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8 of 216 medications
Atropine 0.5%, 1%, 2%
Atropine · Atropine OintmentMydriatics/Cycloplegics
Approved uses
Cycloplegia and mydriasis
1 drop to the conjunctival cul-de-sac 40 minutes before intended maximal dilation, from 3 months of age; may be repeated up to twice daily from 3 years of age.
Dilation begins within 40 minutes, peaks at about 2 hours, and can persist up to 2 weeks.
Penalization of the healthy eye in amblyopia
1 drop to the sound eye once daily; weekend-only dosing (2 days per week) was equally effective at 4 months. The label sets no amblyopia-specific frequency and caps repeat dosing at twice daily from 3 years of age.
Acuity gain equals patching, and weekend-only dosing works as well as daily dosing.
OFF-LABELNot in the FDA label for this product
Myopia progression control in children
1 drop nightly OU of 0.01%, 0.025%, or 0.05% (LAMP) or of 0.01%, 0.1%, or 0.5% (ATOM2); these are prepared low concentrations, not this 1% product.
RCTs · n=438 · US trial null
LAMP randomized 438 children aged 4 to 12 to nightly 0.05%, 0.025%, 0.01%, or placebo, with 1-year spherical equivalent change of -0.27, -0.46, -0.59, and -0.81 D (P < 0.001) and 0.05% still the optimal concentration at 3 years in that Chinese cohort. ATOM2 randomized 400 children aged 6 to 12 to nightly 0.5%, 0.1%, or 0.01% for 2 years (progression -0.30, -0.38, and -0.49 D, differences the authors judged clinically insignificant), and the 0.01% arm had the smallest rebound in the washout year. A US randomized placebo-controlled trial of 0.01% in 187 children found no effect at 24 months (adjusted difference -0.02 D, 95% CI -0.19 to +0.15 D), so benefit at the lowest concentration is not established in every population.
Contraindications
Hypersensitivity or previous allergic reaction to any ingredient in the formulation.
Available Forms1% solution (10 mg/mL atropine sulfate, 8.3 mg/mL base), 2 mL, 5 mL, 15 mL dropper bottles
Mechanism of ActionReversible, relatively nonselective muscarinic antagonist; potency at nicotinic receptors is much lower and other receptor actions are not clinically detectable. Blocking muscarinic activation of the pupillary constrictor leaves sympathetic dilator tone unopposed, giving mydriasis, and weakening ciliary muscle contraction gives cycloplegia with loss of accommodation for near.
Warnings & Precautions
- Photophobia and blurred vision: Pupil unresponsiveness and cycloplegia may last up to 2 weeks.
- Blood pressure elevation: Reported after conjunctival instillation of recommended doses of the 1% solution.
- MAO inhibitor interaction: Concurrent use is generally not recommended, given the potential to precipitate hypertensive crisis.
- Pediatric overdose: 10 mg or less may be fatal in a child; physostigmine reverses delirium and coma but is short lived and may need repeating.
Common Side Effects
- Ocular, most common: Eye pain and stinging on instillation, blurred vision, photophobia, decreased lacrimation, superficial keratitis.
- Ocular, allergic: Papillary conjunctivitis, contact dermatitis, lid edema; less common.
- Systemic: Increased heart rate and blood pressure, dryness of skin, mouth, and throat, flushed skin of face and neck, restlessness, irritability, delirium.
Pregnancy & LactationPregnancy: No adequate and well-controlled studies in pregnant women and no animal development or reproduction studies; use only if the potential benefit justifies the potential fetal risk.
Lactation: Traces have been found in human milk after administration of the injectable solution, and topical dosing produces some systemic absorption.
Pediatric UseNot recommended under 3 months; under 3 years limit to one drop per eye per day.
Cyclopentolate 0.5%, 1%, 2%
Cyclogyl®Mydriatics/Cycloplegics
Approved uses
Mydriasis and cycloplegia
Adults 1 to 2 drops of 0.5%, 1%, or 2%, repeated in 5 to 10 minutes if necessary; children the same with a second application of 0.5% or 1%; small infants a single drop of 0.5% with nasolacrimal pressure for 2 to 3 minutes.
