bilatteral acute angle closure glaucoma
TRANSCRIPT
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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