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Clearkin correctly points out that pupillary block and angle closure glaucoma most frequently occur in conjunction with cocontraction of the iris sphincter and dilator muscles. The conclusion that pupillary dilation alone, as produced by parasympatholytic drugs (or by sympathomimetic agents), will not produce angle closure glaucoma in susceptible eyes is not correct. Most ophthalmologists have seen cases of mydriatic-induced acute attacks produced by either topical or systemic administration of such drugs.Provocative testing for potential angle closure has traditionally employed topical mydriatic agents, most often parasympatholytics. While using a combination of pilocarpine and phenylephrine is more likely to produce angle closure, closure can occur with only parasympatholytic medications in susceptible eyes. Moreover, acute closure is virtually eliminated in such eyes following peripheral iridectomy.Mydriasis may also cause angle closure by mechanisms other than pupillary block. Eyes with so-called plateau iris syndrome will develop angle closure with mydriasis,
Berdy G, Kolker AE. Angle Closure Glaucoma Precipitated by Atropine-Reply. Arch Intern Med. 1992;152(4):880. doi:10.1001/archinte.1992.00400160160037