PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s visual diagnosis competition. It is held annually at the National Conference and Exhibition. This year, all ten finalists will be posted online on and at, one a day with voting opening to AAP Section on Emergency Medicine members thereafter. I hope you enjoy this online-only format, and hope that it will serve to highlight some of the fantastic learning cases that our colleagues submitted this year. It was again very difficult for the panel of judges to select the finalists and I could not have done it without their assistance. As a special treat I’ve included a musical selection form the 1980s as an optional “hint,” and to serve as a soundtrack for your learning.

This PEMPix case was submitted by:

Jennifer White, MD, Pediatric Emergency Medicine Fellow from University of Texas at Austin Dell Children’s Medical Center

Blown out of proportion?

A 10-year-old female presented to ED with a dilated left pupil – and as we’ll see, that’s it. It was actually first noticed an hour prior to presentation by a classmate. A school nurse evaluated her and she was referred to the Emergency Department where she reported blurry vision in the left, affected, eye but otherwise no other symptoms. She denied recent illness, trauma, headache, vomiting, eye pain, tearing, use of eye drops, use of contacts or glasses, eye exam, or any new exposures. Past medical history includes seasonal allergies for which she takes montelukast, and axillary hyperhidrosis. She denies any other medication use.
Her vitals are normal and on examination she is a well-appearing child, with an unremarkable full neurological exam, aside from the dilated left pupil that is round and not reactive to direct or consensual light. Extraocular movement’s are normal, she has no nystagmus, tearing, ptosis, or photophobia. Visual acuity in the right eye is 20/25, left eye 20/25, and bilateral 20/20. This is what her eyes look like – drag the slider to reveal what the eyes look like when exposed to light.

What is the diagnosis?

A. Third cranial nerve palsy

B. Holmes-Adie syndrome

C. Benign episodic unilateral mydriasis

D. Toxic (pharmacologic) pupil

E. Intracranial mass lesion

D. Toxic (pharmacologic) pupil

Given the unclear etiology of symptoms, ophthalmology was consulted.  They felt the case was consistent with pharmacologic induced anisocoria, though the agent was unclear upon further questioning of the patient and family on possible use of hyperhidrosis wipes specifically, they admitted to using QbrexzaⓇ cloth wipes on her hands and feet at night. They did not initially consider this a medication. The patient used the wipes for the first time without supervision the previous night and did not wait for her hands to dry after using them. 
In mid-2018, QbrexzaⓇ cloth (glycopyrroniumtosylate 2.4%) was approved by the U.S. FDA for topical use in cloth towelettes for primary axillary hyperhidrosis. Mydriasis was reported as an adverse event in the phase 3 trial, reported in up to 6.8% of patients. Glycopyrronium is a muscarinic anticholinergic medication. Anticholinergic mydriasis occurs via a blockade of parasympathetic muscarinic acetylcholine receptors on the iris sphincter muscle.
Hyperhidrosis cloth wipes are relatively new, and there are only a few case reports of accidental ocular exposure to topical anticholinergic treatments for hyperhidrosis. Initial non-disclosure of use of these wipes has also been reported in previous cases. As hyperhidrosis wipes become more popular and the use of anticholinergic drugs become incorporated in more topical products, it is important for the Emergency Medicine physician to be aware of this benign etiology of mydriasis for reassurance and to decrease unnecessary testing. Ultimately, this patient had complete reversal of the mydriasis with supportive care only.
This is not likely a third cranial nerve palsy as there is no ptosis or difficulty with extraocular movements. Holmes-Adie syndrome is characterized by unilateral mydriasis (tonic pupil) along with the absence of deep tendon reflexes. This patient had a normal neurological exam. Benign episodic unilateral mydriasis is a diagnosis of exclusion after other causes have been ruled out (Adie pupil, toxic exposure, intracranial pathology, etc). This is more common in women with migraine headaches. An expanding intracranial mass lesion with pupillary mydriasis usually occurs in the setting of worsening mental status and other neurological findings.


Moeller JJ, Maxner CE. The dilated pupil: an update. CurrNeurol Neurosci Rep. 2007;7(5):417‐422. doi:10.1007/s11910-007-0064-9
Pashaei-Marandi A, Assam JH, Arnold A, et al. Reversible anisocoria due to inadvertent ocular exposure to topical anticholinergic treatment for primary axillary hyperhidrosis. Can J Ophthalmol. 2019;54(6):e300‐e302.
Pariser DM, Hebert AA, Drew J, Quiring J, Gopalan R, Glaser DA. Topical Glycopyrronium Tosylate for the Treatment of Primary Axillary Hyperhidrosis: Patient-Reported Outcomes from the ATMOS-1 and ATMOS-2 Phase III Randomized Controlled Trials. Am J Clin Dermatol. 2019;20(1):135‐145. doi:10.1007/s40257-018-0395-0
Potekhina I, Holicki C, Nagia L, et al. Anisocoria? No Sweat! A Case Series of Anticholinergic Mydriasis (4570). Neurology Apr 2020, 94 (15 Supplement) 4570
Shaw, Kathy N, and Richard G. Bachur. Fleisher & Ludwig’s Textbook of Pediatric Emergency Medicine. 2016. Print.