Contraindications
Hypersensitivity to any component of this preparation.
Available FormsOphthalmic solution, 0.5% (15 mL), 1% (2 mL, 5 mL, 15 mL), 2% (2 mL, 5 mL, 15 mL)
Mechanism of ActionAnticholinergic that blocks the response of the iris sphincter and of the ciliary body accommodative muscle to cholinergic stimulation, producing pupillary dilation and paralysis of accommodation. Onset is rapid and duration shorter than atropine, with maximal cycloplegia 25 to 75 minutes after instillation.
Warnings & Precautions
- CNS disturbances: Especially likely in younger age groups and with the stronger solutions, but possible at any age.
- Concentration-dependent CNS risk: Psychotic and behavioral reactions occur mainly in children and especially with 2%; a 2022 mini review recommends avoiding 2% and pairing a lower strength with phenylephrine instead.
- Infant systemic absorption: Infants are especially prone to CNS and cardiopulmonary effects; use one drop of 0.5% per eye, apply pressure over the nasolacrimal sac for two to three minutes, and observe for at least 30 minutes.
- IOP and angle closure: Mydriatics may transiently raise intraocular pressure, and untreated narrow angle glaucoma or anatomically narrow angles may be susceptible to angle closure after instillation.
- Down syndrome: Caution when considering use.
- Preterm infant feeding: Feeding intolerance and necrotizing enterocolitis have been reported after ophthalmic use, causality not established; withhold feeding for 4 hours after examination.
- Cholinergic drug interaction: May interfere with the ocular antihypertensive action of carbachol, pilocarpine, or ophthalmic cholinesterase inhibitors.
- Route restriction: Topical ophthalmic use only, not for injection.
Common Side Effects
- Ocular: Increased intraocular pressure, burning, photophobia, blurred vision, irritation, hyperemia, conjunctivitis, blepharoconjunctivitis, punctate keratitis, synechiae.
- Systemic, CNS: Psychotic reactions and behavioral disturbances, usually in children and especially with the 2% concentration, including ataxia, incoherent speech, restlessness, hallucinations, hyperactivity, seizures, disorientation as to time and place, and failure to recognize people.
- Systemic, anticholinergic: Skin rash, abdominal distention in infants, unusual drowsiness, tachycardia, hyperpyrexia, vasodilation, urinary retention, diminished gastrointestinal motility, decreased salivary and sweat secretion.
- Systemic, severe: Coma, medullary paralysis, and death.
- Preterm infants: Feeding intolerance, and necrotizing enterocolitis reported after ophthalmic use with causality not established.
Pregnancy & LactationPregnancy: No animal reproduction studies have been conducted; whether fetal harm or an effect on reproductive capacity can occur is unknown, so administer only if clearly needed.
Lactation: Excretion in human milk is unknown; exercise caution in a nursing woman.
Pediatric UsePsychotic and behavioral reactions reported; infants and young children are most susceptible.
Homatropine HBr 2%, 5%
HomatropineMydriatics/Cycloplegics
GoodRxApproved uses
Cycloplegic refraction
1 or 2 drops of 5% topically; may be repeated in 5 to 10 minutes if necessary. Heavily pigmented irides may require larger doses.
Uveitis and other inflammatory conditions of the uveal tract
1 or 2 drops of 5% topically up to every 3 to 4 hours.
Contraindications
- Primary glaucoma or a tendency toward glaucoma, such as a narrow anterior chamber angle
- Hypersensitivity to any component
Available FormsOphthalmic solution, 5%, 5 mL plastic bottle
Mechanism of ActionAnticholinergic; blocks the response of the iris sphincter and the accommodative muscle of the ciliary body to cholinergic stimulation, producing mydriasis and paralysis of accommodation. The label characterizes the resulting mydriasis and cycloplegia as moderately long-acting.
Warnings & Precautions
- Route restriction: Topical ophthalmic use only; not for injection.
- Keratoconus: May produce a fixed dilated pupil; weigh risk against benefit.
