Psychosomatics 46:88, February 2005
© 2005 The Academy of Psychosomatic Medicine
Pilocarpine Psychosis
François J. Sirois, M.D., Department of Psychiatry, Laval Hospital, Sainte-Foy, Quebec, Canada
TO THE EDITOR: Treatment of acute glaucoma with a cholinergic medication such as pilocarpine may induce a transient delirium state that resembles paranoid psychosis. Preventive precaution in the administration of topical eye drops and selective use of psychotropic drugs are helpful in situations such as that described in the following clinical case.
Case Report
A psychiatric consultation was requested for Mr. A, a 78-year-old man, regarding his nighttime confusion of 48 hours duration. Mr. A had undergone an operation for an inguinal hernia 4 days earlier, and the course had been uneventful. He had been seen by an ophthalmologist the same day for acute glaucoma, for which Mr. A had been prescribed 4% pilocarpine eye drops four times a day. Two days after the beginning of eye treatment, Mr. A was found to be confused at night with visual hallucinations and disorientation as to time and place. When seen in the morning, the sensorium was rather clear without obnubilation, but Mr. A was anxious and frightened. He was only slightly disoriented as to time, and he indicated that he could not sleep because of strange things going on. He was fearful some pieces of the ceiling would fall upon him, alluded to a ‘‘gang’’ of mobsters hanging around, and was suspicious of ‘‘lousy’’ nurses on the ward. He was not sure that he was in a hospital (derealization) and, while rather calm and composed, was waiting for his son to pick him up. According to the married son with whom the patient lived, he was a quiet old man without any known noticeable cognitive deficit and no psychiatric history. Because the glaucoma was severe, pilocarpine had to be maintained while the patient was waiting for eye surgery. Two interventions were implemented. First, instructions were given to close the inner canthus of the eye while administering the pilocarpine treatment to close the lachrymal canal and prevent systemic absorption of pilocarpine.1 Second, anticholinergic antipsychotic medications were banned, and risperidone, the neuroleptic with the least anticholinergic activity, was prescribed in a small dosage (0.5 mg in the morning and 1 mg at bedtime). The symptoms abated and disappeared within 24 hours under such treatment, and Mr. A was discharged home with precise information about eye drop administration.
Discussion
Such systemic effects of pilocarpine are known but rarely reported and are easily forgotten, since it often is beclouded under reference to aggravation of dementia2 or buried under some unavailable older reports.3 Consulting psychiatrists should keep alert to systemic side effects of topical drugs and refrain from using large doses of antipsychotic medication with known major anticholinergic activity.
REFERENCES
- Casanovas J, Casanovas R: Les dangers de quelques médications ophtalmologiques récentes. Ann Oculist (Paris) 1969; 202:1–22
- Fraunfelder FT, Morgan R: The aggravation of dementia by pilocarpine. JAMA 1994; 271:1742–1743
- Epstein E, Kaufman I: Systemic pilocarpine toxicity from overdosage in treatment of an attack of angle closure glaucoma. Am J Ophthalmol 1965; 59:109–110[Medline]
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