Acute onset of bilateral mydriasis, headache, and vomiting: a challenging diagnosis
DOI:
https://doi.org/10.4081/ecj.2025.14053Keywords:
Bilateral mydriasis, endocranial hypertension, angle-closure glaucomaAbstract
Bilateral fixed mydriasis is a rare condition that can arise from a variety of causes (neurological, pharmacological, toxic or metabolic, para-infectious/autoimmune conditions, and traumatic injuries). We report a 65-year-old woman presenting to the emergency department with bilateral mydriasis and complaining of acute severe headache associated with blurry vision, photophobia, vomiting, and a recent history of fever with respiratory symptoms. All preliminary medical investigations aimed at identifying possible causes of endocranial hypertension as well as intracranial lesions or expansive processes, while focusing on findings consistent with meningoencephalitis. The diagnosis of acute bilateral angle-closure glaucoma was established through a wide range of radiological and laboratory exams, and with the help of different consultants. This unusual case highlights two interesting aspects: the importance of a multidisciplinary diagnostic work-up for challenging clinical presentations, and the critical relevance of a re-evaluation diagnostic strategy to avoid clinical mistakes.
Downloads
References
1. Koss MC. Pupillary dilation as an index of central nervous system α2-adrenoceptor activation. J Pharmacol Methods 1986;15:1–19. DOI: https://doi.org/10.1016/0160-5402(86)90002-1
2. Caglayan HZB, Colpak IA, Kansu T. A diagnostic challenge: dilated pupil. Curr Opin Ophthalmol 2013;24:550–7. DOI: https://doi.org/10.1097/ICU.0000000000000005
3. Simonetto M, Zanet L, Capozzoli F, et al. Unilateral headache with bilateral internal ophthalmoplegia. Neurol Sci 2012;33:1185–7. DOI: https://doi.org/10.1007/s10072-011-0883-y
4. Kang YE, Chae J, Nguyen TT, et al. A Case Report of Acute Bilateral Mydriasis Induced by Herbal Medication. Neuro-Ophthalmol 2024;48:193–7. DOI: https://doi.org/10.1080/01658107.2023.2301363
5. Chean CS, Ali AIAH, Malick H. Bilateral simultaneous acute angle closure glaucoma triggered by an over-the-counter cold and influenza medication. BMJ Case Rep 2024;17:e260950. DOI: https://doi.org/10.1136/bcr-2024-260950
6. Adegoke S, Alo L. Datura stramonium poisoning in children. Niger J Clin Pract 2013;16:116. DOI: https://doi.org/10.4103/1119-3077.106783
7. Cheng KL, Chan YC, Mak TWL, et al. Chinese herbal medicine-induced anticholinergic poisoning in Hong Kong. Hong Kong Med J Xianggang Yi Xue Za Zhi 2013;19:38–41.
8. Sato H, Naito K, Hashimoto T. Acute isolated bilateral mydriasis: case reports and review of the literature. Case Rep Neurol 2014;6:74–7. DOI: https://doi.org/10.1159/000360849
9. Yuan F, Zhang Y, Yan X. Bilateral acute angle closure glaucoma as an initial presentation of Vogt-Koyanagi-Harada syndrome: A clinical case report. Eur J Ophthalmol 2022;32:NP230–4. DOI: https://doi.org/10.1177/1120672120951442
10. Hakim W, Sherman R, Rezk T, Pannu K. An acute case of herpes zoster ophthalmicus with ophthalmoplegia. Case Rep Ophthalmol Med 2012;2012:1–3. DOI: https://doi.org/10.1155/2012/953910
11. Shaw M, Handley SE, Porooshani H. A case of internal ophthalmoplegia associated with varicella zoster. J Pediatr Ophthalmol Strabismus 2012;49:0731-04. DOI: https://doi.org/10.3928/01913913-20120731-04
12. Kaymakamzade B, Selcuk F, Koysuren A, et al. Pupillary involvement in miller fisher syndrome. Neuro-Ophthalmol 2013;37:111–5. DOI: https://doi.org/10.3109/01658107.2013.792356
13. Monaco S, Freddi N, Francavilla E, et al. Transient tonic pupils in botulism type B. J Neurol Sci 1998;156:96–8. DOI: https://doi.org/10.1016/S0022-510X(98)00010-0
14. Figueiredo GS, Kolli SSP, Ahmad S, et al. Urrets-Zavalia syndrome following penetrating keratoplasty for keratoconus. Graefes Arch Clin Exp Ophthalmol 2013;251:809–15. DOI: https://doi.org/10.1007/s00417-012-2148-8
15. Hamel O, Corre P, Ploteau S, et al. Ciliary ganglion afferents and efferents variations: a possible explanation of postganglionic mydriasis. Surg Radiol Anat 2012;34:897–902. DOI: https://doi.org/10.1007/s00276-012-1000-5
16. Zhang CL, Lai WL, Ziyar I, et al. Bilateral simultaneous primary acute angle-closure glaucoma. Precis Clin Med 2020;3:297–300. DOI: https://doi.org/10.1093/pcmedi/pbaa035
17. Khazaeni B, Zeppieri M, Khazaeni L. Acute angle-closure glaucoma. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 May 26]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK430857/
18. Jin G, Hu D, Li Q, et al. A rare case of bilateral malignant glaucoma after cataract surgery with capsular tension ring implantation: a case report. BMC Ophthalmol 2024;24:427. DOI: https://doi.org/10.1186/s12886-024-03692-3
19. Baki E, Scheidhauer K, Schmidt-Graf F. Bilateral mydriasis as first manifestation of Hodgkin’s lymphoma: a case report. BMC Neurol 2022;22:473. DOI: https://doi.org/10.1186/s12883-022-02941-6
20. Du Y, Qi H, Han Z. Bilateral mydriasis due to air embolism. JACC Cardiovasc Interv 2024;17:816–7. DOI: https://doi.org/10.1016/j.jcin.2023.12.026
21. European Glaucoma Society Terminology and Guidelines for Glaucoma, 5th Edition. Br J Ophthalmol 2021;105:1-169. DOI: https://doi.org/10.1136/bjophthalmol-2021-egsguidelines
22. Wagner IV, Stewart MW, Dorairaj SK. Updates on the diagnosis and management of glaucoma. Mayo Clin Proc Innov Qual Outcomes 2022;6:618-35. DOI: https://doi.org/10.1016/j.mayocpiqo.2022.09.007
Downloads
Published
License
Copyright (c) 2025 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