- Increased susceptibility: Down syndrome, children with brain damage, and the elderly; extreme caution in infants and small children.
- Systemic anticholinergic poisoning: Excessive use in pediatric patients, or in those with a history of susceptibility to belladonna alkaloids, may produce systemic symptoms.
- Systemic absorption: Compress the lacrimal sac by digital pressure for 2 to 3 minutes after instillation.
- Amblyopia in early infancy: The cycloplegia produced is possibly associated with development of amblyopia, which is why the drug is not used during the first 3 months of life.
Common Side Effects
- Ocular: Transient stinging and burning; eye irritation not present before therapy; increased sensitivity of the eyes to light.
- Ocular, prolonged use: Local irritation with follicular conjunctivitis, vascular congestion, edema, exudates, and eczematoid dermatitis.
- Systemic: Thirst or dryness of mouth.
Pregnancy & LactationPregnancy: Category C. Animal reproduction studies have not been conducted; give only if clearly needed.
Lactation: Excretion in human milk unknown; use caution.
Pediatric UseNot for use during the first 3 months of life.
Hydroxyamphetamine 1% / Tropicamide 0.25%
Paremyd®Mydriatics/Cycloplegics
GoodRxApproved uses
Mydriasis for diagnostic procedures
One to two drops in the conjunctival sac.
Dilation starts within 15 minutes, peaks by 60 minutes, and most patients recover fully in 6 to 8 hours.
Dilation for binocular indirect ophthalmoscopy
One drop in each eye; the label allows one to two drops in the conjunctival sac.
Dark brown irides dilate more slowly, though one drop dilates adequately at any iris pigmentation.
OFF-LABELNot in the FDA label for this product
Horner syndrome, localising the lesion (single-agent hydroxyamphetamine, not this combination)
The test uses hydroxyamphetamine 1% ALONE. That product is no longer marketed in the United States: hydroxyamphetamine is listed only as a bulk ingredient, and Paremyd adds tropicamide 0.25%, which dilates on its own and so confounds the reading.
n=54 · single agent only
Hydroxyamphetamine releases noradrenaline from an intact third-order neuron, so it separates where cocaine cannot. In 54 patients with Horner syndrome, those with postganglionic damage dilated LESS on the affected side, while almost all with preganglionic lesions dilated MORE. A companion study of 26 normal subjects established the baseline that makes the reading interpretable: a mean 1.96 mm of dilation, and near-symmetric between an individual's two eyes at a mean interocular difference of -0.087 mm, so between-subject variation is much larger than within-subject. Read this row for the pharmacology and the history: the single-agent product it depends on is not available, which is why localisation is now usually left to imaging.
Contraindications
- Angle-closure glaucoma, or narrow angles in whom pupil dilation may precipitate an attack.
- Hypersensitivity to any component.
Available FormsOphthalmic solution, 15 mL bottle, hydroxyamphetamine hydrobromide 1% / tropicamide 0.25%
Mechanism of ActionCombines hydroxyamphetamine, an indirect sympathomimetic that releases endogenous norepinephrine from intact adrenergic nerve terminals with minimal cycloplegic action, and tropicamide 0.25%, a parasympatholytic blocking the iris sphincter and ciliary muscle; the two act at different effector sites, so the mydriatic effect is additive while full cycloplegia does not occur at this anticholinergic concentration. Onset within 15 minutes, maximum effect at 60 minutes, dilation and partial cycloplegia lasting 3 hours, complete recovery in 6 to 8 hours or up to 24 hours in some patients.
Warnings & Precautions
- Angle-closure precipitation: Estimate the depth of the anterior chamber angle before instillation.
- Intraocular pressure elevation: There is evidence that mydriatics may produce a transient rise in patients with open-angle glaucoma; monitor the elderly and others in whom glaucoma or raised pressure may follow administration.
- Cardiovascular and endocrine comorbidity: Monitor patients with hypertension, hyperthyroidism, diabetes, or cardiac disease such as arrhythmias or chronic ischemic heart disease after instillation.
- CNS disturbances: Rare, and may be particularly dangerous in infants, children, or the aged.
