Bruising in a Depressed Patient: Self-Inflicted or Adverse Effect of Antidepressants?: An Unexpected Cause: Scurvy.

leading to anisocoria are Horner syndrome, Adie pupil, third nerve palsy, or other ocular conditions that keep the large pupil from constricting (seeSupplementaryTableS1, Supplemental Digital Content, http://links.lww. com/JCP/A501). Nonetheless, pupillomotor functioning can be affected by exposure to pharmacological agents both intentionally and unintentionally. So far, a number of cases of pharmacological anisocoria have been reported in the literature, mostly related to drugs with a known effect on sympathetic or parasympathetic pathways. Interestingly, few cases of SSRI-related anisocoria have been reported. However, this is the first case of anisocoria associated with citalopram, an SSRI commonly used for the treatment of depression. It is noteworthy that SSRIs, unlike the other common drugs listed in Supplementary Table S1, Supplemental Digital Content, http:// links.lww.com/JCP/A501, have no significant effect on the sympathetic or parasympathetic system. Recently, Yucel et al suggested that anisocoria might be related to anticholinergic effects of escitalopram, the S-enantiomer of citalopram. However, this hypothesis is unlikely, considering that no case of anisocoria has been reported with the use of tricyclic antidepressants, which have a significant anticholinergic action. On the other hand, it is known that 5-hydroxytryptamine 1A (5-HT1A), 5-HT2A, 5-HT2C, and 5-HT7 serotonin receptors play a role in eye functioning. Richa and Yazbek suggested that one mechanism by which SSRIs may cause pupillary dilatation is the stimulation of the 5-HT7 receptors in the sphincter muscle of the pupil, which leads to activation of adenylate cyclase and subsequentmuscle relaxation. So far, the mydriatic effect of SSRIs has been investigated in few studies. All these studies found a significant pupillary dilatation associated with SSRIs. Schmitt et al first demonstrated amydriatic effect of citalopram. In their study, both sertraline and citalopram were associated with an acute and steady increase in pupil diameters that remained stable for the duration of the study (15 days). However, all these findings do not clarify the pharmacological mechanism underlying the onset of unilateral mydriasis with anisocoria. It might be speculated that in our patient a different distribution of innervation led to a distinct balance between dilator and sphincter mussels in the 2 eyes and therefore a different susceptibility to an SSRI. It should be noticed that in 3 of the 5 cases of SSRIrelated anisocoria reported in the literature, the patients involved were a medical student, a junior doctor, and a nurse, all of whom probably paid more attention to their own physical signs. Therefore, it is possible that the prevalence of anisocoria is underestimated in patients taking SSRIs.