CORRESPONDENCE
technique of carotid massageand likely jump to pharmacologictherapy soonerthan is absolutely necessary. I am very impressedwith a conversion rate of "at least 60%" and hope Or Pemeroycan see his way to publishing these data (even retrospectively).
Stephen J Jameson, MD Departmentof EmergencyMedicine Medical Collegeof Wisconsin Milwaukee
8 6/ 11 7 0
Flea Collar Pupil To the Editor. A 36-year-oldhealthy woman presented to our emergencydepartment with the complaint of unequal pupils. She worked as an interior decorator and the day before presentation was struck on the head with a hammer that had fallen 1 ft from the top of a ladder. It was a "glancing blow" and appearedinconsequential. However,the following morning, she happenedto look in the mirror and noticed that her left pupil was "tiny" while her right pupil appeared normal to her. Now, concerned about the unequal pupils and the head trauma from the prior day, she came to the ED. The intern's evaluation revealeda healthy, comfortable woman with a left pupil measuring3 mm (though the patient had describeda "pinpoint" pupil) and a right pupil measuring 4 mm. Both pupils were reactive and visual acuity was normal. Head, fundoscopic,and neurologic examinationswere within normal limits. Repeatexaminationwith the attending physicianapproximately 20 minutes later revealedequal and reactive pupils. On further questioning, it was discoveredthat sometime before she looked into the mirror, she had changed her dog's flea collar and soon afterwards put in her left contact lens (she wore only one contact lens). She removedthe lens before coming to the hospital.
The logical explanationfor her transient miosis was that she had inadvertently placed some of the flea collar's "dust" into her left eye while putting in her contact lens. The active ingredient in this particular flea collar was O-isopropoxyphenyl methylcarbamate,which is a carbamate. Carbamates,like the organophosphates,are cholinesterase inhibitors that produceamong other effects, miosis.1 In this particular case, the diagnosis was made exclusivelyby the history, and the patient's impressions were initially misleading. For the pupil learning to take a good history, there may be more to the story than meets the eye!
Dale J Ellenberg, MD, FACEP Laurence D Specter, MD, FACEP Andrew Lee, MD Brockton Hospital Departmentof EmergencyServices Brockton, Massachusetts 1. Goodman A, Gilman P: The
Pharmacological Basis of Therapeutics, ed 5. New York, Macmillan Publishing Co, 1975, p 453.
ANNALS OF EMER6ENCY MEDICINE
21:9
SEPTEMBER 1992
technique of carotid massageand likely jump to pharmacologictherapy soonerthan is absolutely necessary. I am very impressedwith a conversion rate of "at least 60%" and hope Or Pemeroycan see his way to publishing these data (even retrospectively).
Stephen J Jameson, MD Departmentof EmergencyMedicine Medical Collegeof Wisconsin Milwaukee
8 6/ 11 7 0
Flea Collar Pupil To the Editor. A 36-year-oldhealthy woman presented to our emergencydepartment with the complaint of unequal pupils. She worked as an interior decorator and the day before presentation was struck on the head with a hammer that had fallen 1 ft from the top of a ladder. It was a "glancing blow" and appearedinconsequential. However,the following morning, she happenedto look in the mirror and noticed that her left pupil was "tiny" while her right pupil appeared normal to her. Now, concerned about the unequal pupils and the head trauma from the prior day, she came to the ED. The intern's evaluation revealeda healthy, comfortable woman with a left pupil measuring3 mm (though the patient had describeda "pinpoint" pupil) and a right pupil measuring 4 mm. Both pupils were reactive and visual acuity was normal. Head, fundoscopic,and neurologic examinationswere within normal limits. Repeatexaminationwith the attending physicianapproximately 20 minutes later revealedequal and reactive pupils. On further questioning, it was discoveredthat sometime before she looked into the mirror, she had changed her dog's flea collar and soon afterwards put in her left contact lens (she wore only one contact lens). She removedthe lens before coming to the hospital.
The logical explanationfor her transient miosis was that she had inadvertently placed some of the flea collar's "dust" into her left eye while putting in her contact lens. The active ingredient in this particular flea collar was O-isopropoxyphenyl methylcarbamate,which is a carbamate. Carbamates,like the organophosphates,are cholinesterase inhibitors that produceamong other effects, miosis.1 In this particular case, the diagnosis was made exclusivelyby the history, and the patient's impressions were initially misleading. For the pupil learning to take a good history, there may be more to the story than meets the eye!
Dale J Ellenberg, MD, FACEP Laurence D Specter, MD, FACEP Andrew Lee, MD Brockton Hospital Departmentof EmergencyServices Brockton, Massachusetts 1. Goodman A, Gilman P: The
Pharmacological Basis of Therapeutics, ed 5. New York, Macmillan Publishing Co, 1975, p 453.
ANNALS OF EMER6ENCY MEDICINE
21:9
SEPTEMBER 1992