- Route restriction: Topical ophthalmic use only, not for injection.
Common Side Effects
- Ocular: Transient stinging, blurred vision, photophobia with or without corneal staining; increased intraocular pressure reported following mydriatics.
- Systemic: Dry mouth, tachycardia, headache, allergic reactions, nausea, vomiting, pallor, muscle rigidity, CNS disturbances.
- Serious cardiovascular events: Rare reports shortly after instillation, including death due to myocardial infarction, ventricular fibrillation, and significant hypotensive episodes.
- Anticholinergic class effects: Psychotic reactions, behavioral disturbances, and vasomotor or cardiorespiratory collapse.
Pregnancy & LactationPregnancy: Category C; no animal reproduction studies have been conducted and fetal harm is unknown; give only if clearly needed.
Lactation: Excretion in human milk is unknown; exercise caution in a nursing woman.
Pediatric UseSafety and effectiveness not established; rare CNS disturbances may be dangerous in infants and children.
Phenylephrine 2.5%, 10%
PhenylephrineMydriatics/Cycloplegics
GoodRxApproved uses
Mydriasis, age 1 year and older
1 drop of 2.5% or 10% every 3 to 5 minutes, maximum 3 drops per eye, repeated if necessary
Mydriasis, infants under 1 year
1 drop of 2.5% at 3 to 5 minute intervals, maximum 3 drops per eye
OFF-LABELNot in the FDA label for this product
Horner syndrome, denervation supersensitivity testing
1 drop of a 1% dilution in each eye, pupils measured 1 hour later in bright light; 1% is not a marketed strength and must be diluted
Observational · 71% sensitive
In a standardized series, 71% of sympathetically denervated or decentralized Horner pupils were supersensitive to 1%; a normal 20-year-old dilates by no more than 2.1 mm in bright light at 1 hour, sensitivity rises 0.23 mm per decade, and the interocular difference should not exceed 0.7 mm. The author concluded that supersensitivity is a useful but not invariable feature, so a negative test does not exclude the diagnosis.
Episcleritis versus scleritis, vasoconstriction test
Topical instillation over the injected sector, then re-examine those vessels for blanching; no standardized concentration, and 10% was the strength used in the single reported case
Review + case report
A vasculitis review states that episcleritis blanches on instillation of topical phenylephrine while scleritis is painful and does not blanch, without specifying a concentration; in a reported case of nodular anterior scleritis, hyperemia persisted after 10%. No study of diagnostic accuracy and no standardized concentration or reading time was found, so treat the result as supportive rather than definitive.
Contraindications
- Hypertension or thyrotoxicosis, for the 10% solution; the 2.5% solution should be used in these patients.
- Age less than 1 year, for the 10% solution, due to increased risk of systemic toxicity; the 2.5% solution should be used in these patients.
Available FormsOphthalmic solution, 2.5% (10 mL, 15 mL), 10% (5 mL fill in a 10 mL bottle)
Mechanism of ActionAlpha-1 adrenergic receptor agonist that acts locally as a potent vasoconstrictor and mydriatic, constricting ophthalmic blood vessels and contracting the radial muscle of the iris. Maximal mydriasis occurs at 20 to 90 minutes with recovery after 3 to 8 hours, and systemic absorption can raise blood pressure, sometimes with a reflex atropine-sensitive bradycardia.
Warnings & Precautions
- Cardiovascular reactions, 10%: Ventricular arrhythmias and myocardial infarction, some fatal, usually in patients with pre-existing cardiovascular disease; the 2.5% solution should be used in these patients.
- Blood pressure elevation: Not common but reported after recommended doses of the 10% solution, and less likely with 2.5%; caution with 10% in children under 5 years and in hyperthyroidism or cardiovascular disease, and monitor post-treatment blood pressure in cardiac or endocrine disease and in anyone who develops symptoms.
- Rebound miosis: Reported one day after instillation, with a lesser mydriatic effect on re-instillation.
- Pressor interactions: Concomitant atropine may enhance the pressor effect and induce tachycardia, and the cardiovascular depressant effects of some inhalation anesthetics may be potentiated.
