Systemic exposure cocaine, other sympathomimetics; or systemic exposure to parasympatholytics→ atropine
Instillation of dilating drops into both eyes - history should be revealing; inadvertent exposure of eyes to anticholinergics as w/nebs from poor fitting mask hitting eye→ dilation
Prior eye surgery, trauma, injury to pupilary dilators/constrictors; history should be revealing; license/other pix to assess stability/newness is helpful; shouldn't have acute sx