Case Study 77 Topamax-Induced Angle Closure

Abstract

LA is a 50-year-old man who presented with complaints of a rapid reduction in vision and moderate aching pain over the past 24 h. He denied any previous history of a similar event. His past medical history was positive for a seizure disorder and a recent increase in vascular headaches. He had taken two doses of Topamax starting 2 days previously. Clinical examination found visual acuity in both eyes of less than 20/400, but this was improved to 20/70 OD with a −2.50 sphere and 20/80 OS with a −3.50 sphere. He had no history of wearing glasses or contact lenses. There was 2+ corneal edema bilaterally and intraocular pressures of 45 OD and 47 OS. The indirect ophthalmoscope could visualize the optic nerves with a cup to disc ratio of 2/10 OU.

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LA is a 50-year-old man who presented with complaints of a rapid reduction in vision and moderate aching pain over the past 24 h. He denied any previous history of a similar event. His past medical history was positive for a seizure disorder and a recent increase in vascular headaches. He had taken two doses of Topamax starting 2 days previously. Clinical examination found visual acuity in both eyes of less than 20/400, but this was improved to 20/70 OD with a −2.50 sphere and 20/80 OS with a −3.50 sphere. He had no history of wearing glasses or contact lenses. There was 2+ corneal edema bilaterally and intraocular pressures of 45 OD and 47 OS. The indirect ophthalmoscope could visualize the optic nerves with a cup to disc ratio of 2/10 OU.

Immersion scanning was performed with a 20 MHz probe and then an ultrasound biomicroscope (UBM; 50 MHz). The angle was very narrow and the ciliary processes were rotated anteriorly (Fig. 1). He was treated conservatively with topical pressure lowering agents and the Topamax was discontinued. The pressure returned to normal within 3 days, the corneal edema resolved, and the myopia disappeared.

Fig. 1

Ultrasound biomicroscopy (35 MHz) of anterior rotation of ciliary body (arrows)

Uveitic conditions can result in media opacities that obscure a view of the posterior segment. Chronic inflammation may lead to anterior chamber reaction, posterior synechiae with a miotic or, ultimately, an occluded pupil and cataract formation. Such sequelae of uveitis can result in a hazy view of the vitreous cavity and fundus. Such patients often come to cataract surgery and a preoperative ultrasound is mandatory to evaluate the globe.