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Cyclopentolate

Cyclopentolate is a synthetic medication formulated as an ophthalmic solution, primarily used to induce (pupil dilation) and (temporary paralysis of the ) for diagnostic eye examinations. As cyclopentolate hydrochloride, it has the molecular formula C₁₇H₂₅NO₃·HCl and acts by blocking muscarinic receptors in the and , leading to relaxation of the sphincter muscle and inhibition of accommodation. First approved by the FDA in 1974, it is available in concentrations of 0.5%, 1%, and 2% and offers a faster onset (within 30 minutes) and shorter duration (up to 24 hours) compared to alternatives like atropine. In clinical practice, cyclopentolate is instilled as 1-2 drops into the eye, with effects peaking in 15-60 minutes and recovery typically occurring within 6-24 hours, though it may last longer in children or infants. Beyond routine and fundus examinations, it aids in diagnosing refractive errors such as hyperopia and pseudomyopia, particularly in pediatric patients, and serves as an adjunct in treating anterior by preventing posterior synechiae and reducing ciliary pain. Its cycloplegic effect is more potent than tropicamide, with residual of 0.5-1.75 diopters, making it suitable for accurate in children where active can obscure results. Precautions are essential due to potential systemic absorption, especially in young children, where it may cause effects like hallucinations, , or seizures; monitoring for 30 minutes post-administration is recommended, and feeding should be delayed for at least 4 hours in infants. Contraindications include to the drug and narrow-angle , as it can increase . Common adverse reactions involve ocular irritation, , , and stinging upon instillation, while rare systemic risks underscore the need for compression to minimize absorption.

Medical Use

Indications

Cyclopentolate is primarily administered as ophthalmic to induce , or pupil dilation, and , or temporary paralysis of the , facilitating various diagnostic eye examinations. It is commonly employed for cycloplegic to determine accurate refractive errors, as well as for and to visualize the and assess visual function without interference from active . These effects enable precise evaluation of ocular structures and are particularly valuable in clinical settings where pupil constriction or focusing could obscure results. In pediatric , cyclopentolate holds specific benefits due to children's strong accommodative ability, which can mask underlying refractive errors during standard exams. By inducing , it ensures reliable refraction measurements, especially for detecting hyperopia or in young patients, making it a standard agent for routine pediatric eye assessments. The duration of these effects varies: typically persists up to 24 hours, while generally lasts 6 to 24 hours, allowing sufficient time for the with gradual recovery of normal vision. Additionally, cyclopentolate is used as an adjunct in the of anterior to prevent posterior synechiae formation and relieve pain from ciliary muscle spasm. Cyclopentolate is included on the World Health Organization's Model List of , recognized in the 21st list published in 2019 and confirmed in the 22nd list of 2021, and remaining in the 24th list published in 2025, underscoring its importance as a cost-effective and essential tool for basic eye care in health systems worldwide. Off-label, cyclopentolate has been investigated for its potential as an to counteract muscarinic and effects of cholinomimetic agents, including in cases of , though clinical applications remain limited and primarily supported by animal studies demonstrating protective effects when administered systemically.

Dosage and Administration

Cyclopentolate is available as an ophthalmic solution in concentrations of 0.5%, 1%, or 2%. For adults, the standard dose is one or two drops of 1% or 2% solution instilled into the conjunctival sac of the affected eye, which may be repeated after five to ten minutes if necessary for adequate or . For refraction procedures, the drops are typically administered 40 to 50 minutes prior to the examination. In pediatric patients over one year of age, one or two drops of 1% solution are instilled into each eye, with a possible second application of 0.5% or 1% solution after five to ten minutes; for heavily pigmented irides, 2% may be used. For infants up to one year old, only one drop of 0.5% solution per eye is recommended, limited to a maximum of three doses at five- to ten-minute intervals, to minimize systemic risks. In neonates and infants under six months, lower concentrations or agents are preferred due to heightened to systemic effects from increased . To administer, patients should wash their hands thoroughly, tilt the head back, and gently pull down the lower to form a pocket in the conjunctival sac; the dropper tip should be held close to the eye without touching it or any other surface, and one drop squeezed into the pocket. After instillation, the eye should be closed gently, and finger pressure applied to the nasolacrimal sac for two to three minutes to reduce drainage and systemic exposure. Patients are advised to use following administration due to induced , and contact lenses should be removed beforehand as the solution contains preservatives like . Prior to use in patients suspected of glaucoma or with narrow angles, intraocular pressure should be measured to assess risk of elevation. Infants and young children require close observation for at least 30 minutes post-administration for signs of central nervous system or cardiopulmonary effects, with feeding withheld for four hours in infants to prevent aspiration. The mydriatic and cycloplegic effects typically last up to 24 hours, necessitating follow-up examinations within this period if further assessment is needed.

