ARCH SOC ESP OFTALMOL 2007; 82: 521-522
ANISOCORIA RELATED TO BUPROPION IN MIGRAINE
ANISOCORIA PRODUCIDA POR BUPROPIÓN EN PACIENTE
VLEMING EN1, GUTIÉRREZ-ORTIZ C2, TEUS MA2
Bupropion is used to help people stop
El bupropión se usa como deshabi-
smoking. This drug can cause visual alterations but,
tuante del hábito tabáquico. Puede provocar altera-
up to now, its use was not associated with anisocoria.
ciones visuales, pero hasta el momento no se había
A 40 year-old woman with a personal
comunicado la aparición de anisocoria.
history of migraines, presented with monocular
Mujer de 40 años con migrañas, en
mydriasis during treatment with bupropion. Both
tratamiento con bupropión presentó midriasis
pupils dilated equally after a 5% cocaine test, and
monocular. Instilando cocaína al 5%, ambas pupilas
constricted equally after a 0.025% Pilocarpine test.
dilataron de la misma manera. Con pilocarpina
The anisocoria disappeared after the treatment with
0,025% ambas pupilas contrajeron de forma simi-
lar. La anisocoria cesó al suspender el tratamiento.
Bupropion inhibits neural uptake of
El bupropión es inhibidor selectivo de la
norepinephrine and dopamine. Patients with
recaptación de noradrenalina y dopamina. La vía
migraine could have a minor unilateral sympathetic
pupilar simpática podría tener una cierta hipersensi-
pupillary deficit. This deficit could cause hypersen-
bilidad en pacientes migrañosos por denervación
sitivity in the oculosympathetic pathway that could
que podría estimularse con el tratamiento con estos
be stimulated with bupropion treatment. This featu-
fármacos, lo que explicaría la anisocoria. Por otra
re could explain the mydriasis in our patient. Anot-
parte el estímulo midriático del bupropion podría
her explanation could be that bupropion could
haber desenmascarado una anisocoria fisiológica.
unmask a physiological anisocoria (Arch Soc EspOftalmol 2007; 82: 521-522).
Bupropión, anisocoria, migraña,
síndrome de Horner, anisocoria fisiológica.
Bupropion, anisocoria, migraine, Hor-
ner syndrome, physiological anisocoria.
patients to stop smoking. It is a selective inhibitor
In recent times, the administration of Bupropion
of the neuronal reuptake of catecholamines (nora-
has been widely prescribed for tobacco cessation.
drenaline and dopamine) with minimal impact on
Received: 31/5/06. Accepted: 18/6/07.
Ophthalmology Service of the Prince of Asturias University Hospital. Alcalá de Henares (Madrid), Spain.
1 Graduate in Medicine.
2 Ph.D. in Medicine.
Correspondence:C/. Arturo Soria, 337 3.º B28033 MadridSpainE-mail: firstname.lastname@example.org
indolamine reuptake (serotonin) and in addition it
assumption that migraines are associated with a
does not inhibit the action of monoaminooxidase.
sympathetic deficit which is larger on the side
The mechanism by which Bupropion boosts the
where migraines occur (2). In other words, there
ability of patients to abstain from smoking
could be a subclinical «Horner Syndrome» with the
remains unknown. However, it is assumed that its
subsequent slight hypersensitivity due to denerva-
action is aided by noradrenergic and/or dopamin-
tion. In these patients, inhibiting the reuptake of
dopamine, an immediate metabolic precursor of
Although this medication is known to cause cer-
noreprinephrine and epinephrine, by means of
tain types of visual alterations during treatment, the
drugs such as bupropion, may cause pupils suffer-
emergence of anisocoria has not been confirmed so
ing from this potential hypersensitivity to dilate
far. The case described herein is that of an adult
unilaterally due to this increase in vasoactive sub-
female suffering from anisocoria associated with
Furthermore, bupropion may lead to mydriasis
when administered in high doses in animals usedfor experimental purposes (3).
In the present case, the Addie Syndrome was
discarded due to the symmetry of response to .125
A 40-year-old woman reported mydriasis in the
percent pilocarpine. A slight alteration in the
right eye after a 4-week-long treatment with
sympathetic pupillary pathway could possibly
300 mg/d of Bupropion, prescribed for tobacco ces-
result in a slight hypersensitivity due to denerva-
sation. The only significant element in her personal
tion and unilateral dilation caused by the
history was migraine. Ophthalmologic exploration
decreased reuptake of vasoactive amines induced
revealed the following: normal visual acuity, anteri-
by bupropion. In any case, the response to the
or and posterior pole. Intraocular pressure was
cocaine test was negative, which raised doubts
regarding the likelihood of a Horner Syndrome
The right eye pupil measured 4.5 mm and the left
eye’s was 3.5 mm. After instilling 5 percent
On the other hand, the most frequent causes of
cocaine, both pupils dilated in similar ways. After
anisocoria in human populations are physiological
instilling .025 percent pilocarpine, both pupils con-
(4), arising in some cases arises intermittently. The
response to the eyedrop test in physiological aniso-
Anisocoria subsided one week after suspending
coria is similar for both eyes, since there are only
differences in the sympathetic tone. In patients suf-fering from physiological anisocoria, the latter ismore evident in darkness. Bupropion triggers a
mydriatic stimulus that could have unmasked aphysiological anisocoria.
Some patients with a history of migraine suffer
during and between headaches a compromise of thesympathetic ocular fluid and the subsequent unilat-
eral alteration of the sympathetic pupillary pathway.
1. Drummond PD. Disturbances in ocular sympathetic func-
In darkness, the symptomatic pupil in these patients
tion and facial blood flow in unilateral migraine heada-
dilates less and more slowly (1) than the contralat-
che. J Neurol Neurosurg Psychiatry 1990;53:121-125.
eral pupil. The average pupillary diameter of
2. Drummond PD. Pupil diameter in migraine and tension
headache. J Neurol Neurosurg Psychiatry 1987;50:228-
patients suffering from migraine has also been stud-
ied during and after these episodes. The average
3. Bo P, Patrucco M, Savoldi F, Formigli L, Manzo L. Beha-
diameter is smaller in patients suffering from
vioral and eegraphic changes induced by dopaminergic
migraines during their onset than in normal individ-
antidepressants in rabbits. Farmaco [Sci] 1985; 40: 608-
uals. However, after a migraine episode, both pupils
4. Lam BL, Thompson HS, Corbett JJ. The prevalence of
have the same size. These findings back the
simple anisocoria. Am J Ophthalmol 1987; 104: 69-73.
Assessing the impact of Cry1Ab-expressing corn pollen on monarch butterfly larvae in field studies Diane E. Stanley-Horn*†, Galen P. Dively‡, Richard L. Hellmich§, Heather R. Mattila*, Mark K. Sears*, Robyn Rose‡, Laura C. H. Jesse¶, John E. Losey ʈ , John J. Obrycki¶, and Les Lewis§ *Department of Environmental Biology, University of Guelph, Guelph, ON, Canada N1G 2W1; ‡Depa
Eur J Clin PharmacolDOI 10.1007/s00228-007-0394-1Identification of severe potential drug-drug interactionsusing an Italian general-practitioner databaseL. Magro & A. Conforti & F. Del Zotti & R. Leone &M. L. Iorio & I. Meneghelli & D. Massignani & E. Visonà &U. MorettiReceived: 9 July 2007 / Accepted: 27 September 2007number of different types of severe potenti