Case report: Teenage cheerleader presents with bilateral mydriasis, cycloplegia
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Unexplained mydriasis with cycloplegia in children and teens can cause great parental concern, especially if the patient reports an inability to do schoolwork.
While pupil dilation can bring out fears of dangerous neurologic conditions, ocular and physical exam often leads the practitioner to suspect a more benign pharmacologic cause. Whether the inciting agent is used purposefully or inadvertently encountered, the identity of such an agent can frequently be difficult to elucidate. Below is a case of a new and less well-known agent of interest to the pediatric medical community.
Bilateral mydriasis and cycloplegia
One week after school began, a 14-year-old female cheerleader presented in uniform to the outpatient pediatric ophthalmology office reporting 2 weeks of intermittent bilateral blurred vision and pupil dilation. She initially experienced left eye pupillary dilation for 3 days and then a second episode in the left eye lasting 2 days. At presentation, she had several days of continuous mydriasis in both eyes with blurry vision preventing homework completion. She had a medical history of ADHD treated with Vyvanse (lisdexamfetamine dimesylate, Takeda Pharmaceuticals) and clonidine but had not taken the medications during summer break when the pupillary changes began. She was taking no other oral or topical ocular medications.
On exam, the patient was alert, oriented and without distress. Uncorrected distance vision was 20/20 in the right eye, 20/20 in the left eye and 20/15 in both eyes. Pupils measured 8 mm in the right eye and 9 mm in the left eye with minimal light reaction in the right eye and almost no light reaction in the left eye. Dynamic retinoscopy showed reduced but present accommodation in the right eye, somewhat worse in the left eye. She was orthophoric in all fields, with full extraocular motion. Near point of convergence was 3 cm. The slit lamp exam was nonsignificant in both eyes, with no vermiform pupil movements in either eye, and the eye exam was otherwise normal.
The primary diagnosis considered was pharmacologic dilation/cycloplegia, with much less likely possibility of bilateral Adie’s pupils. The inciting agent was uncertain, although Munchausen purposeful deleterious medication use was considered given the increased frequency of functional visual complaints at the beginning of the school year and that the patient showed minimal distress and continued full cheerleading activity but “just couldn’t do schoolwork.” Reading glasses were recommended so that schoolwork could resume.
After the exam, discussion ensued about the patient’s use of Qbrexza (2.4% glycopyrronium, Journey Medical Corporation) cloths at bedtime to treat palmar hyperhidrosis. The Qbrexza wipes used for her hyperhidrosis were not initially recognized as a medication but quickly became the obvious agent once the anticholinergic nature of the substance was realized, and the family was told to discontinue their use.
Discussion
Glycopyrronium has been reported to cause mydriasis as an unwanted side effect after topical application, especially in individuals with poor hand hygiene or soft contact lens use or simply with accidental ocular contact. Cases have been previously reported of anisocoria and mydriasis due to topical glycopyrronium use in both pediatric and adult cases. Fewer cases have focused on Qbrexza use in palmar hyperhidrosis.
Our patient’s sweaty palms posed a true safety risk during cheerleading stunts. It is currently recommended that gloves be worn while applying Qbrexza to areas such as the axilla; however, this is not possible in the case of palmar hyperhidrosis. Our patient was using the wipes just before bedtime and could neither avoid nor be aware if she rubbed her eyes during sleep.
A 2022 cohort study examining topical glycopyrronium 2.4% specifically in palmar hyperhidrosis found that the drug should remain on the hands unobstructed for 30 minutes to achieve the greatest reduction in palmar hyperhidrosis symptoms. Thus, palmar Qbrexza would be better applied during a time of day that eye touching can be monitored. However, given the difficulty in assuring no eye touching after use even when awake, perhaps the medication should not be used on the hands at all, especially in those who could be expected to touch their eyes, such as contact lens wearers, those with ocular allergy and those who use frequent eye makeup. This case illustrates that alternative solutions to anticholinergic hand wipes may be necessary in the treatment of palmar hyperhidrosis, especially in those patients for whom sweaty palms pose a safety threat, such as in sports, given the limited ability to avoid inadvertent ocular exposure and simultaneous effective medication application. Additionally, physicians should avoid assumption of Munchausen in pediatric patients, and detailed medication and medical history review should be conducted in all cases.
- References:
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- For more information:
- Tarab Ajjan, an MD candidate at the Medical College of Georgia, can be reached at tajjan@augusta.edu.
- Marc F. Greenberg, of Eye Consultants of Atlanta, Pediatric Center, in Marietta, Georgia, can be reached at mgreenberg@eyeconsultants.net.
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