Adverse Effects

Ocular Effects

Cyclopentolate commonly causes transient stinging or burning sensation upon instillation, which typically resolves quickly after application. results from cycloplegia-induced loss of and is common, often persisting for several hours. , due to , lasts up to 24 hours in most cases and can be managed with UV-blocking or tinted lenses. Mild conjunctival hyperemia, or redness, occurs in approximately 10.5% of pediatric patients receiving 1% cyclopentolate. Less common ocular effects include increased , which carries a risk of angle-closure in predisposed individuals. Punctate and eyelid have also been reported, though these are generally mild and self-limiting. In rare instances, synechiae may form due to prolonged pupil dilation. Management of these effects focuses on supportive measures; for example, occlusion after instillation can minimize systemic absorption. If reversal is needed, miotics such as can be used to counteract and , though efficacy varies. Cyclopentolate should be avoided in patients with narrow-angle due to the risk of IOP elevation. Prolonged beyond 24 hours occurs in some cases and may require protective eyewear or monitoring until resolution, which can extend to several days.

Systemic Effects

Systemic absorption of cyclopentolate, an agent, can lead to various non-ocular adverse effects, primarily due to its muscarinic receptor blockade. Common manifestations include dry mouth, , facial flushing, thirst, and , which arise from reduced salivary secretion, increased , , and impaired , respectively. These effects occur more frequently in children than adults, with incidence rates reported up to 10% following topical ophthalmic use, attributed to greater systemic absorption relative to body size. Neuropsychiatric effects are particularly concerning in vulnerable populations such as infants, the elderly, and individuals with , where cyclopentolate can cross the blood-brain barrier and cause disturbances. Reported symptoms include , hallucinations, , and seizures, with pediatric cases documenting transient characterized by disorientation, visual disturbances, and incoherent speech. These reactions are more prevalent in young children due to immature metabolic pathways and higher relative drug exposure. In overdose scenarios, severe effects may include , from diminished gastrointestinal motility, and potentially , reflecting profound . Animal toxicity data indicate an oral LD50 of 4000 mg/kg in rats and 960 mg/kg in mice, underscoring the drug's relative safety at therapeutic doses but potential for harm with excessive exposure. Overdose management primarily involves supportive care, such as monitoring vital signs and ensuring hydration, with administered as an for life-threatening anticholinergic symptoms like severe or respiratory compromise, as it reversibly inhibits to counteract central effects. Risk factors for systemic effects include neonatal age, where absorption can be substantial due to lower body mass and leading to higher concentrations; a history of , which may exacerbate risk; and concurrent use of other agents, potentiating toxicity. Most symptoms are self-limiting and resolve within 24-48 hours as the drug's short allows for natural elimination.

Pharmacology

Mechanism of Action

Cyclopentolate functions as a non-selective competitive of muscarinic receptors (mAChRs), predominantly acting on those in the sphincter and . This inhibits the binding of to these receptors, thereby blocking parasympathetic in the eye. The drug's stereoisomer (-)-cyclopentolate is primarily responsible for its pharmacological activity. By antagonizing receptors in the , cyclopentolate prevents parasympathetic-mediated contraction, resulting in unopposed sympathetic dilation of the and . Similarly, blockade of receptors in the inhibits its contraction, leading to relaxation of the suspensory ligaments and of (), which impairs the eye's ability to on near objects. The onset of mydriasis occurs within 15–30 minutes after topical administration. Compared to atropine, another , cyclopentolate demonstrates lower binding affinity and faster dissociation from receptors, contributing to its shorter duration of action while achieving comparable cycloplegic effects. In experimental models, cyclopentolate has also shown potential as an antidote for by competitively occupying muscarinic sites to reverse excessive stimulation, as demonstrated in studies using parenteral administration.

