Pilocarpine
Glaucoma · Rx
Trade namesIsopto Carpine, Vuity (1.25%, presbyopia)
Drug classCholinergic (muscarinic) agonist / miotic
Strength1%, 2%, 4% (glaucoma); 1.25% (Vuity, presbyopia)
AvailabilityRx
Mechanism of actionDirect muscarinic agonist; contracts the ciliary muscle to open the trabecular meshwork (increases outflow) and contracts the iris sphincter (miosis, pulls peripheral iris away from the angle).
Indication / reason for useAcute and chronic angle-closure (breaks pupillary block once the iris is not ischemic), before/after laser peripheral iridotomy, plateau iris, pilocarpine test for Adie pupil; Vuity 1.25% for presbyopia (pinhole effect).
Usual adult dosingAngle-closure: 1-2% one drop, may repeat once after 15 min then reassess. Chronic: QID. Vuity: 1 drop each eye once daily.
PreservativeBAK
Contact lensesRemove lenses; reinsert after 15 minutes.
Common / important adverse effectsBrow ache / accommodative spasm (marked in young patients), dim vision especially at night (miosis), induced myopia, retinal detachment risk (traction on the peripheral retina, examine high-risk eyes first), increased risk of posterior synechiae in uveitis, rarely precipitates angle-closure by anterior lens movement.
Contraindications & cautionsUveitic and neovascular glaucoma, most secondary angle-closure not due to pupillary block, malignant glaucoma, peripheral retinal pathology / high myopia (relative), pupillary-block angle-closure with an ischemic (fixed) iris, pilocarpine won't work until IOP is lowered medically.
Pregnancy / lactationLimited data; use only if clearly needed.
Practice notesIn an acute angle-closure attack, the sphincter is often ischemic and unresponsive until IOP is brought down with systemic agents, don't rely on pilocarpine alone.
Chair-side reference only. Dosing, contraindications and pregnancy guidance here are not exhaustive. Confirm against the current prescribing information and the patient’s full history before prescribing or advising.