Dilated pupils in an anxious patient
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Dilated pupils in an anxious patient Murshidah Hassan Basri1 · Ching Soong Khoo2 · Jemaima Che Hamzah1 Received: 3 August 2020 / Accepted: 5 October 2020 © Belgian Neurological Society 2020
Keywords Mydriasis · Alprazolam · Anxiety A 21-year-old woman with underlying anxiety disorder presented with a 1-week history of light-headedness and blurred vision. Apart from her alprazolam 0.5 mg on nocte and escitalopram 10 mg once daily for anxiety disorder, she was not on any other medications. She had been taking alprazolam intermittently for 11 months prior to her symptoms. Her initial symptoms were followed by a brief jerky movement of her left leg, which lasted about five minutes and aborted spontaneously. She reported no syncopal attack, prolonged fever, severe headache or vomiting. On examination, she looked comfortable and euthymic. Vitals were within normal limits and there was no postural hypotension. Best corrected visual acuity was 6/12 in the right eye, and 6/9 in the left eye. Ocular examination revealed dilated pupils of 6 mm in diameter in both eyes, which did not constrict to light or convergence (Fig. 1). The intraocular pressure was 22 mmHg (normal range: 10–21 mmHg) in each eye. Gonioscopy was not performed on the dilated eyes. The rest of the anterior segment and fundi examination showed no abnormalities. Other cranial nerves were intact. Review of her other systems was unremarkable. All her blood tests including toxicology screen were within normal limits. Both her electroencephalogram and brain magnetic resonance of imaging were normal. Her jerky movements were functional, which were in relation to her underlying anxiety disorder. Alprazolam was identified as the offending agent and subsequently Murshidah Hassan Basri, Ching Soong Khoo have contributed equally to this work. * Ching Soong Khoo [email protected] 1
Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia
Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
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discontinued. After stopping alprazolam for 2 weeks, both her pupils returned to 3 mm in size, which constricted well to light and convergence. The repeat intraocular pressure was about 14 mmHg in each eye (Fig. 2). There are many causes of mydriasis, such as angle closure glaucoma, third cranial nerve palsy, intracranial space occupying lesions and medications. Among all these etiologies, drug-related mydriasis is the most common. Medications causing mydriasis include anti-cholinergic agents, such as scopolamine, atropine; and adrenergic agents such as cocaine and phenylephrine [1]. Alprazolam is a triazolobenzodiazepine, which has anxiolytic, anticonvulsant and muscle relaxant properties. It exerts its effect through interaction to gamma-aminobutyric acid (GABA)-A receptor, which enhances GABA neurotransmitter that is inhibitory in nature, and thu
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