Atropine Use in Patients with Increased Intraocular Pressure

Contraindication and Precautions

The American Academy of Pediatrics explicitly states that ketamine (and by extension, anticholinergics like atropine) should be avoided in patients with increased IOP or increased intracranial pressure 1
Atropine should be avoided in patients with increased intraocular pressure or glaucoma, as it poses a risk of elevating IOP through pupillary dilation and potential angle closure, despite some evidence suggesting it may not significantly raise IOP in most myopic children 1
The American Academy of Pediatrics recommends performing gonioscopy to assess angle anatomy in patients at risk for angle closure 1
The American Academy of Pediatrics identifies high-risk patients, including those with narrow angles, family history of glaucoma, or pre-existing elevated IOP 1
Absolute contraindications for atropine use include known angle-closure glaucoma, increased IOP, or increased intracranial pressure, as stated by the American Academy of Pediatrics 1
Relative contraindications for atropine use include narrow angles on gonioscopy and family history of angle-closure glaucoma, as stated by the American Academy of Pediatrics 1

The theoretical concern is that mydriasis from atropine may reduce aqueous outflow through the trabecular meshwork in susceptible eyes, according to the American Academy of Pediatrics 1