Douglas J. Rhee, MD

60E. MIOTICS 1 (GREEN TOP)Mechanism of Action: Direct cholinergics stimulate muscarinic receptors, indirect cholinergics block acetylcholinesterase. Mioticscause pupillary muscle constriction which is believed to pull open the trabecular meshwork to increase trabecular outflow.Side Effects:Direct Cholinergic Local: Brow ache, breakdown of blood/aqueous barrier, angle closure (increases pupillary block and causes thelens/iris diaphragm to move anteriorly), decreased night vision, variable myopia, retinal tear/detachment,and possibly anterior subcapsular cataracts.Systemic: Rare.Indirect Cholinergic Local: Retinal detachment, cataract, myopia, intense miosis, angle closure, increase bleeding post surgery,punctal stenosis, increase formation of posterior synechiae in chronic uveitis.Systemic: Diarrhea, abdominal cramps, enuresis, increases effect of succinylcholine.Contraindications:Direct Cholinergic: Peripheral retinal pathology, central media opacity, young patient (increases myopic effect), uveitis.Indirect Cholinergic: Succinylcholine administration, predisposition to retinal tear, anterior subcapsular cataract, ocular surgery,uveitis.