Post card from Barbados: Horner’s or Gardener’s Syndrome?

A fifty year old Caucasian lady called me in the middle of a busy clinic, in a panic. For the last 5 days, one of her pupils appeared much smaller than the other, the eye had been a little red and her vision in the eye seemed different.

Image reproduced from Clinical Ophthalmology (J Kanski) with kind permission from Elsevier Health Ltd.

She was nearly hysterical as she had been on the internet! I got her to come straight in. 

I examined her, and she did indeed have a smaller pupil in the right eye, which was more marked in dimmer lighting. She had no ptosis. Her VA was normal and Rx was unchanged. Eyes were healthy with no signs of iritis. IOP was 14mmHg R&L.

Everything pointed towards an acute onset Horner’s syndrome.

Everything, that is apart from the history. She told me about spraying insecticide the day prior to noticing her small pupil. Could it be linked? It seemed a long shot!

I calmly dispatched her with the reassurance that I would seek more expert advice and call her back. I contacted the local friendly Ophthalmologist for his input. He agreed that we should probably hold off on sending her for chest X-rays, carotid artery scans etc.. for a couple of days to see if the pupil redilated.

I saw her after 48 hours and the pupils were indeed equal.

Diagnosis: ‘gardener’s syndrome!’

The bug-spray that she had used in her garden had contained ‘carbaryl’, which is a carbamate – an insecticide chemical. Carbamates are acetyl-choline-esterase (AChE) inhibitors and have a parasympathomimetic effect very similar to physostigmine (if you remember your University pharmacology). These chemicals have a long-lasting effect on pupil size as they lead to extraordinary aggregation of acetyl-choline (ACh) at the parasympathetic nerve endings. Once the carbamate concentration reduces it takes a while before new acetyl-chloline-esterase is synthesized and a little longer still until it starts to break down the ACh.

She must have inadvertently wiped a pretty hefty dose of this bug-goo into her right eye!

She won’t do that again in a hurry. 
 
I don’t think this would go down too well in Barbados though!

Share This