- Sympathomimetic cautions: A review of systemic reactions to ophthalmic drugs associates both 2.5% and 10% with cardiovascular effects and advises caution with monoamine oxidase inhibitors, tricyclic antidepressants, and atropine, and in hypertension, advanced arteriosclerotic change, aneurysm, orthostatic hypotension, long standing insulin dependent diabetes, and low bodyweight children.
- Overdose response: Rapid rise in blood pressure, headache, anxiety, nausea, vomiting, and ventricular arrhythmias; prompt injection of a rapidly acting alpha-adrenergic blocking agent such as phentolamine has been recommended.
- Route restriction: Topical ophthalmic use only, not for injection.
Common Side Effects
- Ocular: Eye pain and stinging on instillation, temporary blurred vision, photophobia, conjunctival sensitization.
- Cardiovascular, 10%: Marked blood pressure increase, syncope, myocardial infarction, tachycardia, arrhythmia, and subarachnoid hemorrhage, occurring primarily in hypertensive patients.
- Blood pressure, high-risk groups: Marked increase reported particularly, but not limited to, low weight premature neonates, infants, and hypertensive patients.
- Frequency: Spontaneous postmarketing reports from a population of uncertain size; rates and causality are not reliably estimable.
Pregnancy & LactationPregnancy: Animal reproduction studies have not been conducted with the topical drug and fetal harm potential is unknown; give only if clearly needed.
Lactation: Excretion in human milk is unknown; exercise caution in a nursing woman.
Pediatric UseThe 10% solution is contraindicated under 1 year of age; use 2.5%.
Tropicamide 0.5%, 1%
Mydriacyl®Mydriatics/Cycloplegics
Approved uses
Cycloplegic refraction
1 or 2 drops of 1% in the eye(s), repeated in 5 minutes.
Cycloplegic shift averages 0.11 D less than cyclopentolate 1%, judged clinically insignificant.
Mydriasis for fundus examination
1 or 2 drops of 0.5% instilled 15 or 20 minutes before examination; heavily pigmented irides may require the higher strength or more doses.
Mydriasis begins in 15 to 30 minutes and reverses in 4 to 8 hours, up to 24 hours in some patients.
OFF-LABELNot in the FDA label for this product
Accommodative spasm (pseudomyopia)
1% BID, tapered against symptomatic response over about 2 months, alongside a single vision plus lens.
Case report · n=2
Evidence is a case report of 2 patients in Nepal with sudden fluctuating myopic refraction that shifted hyperopic under cycloplegia; both were managed with 1% twice daily plus a single vision plus lens and avoidance of triggering near work, with the dose tapered against symptomatic response and no recurrence reported over the follow-up. Case report level only: no control group, no comparison with cyclopentolate or atropine, and no dose-finding data.
Contraindications
Hypersensitivity to any component of this preparation.
Available FormsOphthalmic solution, 1% (3 mL, 15 mL) in plastic DROP-TAINER dispensers
Mechanism of ActionAnticholinergic that blocks the response of the iris sphincter and the ciliary muscle to cholinergic stimulation, dilating the pupil; the 1% strength also paralyzes accommodation, while 0.5% produces mydriasis with only slight cycloplegia. Acts in 15 to 30 minutes with roughly 3 to 8 hours of activity, and complete recovery from mydriasis requires 24 hours in some patients.
Warnings & Precautions
- CNS disturbances: May be dangerous in pediatric patients; psychotic reactions and behavioral disturbances from anticholinergic hypersensitivity should be considered.
- Intraocular pressure elevation: Mydriatics may produce a transient rise.
- Systemic absorption: The lacrimal sac should be compressed by digital pressure for two to three minutes after instillation to reduce excessive systemic absorption.
- Contact lenses: Remove before use.
- Cholinergic drug interference: May interfere with the antihypertensive action of carbachol, pilocarpine, or ophthalmic cholinesterase inhibitors.
- Route restriction: Topical ophthalmic use only, not for injection.
Common Side Effects
- Ocular: Transient stinging, blurred vision, photophobia, superficial punctate keratitis; increased intraocular pressure reported following mydriatics.
