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Introduction: Bupropion is used to help people stop
Introducción: 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 Case report: A 40 year-old woman with a personal
comunicado la aparición de anisocoria.
history of migraines, presented with monocular Caso clínico: 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.
Discussion: Bupropion inhibits neural uptake of
Discusión: 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). Palabras clave: Bupropión, anisocoria, migraña,
síndrome de Horner, anisocoria fisiológica.
Key words: 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: 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 DISCUSSION
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- REFERENCES
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.


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