https://doi.org/10.4081/ecj.2023.11320
A case of cardiotoxicity following intramuscular injection of tropicamide and phenylephrine ophthalmic solution in a drug-addicted young woman
Submitted: 17 March 2023
Accepted: 21 August 2023
Published: 7 September 2023
Accepted: 21 August 2023
Abstract Views: 766
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Authors
We report the case of a 40-year-old woman with a history of an opioid use disorder who presented to our emergency department complaining of palpitations, chest pain, and headache after the intramuscular injection of an ophthalmic solution containing tropicamide and phenylephrine (Visumidriatic Phenylephrine® 100 mg/mL + 5 mg/mL, Visufarma S.p.A., Italy) a few hours earlier for a voluntary purpose. She developed cardiac toxicity with hypertension, tachycardia, and high levels of high-sensitivity cardiac troponin I, which required continuous cardiac monitoring for 48 hours with complete resolution of the cardiac damage without complications. Based on the current literature, this is the first reported case of cardiotoxicity induced by an ophthalmic solution of tropicamide and phenylephrine used intramuscularly for voluntary purposes.
K Lodhi SA, Ramsali MV, Kulkarni DK, et al. Safety of tropicamide and phenylephrine in pupillary mydriasis for cataract surgery. Saudi J Ophthalmol 2022;35:108-111.
DOI: https://doi.org/10.4103/1319-4534.337859
Nucci P, Lembo A, Caputo R, et al. Efficacy and safety of intraoperative use of tropicamide 0.02%/phenylephrine0.31%/lidocaine1% intracameral combination during pediatric cataract surgery. Int Ophthalmol 2022;10.1007/s10792-022-02501-4.
DOI: https://doi.org/10.21203/rs.3.rs-1458073/v1
Hamasaki I, Hasebe S, Kimura S, et al. Cycloplegic effect of 0.5% tropicamide and 0.5% phenylephrine mixed eye drops: objective assessment in Japanese schoolchildren with myopia. Jpn J Ophthalmol 2007;51:111-115.
DOI: https://doi.org/10.1007/s10384-006-0400-7
Sbaraglia F, Mores N, Garra R, et al. Phenylephrine eye drops in pediatric patients undergoing ophthalmic surgery: incidence, presentation, and management of complications during general anesthesia. Paediatr Anaesth 2014;24:400-405.
DOI: https://doi.org/10.1111/pan.12329
Tropicamide, Editor(s): J.K. Aronson, Meyler's Side Effects of Drugs (Sixteenth Edition), Elsevier, 2016, Page 216, ISBN 9780444537164.
DOI: https://doi.org/10.1016/B978-0-444-53717-1.01604-8
Fraunfelder FT, Scafidi AF. Possible adverse effects from topical ocular 10% phenylephrine. Am J Ophthalmol. 1978;85(4):447-453.
DOI: https://doi.org/10.1016/S0002-9394(14)75239-0
Kumar V, Schoenwald RD, Chien DS, et al. Systemic absorption and cardiovascular effects of phenylephrine eyedrops. Am J Ophthalmol 1985;99(2):180-184.
DOI: https://doi.org/10.1016/0002-9394(85)90229-6
Wilensky JT, Woodward HJ. Acute systemic hypertension after conjunctival instillation of phenylephrine hydrochloride. Am J Ophthalmol 1973;76(1):156-157.
DOI: https://doi.org/10.1016/0002-9394(73)90023-8
Chin KW, Law NM, Chin MK. Phenylephrine eye drops in ophthalmic surgery--a clinical study on cardiovascular effects. Med J Malaysia 1994;49(2):158-163.
Malhotra R, Banerjee G, Brampton W, Price NC. Comparison of the cardiovascular effects of 2.5% phenylephrine and 10% phenylephrine during ophthalmic surgery. Eye (Lond) 1998;12 (Pt 6):973-975.
