How Do Cycloplegics/Mydriatics Work?

• How They Work
  • What are cycloplegics/mydriatics and how do they work?
• Uses
  • How are cycloplegics/mydriatics used?
• Side Effects
  • What are side effects of cycloplegics/mydriatics?
• Drug Names
  • What are names of some cycloplegic/mydriatic drugs?

Cycloplegics/mydriatics are ophthalmic medications that are used to dilate the pupil (mydriasis). Each cycloplegic/mydriatic drug works in a different way to maintain dilation in the pupil for a specified period. Cycloplegics/mydriatics work in the following ways to achieve mydriasis:

• Paralyze the ciliary muscle (cycloplegia), which adjusts the lens shape and thickness to enable us to focus on near and far objects. The ability to focus at different distances is known as eye accommodation.
• Paralyze the sphincter muscle which encircles the pupil and helps contract the pupil in bright light.
• Activate contraction of the dilator (radial) muscle of the iris which dilates the pupil.

Some cycloplegics/mydriatics are anticholinergic. Ophthalmic anticholinergics block the activity of acetylcholine, a substance that activates the contraction of ciliary and sphincter muscles inside the eye, resulting in temporary paralysis of those muscles.

Acetylcholine is a neurotransmitter that motor nerve cells (neurons) in neuromuscular junctions release to activate muscles.

Other cycloplegics/mydriatics are alpha agonists that stimulate alpha adrenergic receptors and cause contraction of dilator muscles of the iris and constriction of blood vessels. Alpha adrenergic receptors are proteins that make smooth muscles contract in response to hormones (catecholamines) epinephrine and norepinephrine released by the adrenal gland.

Cycloplegics/mydriatics are often administered as combination drugs to achieve dilation of the pupil. Cycloplegic/mydriatic medications may be combined with an ophthalmic non-steroidal anti-inflammatory drug (NSAID) to prevent pain and inflammation from eye surgery.

Cycloplegics/mydriatics are ophthalmic solutions or ointments topically administered in the eye. Cycloplegics/mydriatics are used for the following purposes:

• Dilation of the pupils for diagnostic or surgical procedures
• Treatment of eye redness
• As part of the treatment for uveitis (inflammation of uvea, the middle layer of the eye) to:
  • Relieve pain by preventing movement of the iris
  • Prevent the iris from adhering to the lens (posterior synechiae)
  • Prevent further flare-up of uveitis
• Cataract and intraocular lens replacement surgery

Side effects of cycloplegic/mydriatic drugs may include the following:

Ocular side effects:

• Irritation and foreign body sensation
• Stinging or burning sensation in the eye
• Blurred vision
• Sensitivity to light
• Hyperemia (dilation of blood vessels)
• Dry eyes
• Vascular congestion (congestion in the eye’s blood vessels)
• Fluid leakage (exudate) from capillaries
• Eye edema
• Allergic conjunctivitis (inflammation of the conjunctiva, the clear membrane that covers the eye and the inner surface or the eyelids)
• Follicular conjunctivitis (collection of lymphocytes [follicles] in the conjunctiva)
• Increased intraocular pressure
• Inflammation in the cornea (keratitis)
• Anticholinergic toxicity
• Rebound myosis (constriction of the pupils)
• Reactive hyperemia
• Corneal abrasions
• Anterior chamber inflammation (inflammation of uvea, iris and ciliary muscle, also known as anterior uveitis)
• Posterior capsule opacification (opacity of the posterior side of the clear membrane that encapsulates the lens)

Systemic side effects:

• Headache or brow ache
• Dermatitis
• Drowsiness
• Hyperreactive response in children with Down’s syndrome
• Dry mouth
• Nausea
• Vomiting
• Allergic reactions
• Muscle rigidity
• Fainting (syncope)
• Stimulation of parasympathetic nervous system

Rare but severe side effects include:

• High blood pressure (hypertension)
• Palpitations
• Rapid heart rate (tachycardia)
• Premature ventricular contractions
• Irregular heartbeat (arrhythmia)
• Vasodilation
• Cardiorespiratory collapse
• Myocardial infarction (heart attack)
• Ventricular fibrillation
• Drop in blood pressure (hypotension)
• Subarachnoid hemorrhage (bleeding in the membrane over the brain)
• Lack of coordination (ataxia)
• Confusion
• Occipital headache
• Psychotic reactions and behavioral disturbances
• Seizure
• Tremors
• Increased perspiration
• Pallor or blanching

Information contained herein is not intended to cover all possible side effects, precautions, warnings, drug interactions, allergic reactions, or adverse effects. Check with your doctor or pharmacist to make sure these drugs do not cause any harm when you take them along with other medicines. Never stop taking your medication and never change your dose or frequency without consulting your doctor.

Generic and brand names of some cycloplegic/mydriatic drugs include:

Anticholinergic agents:

• Atropine sulfate (Isopto Atropine)
• Cyclopentolate hydrochloride (Cyclogyl, AK-Pentolate)
• Tropicamide (Mydriacyl, Tropicacyl)

Alpha adrenergic agonists:

• Phenylephrine hydrochloride

Combination drugs

• Anticholinergic/alpha agonist:
  • Cyclopentolate hydrochloride/phenylephrine hydrochloride (Cyclomydril)
• Alpha agonist/anticholinergic:
  • Hydroxyamphetamine hydrobromide/tropicamide (Paremyd)
• Ophthalmic NSAID/alpha agonist:
  • Ketorolac tromethamine/phenylephrine hydrochloride (Omidria)
• Anticholinergic/alpha agonist:
  • Tropicamide/phenylephrine hydrochloride (MydCombi) - Pending FDA approval