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Gilles Martin, Charlotte Denier, Caroline Séghir, Pierre-Antoine Aymard, Marc Mordekhai Abitbol, Nathalie Boddaert, David Grévent, Dominique Bremond-Gignac, Matthieu Robert; Safety and interest of cocaine drops in infant anisocoria. Invest. Ophthalmol. Vis. Sci. 2016;57(12):4567.
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© ARVO (1962-2015); The Authors (2016-present)
The availability of apraclonidine has progressively eclipsed cocaine test in the exploration of unilateral myosis in adults. In infants, however, alpha-2-agonists cannot be used because of the risk of central nervous system depression. We performed a retrospective, observational clinical study to assess the safety and interest of cocaine drops in infantile anisocoria.
Children referred to the neuro-ophthalmology clinic between November 1, 2009 and November 1, 2015, for unilateral myosis were reviewed. Cases with already known diagnosis explaining anisocoria, and cases having presented with myosis after the age of 1, were excluded. All infants underwent the following protocol: (1) in case of isolated and significant myosis, cocaine test was performed (observation and photographs of the pupils at baseline and 45 minutes after two instillations of 5% cocaine drops in both eyes, under clinical surveillance). When no dilation was noticed in the myotic eye, imaging was performed (MRI or CT of the head, neck and chest). Obvious pupil dilation in both eyes led to simple clinical follow-up. (2) In case of myosis associated with frank ptosis or iris heterochromia, imaging alone was performed.
Thirty-one children (21 males) were included. Myosis had been noticed at a median age of 2,1 ± 2,7 months. Twenty-four patients presented myosis without any other abnormality; 4 with ipsilateral ptosis, 1 with iris heterochromia, 1 with absent pupillary reflex, and 1 with myosis, ptosis, heterochromia and facial anhidrosis. Cocaine test was performed on the 24 patients with isolated myosis and led to imaging in 5 patients, which was always normal. No side effect of the test was ever noticed. One patient presenting with myosis and ptosis was diagnosed with neuroblastoma, while in the one with no pupillary reflex, imaging showed an intraorbital hemolymphangioma. Imaging was avoided for 19 patients thanks to negative cocaine test.
Urgent specific imaging is mandatory in infants presenting with myosis, when associated with any other localizing sign on the sympathetic nerve pathway (Horner syndrome). Since the uselessness of imaging in isolated significant infantile myosis cannot be proven so far, cocaine test remains the gold standard in this situation: it appears to be safe, cheaper and less stressful for both parents and children than systematic imaging.
This is an abstract that was submitted for the 2016 ARVO Annual Meeting, held in Seattle, Wash., May 1-5, 2016.
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