5 When administered directly to the eye, ipratropium bromide paralyzes the parasympathetic nerve endings and results in unopposed mydriasis. 1 It is a derivative of atropine, and the medication antagonizes muscarinic acetylcholine receptors, decreasing contractility of smooth muscle. Ipratropium bromide is an anticholinergic agent that is used frequently in the treatment of reversible airway disease owing to its bronchodilatory and antisecretory properties. 1-3 Proper face mask fit is particularly difficult for pediatric patients the masks inevitably leak aerosol, leading to significant facial and eye deposition. Ipratropium bromide has long been recognized as a cause of transient anisocoria, particularly in association with ill-fitting face masks, in children and adults. In this case, given the girl’s otherwise normal neurologic examination findings and onset after administration of aerosolized ipratropium bromide, her anisocoria was believed to have been caused by the medication. In an asymptomatic patient without recent history of trauma or concerning past medical history, pharmacologic causes should be considered. 1 Determining the cause might require costly studies such as magnetic resonance imaging. On telephone follow-up approximately 24 hours later, the girl’s anisocoria had almost completely resolved.Īnisocoria is a concerning finding on physical examination and might suggest an impending neurologic emergency. Her mother was instructed to follow up with her pediatrician the next morning, and strict return instructions were given. The girl remained asymptomatic but remarked that she felt like “something was getting in (her) eye” during the nebulizer treatment. Of note, her pupils had been equal and reactive at the time of the initial physical examination. She was asymptomatic, with otherwise nonfocal neurologic examination findings, and was jumping around the room, ready to go home. Her left pupil was 5 mm and nonreactive, while the right pupil was 3 mm and reactive. On reassessment, however, she was noted to have unequal pupils. She remained well appearing and without hypoxia, and she was being prepared for discharge. Her asthma symptoms improved after several nebulizer treatments. She was treated with albuterol and ipratropium bromide inhaled nebulizer treatments and was given oral dexamethasone. Physical examination findings were unremarkable except for the presence of mild respiratory distress, subcostal retractions, and expiratory wheezes. Her mother denied the presence of fever in the girl. She had been taking albuterol at home without much improvement. A 6-year-old girl with a history of asthma presented to the emergency department for an acute asthma exacerbation.
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