Traumatic Mydriasis- No Improvement

[lfsk092093]

A month ago I was hit in the eye with a golf ball. Went to the ER and was diagnosed with Traumatic Iritis and “blown pupil”. No global rupture or “tears”. My eye was pretty dilated but still constricted. Not sure if it was reacting to light or not. Went to outpatient Ophtho and pressure was 56. Was prescribed 3 pressure reduction drops (two twice daily, one once daily) and Prednisolone 4 drops daily. For the first four days it looked like it was improving but now after 4 weeks looks like it has been getting worse, severely more dilated. Vision was blurry at first but now is normal. Now prescribed Pilocarpine for Traumatic Mydriasis. No reaction to light but responds to Prednisolone. Ophthalmologist said there is no visible tearing. Hoping to reach Dr. Hagan for advice or any others with similar experience.

[John C Hagan III, MD, FACS, FAAO]

You have a very, very serious problem. The dilated pupil is the least of them. You have traumatic glaucoma, traumatic iritis and you are at high risk for a retinal detachment (RD)  and traumatic cataract.  There are some good reasons that many ophthalmologists would feel you absolutely should not be on pilocarpine. (hopefully you aren't) as it increases the risk of RD and makes traumatic iritis worse. You can look up the contra-indications. My suggestions would be to see a Eye MD specialzing in retina/vitreous for special tests of your eye to be sure there are no difficult to see retinal tears/detachments.  Ask the retina MD about pilocarpine, I don't think they will feel you should be on it.  Also if you have access to a Eye MD that specializes in glaucoma I would see one as soon as possible. You need a test called gonioscopy, and will need ongoing management of the pressure in your eye. I am concerned about your eye and you should be also. I think your problem is too complex for a general ophthalmologist and needs a retina and glaucoma subspecialist

[lfsk092093]

Thank you Dr. Hagan. I have been to a MD Ophthalmologist who specializes in retina and vitreous, retinal holes/tears, detachments, flashes/floaters, uveitis. First visit was within 18 hours of accident (56 pressure). I took pressure meds/prednisolone as soon as they were ready at pharmacy (w/in 24 hours of accident). 2nd visit 2 days after accident, pressure was in the mid-10s.  Vision improving. 3rd visit  5 days after pressure was low 10s. 4th visit 3 week checkup the blood in the back of my eye was almost gone and there was no retinal tear. Pressure was in low 10’s. I was prescribed Pilo that week (Dr. said I can wait a week to use and stop if it hurts, originally said would prescribe at week 5). I used it sparingly for one week (wanted to see if responded to any input). During Pilo use: When I moved my eye it looked like some gel was “jiggling” around in the space where my iris is, but iris contracted. 4-week visit (pressure about 20s) and Dr said the iritis has resolved completely. There was initially blood in the back of my eye which had resolved. I had a scan of my retina and it is equal to the good eye, no tears. I still have what looks like a small red scratch on the white by the bottom of my iris which was said to continue to heal, although to me it looks like it is somewhat distorting the roundness of my iris (i.e., pushing” it upward, outer layer of pigment looks blueish as well). I go back in in 2-3 weeks to have my “drainage” checked. Still on 2 pressure meds (Brimonidine/Latanoprost), tapering prednisolone. Not going to take the Pilo for some time.

[John C Hagan III, MD, FACS, FAAO]

You seem very capable of self research. Just look up pilocarpine drops and the contraindications and side effects.  In a similiar situation i would not prescribe them.  Sounds like you are going to have a gonioscopy to check the 'filtering angle"  I'm sure you have angle recession glaucoma. Best of luck. Hope these comments have been helpful

[lfsk092093]

**Respods to Pilocarpine