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Toxidromes are well known to emergency physicians. An unclear or incomplete history and subtle findings on physical examination make the diagnosis of poisonings challenging. This article reports a patient who had an acute onset of visual hallucinations, pressured speech, and mania. Although she denied taking any medications, she was ultimately diagnosed as having anticholinergic toxicity. On further questioning of family members, it was discovered that she was being treated for anterior uveitis with 5% homatropine. This case illustrates the potential role of ocular medications in systemic toxicity. Patients often do not consider eyedrops to be medications, and their use may be overlooked in the medical history. It also is important to educate patients and medical staff in methods to minimize systemic toxicity when using ocular medication.Key words: anticholinergic toxicity; ophthalmic medications; drug-induced toxicity; homatropine. I Toxicity related to anticholinergic agents is well known. Although toxidromes are often caused by medicines administered orally, it is important to remember that ocularly applied drugs can cause toxicity as well. We report a case of anticholinergic poisoning from ocular application of homatropine for the purpose of illustrating the potential role of ocular medications in producing systemic toxicity and to emphasize means to minimize systemic toxicity when using these agents. The patient was a 55-year-old Polish cleaning woman who presented to the Albany Medical Center ED with an acute onset of agitation, paranoid ideation, and pressured speech. According to her husband, the patient returned from her job "speaking wildly" and "afraid [that] people were after her." Later that evening she thought she saw herself performing on television, then claimed to be followed by men. The following day florid visual hallucinations ensued concerning "bloody babies" and "piles of money." Her past medical history included possible hypertension, but the husband noted In the ED, the patient was pacing the hallway and shouting in Polish to her husband and other patients near her. Her only discernible English words were "I not crazy" and "Mario Cuomo." The vital signs were: oral temperature 38.2"C (100.8"F), blood pressure 170/100 mm Hg, pulse 100 beats/min, and respiratory rate 20 breathdmin. Her skin and mucous membranes were flushed and dry. The pupils were reactive to light and dilated (more so on the left). Funduscopic examination revealed sharp disk margins. No hernotympanum was found. The neck was supple and no adenopathy was palpable. The lungs were clear and the cardiac examination revealed a regular tachycardia at a rate of 100 beatshin. The abdomen was distended and slightly tympanitic with diminished bowel sounds. The neurologic examination showed intact cranial nerves 2-12. The upper extremities and lower extremities were of equal 5/5 motor strengths. Sensation was intact to light touch and pinprick. Deep tendon reflexes were not obtainable secondary to agitation.Laboratory studies...

Fifty cases of retinal detachment with a giant retinal tear were managed using perfluoroperhydrophenanthrene (Vitreon) as an intraoperative and postoperative tool. The giant tear was less than 180° in 76% of the eyes, greater than 180° in 22%, and greater than 270° in 2%. Proliferative vitreoretinopathy was present in 40%. Vitreon was used only intraoperatively in 84% of the eyes, and was left in 16% for up to 4 weeks. Intraoperative retinal reattachment was achieved in 98%. Retinal attachment was maintained in 88%, with a mean follow up of 8.6 months. Postoperative visual acuity was better than 20/400 in 52%. Postoperative complications included cataract in 23%, choroidal effusion in 2%, hypotony in 4%, and recurrent retinal detachment with proliferative vitreoretinopathy in 26%.

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