Pharmacokinetics

Cyclopentolate demonstrates rapid absorption following topical ocular administration, primarily through corneal penetration and nasolacrimal drainage, with additional contributions from transconjunctival routes. Systemic absorption is generally minimal but can lead to detectable plasma levels, reaching peak concentrations within 10 to 60 minutes after instillation. In children, particularly infants, systemic exposure is heightened relative to adults due to lower body weight and blood volume, resulting in plasma concentrations ranging from undetectable to 5.8 ng/mL after a 1 mg dose (one drop of 1% solution per eye). Nasolacrimal occlusion by applying pressure to the lacrimal sac for 2–3 minutes post-administration reduces systemic absorption by up to 60%, a practice especially recommended in pediatric patients to mitigate adverse effects. Following absorption, cyclopentolate distributes readily to ocular tissues, penetrating the aqueous humor where concentrations are approximately 3000 times higher than corresponding plasma levels, enabling its therapeutic action on muscarinic receptors in the and . Systemic distribution occurs via the bloodstream, though the volume of distribution remains poorly characterized due to the predominance of the topical route and limited systemic exposure. Cyclopentolate undergoes metabolism primarily through hydrolysis by plasma pseudocholinesterase and hepatic ases, yielding inactive metabolites through . This inactivates the drug, contributing to its relatively short systemic persistence. of cyclopentolate and its metabolites occurs mainly via the renal route. The elimination averages 100–111 minutes across formulations and populations, though mydriatic and cycloplegic effects may last 6–24 hours or longer due to sustained receptor occupancy.

Chemistry

Chemical Properties

Cyclopentolate is a synthetic agent with the C17H25NO3 for its form and a of 291.39 g/. The salt, commonly used in pharmaceuticals, has the formula C17H26ClNO3 and a of 327.85 g/. Its IUPAC name is 2-(dimethylamino)ethyl 2-(1-hydroxycyclopentyl)-2-phenylacetate . Cyclopentolate contains a chiral center at the 2-position of the acetic acid chain and is typically employed as a . The molecular structure features an ester linkage between 2-(dimethylamino)ethanol and 2-(1-hydroxycyclopentyl)-2-phenylacetic acid, resembling a tropic acid derivative but with a cyclopentyl ring replacing the tropane system found in natural anticholinergics. As a white to off-white crystalline powder, cyclopentolate hydrochloride exhibits good solubility in water (greater than 10 mg/mL) and alcohol, while being only slightly soluble in ether; a 1% aqueous solution typically has a pH of 4.5 to 5.5. The for the tertiary amine group is approximately 8.0 (experimental value ~7.93), indicating basic character that facilitates in acidic environments. is stable under acidic conditions but undergoes in alkaline solutions, following pseudo-first-order with degradation accelerating at higher levels, primarily yielding and other fragments. In pharmaceutical formulations, it is typically prepared as an ophthalmic solution with a range of 3.0 to 5.5 to optimize stability, corneal penetration, and compatibility with ocular tissues, often including preservatives like . Regarding toxicity, the acute oral LD50 in rats exceeds 4000 mg/kg, suggesting low acute systemic toxicity via this route, while no data indicate carcinogenic potential, and it is not classified as a carcinogen by major regulatory bodies.