DOI: https://doi.org/10.1038/eye.1998.252
Kenawy NB, Jabir M. Phenylephrine 2.5% and 10% in phacoemulsification under topical anaesthesia: is there an effect on systemic blood pressure? Br J Ophthalmol 2003;87(4):505-506.
DOI: https://doi.org/10.1136/bjo.87.4.505
Foglio illustrativo: informazioni per il paziente VISUMIDRIATIC FENILEFRINA 100mg/ml + 5mg/ml Collirio, Soluzione Fenilefrina cloridrato, tropicamide flacone da 10 ml. Accessed 6 March 2023. Available from: https://farmaci.agenziafarmaco.gov.it/aifa/servlet/PdfDownloadServlet?pdfFileName=footer_000902_020698_FI.pdf&sys=m0b1l3
Bellman V, Ukolova A, Erovichenkova E, et al. Abuse of tropicamide eye drops: review of clinical data. Revista brasileira de psiquiatria 2022;44:522–531.
DOI: https://doi.org/10.47626/1516-4446-2021-2446
Bersani FS, Corazza O, Simonato P, et al. Drops of madness? Recreational misuse of tropicamide collyrium; early warning alerts from Russia and Italy. General Hospital Psychiatry 2013;35:571–573.
DOI: https://doi.org/10.1016/j.genhosppsych.2013.04.013
Broderick ED, Metheny H, Crosby B. Anticholinergic toxicity. In: StatPearls [Internet]. 2020 [cited 2022 Mar 21]. www.ncbi.nlm.nih. gov/books/NBK534798/
Betz AJ, McLaughlin PJ, Burgos M, et al. The muscarinic receptor antagonist tropicamide suppresses tremulous jaw movements in a rodent model of parkinsonian tremor: possible role of M4 receptors. Psychopharmacology 2007;194:347–359.
DOI: https://doi.org/10.1007/s00213-007-0844-6
Dawson A H, Buckley NA. Pharmacological management of anticholinergic delirium - theory, evidence and practice. Br J Clinical Pharmacol 2016;81:516–524.
DOI: https://doi.org/10.1111/bcp.12839
Bersani FS, Imperatori C, Prilutskaya M, et al. Injecting eye-drops: a mini-review on the non-clinical use of tropicamide. Human Psychopharmacol 2015;30:262–264.
DOI: https://doi.org/10.1002/hup.2481
Richards E, Lopez MJ, Maani CV. Phenylephrine. 2022 Jul 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. PMID: 30521222
Prescott F. Clinical evaluation of the pressor activity of methedrine, neo-synephrine, paredrine, and pholedrine. Br Heart J 1944;6:214-20.
DOI: https://doi.org/10.1136/hrt.6.4.214
Kanfer I, Dowse R, Vuma V. Pharmacokinetics of oral decongestants. Pharmacotherapy 1993;13:116S-128S; discussion 143S-146S.
DOI: https://doi.org/10.1002/j.1875-9114.1993.tb02780.x
Li Q, Pang J, Deng Y, et al. Adverse Cardiovascular Effects of Phenylephrine Eye Drops Combined With Intravenous Atropine. Frontiers in pharmacology 2021;11:596539.
DOI: https://doi.org/10.3389/fphar.2020.596539
VAZCULEP (phenylephrine hydrochloride) Label; Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/204300lbl.pdf
Dipartimento Nazionale per le Politiche Antidroga. Sistema Nazionale di Allerta Precoce. Available from: https://www.politicheantidroga.gov.it/it/attivita/sistema-nazionale-allerta-precoce/sistema-nazionale-di-allerta-precoce
How to Cite
Agosti, A., Vercelli, A., Demichele, E., Mariani, F., Biagi, A., Ferraro, S., Cervellin, G., & Poggiali, E. (2023). A case of cardiotoxicity following intramuscular injection of tropicamide and phenylephrine ophthalmic solution in a drug-addicted young woman. Emergency Care Journal, 19(3). https://doi.org/10.4081/ecj.2023.11320
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