fixed, dilated pupil can be caused by midbrain damage (vascular accidents, tumor, degenerative and infectious diseases), a damage to the third nerve or a damage to the iris (degenerative or inflammatory diseases, acute rise of intraocular pressure, blunt injury, pharmacologic blockade). Thus, it is important to recall that a simple test can identify mydriasis induced by anticholinergic drugs [10]. Atropinic drugs are competitive antagonists of pilocarpine. Blockage of the iris sphincter by anticholinergic drugs does
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not allow the constriction of the pupil, while a third nerve palsy does not affect it. However, damage to the sphincter muscle by high intraocular pressure or trauma may impair pupil constriction and must be ruled out during the collection of patient’s medical data [10]. When the eye has not been injured, and a normal intraocular pressure is observed, the failure of constriction within 30 min after instillation of 0.5–1% pilocarpine is indicative of a pharmacological blockage [8]. Pilocarpine has to be instilled in both eyes to avoid false-negative results. Constriction of the normal pupil indicates that enough pilocarpine has been used [9]. According to the Naranjo adverse drug reaction probability scale [11], the score obtained in our patient’s case, 7, suggests probable adverse drug reactions.
Conclusion The present clinical case recalls the relevance of potential ocular adverse side effects due to scopolamine patches. Patients and nurses’ education is very important when scopolamine patches are prescribed. Patients have to wash their hands conscientiously after insertion, removal or any other manipulation of the disk because of skin irritation risks. Touching the post-auricular area and the eyes must be avoided as much as possible. These simple tips given by the physician and the pharmacist can prevent ocular side effects. If an ocular side effect is suspected, pilocarpine test is a safe and valid method to determine whether it is due to unilateral mydriasis of iatrogenic origin. Misinterpretation of clinical signs such as unilateral mydriasis may have significant pharmacoeconomic consequences since this may cause misdiagnoses and delays in the initiation of useful treatments. Conflicts of interest Funding
None.
None.
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