What is the appropriate management for mydriasis?

Management of Mydriasis

The appropriate management of mydriasis depends on identifying and addressing the underlying cause, with treatment directed at the specific etiology rather than the mydriasis itself.

Causes of Mydriasis

Physiological Causes

• Emotional stress or anxiety can cause episodic unilateral mydriasis that is benign and self-limiting 1
• Low light conditions trigger normal pupillary dilation

Pharmacological Causes

• Anticholinergic medications (e.g., atropine, glycopyrrolate) can cause mydriasis, particularly at high doses 2
• Supplement powders containing stimulant compounds may cause unilateral mydriasis through accidental contact 3
• Amantadine has anticholinergic effects that can cause mydriasis and should not be used in patients with untreated angle closure glaucoma 4

Pathological Causes

• Smooth muscle dysfunction syndrome (associated with ACTA2 gene mutation) presents with congenital mydriasis 4
• Neurological conditions affecting pupillary innervation:
  • Oculomotor nerve (CN III) compression from cerebral edema after stroke can cause ipsilateral pupillary dilation 4
  • Traumatic brain injury with increased intracranial pressure may present with pupillary abnormalities 4
• Post-surgical complications such as after gonioscopy-assisted transluminal trabeculotomy 5

Diagnostic Approach

History

• Onset and duration of mydriasis (episodic vs. persistent) 1
• Associated symptoms (headache, visual disturbances, pain) 6
• Medication use, including supplements 3
• Recent eye procedures or trauma 5
• Family history of genetic conditions 4

Examination

• Pupillary light reflex (direct and consensual) 3
• Response to pilocarpine challenge (to differentiate pharmacological from neurological causes) 3, 6
• Complete neurological examination 1
• Ocular examination for signs of glaucoma or other eye conditions 2

Management Strategies

For Pharmacological Mydriasis

1. Discontinue offending agent if possible 4
2. For anticholinergic exposure:
   • Observation for mild cases as effects are usually self-limiting 3
   • Pilocarpine eyedrops may be used to counteract mydriasis in selected cases 2
   • For patients requiring anticholinergic medications who are at risk for angle-closure glaucoma, continue miotic therapy before, during, and after administration 2

For Neurological Causes

1. For increased intracranial pressure:
   • Frequent monitoring of pupillary size and reactivity 4
   • Address underlying cause (e.g., management of cerebral edema, evacuation of hematoma if indicated) 4
   • Consider individualized intracranial pressure monitoring and management in traumatic brain injury 4

For Persistent Symptomatic Mydriasis

• For patients with intolerable photosensitivity and glare due to persistent mydriasis, surgical interventions such as iris cerclage pupilloplasty may be considered 5

For Benign Episodic Mydriasis

• Reassurance about the benign nature of the condition 1
• Management of underlying triggers such as anxiety or stress 1
• For mydriasis associated with migraine:
  • Appropriate migraine prophylaxis and treatment 6
  • Episodes typically resolve spontaneously within minutes to hours 6

Special Considerations

Air Travel

• Dim lighting in airplane cabins can cause mydriasis and increase risk of pupillary block, potentially leading to acute angle closure glaucoma in susceptible individuals 4
• Patients with untreated angle closure glaucoma should take precautions when flying 4

Genetic Conditions

• Patients with smooth muscle dysfunction syndrome (ACTA2 mutation) may have congenital mydriasis requiring specialized management 4
• Genetic counseling may be appropriate for families with heritable conditions 4

Follow-up

• Patients with unexplained persistent mydriasis should undergo appropriate neuroimaging to rule out structural lesions 1
• Regular monitoring of intraocular pressure in patients with risk factors for glaucoma 2
• Reassessment of pupillary function after resolution of acute causes 3, 6