The "Blown Pupil": Imminent Death or Harmless Contamination?

Acute anisocoria and unilateral mydriasis is physically alarming to patients and diagnostically worrisome to clinicians. We report the case of a 14-year-old girl who presented to the pediatric emergency department with acute anisocoria and unilateral mydriasis after contacting an Angel's trumpet plant and who had complete resolution of symptoms four days following eye contamination. The Angel's trumpet plant contains three active components which can result in mydriasis: hycosamine, atropine, and scopolamine. The three active components occur in different parts of the plant, including on the small glandular hairs that cover the entire plant. This likely explains why even brief contact with the plant can result in unintentional contamination of the eye and in mydriasis. It is critical when obtaining a history from a patient with such a presentation to ask explicitly about any contact with plants prior to onset of symptoms. Although eye contamination with the Angel's trumpet plant is self-limited and resolves within a week, the appearance of a persistently unilateral mydriatic eye can be alarming to patients and clinicians, which too often results in an unnecessary, costly workup.