Synthesis

Cyclopentolate was originally synthesized in through a multi-step process outlined in US Patent 2,554,511, developed by Gino R. Treves and assigned to Schieffelin & Co. The synthesis begins with the preparation of the key intermediate, 2-phenyl-2-(1-hydroxycyclopentyl)ethanoic acid (also known as 1-hydroxycyclopentylphenylacetic acid), via a for carbon-carbon bond formation. Sodium phenylacetate reacts with magnesium turnings and isopropyl bromide in anhydrous ether to generate the , which is then added to under reflux conditions. The adduct is hydrolyzed with dilute and extracted with sodium hydroxide solution, followed by acidification to isolate the intermediate acid in yields suitable for further processing. This intermediate undergoes esterification to form the target compound. In the patented method, the acid is refluxed with β-chloroethyl dimethylamine in for 16 hours, yielding the hydrochloride after , solvent evaporation, and from , with the product exhibiting a of 134–136°C. Alternative routes, as described in pharmaceutical , involve reaction of the acid with 2-(dimethylamino)ethyl chloride in the presence of a base such as triethylamine to form the , followed by salt formation; this approach optimizes yields and simplifies purification in pharmaceutical production. Modern processes often use base-catalyzed addition of to in aprotic solvents with bases to form the key intermediate, followed by esterification, achieving improved yields. Cyclopentolate was designed as a structural analogue of atropine, replacing the tropane ring with a moiety to achieve a faster (typically 30–45 minutes) and shorter duration while minimizing systemic toxicity compared to atropine, which has a higher incidence of side effects such as flushing and fever. The initial confirmed the structure using classical methods including and , with later verifications employing (NMR) spectroscopy to ensure purity in production batches.

History and Development

Discovery

Cyclopentolate was first synthesized in 1951 by G. R. Treves and F. C. Testa at Schieffelin & Co. as part of efforts to develop atropine-like agents with reduced duration of action and fewer systemic side effects. The compound, chemically known as 2-(dimethylamino)ethyl 1-hydroxy-α-phenylacetate hydrochloride, featured a ring in place of the tropane structure found in atropine and related alkaloids, aiming to maintain potent muscarinic while improving the therapeutic profile. The initial rationale focused on developing safer alternatives to atropine for systemic applications, particularly as agents for gastrointestinal disorders, where atropine's prolonged effects and limited utility. Preclinical testing began with in vitro and evaluations of anticholinergic potency, revealing strong inhibition of acetylcholine-induced contractions in isolated preparations. Early animal studies demonstrated cyclopentolate's potent mydriatic effects in rabbits and , with rapid onset of pupil occurring within 5-15 minutes after topical ocular administration and recovery typically within 4-6 hours, contrasting with atropine's longer duration. These findings highlighted its superior profile compared to , another shorter-acting mydriatic, due to faster action and lower systemic absorption. The low observed in these models—minimal cardiovascular or respiratory effects even at high doses—prompted a shift in focus from gastrointestinal use to topical ophthalmic applications for diagnostic pupillary and . The compound was first described in detail in a 1953 publication in the American Journal of Ophthalmology, which detailed its synthesis and preliminary pharmacological evaluation, establishing it as a promising anticholinergic for clinical exploration. This work underscored cyclopentolate's potential to address limitations of existing agents in ophthalmology, setting the stage for further targeted research.

Introduction to Clinical Use

Cyclopentolate transitioned from preclinical synthesis in 1951 to initial clinical evaluation in the early 1950s through ophthalmic studies focused on its cycloplegic and mydriatic properties for pediatric refraction, confirming safety and efficacy in dilating pupils and relaxing accommodation in children. These mid-1950s human trials emphasized its rapid onset and shorter duration compared to traditional agents, paving the way for regulatory approval. It was initially introduced to the market in 1953 by Schieffelin & Co., with the U.S. Food and Drug Administration granting approval in 1974 for Cyclogyl by Alcon, marking its formal recognition as a standard agent for eye examinations requiring cycloplegia. Pivotal clinical studies in the and demonstrated cyclopentolate's superior efficacy for cycloplegic in pediatric populations, achieving adequate of with residual effects of 0.5-1.75 diopters, while exhibiting fewer systemic side effects than atropine, which often caused prolonged times of 6-12 days. These trials, including comparisons in preschool children, highlighted cyclopentolate's faster (6-24 hours) and reduced toxicity, leading to its widespread adoption in routine ophthalmic practice. Cyclopentolate was added to the World Health Organization's Model List of in 2021 as a cycloplegic , and remains included as of the 24th list (September 2025). Regulatory milestones included approvals across , such as in in 1965 and broader marketing authorizations in the , facilitating global access. Warnings for pediatric risks, including behavioral disturbances and transient , were strengthened in product labels during the 1990s based on reported cases of central nervous system effects like hallucinations and in young children. Dosage refinements in the stemmed from pharmacokinetic studies revealing systemic absorption and associated adverse effects, prompting recommendations to limit concentrations to 0.2-1% and instill 1-2 drops with nasolacrimal to minimize exposure, particularly in low-body-mass-index children where double dosing increased risks of and CNS disturbances. These adjustments, informed by trials showing reduced and elevated levels in neonates, optimized without compromising cycloplegic for .

