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To the Editor.—
It is unfortunate to subject anyone to extensive neurological evaluation when a simple test exists to diagnose atropine-caused dilated fixed pupils. Pilocarpine 1% will constrict a neurologically dilated pupil, but it will have no effect on the atropinized eye. If the pupil does not constrict in 15 to 30 minutes with two to three instillations of pilocarpine, the pupil is dilated because of medication. I know of no exception to this rule.No danger is associated with the use of pilocarpine. It is a parasympathomimetic agent that acts directly to stimulate the synapse of the postganglionic fibers of the parasympathetic nerve endings on the smooth muscle of the iris and ciliary body. This causes constriction of the iris sphincter unless atropine or other postsynaptic blockers such as homatropine, cyclopentolate hydrochloride (Cyclogyl), or tropicamide (Mydriacyl) have been used.A few drops of pilocarpine may avert a costly, risky,
Winslow RL. Atropine Pupils. JAMA. 1974;229(14):1863–1864. doi:10.1001/jama.1974.03230520011005
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