contemplation objective: To evaluate the general intents of nebulized ipratropium bromide in succession intraocular pressures and pupillary answers in children with asthma.

Design: A double-blind, randomized, crossover study

Setting: Children's Hospital of Winnipeg, University of Manitoba.

Patients or participants: Age 6 to 17 years with asthma.

Intervention: Nebulized ipratropium bromide added to albuterol sulfate, albuterol alone, or saline solution was given from face mask and nebulizer. Before and 05 h after nebulization, intraocular compressings (mm Hg), pupillary size (mm) and pupillary replys were measured. In a following open study, patients who had been admitted to hospital with acute asthma who were treated with nebulized ipratropium bromide were recruited for measurement of intraocular squeezings pupillary size, and pupillary responses

Measurements and results: Twenty patients complet the double-blind studious mood and 26 patients completed the make open study. There were no changes in intraocular urgencys pupillary size, or pupillary answer after any treatment on any consideration day in either the double-blind or the unclose studies.

Conclusion: In children with asthma, who have no pre-existing ocular abnormalities, the risk of an adverse reaction to nebulized ipratropium bromide delivered at face mask inadvertently absorbed in the organ of vision is extremely small.

I pratropium bromide, a topically active quarternary derivative of n-isopropyl noratropine, is widely used as a nonselective muscarinic receptor antagonist. For treatment of acute bronchospasm in adults and children, it is administered with a [[beta].sub.2]-adrenergic agonist.[1-5]

Administration of ipratropium bromide at nebulizer and face mask has been reported to be associated with acute angle-closure glaucoma[6-11] and unilateral fixed dilated pupil.[12-14] In the reports of glaucoma, patients complained of blurring of vision and ocular pain within minutes of ipratropium administration. The increased intraocular presss responded to appropriate treatment with intravenous or oral acetazolamide, topical pilocarpine, and analgesia. Patients with a unilateral dilated pupil also reported symptoms within minutes of ipratropium bromide administration, with resolution through 6 to 8 h.

These adverse drifts have been attributed to ipratropium bromide escaping from the face mask and being absorbed locally in the eye[1314] Approximately 90 percent of the medication delivered at face mask and nebulizer escapes into the air or is left in the nebulizer. a hospitals now recommend ipratropium bromide be delivered solitary by metered-dose inhaler or from mouthpiece with a nebulizer, and not by way of face mask; however, children may not cooperate with the use of mouthpieces.

To date, and to our knowledge, there are no data onward the effect of nebulized ipratropium bromide onward intraocular pressure or pupillary rejoinders in children. It is not known if children are at risk for ocular complications from ipratropium bromide. We hypothesized that nebulized ipratropium bromide, when combined with a [[beta].sub.2]-adrenergic agonist, would not significantly affect intraocular influences pupillary size, or change in pupillary rejoinders in children. We performed a double-blind, placebo-controlled, crossover application of mind of nebulized ipratropium bromide and albuterol alone, and saline solution to assess this hypothesis.

METHODS

The application of mind was approved by the Faculty Committee onward the Use of Human make submissives in Research at the University of Manitoba. All patients and/or parents gave written informed assent before study entry. Patients were eligible for meditation if they were aged 6 to 17 years, had moderate to morose asthma, and had previously used ipratropium bromide during asthma exacerbations. Patients were exclud from close attention if they had a history of bitter eye injury or congenital estimate disorders, including congenital glaucoma.

All patients arrived at the Pediatric Allergy Laboratory in the Health Sciences Clinical Research Center at 7:30 AM, having used no bronchodilator medications on face mask and nebulizer within the previous 12 h Baseline intraocular crushings were measured using a Goldmann applanation tonometer (Haag-Streit, Bern, Switzerland), attached to a slit lamp for ophthalmologic examinations. Before each measurement, proparacaine hydrochloride 05 percent 1 pendant was instilled in each judgment for local anesthesia.

In a double-blind, randomized three-way crossover fashion, patients received nebulized ipratropium bromide, 250 [mu]g if they weighed [les than] 40 kg and 500 [mu]g if they weighted [greater than] 40 kg added to albuterol sulfate, 01 mg/kg (maximum dose, 50 mg) albuterol alone, or saline solution alone via face mask and nebulizer. The medications were delivered by dint of a jet nebulizer (Bennett Twin) driven according to 5 L of oxygen by means of minute via a loose-fitting face mask. The nebulization was continued until all medication was delivered. At the completion of the nebulization, patients were questioned with regards to possible adverse tenors including dry mouth, bad taste, blurr vision, palpitations, or tremor. Before and 05 h after completion of the nebulization, intraocular influence (mm Hg), pupillary size (mm) and pupillary answer (0, no response; 1, sluggish; 2 brisk) were measured. Pupillary size was declareed as the diameter in millimeters using light from the slit lamp as the no other than light source. Pupillary response was assessed in a darkened stead after shining a beam of light into the organ of vision Patients returned to the Health Sciences Clinical Research midmost point on two additional occasions to receive the alternate medications by means of face mask nebulizer. All visits occurr at least 48 h apart. An intraocular constraining force increase of 3 mm Hg or more was considered to be significant.[15]

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