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Published byMilo Thomas Modified over 9 years ago
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Ditropan-associated Esotropia Dr. Elaine Wong Dr. Lionel Kowal Ocular motility clinic, RVEEH CERA, Uni Melb, RVEEH
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Ditropan-associated ET 5 yo girl PMHx Hypothyroidism – on oroxine Enuresis HOPC Recent onset intermittent ET Closing L eye when drawing or reading Recently started on Ditropan (Oxybutynin) for enuresis
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Examination @ presentation VAR 6/8VAL 6/8 Near VAR 6/9 VAL 6/8 Stereopsis: Titmus fly 100” CT: D) RET 15ΔN) RET’ 35Δ OM: normal Polarised 4 dot test: R suppression Cycloplegic refraction: R: +3.25; L + 2.75
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Ditropan-associated ET After cessation of Oxybutynin VAR 6/8VAL 6/8 Near VAR 6/6VAL6/8 CT: D) orthophoria N) orthophoria ELAINE : CHECK THE DATA ON THIS SLIDE PLS Polarised 4 dot test: Fusion Stereopsis: Titmus fly 100”
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Discussion - Oxybutynin Muscarinic receptor antagonist often used for overactive bladder Muscarinic receptor antagonist often used for overactive bladder COMMONLY PRESCRIBED COMMONLY PRESCRIBED Anticholinergic systemic SE Anticholinergic systemic SE Ocular effects Ocular effects Ciliary ganglion – accomodationCiliary ganglion – accomodation Pterygopalatine ganglion – lacrimationPterygopalatine ganglion – lacrimation
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Ocular side-effects of tolterodine and oxybutynin, a single-blind prospective randomized trial Altan-Yaycioglu et al. Br J Clin Pharmacol 95:5, 588-592 52 patients, 104 eyes Randomised into Tolterodine 2mg bd – 28 pts Tolterodine 2mg bd – 28 pts Oxybutynin 5 mg tds – 24 pts Oxybutynin 5 mg tds – 24 pts All examined by ophthalmologists Schirmer’s Schirmer’s Accomodative amplitude Accomodative amplitude Pupillary diameter PD Pupillary diameter PD
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Discussion TolterodineOxybutynin Accom amp (DS)2.06 to 1.652.18 to 1.80 ( p = 0.07)(p = 0.003) Schirmer’s (mm)12.82 to 12.3212.21 to 14.83 (p = 0.698)(p = 0.342) PD bright (mm)1.94 to 2.022.07 to 2.08 (p = 0.174)( p = 0.953)
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Discussion In this case Oxybutynin Impairs accommodation Impairs accommodation Pre-existing moderate uncorrected + Pre-existing moderate uncorrected + To accommodate sufficiently to see, the pt converges, and the CA/C ratio then generates accommodation To accommodate sufficiently to see, the pt converges, and the CA/C ratio then generates accommodation hence ESOTROPIA!!! hence ESOTROPIA!!! ? Is Tolterodine (Detrusitol) safer ? Is Tolterodine (Detrusitol) safer
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Ditropan Frequently prescribed Has never been described as cause of ET! Likely to cause accommodation and convergence Dit + hyperopia likely to cause ET Almost certainly underrecognised
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