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Muscarinic receptor antagonists block the cholinergic responses of the pupillary sphincter
muscle of the iris and the ciliary muscle controlling lens curvature (see Chapter 63). Thus, they
dilate the pupil (mydriasis) and paralyze accommodation (cycloplegia). The wide pupillary
dilation results in photophobia; the lens is fixed for far vision, near objects are blurred, and
objects may appear smaller than they are. The normal pupillary reflex constriction to light or
upon convergence of the eyes is abolished. These effects can occur after either local or systemic
administration of the alkaloids. However, con- ventional systemic doses of atropine (0.6 mg) have
little ocular effect, in contrast to equal doses of scopolamine, which cause definite mydriasis and
loss of accommodation. Locally applied atropine or scopolamine produces ocular effects of
considerable duration; accom- modation and pupillary reflexes may not fully recover for 7 to 12
days. Other muscarinic receptor antagonists with shorter durations of action are therefore
preferred as mydriatics in ophthalmological prac- tice (see Chapter 63). Sympathomimetic agents
also cause pupillary dilation but without loss of accommodation. Pilocarpine, choline
esters,physostigmine(ophthalmicsolutiondiscontinuedintheUnited States), and isoflurophate
(DFP) in sufficient concentrations can par- tially or fully reverse the ocular effects of atropine.

Muscarinic receptor antagonists administered systemically have lit- tle effect on intraocular
pressure except in patients predisposed to nar- row-angle glaucoma, in whom the pressure may
occasionally rise dan- gerously. The rise in pressure occurs when the anterior chamber is narrow
and the iris obstructs outflow of aqueous humor into the trabec- ulae. Muscarinic antagonists may
precipitate a first attack in unrecog- nized cases of this relatively rare condition. In patients with
open-angle glaucoma, an acute rise in pressure is unusual. Atropinelike drugs gen- erally can be
used safely in this latter condition, particularly if the patient also is adequately treated with an
appropriate miotic agent.