Mydriatics and Cycloplegics

Staci Grimes, BS OMT

Jones Eye Institute
University of Arkansas for
Medical Sciences
 The iris muscles
Iris, ciliary body, sphincter and ciliary muscles
are innervated by CN III

Iris Sphincter
Iris Dilator
Agonists/antag-
onists
2 autonomic
receptors
cholinergic
adrenergic
 Agonists/Antagonists
Agonists Antagonists
Sphincter stimulators produce 2 mechanisms of action for the
responses similar to ACh action of dilator blockers
2 mechanisms of action 1-inhibit release of
norephinephrine (NE) at
1-direct thru Acetylcholine
myoneural junction by
(Ach), carbachol,or pilocarpine
Ismelin/depletes NE stores at
2-Inhibition of never terminals
Acetylcholinesterase (AChE)
2-blockage of alpha-adrenergic
either reversibly with
receptors of dilator by
physostigmine (Eserine) or
thymoxamine, which prevents
neostigmine (Prostigmin) or
contraction and produces
irreversibly with echothiophate
miosis
iodide (Phospholine iodide)
 Pharmocological Mydriasis
Mydro = to widen
Contracts the iris
dilator
Contracts smooth
muscles of the
conjunctiva
arterioles
No effect on ciliary
muscle
 Rx for Pharmacological Mydriasis
Phenylephrine HCl (2.5% and 10%)
AK-Dilate (2.5% and 10%)
Mydrin (2.5% and 10%)
Neofrin (2.5% and 10%)
Neo-Synephrine (2.5% and 10%)
Neo-Synephrine Viscous (10% only)
 Pharmacological Mydriasis
9 For routine dilation of the
pupil, adrenergic agonists
are used.
PHARMACOLOGICAL 9 Phenylephrine (Neo-
MYDRIASIS: Synephrine) is used
Increase in pupil size clinically.
PHENYLEPHRINE 9 Epinephrine (Epifrin) is not
EPINEPHRINE used clinically for mydriasis.
9 Produces mydriasis without
cycloplegia.
9 Rapid effect and moderately
prolonged action.
 Phenylephrine
Synthetic alpha-receptor agonist
Direct acting adrenergic agents
Contracts the iris dilator muscle paralysis of entire
sphincter.
Produces vasoconstriction (contracts smooth muscles
of conj arterioles) produces blanching of the
conjunctiva
Muellers muscle of the upper lid may be stimulated,
temporarily widening the palpebral fissure.
2.5% and 10% concentrations are used for pupillary
dilation (2.5% used most often clinically)
Little or no effect on ciliary muscle. (no cycloplegia)
accomodation is not impaired.
 Clinical Indications for
Pharmocological mydriasis
Vasoconstrictors and pupil dilation
Uveitis: to prevent formation of synechiae or to free
recently formed posterior synechiae.
Glaucoma: along with miotics to increase visual acuity in
pts. with OAG
Miotics improve VA in Open Angle Glaucoma pts
because of the pin hole effect produced by pupil
constriction with miotics
Surgery: short-acting mydriatic needed for wide dilation
before intraocular surgery.
Fundoscopy
To diagnose Horner Syndrome
 Phenylephrine 1% or Cocaine
Used to diagnose HORNER syndrome.
Pharmacologically confirms oculosympathetic
dysfunction.
Normally after instillation of Phenylephrine, the pupil
dilates, but with 1st or 2nd order Horner syndrome, the
pupil dilates poorly because little or no norepinephrine is
being released in the synaptic cleft.
Cocaine blocks the re-uptake of norepinephrine released
at neuromuscular junctions of the iris dilator muscle,
increasing the amount of norepinephrine available to
stimulate the muscle.
Cycloplegics
 Pharmacological Cycloplegia
Cyclo = ciliary
Plegic = paralysis or palsy
Cyclo + plegia = ciliary paralysis
Uses anticholinergic agents
Blocks response of ciliary muscle
sphincter
Mydriasis is also produced by blocking
response of the iris sphincter
 CONVERGENCE
ACCOMODATION
MIOSIS

Cycloplegia

Inactivates the accommodation-

convergence portion of the
synkinetic response
 Pharmacological cycloplegia
clinical uses
Esotropia full amount of hyperopia is revealed
ACCOMODATIVE ESOTROPIA
Atropine < 4yo
Cyclopentolate > 4 yo accommodative
Manifest Refraction with benefit of no
accommodative response
Uveitis inflammation of iris, CB, choroid
t-cells (pain, photophobia, blurry vision)
prevents posterior synechia formation and
relieves pain and photophobia
 Pharmocological cycloplegia
precautions
Precaution with Downs pts.
Precaution with Glaucoma and narrow
angles
Posterior synechia
Acute or chronic cases of increased IOP
Psychotic episodes
 Mydriatics and Cycloplegics

90
80
70
60
50 0.12% Phenylephrine HCL

40 2.5 % Phenylephrine HCL

30
10% Phenylephrine HCL
20
10
0
Minutes Minutes
(minimum) (maximal)

Average Effective Time for

Mydriasis/ Vasoconstriction

Ophthalmic Drug Facts

 Mydriatics and Cycloplegics

4
0.12% Phenylephrine HCL
3
2.5 % Phenylephrine HCL
2
10% Phenylephrine HCL

0
Recovery
time (hr)

Recovery Time from

Mydriasis/Vasoconstriction
due to Phenylephrine HCL
Ophthalmic Drug Facts
 Mydriatics and Cycloplegics
Cycloplegic Drugs
Longest Acting: Atropine
Mydriasis & Cycloplegia Scopolamine
Peak Time Homatropine
Cyclopentolate
Shortest Acting: Tropicamide
130
120
110
100
90 Atropine
80
Scopolamine
70
60 Homatropine
50 Cyclopentolate
40
Tropicamide
30
20
10
0
Peak Mydriasis (min) Peak Cycloplegia (min)

Ophthalmic Drug Facts

Mydriatics and Cycloplegics

Cycloplegic Drugs
A S H C T
Longest Acting: Atropine
Scopolamine
Cycloplegic Drugs Homatropine
Mydriasis & Cycloplegia Recovery Cyclopentolate
Shortest Acting: Tropicamide
Time
10

7 Atropine
6 Scoplamine
5 Homatropine
4 Cyclopentolate
3 Tropicamide
2

0
Mydriasis Recovery Cycloplegia Recovery Ophthalmic Drug Facts
(days) (days)
 References
Facts and Comparisons,part of Wolters
Kluwer Health,Ophthalmic Drug Facts,
2005 edition, Chapter 4.
BCSC, Section 2. 2005-2006
edition;American Academy of
Ophthalmology,p.308-309.
Cassin, Barbara. Ophthalmic Technical
Personnel, editor Latif M. Hamed; W. B.
Saunders Company 1995, p.39-43.