Remain calm, twenty minutes at this point can seem like an hour. 50mmHg the eye's sphincter muscle becomes paralyzed and pilocarpine treatment is not affective. You must get these patients to a ophthalmologist for management and possible laser peripheral iridotomy. The availability of secondary intervention is the very reason you're doing the dilation in the morning. It should be noted pilocarpine when used on patients under 40 years of age will cause headaches and increase in myopia caused by induced ciliary muscle spasms.
Pilocarpine is a direct-acting cholinergic agonist.
Because of its activity at the cholinergic receptor sites on the iris sphincter and ciliary muscle, it causes pupillary constriction and varying degrees of ciliary spasm. The precise mechanism by which pilocarpine reduces intraocular pressure is not known. The most widely accepted explanation is its direct stimulation of the longitudinal muscle of the ciliary muscle, which in turn, exerts an effect at the scleral spur thus widening the trabecular spaces and increases aqueous outflow. Dr. Malinovski, in another class, will go into more detail on this very subject. The ora is narrowest nasally and widest temporally.