- Systemic: Dry mouth, tachycardia, headache, allergic reactions, nausea, vomiting, pallor, CNS disturbances, muscle rigidity.
- Anticholinergic class effects: Psychotic reactions, behavioral disturbances, and vasomotor or cardiorespiratory collapse in children.
Pregnancy & LactationPregnancy: No animal reproduction studies have been conducted and fetal harm is unknown; give only if clearly needed.
Lactation: Excretion in human milk is unknown; exercise caution in a nursing woman.
Pediatric UseMay rarely cause CNS disturbances that may be dangerous in pediatric patients.
Tropicamide 1% / Phenylephrine 2.5%
Mydcombi®Mydriatics/Cycloplegics
Approved uses
Mydriasis for diagnostic procedures
One metered spray to the cornea of each eye to be dilated, repeated after 5 minutes.
Dilation begins in 15 to 30 minutes, is maximal at 20 to 90 minutes, and recovers in 3 to 8 hours.
Pupillary dilation in children
One metered spray per eye repeated after 5 minutes; younger than 1 year, one metered spray per eye to a maximum of 3 sprays per eye per day.
In children the spray widens pupils 2.48 mm, matching standard drops.
Contraindications
Known hypersensitivity to any component of the formulation.
Available FormsOne-cartridge carton, box with one cartridge plus one dispenser base, five-cartridge box, 2 mL cartridge holding approximately 180 metered sprays, tropicamide 1% / phenylephrine HCl 2.5%, 0.008 mL per spray delivering 0.08 mg and 0.2 mg respectively, cartridge works only with the matching dispenser base
Mechanism of ActionFixed combination of an anticholinergic, tropicamide, which blocks the response of the iris sphincter muscle to dilate the pupil, and an alpha-1 adrenergic agonist, phenylephrine, which contracts the iris dilator muscle. Onset 15 to 30 minutes, maximal mydriasis at 20 to 90 minutes, spontaneous recovery in 3 to 8 hours and up to 24 hours in some patients.
Warnings & Precautions
- Blood pressure elevation: Caution in pediatric patients under 5 years of age and in hyperthyroidism or cardiovascular disease; monitor post-treatment blood pressure in cardiac and endocrine disease and in anyone who develops symptoms.
- CNS disturbances: The tropicamide component may cause CNS disturbances that may be dangerous in pediatric patients, including psychotic reactions and behavioral disturbances from anticholinergic hypersensitivity.
- Intraocular pressure elevation: Mydriatics may produce a transient rise.
- Rebound miosis: Reported one day after an alpha-1 agonist ophthalmic solution, with a lesser mydriatic effect on re-administration.
- Pressor response interactions: Phenylephrine may enhance the pressor effect of atropine-like drugs and induce tachycardia, and may potentiate the cardiovascular depressant effects of some inhalation anesthetics.
- Cholinergic drug interference: May interfere with the antihypertensive action of carbachol, pilocarpine, or ophthalmic cholinesterase inhibitors.
- Route restriction: Topical ophthalmic use only, not for injection.
Common Side Effects
- Ocular, incidence under 2%: Transient blurred vision, reduced visual acuity, photophobia, mild eye discomfort.
- Ocular, additional: Superficial punctate keratitis; increased intraocular pressure reported following mydriatics.
- Systemic: Dry mouth, tachycardia, headache, allergic reactions, nausea, vomiting, pallor, CNS disturbances, muscle rigidity reported with tropicamide.
- Marked blood pressure increase: Reported with phenylephrine, particularly but not limited to low weight premature neonates, infants, and hypertensive patients.
- Anticholinergic class effects: Psychotic reactions, behavioral disturbances, and vasomotor or cardiorespiratory collapse in children.
Pregnancy & LactationPregnancy: No data in pregnant women or in animals to inform drug-associated risk; give only if clearly needed.
Lactation: No data on presence in human milk, effects on the breastfed infant, or effects on milk production.
Pediatric UseLabeled dosing extends below 1 year of age (maximum 3 sprays per eye per day); rare CNS disturbances may be dangerous in children.