Recommendations for the evaluation of paediatric anisocoria: Utility of topical cocaine testing

Abstract

Purpose: To propose recommendations for the evaluation of children with asymptomatic unilateral miosis, based on an evaluation of the outcomes of topical cocaine testing at the Queensland Children's Hospital, Australia, over the past four years. Methods: A retrospective review of children under the age of 16 tested using 5% topical cocaine. Data on demographic information, clinical findings, test outcomes, neuroimaging results, and the final diagnoses were collected. Results: Eighty-seven patients (median age six months, interquartile range = 13.25) were included. 69 (79.3%) patients presented with anisocoria only and 18 patients (20.7%) presented with anisocoria alongside ptosis and/or iris heterochromia (anisocoria plus). There were no cases of malignancy detected. Overall 13 (14.9%) children tested positive, 11 had idiopathic Horner syndrome, one had recent neck surgery and one had a traumatic birth. Children with anisocoria plus were more likely to have a positive cocaine test compared to anisocoria only (38.9% vs 8.7%, p < 0.01). 70 patients with a negative test had physiological anisocoria. 4 patients with an equivocal test were subsequently confirmed to have physiological anisocoria. Conclusions: In children, referrals for asymptomatic unilateral miosis are mostly physiological anisocoria. Isolated anisocoria does not require any further investigation. The cocaine test should be used as first line investigation for children with anisocoria plus other features of Horner syndrome. Children with a positive test should undergo neuroimaging and those with a negative test should have educational information on warning signs and clinical follow-up.L6366695282021-12-27 <br />