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PHOTO ESSAY
Year : 2019  |  Volume : 67  |  Issue : 9  |  Page : 1466-1467

Ciliochoroidal effusion in topiramate-induced bilateral acute angle closure glaucoma


Advanced Eye Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission02-Feb-2019
Date of Acceptance25-Apr-2019
Date of Web Publication22-Aug-2019

Correspondence Address:
Dr. Aniruddha Agarwal
Advanced Eye Center, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_245_19

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  Abstract 


Keywords: Angle closure glaucoma, choroidal effusion, obesity, topiramate, ultrasound biomicroscopy


How to cite this article:
Agarwal A. Ciliochoroidal effusion in topiramate-induced bilateral acute angle closure glaucoma. Indian J Ophthalmol 2019;67:1466-7

How to cite this URL:
Agarwal A. Ciliochoroidal effusion in topiramate-induced bilateral acute angle closure glaucoma. Indian J Ophthalmol [serial online] 2019 [cited 2019 Sep 21];67:1466-7. Available from: http://www.ijo.in/text.asp?2019/67/9/1466/265112



A 25-year-old female presented with a 3-hour history of rapidly decreasing distance visual acuity in both eyes and nausea. Previous examination revealed no ocular abnormality and hypermetropia of 0.75 diopters. Past medical history was positive for morbid obesity and obstructive sleep apnea. The body-mass index (BMI) measured 55.07kg/m 2. She had recently been started on a combination weight-loss drug, phentermine hydrocholoride 3.75 mg/topiramate 23 mg extended-release daily 11 days prior to presentation. Ocular examination revealed mild ciliary congestion and bilateral shallow anterior chamber. Gonioscopy revealed closed angles in both eyes (grade 0 by Shaffer's classification in all circumferences). Visual acuity was decreased in both eyes and measured 20/125 (6/36) in the right (OD) and 20/200 (6/60) in the left eye (OS) with pin-hole correction. The intraocular pressure (IOP) (Goldmann applanation tonometry) was elevated in both eyes and measured 42mm Hg in the OD and 44mm Hg in OS. In addition, there was a myopic shift from baseline of −4.5 diopters in both eyes. Therefore, the patient was diagnosed with topiramate-induced acute angle closure glaucoma.[1],[2] There was accumulation of fluid in the suprachoroidal space. Anterior-segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) of both eyes showed bilateral angle closure secondary to ciliochoroidal effusion [[Figure 1] part a and b; only left eye shown]. The weight-loss drug was stopped and the patient was started on topical atropine 2% two times a day, brimonidine 0.2%/timolol 0.5% fixed-combination twice a day, and difluprednate 0.05% four times a day. At the two-week follow-up, AS-OCT and UBM imaging showed opening of the angle with complete resolution of the ciliochoroidal effusion in both the eyes [[Figure 1] part c and d]. The IOP was maintained at 13 mm Hg and visual acuity improved to 20/20 in both eyes. Visual acuity was stable and IOP maintained in the normal range subsequent to a stepwise withdrawal of all topical medications.
Figure 1: Ciliochoroidal effusion in topiramate-induced acute angle closure (only left eye shown). (a) Ultrasound biomicroscopy (UBM) with straight arrows showing ciliochoroidal effusion. (b) Anterior segment optical coherence tomography (AS-OCT) with curved arrows showing narrowing of the anterior chamber angle due to forward rotation of the iris-lens diaphragm. The trabecular meshwork is covered with the iris tissue (white arrowhead). (c) UBM after initiating topical hypotensive, antiinflammatory and cycloplegic therapy, and cessation of topiramate showing resolution of the choroidal effusion. (d) AS-OCT showing opening of the anterior chamber angle after treatment; the Schlemm's canal is marked by a white asterisk

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None of the three phase III clinical trials—EQUATE,[3] EQUIP,[4] and the CONQUER [5]—have reported any ocular adverse events with fixed-dose combination of phentermine and topiramate. Careful clinical evaluation and multimodal imaging enabled accurate diagnosis and documentation of the ciliochoroidal effusion in this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fraunfelder FW, Fraunfelder FT, Keates EU. Topiramate-associated acute, bilateral, secondary angle-closure glaucoma. Ophthalmology 2004;111:109-11.  Back to cited text no. 1
    
2.
Rapoport Y, Benegas N, Kuchtey RW, Joos KM. Acute myopia and angle closure glaucoma from topiramate in a seven-year-old: A case report and review of the literature. BMC Pediatr 2014;14:96.  Back to cited text no. 2
    
3.
Aronne LJ, Wadden TA, Peterson C, Winslow D, Odeh S, Gadde KM. Evaluation of phentermine and topiramate versus phentermine/topiramate extended-release in obese adults. Obesity 2013;21:2163-71.  Back to cited text no. 3
    
4.
Allison DB, Gadde KM, Garvey WT, Peterson CA, Schwiers ML, Najarian T, et al. Controlled-release phentermine/topiramate in severely obese adults: A randomized controlled trial (EQUIP). Obesity 2012;20:330-42.  Back to cited text no. 4
    
5.
Gadde KM, Allison DB, Ryan DH, Peterson CA, Troupin B, Schwiers ML, et al. Effects of low-dose, controlled-release, phentermine plus topiramate combination on weight and associated comorbidities in overweight and obese adults (CONQUER): A randomised, placebo-controlled, phase 3 trial. Lancet 2011;377:1341-52.  Back to cited text no. 5
    


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