A 73-year-old woman developed ataxia after being treated with cyclopentolate eye drops by her ophthalmologist. At the emergency department, she was unable to walk and had mydriatic pupils but normal neurological examination otherwise. It was determined that her symptoms were caused by systemic absorption of the cyclopentolate. Her ataxia resolved after 4 hours of observation. Cyclopentolate is commonly used as a mydriatic and cycloplegic, but can cause side effects like ataxia and delirium in some patients due to topical absorption through the nasal and oral routes.

1. Ataxia by
cycloplegic
Agustín Arévalo Velasco
Rosa M. Herrero Antón
Emergency department. Hospital
Universitario de Salamanca.

2. Introduction
Cyclopentolate is commonly used as a mydriatic
and cycloplegic. The occurrence of side effects of
its anticholinergic action at appropriate doses is
unlikely. Confusional states have been reported
with abnormal behavior, visual and auditory
hallucinations and cerebellar as typical clinical
manifestations of toxic doses. We present the
case of a patient who developed ataxia after
exposure to a cycloplegic eye drops, the
literature is reviewed.

3. Case presentation
73 year old woman who complains of
loss of strength in lower extremities.
Arrives by ambulance after being treated
in the street with suspected stroke.
The patient reported that going to take
the bus crashes, legs fail him and feels
he can not walk. It has no other
symptoms: no chest pain, no headache,
no dizziness, no loss of consciousness,
speech correction, no difficulty moving
the upper extremities.

4. As background is hypertensive, dyslipidemic,
no drug allergies and usually takes diltiazem.
On examination we found a patient was
awake and oriented, eupneic, mydriatic
pupils with normal cardiopulmonary
auscultation, normal, abdomen, extremities
without edema, strength and sensitivity
preserved tendon reflexes osteo-normal,
bilateral plantar flexor. Ataxic, unable to walk.
Routine tests are normal.
Asked, the patient tells us that in the hours
before the review has been to your
ophthalmologist and had been cyclopentolate
instilled in both eyes.

5. We decided to adopt an expectant
attitude and after four hours, the patient
may be standing alone. Given the
apparent improvement propose to
follow the patient observation in the
hospital, but given its convenient
location the patient decides outpatient
control. Contacted the patient at 36
hours, and do your usual tasks and
symptoms have disappeared “ 'm not as
drunk.”

6. Comment
Approximately 10% of patients treated
with topical anticholinergic side effects
may occur. Most dizziness, ataxia and
delirium. Topical absorption is also
nasal and oral. Typically, we administer
more doses by the possibility of loss of
substance and therefore continue
instilling the drug reaching toxic doses.

7. Bibliography
Efecto neurotóxico inducido por administración
tópica de cicloplejico. Presentación de un caso y
revisión de literatura. Jiménez FJ, Alonso H,
Fernández A, Adeva MT, Ruiz JJ, Martín M.
Rev Neurol. 2006 Nov 16-30;43(10):603-9.
Acute phychotic reaction caused by topical
ciclopentolate use for cycloplegic refraction before
refractive surgery: case report.Mirshahi A, Kohnen
T.
J Cataract Refract Surg. 2003 May;29(5):1026-30.