Images in Clinical Medicine

Nebulizer-Associated Anisocoria

Neil Iosson, M.R.C.P., M.B., B.Chir.

N Engl J Med 2006; 354:e8March 2, 2006

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A 42-year-old intravenous drug user was transferred to the ward for noninvasive respiratory support after discharge from the intensive care unit, where she had been treated for fungal pneumonia and septicemia. She had alcoholic cirrhosis, chronic active hepatitis B, and hepatitis C. She had a test negative for the human immunodeficiency virus. She received oxygen and nebulized albuterol (salbutamol) and ipratropium bromide through a face mask that was attached to a noninvasive bilevel positive-airway-pressure (BiPAP) ventilator. She was recovering well when her right pupil became fixed and dilated. Examination of the cranial nerves showed no other abnormalities. A computed tomographic scan of her head, performed to search for an intracranial cause of partial palsy of the right third cranial nerve, was normal. The BiPAP face mask was found to fit imperfectly and leak slightly to the right. The anisocoria resolved within 24 hours after the patient stopped receiving ipratropium. If the conjunctiva is exposed to ipratropium (an anticholinergic agent) by means of metered-dose inhalers or nebulizers, mydriasis as well as acute glaucoma may occur.

Neil Iosson, M.R.C.P., M.B., B.Chir.
Southampton University Hospitals, National Health Service Trust, Southampton SO16 6YD, United Kingdom

Citing Articles (6)

Citing Articles

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   P. Worth Longest, Geng Tian, Michael Hindle. (2011) Improving the Lung Delivery of Nasally Administered Aerosols During Noninvasive Ventilation—An Application of Enhanced Condensational Growth (ECG). Journal of Aerosol Medicine and Pulmonary Drug Delivery 24:2, 103-118
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   Edgard Wehbe, Smyrna Abou Antoun, Jany Moussa, Imad Nassif. (2008) Transient Anisocoria Caused by Aerosolized Ipratropium Bromide Exposure From an Ill-Fitting Face Mask. Journal of Neuro-Ophthalmology 28:3, 236-237
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   Jeremy J. Moeller, Charles E. Maxner. (2007) The dilated pupil: An update. Current Neurology and Neuroscience Reports 7:5, 417-422
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   David E. Geller. (2007) Clinical Side Effects during Aerosol Therapy: Cutaneous and Ocular Effects. Journal of Aerosol Medicine 20:s1, S100-S109
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   Dean R. Hess. (2007) The Mask for Noninvasive Ventilation: Principles of Design and Effects on Aerosol Delivery. Journal of Aerosol Medicine 20:s1, S85-S99
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