Miotic cholinergic agonist (direct-acting)
Pregnancy: Use only if essential. Cholinergic effects possible in neonate.
Pilocarpine 2% Eye Drops
Brand names: Minims Pilocarpine
Adult dose
Dose: 1 drop every 5–10 minutes for 3–4 doses (acute angle-closure); 1 drop 3–4 times daily (chronic)
Route: Ophthalmic
Frequency: Every 5–10 min (acute emergency); 4 times daily (maintenance)
Max: 1 drop per application
Acute angle-closure glaucoma: 2% pilocarpine 1 drop every 5 min for 3–4 doses (to constrict pupil and open trabecular meshwork). Continue every 6 hours whilst awaiting surgery. Reverse pharmacological mydriasis: 2% pilocarpine once.
Paediatric dose
Route: Ophthalmic
Frequency: As needed
Max: 1 drop per application
Paediatric specialist use. Same concentration as adults. Children: 1% may be used initially. Very high systemic absorption in neonates/infants — punctal occlusion essential.
Dose adjustments
Renal
No adjustment (topical).
Hepatic
No adjustment (topical).
Clinical pearls
- In acute angle-closure: dilated pupil blocks trabecular outflow — pilocarpine mioises pupil to relieve obstruction
- Best effect when IOP lower (use after IV acetazolamide and osmotic agents)
- Use 2% for acute angle-closure; 1% for chronic use in some patients
- Headache/brow ache most common reason for non-adherence
- Discontinued when laser iridotomy performed (definitive treatment)
Contraindications
- Anterior uveitis (miosis increases pain)
- Narrow anterior chamber or acute inflammation (relative)
Side effects
- Miosis (pupil constriction) — reduced vision in dim light
- Brow ache / frontal headache (ciliary muscle spasm)
- Induced myopia
- Retinal detachment risk (vitreoretinal traction with pupil constriction — rare)
- Systemic cholinergic effects (salivation, lacrimation, GI cramps — with excessive doses)
Interactions
- Anticholinergics (atropine) — antagonistic
- Beta-blockers — additive IOP reduction
Monitoring
- IOP
- Vision (miosis may reduce acuity)
- Pupil response
Reference: BNFc; BNF; NICE CG85; AAO Glaucoma guidelines. Verify against your local formulary and the latest BNF before prescribing.
Related
Curated clinical cross-links plus same-class fallbacks.
Pathways
- Acute Red Eye / Vision Loss Screen · RCOphth 2020; NICE CKS
- Idiopathic Intracranial Hypertension · ABN; consensus 2018
- Acute Red Eye Assessment · RCOphth / AAO
- Acute Angle Closure Glaucoma · RCOphth / EGS Guidelines
- Retinal Detachment · RCOphth Guidelines / EURETINA
- Diabetic Retinopathy — Screening and Management · NICE NG28 2016 / NHS DES Programme