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Ahmed ALgihady

Resident ,DHO

A case report

Bilateral acute onset angle closure glaucoma after oral topiramate

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A 40-year-old female was seen in

our emergency department with

Two days history of severe

headache,

Painful red eyes, Bilateral blurring of vision with

photophobia.

She was a known sufferer of

migraine but had no previous

ocular problems and had neverrequired glasses.

Personal history and Complaints

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There was no ocular disease of

significance within the family history.

She had no history of drug allergy.

Four days prior to the onset of her ocular

problems, she consulted a neurologist and

started a daily dose of25mg Topiramate

for her migraine.

Family, past history and medications

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Examination- signs

OSOD

3/603/60Visual acuity

normalnormalEye lid

Edema & circum

corneal

congestion

Edema & circum

corneal

congestion

Conjctivia

edemaedemaCornea

ShallowShallowAC

59 mmhg54 mmhgIOP

Mid dilated fixedMid dilated fixedPupil

Slit lamp biomic

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Roughly seen due to hazy media by corneal edema but

bilateral optic disc edema and hyperemia is noted more

evident on the left eye with healthy rim tissue and 0.2-

0.3 cup to disc ratios in both eyes. Query mild choroidal

effusion is suspected.

Fundus Examination

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B scan on the next

day revealed

choroidal thickening

which correlates withchoroidal effusion.

B - scan ultrasonography

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Differential Diagnosis of causes of bilateral ACG

It is a rare entity but it is usually

precipitated by an external factor

mostly drugs.

Suspicion for medication

induced angle closure glaucomashould be higher whenever

angle closure presents

bilaterally.

Examples to reported drugs

include: Venalexine, general

anaesthetics, Citalopram ,

flavoxate, paroxetine,

trimethoprim, sulfamethoxazole

and Topiramate.

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There was no ocular

disease of significance

within the family

history.

She had no history ofdrug allergy.

Four days prior to the

onset of her ocular

problems, she

consulted a neurologist

and started a daily dose

of

25 mg Topiramate

for her migraine.

Family, past history and medications

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1- Aggressive topical

aqueous suppressants

(B-blockerantiglaucomatous eye

drops; Timolol 0.5%)

2- IV mannitol (1mg/kg)

3- Dexamethasone eye

drops.

Withdrawal of the drug-4

with referral to her

neurologist.

Management

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Follow up visits

sluggish mid dilated pupils)(glaucomfleckenpupil

gradual decrease in intraocular pressure from 24

mmHg on the second day to 7.5 mmHg within 10

days of follow up

IOP

the visual acuity also improved from3/60 OU within 2 days of management to 6/18 OD

and 6/36 OS within 10 days of follow up

V/A

10 days

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Fundus examination

was normal and optic

disc congestion wasreduced within 10

days.

Follow up visits

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Follow up visits

Improvement of visual acuity and IOP

OSOD

6/96/6Visual acuity

16.

5 mmgh12 mmghIOPMid dilated fixedMid dilated fixedPupil

refraction

OSOD

axiscylSph

0.00+0.25

24+0.75+0.25

Follow up visits (after1 month)

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Follow up visits (after1 month)

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Topiramateis an oral sulphamate

medication primarily used forseizure, migraine and

neuropathic pain.

It has been associated with

secondary angle closure, whichcan mimic acute angle closure

glaucoma and myopia .

Topamax

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Topiramatewas first implicated as a

cause of bilateral acute angle closureglaucoma in 2001. A recent review of

case reports of adverse effects of

topiramate use revealed abnormal

vision, acute secondary angle closure

glaucoma, acute myopia andsuprachoroidal effusions.

The proposed mechanism of myopia and

secondary angle closure is choroidal

effusion and forward rotation of the iris-

lens diaphragm. The effusion places

pressure on the vitreous body andcompresses the lens-iris diaphragm,

causing anterior displacement and

closure of the angle.

Banta JT, Hoffman K, Budenz DL, Ceballos E, Greenfield DS. Presumed topiramate induced bilateral acute angle closure glaucoma.

Am J Ophthalmol2001; 132: 112-114.

FraunfelderFW, Fraunfelder FT, Keates EU. Topiramate associated acute, bilateral, secondary angle closure glaucoma.Ophthalmology 2004; 111: 109-111.

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The treatment for topiramate

induced secondary angle closure

are cycloplegia and topical

corticosteroids.

Cycloplegia relaxes the ciliary

body and tighten the zonules,

keeping the iris-lens diaphragm in

check.

Most cases of topiramate-

associated angle-closure

glaucoma present within the first 2weeks of treatment but reactions

have been reported within hours

of the first dose or as long as

seven weeks after onset of

therapy.

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Thank you