Group Title: Journal of Medical Case Reports 2008, 2:1
Title: Acute bilateral simultaneous angle closure glaucoma after topiramate administration: a case report
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Title: Acute bilateral simultaneous angle closure glaucoma after topiramate administration: a case report
Series Title: Journal of Medical Case Reports 2008, 2:1
Physical Description: Archival
Creator: Chalam KV
Tillis T
Syed F
Agarwal S
Brar VS
Publication Date: 39455
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Bibliographic ID: UF00100181
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
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Case report

Acute bilateral simultaneous angle closure glaucoma after
topiramate administration: a case report
Kakarla V Chalam*, Tina Tillis, Farhana Syed, Swati Agarwal and
Vikram S Brar


Address: Department of Ophthalmology, University of Florida-Jacksonville. Jacksonville, USA
Email: Kakarla V Chalam* kchalam@jax.ufl.edu; Tina Tillis tina.tillis@jax.ufl.edu; Farhana Syed farhana.syed@jax.ufl.edu;
Swati Agarwal swati.agarwal@jax.ufl.edu; Vikram S Brar vikram.brar@jax.ufl.edu
* Corresponding author


Published: 8 January 2008
journal of Medical Case Reports 2008, 2:1 doi: 10.1 186/1752-1947-2-


Received: 25 July 2007
Accepted: 8 January 2008


This article is available from: http://www.jmedicalcasereports.com/content/2/l/I
2008 Chalam et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Abstract
Introduction: 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. 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.
Conclusion: Intraocular 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.


Introduction
Banta et al [1] reported the first case of topiramate
(Topomax; Ortho-McNeil) induced acute-angle closure
glaucoma in a 51-year-old man who recently initiated the
medication for mood-stabilization. Topiramate, a sulfa-
mate derivative, is primarily used in the management of
seizure disorders, however has also demonstrated efficacy
in the treatment of bipolar disease and migraine. In the
case of migraine, the symptoms of elevated intraocular
pressure secondary to angle closure may mimic those of
the primary condition, thus it is important to be aware of


this association as the symptoms typically resolve with
cessation of the medication and management of the
intraocular pressure. We present a case of bilateral acute
angle closure glaucoma occurring within 10 days of initi-
ating therapy with topiramate for symptoms related to
migraine.

Case presentation
A 34-year-old woman with migraine, hypertension and
hypothyroidism presented with acute bilateral severe vis-
ual loss after increasing her dose of topiramate from 50


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Open Access







http://www.jmedicalcasereports.com/content/2/1/


mg to 100 mg daily. She had initiated the medication 1
week prior, however, her symptoms did not respond to
the initial dose. Her other medications were levothyrox
ine, methyclothiazide, and triamterene. Best corrected vis-
ual acuity was counting fingers OU. Anterior segment
examination demonstrated bilateral conjunctival chemo-
sis, corneal edema, markedly shallow anterior chamber,
and closed angles on gonioscopy. Intraocular pressures
(IOP) were elevated in both eyes at 49 mmHg and 51
mmHg respectively. Peripheral iridotomy was performed
on both eyes due to suspected papillary block. B-scan
ultrasound revealed annular (3600) peripheral choroidal
effusions (Figure 1). Topiramate was discontinued and
topical Cosopt (Merck, timolol + dorzolamide); Alphagan
P (Allergan, brimonidine 0.1%) and Maxidex (Alcon, dex-
amethasone) were started. On follow up the next day, the
anterior chamber remained shallow; however the IOP had
improved to 24 mmHg and 18 mmHg respectively. Deep-
ening of the anterior chamber was noted following dila-
tion of the pupil.

On day five, visual acuity improved to 20/400 with reso-
lution of the conjunctival chemosis and corneal edema.
Intraocular pressures were controlled and the anterior
chamber was deep (Figure 2A, B). Fundus examination
showed cup to disc ratio of 0.1 in both eyes and was oth-
erwise unremarkable. Ultrasound demonstrated mild
residual choroidal effusion in both eyes which resolved
two weeks later. At this point, the BCVA were 20/25 OD
and 20/40 OS with the intraocular pressures and anterior


Figure I
Slit-lamp photograph at presentation, revealing conjunctival
chemosis, corneal edema and markedly shallow anterior
chamber in right (A) and left eye (B). Insets: Slit-image show-
ing shallow peripheral anterior chamber; depth is marked
with line. B-scan ultrasound at presentation showed periph-
eral choroidal effusions (arrow) in Right (C) and left (D)
eyes.


Figure 2
Slit-lamp photograph at day 5, revealing deep anterior cham-
ber with resolution of corneal edema and conjunctival chem-
osis in right (A) and Left (B) eyes. Insets: Slit-image showing
deep peripheral anterior chamber, depth is marked with line.
B) B-scan ultrasound at 2 weeks shows resolution of choroi-
dal effusions (arrow) in Right (C) and left (D) eyes.



chamber depth remaining stable (Figure 2C, D). Topical
aqueous suppressants were discontinued.