Society and Culture

Brand Names

Cyclopentolate is marketed under several brand names worldwide, primarily as an ophthalmic solution for inducing and . The most prominent brand in the United States is Cyclogyl, produced by Laboratories, which is available in concentrations of 0.5%, 1%, and 2% as cyclopentolate . Other U.S. brands include AK-Pentolate (formerly by Pharmaceuticals, discontinued after 2023 manufacturer closure) and Pentolair, also in 1% concentration. In the , Mydrilate is a key brand, offered by Esteve Pharmaceuticals in 0.5% and 1% strengths for diagnostic eye examinations. Generic versions of cyclopentolate ophthalmic solution have been widely available since the expiration of key patents in the late , allowing multiple manufacturers to produce equivalents in standard concentrations of 0.5%, 1%, and 2%. Current producers include and , which supply 1% solutions in 15 mL bottles for clinical use. Cylate serves as a common equivalent, typically in 1% . Some formulations combine cyclopentolate with to enhance mydriatic effects, such as Cyclomydril (0.2% cyclopentolate with 5% ) by . Historically, Cyclogyl was developed and initially marketed by before transitioning to Laboratories following corporate acquisitions. Regional variations exist, with brands like Cyclogyl (by ) and Cyclomid (by Jawa Pharmaceuticals) available in , often in 1% drops. No major brand discontinuations have been reported as of 2025, maintaining broad accessibility across markets.

Availability and Regulation

Cyclopentolate is available exclusively as a prescription worldwide and is not approved for over-the-counter use in any country. It is routinely stocked in hospitals, clinics, and practices for diagnostic purposes, given its role in inducing and . In the United States, the (FDA) classifies cyclopentolate as C, indicating that animal reproduction studies have shown adverse effects on the , but there are no adequate and well-controlled studies in humans, and it should be used during only if the potential benefit justifies the potential risk. Cyclopentolate is not a under the DEA schedules, as it is a non-narcotic agent. In the , the (EMA) has approved cyclopentolate for diagnostic use in , with national authorizations ensuring its availability through regulated channels. In the United States as of 2025, a 1% ophthalmic solution of cyclopentolate typically costs between $3 and $15 per 2 mL bottle, depending on the and discounts, making it an affordable option for routine clinical use. Prices are significantly lower in developing countries, often under $5 per bottle, facilitated by (WHO) essential medicines programs that promote access through bulk procurement and manufacturing. Supply shortages of cyclopentolate have occurred intermittently in the , primarily due to manufacturing disruptions, such as the closure of Pharmaceuticals in 2023 and raw material constraints during the , though alternative suppliers like and have helped mitigate impacts. No major bans or widespread restrictions on its use exist globally. Internationally, cyclopentolate is recognized as an essential medicine by the WHO, included on the Model List of since at least the 22nd edition in 2021 and retained in subsequent updates, ensuring its prioritization in over 100 countries for ophthalmic diagnostics. Export controls on cyclopentolate are minimal, as it is not classified as a dual-use substance under major international regimes, but its potential application as a mydriatic in chemical, biological, radiological, and (CBRN) incident management prompts monitoring in and emergency contexts.

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