Anisocoria Medication

Updated: Dec 27, 2018
  • Author: Eric R Eggenberger, DO, MS, FAAN; Chief Editor: Edsel B Ing, MD, MPH, FRCSC  more...
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Medication

Medication Summary

Drugs commonly used in the diagnosis of anisocoria include cocaine, hydroxyamphetamine, and pilocarpine (0.1-1%).

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Topical anesthetic agents

Class Summary

This agent is used for diagnostic testing to detect Horner syndrome.

Cocaine

Prevents norepinephrine reuptake and accordingly dilates eye with intact sympathetic nervous system supply. Decreases membrane permeability to sodium ions, which, in turn, inhibits depolarization and blocks conduction of nerve impulses.

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Cholinergic agents

Class Summary

This agent is used for diagnostic testing related to tonic pupil (0.1% concentration) or pharmacologic dilation-induced anisocoria (1% concentration).

Pilocarpine ophthalmic (Isopto)

Does not normally constrict pupil; however, with tonic pupil, produces miosis due to cholinergic supersensitivity. Constricts normal pupil or mydriatic pupil due to oculomotor palsy; however, after pharmacologic dilation (eg, atropinelike agents), pilocarpine has no miotic effects.

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Sympathomimetic agents

Class Summary

Hydroxyamphetamine is useful diagnostically to test integrity of the third-order sympathetic neuron.

Hydroxyamphetamine (Paredrine)

Dilates pupil if third-order sympathetic neuron intact, and fails to dilate pupil if third-order neuron impaired.

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Alpha2-adrenergic agonist agent, ophthalmic

Class Summary

These agents decrease IOP by reducing aqueous humor production.

Apraclonidine (Iopidine)

Potent alpha-adrenergic agent selective for alpha2-receptors with minimal cross-reactivity to alpha1-receptors. Suppresses aqueous production. Reduces elevated, as well as normal, intraocular pressure (IOP) whether accompanied by glaucoma or not. Apraclonidine is relatively selective alpha-adrenergic agonist that does not have significant local anesthetic activity. Has minimal cardiovascular effects.

Due to the weak, direct alpha-1 and alpha-2 receptor agonist effect, apraclonidine may reverse the Horner anisocoria (no effect on normal pupil, but Horner syndrome-related denervation supersensitivity produces pupil dilation).

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