Abstract
IntroductionA case of severe acute bilateral angle closure glaucoma with complete visual loss after oral topiramate therapy.Case presentationA 34 year-old woman developed bilateral severe visual loss 2 days after doubling the dosage of topiramate. Her best-corrected visual acuity (BCVA) was counting fingers in both eyes (OU). Intraocular pressures were 49 mm and 51 mm of Hg in right and left eyes respectively, with conjunctival chemosis, corneal edema, shallow anterior chamber and closed angles on gonioscopy. B-scan ultrasound revealed annular peripheral choroidal effusions in both eyes.ConclusionIntraocular pressures and anterior chamber depth were normalized after discontinuation of topiramate and initiation of antiglaucoma therapy. Two weeks later, visual acuities improved to 20/25 in the right eye and 20/40 in the left eye. B-scan ultrasound showed resolution of choroidal effusion. Topiramate, an oral sulpha-derivative medication is known to cause ciliochoroidal effusions, which lead to forward rotation of the ciliary body and displacement of the lens-iris diaphragm, with resultant acute angle closure glaucoma and myopic shift.
Highlights
A case of severe acute bilateral angle closure glaucoma with complete visual loss after oral topiramate therapy.Case presentation: A 34 year-old woman developed bilateral severe visual loss 2 days after doubling the dosage of topiramate
Intraocular pressures and anterior chamber depth were normalized after discontinuation of topiramate and initiation of antiglaucoma therapy
Topiramate, an oral sulpha-derivative medication is known to cause ciliochoroidal effusions, which lead to forward rotation of the ciliary body and displacement of the lens-iris diaphragm, with resultant acute angle closure glaucoma and myopic shift
Summary
Topiramate was started for treatment of migraine. As the patient's symptoms did not respond, her neurologist increased the dosage two days prior to presentation. Presence of choroidal effusion suggests an association between topiramate induced forward rotation of the ciliary process and forward displacement of the lens iris diaphragm which contributed to myopic shift, anterior chamber shallowing and resultant angle closure glaucoma. The management of topiramate related acute angle closure glaucoma requires cessation of the drug in concert with the primary physician and use of topical and oral aqueous suppressants. Peripheral iridotomy, a traditional treatment for angle closure glaucoma, may not be of value as precipitating mechanism is not pupillary block. Topiramate induced angle closure glaucoma and transient myopia usually resolves with discontinuation of the drug. This report highlights the need for a high index of suspicion when dealing with acute angle closure glaucoma in patients using topiramate, as this condition is reversible and treatment is typically supportive. A copy of the written consent is available for review by the Editor-in-Chief of this journal
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