Conclusion
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.
Patient's symptoms worsened with sudden decrease in
vision and extreme ocular pain. Presence of choroidal
effusion suggests an association between topiramate
induced forward rotation of the ciliary process and for-
ward displacement of the lens iris diaphragm which con-
tributed to myopic shift, anterior chamber shallowing and
resultant angle closure glaucoma. Though the exact mech-
anism is not clear, the fluid movement in choroidal effu-
sion is related to drug induced changes in membrane
potential. [1-5]

Topiramate is an oral sulfamate medication used prima-
rily for epilepsy and migraine. [6] Other uses of topiram-
ate include use in management of peripheral
neuropathies [7] and radiculopathies [8], idiopathic
intracranial hypertension [9], adjunctive therapy in alco-
hol dependence [10] and nicotine cessation. [11] There
have been several reports of topiramate associated angle
closure and myopic shift. Most cases have been reported
to occur within 2 weeks of starting topiramate or within
hours of doubling the doses. [1-3]

In our case, the neurologist doubled the dose of topiram-
ate to alleviate non-responding headache. In retrospect,


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Journal of Medical Case Repotts 2008, 2:1


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Journal of Medical Case Reports 2008, 2:1


these symptoms may have been related to elevated IOP
and not migraine as evident on tonometry and B-scan
ultrasonography. Therefore, increased awareness is
needed before initiating or modifying topiramate therapy
as persistence or worsening of patients' headache may be
attributed to raised intraocular pressures as opposed to
lack of response to therapy.

Topiramate induced angle closure is an indiosyncratic
reaction and can occur in otherwise normal eyes with nor-
mal anterior chamber angles. The management of topira-
mate related acute angle closure glaucoma requires
cessation of the drug in concert with the primary physi-
cian and use of topical and oral aqueous suppressants.
Use of pilocarpine can lead to further narrowing of the
angles and worsening of signs and symptoms. Peripheral
iridotomy, a traditional treatment for angle closure glau-
coma, may not be of value as precipitating mechanism is
not pupillary block. Topical cycloplegic agents can be
given as they lower intraocular pressures by retracting the
cilliary process. [3]

Topiramate induced angle closure glaucoma and transient
myopia usually resolves with discontinuation of the drug.
Visual outcome is usually good and episodes resolve
within few weeks. In addition to its use in epilepsy, topira-
mate has demonstrated efficacy in other diseases and dis-
ciplines. This report highlights the need for a high index
of suspicion when dealing with acute angle closure glau-
coma in patients using topiramate, as this condition is
reversible and treatment is typically supportive. Thus,
patients should be cautioned about this potential side-
effect, and instructed to seek attention should they
develop blurred vision and/or eye pain following initia-
tion or dose escalation of topiramate.

Abbreviations
IOP Intraocular Pressure

OD Ocular Dexter

OS Ocular Sinister

OU Ocular Utrique

BCVA Best-corrected visual acuity

Competing interests
The authors) declare that they have no competing inter-
ests.

Authors' contributions
KVC and TT identified the case and directly participated in
management. They also revised the manuscript and veri-
fied its intellectual content.


http://www.jmedicalcasereports.com/content/2/11




FS, SA, and VSB worked in collaboration to collect data,
acquire clinical photographs, and draft, revise, and refer-
ence the manuscript.

All authors read and approved the final manuscript

Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.

References
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sumed Topiramate-induced Bilateral Acute Angle-closure
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2. Levy J, Yagev R, Petrova A, Lifshitz T: Topiramate-induced bilat-
eral angle-closure glaucoma. Can Ophthalmol 2006, 41:221-5.
3. Fraunfelder FW, Fraunfelder FT, Keates EU: Topiramate-Associ-
ated Acute, Bilateral, Secondary Angle-Closure Glaucoma.
Ophthalmology 2004, 1 I1:109- I.
4. CraigJE, OngTJ, Louis DL, Wells JM: Mechanism of Topiramate-
induced Acute-onset Myopia and Angle Closure Glaucoma.
Am j Ophthalmol 2004, 137:193-5.
5. Medeiros FA, Zhang XY, Bernd AS, Weinreb RN: Angle-Closure
Glaucoma Associated With Ciliary Body Detachment in
Patients Using Topiramate. Arch Ophthalmol 2003, 121:282-5.
6. Silberstein SD, et at: Topiramate Chronic Migraine Study
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of chronic migraine: a randomized, double-blind, placebo-
controlled trial. Headache 2007, 47(2):170-180.
7. Eisenberg E, River Y, Shifrin A, Krivoy N: Antiepileptic drugs in
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cebo in painful diabetic neuropathy: analgesic and metabolic
effects. Neurology 63(5):865-73. 2004 Sep 14
9. Celebisoy N, Gokcay F, Sirin H, Akyuirekli O: Treatment of idio-
pathic intracranial hypertension: topiramate vs acetazola-
mide, on open-label study. Acta Neurol Scand 2007, I 16(5):322-7.
10. Johnson BA, et at: Topiramate for Alcoholism Study Group.
Topiramate for treating alcohol dependence: a randomized
control trial. JAMA 298(14):1641-51. 2007 Oct 10
II. Johnson BA, Ait-Daoud N, Akhtar FZ, Javors MA: Use of oral
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