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NEW ORLEANS -- "Blown" pupils were linked with exposure to prescription glycopyrronium (Qbrexza) wipes, most likely from touching the eyes after using the antiperspirant cloths, according to a pediatric case series.

These wipes should appear on the list of suspects in cases of medication-induced pupil changes, said Adam J. Cantor, MD, of Texas Children's Hospital in Houston. "A careful patient history and exam can help save patients from stress and unnecessary testing," he told 番茄社区app at a presentation at the American Academy of Ophthalmology annual meeting.

However, Cantor and colleagues reported that all cases in their series resolved on their own within hours or days.

Other case reports have noted anisocoria (unequal pupil size) and mydriasis (dilated pupils) in adult users of glycopyrronium wipes, but this report is the first to describe multiple cases in children, according to Cantor's group.

They conducted a retrospective chart review and identified six cases from June 1, 2018 to Dec. 1, 2020. The majority of cases were female (n=5) and the mean age was 14.7 years.

In terms of symptoms, all had unilateral dilated pupils, and one had unilateral headache. Co-author Joseph Pecha, a medical student at Baylor College of Medicine in Houston, told Medpage Today that four of the children complained of blurry vision, similar to that experienced by patients when their eyes are dilated. "Anticholinergic medications block the pupillary sphincter muscles in the eye from contracting and can paralyze the ciliary muscles, which help the lens to focus up close-up. The result is pupil dilation and trouble focusing at close distances," Pecha explained.

Three patients presented to the emergency department (ED) and three to primary care physicians.

In three of these cases, clinicians didn't immediately ask about use of glycopyrronium wipes, and neuroimaging was ordered. While anisocoria can be benign, "sometimes it can be a sign of a serious life-threatening issue such as stroke, bleeding, or tumor in the brain, so it requires a careful history and exam," Cantor said. "In my experience, most patients -- and parents in pediatric cases -- experience significant stress when they notice a sudden pupil abnormality."

In one case, the patient was discharged with a diagnosis of sinusitis due to headache, returned to the ED 2 months later, and was discharged again without a diagnosis. Later, the dermatologist who prescribed the wipes realized they were the cause, according to Cantor.

When making the diagnosis in one case, Cantor explained that "I saw the degree of mydriasis -- at least an 8-mm diameter pupil -- and immediately suspected a pharmacologic cause," he said. "[The female patient] wasn't ill-appearing and had no strabismus nor ptosis; findings that could be associated with a third cranial nerve palsy or Horner's syndrome, which are other causes of ptosis."

Cantor said the parent denied the child was taking any medications, but confirmed that she was using an antiperspirant wipe -- which can also be bought -- and "Sometimes patients or parents don't consider wipes to be a medication."

As for what can help symptoms resolve, "Patients may be light-sensitive, so sunglasses may be helpful...In addition to pupil dilation, glycopyrronium can cause cycloplegia: paralysis of accommodation. These kids may have difficulty focusing on near objects for several days if this is the case. Pupil dilation can also cause photophobia," Cantor noted.

Cantor advised hand-washing after application of wipes as "the likely cause of mydriasis is when they inadvertently rub their eyes with their hands after using the wipes." Also, wearing gloves while using the wipes is another option, according to the researchers.

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