A woman, aged 70 years, developed anisocoria after applying homeopathic eye drops (Similasan Pink Eye Relief) to her left eye. Her pupil was dilated for two weeks and did not respond to light or near stimuli for one week. Both 0.1% and 1% pilocarpine failed to constrict her left pupil, and magnetic resonance imaging of her brain did not reveal any abnormality. The eye drops she had used contain belladonna extracts which have a natural atropine component. This case demonstrates the importance, when evaluating a patient presenting with anisocoria, of knowing the chemical ingredients of the homeopathic eye drops, which often are not listed. A nisocoria could suggest a life-threatening event due to its association with cranial third-nerve palsy or Horner's syndrome. Pharmacological mydriasis is one of the benign etiologies of anisiocoria. Although it is common knowledge that the vasoconstrictor in over-thecounter (OTC) eye drops can cause adrenergic mydriasis, 1 there has never been a published report on the pupillary effect from OTC homeopathic eye drops.Homeopathy, treating illness with a holistic and natural approach, has become a popular alternative medicine practice, even in the Western world.2 Homeopathic eyedrops (from companies such as Similasan, Highlands Ranch, Colorado), derived from natural sources are now readily available at local retail stores. Two of the nine OTC drops produced by Similasan contain active ingredients obtained from Atropa belladonna, a perennial herbaceous plant commonly known as deadly nightshade. The extracts of the plant have long been used to dilate the pupil in the treatment of iritis due to its tropane alkaloids (atropine, scopolamine, and hyoscyamine). This report describes a case of anisocoria secondary to anticholinergic mydriasis caused by use of Similasan's Pink Eye Relief drops.
Case ReportA Caucasian woman, aged 70 years, presented with a 5-day history of dilated left pupil. She denied any vision problems, eye pain, double vision, or eyelid drooping. She had no headache, dizziness, or imbalance. She reported that 5 days prior, when she noticed a larger pupil as well as some irritation in the left eye, she started self-treating her left eye twice a day with an OTC "pink eye relief" drop. She stopped using the drops 2 days prior to presentation because they were not effective. She denied using any other drops, perfume spray, or motion sickness patch. She had a medical history of hypertension, hyperlipidemia, and breast cancer, but no history of diabetes mellitus. She had previous annual eye examinations with documented equal pupil size.On examination, her vision was 20/25 for each eye. Her right pupil was 3 mm and 5 mm under bright and dim light, respectively; however, her left pupil remained at 7.5 mm with no constriction to light or near stimulation. There was no left relative afferent pupil defect by reverse, no left ptosis, nor extraocular movement abnormality. Intraocular pressure, anterior segment, and posterior segment were unremarkable, except for mild nucleus scler...