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Year : 2006  |  Volume : 54  |  Issue : 3  |  Page : 195-197

Acute myopia and angle closure caused by topiramate, a drug used for prophylaxis of migraine

Department of Ophthalmology, MGM Hospital, Kamothe, Navi Mumbai, Maharashtra, India

Correspondence Address:
Suresh J Ramchandani
Shivam Eye Clinic, Plot No 29, Snehal Co-op HSG Society, Nerul, Navi Mumbai - 400 706
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.27072

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Acute transient myopia with shallowing of the anterior chamber is a rare idiosyncratic response to many systemic and topical medications, including sulfonamides. Several such cases have been reported in the past, but are less frequently reported in recent times. We report a case of acute progressive myopia and bilateral angle closure due to Topiramate - a drug used for epilepsy and migraine prophylaxis

Keywords: Angle closure, migraine, myopia, topiramate.

How to cite this article:
Desai CM, Ramchandani SJ, Bhopale SG, Ramchandani SS. Acute myopia and angle closure caused by topiramate, a drug used for prophylaxis of migraine. Indian J Ophthalmol 2006;54:195-7

How to cite this URL:
Desai CM, Ramchandani SJ, Bhopale SG, Ramchandani SS. Acute myopia and angle closure caused by topiramate, a drug used for prophylaxis of migraine. Indian J Ophthalmol [serial online] 2006 [cited 2023 Feb 5];54:195-7. Available from: https://www.ijo.in/text.asp?2006/54/3/195/27072

Migraine is a highly prevalent disorder, affecting about 6% of men and 15 to 18% of women. Migraine prevalence is highest between the ages of 25 and 55 years, accounting for its enormous impact in the workplace.[1] It is two to three times more common in females than in males.[1] Topiramate, a drug used as the second line treatment for epilepsy, is also being used for Lennox Gestaut syndrome , migraine prophylaxis, essential tremor and bulimia.[2] It can cause an adverse reaction of acute myopia progressing to angle closure glaucoma, which is rapidly reversible on discontinuation of the drug.[3],[4],[5] We report a case of one such reaction to Topiramate used for migraine prophylaxis, which was diagnosed before progression to glaucoma. It is unique, in that it is the only known case monitored on an hourly basis.

  Case Report Top

A 36 year old female medical practitioner, a non smoker and wife of an ophthalmologist, presented with sudden painless, blurring of vision in both eyes. As per her prescription prior to this episode, she was myopic with the best corrected visual acuity (BCVA) of 20/20, N 6 with -1.0 Dioptres Cylinder (DCyl) at 160 degrees in the right eye and 20/20, N6 with -0.75 DCyl at 20 degrees in the left eye. She had no history of hypertension, diabetes or glaucoma. She had no history of iridocyclitis, excessive reading, or hysteria. She was on sodium valproate -500 mg/day and topiramate - 25 mg/day for the prophylaxis of migraine, for ten days prior to the onset of these symptoms.

On examination at 10.00 am on the first day, BCVA was 20/20 and N6 in either eye with -1.50 Dioptres Spherical (DSph) and -1.00 DCyl at 160 degrees in right eye and -2.0 DSph and -0.75 DCyl at 20 degrees in left eye. Her intraocular pressures were 17 mm Hg by applanation in each eye. Ophthalmic examination was unremarkable, except for slight shallowing of the anterior chambers in both the eyes [Figure - 1].

By 1.00 pm, her BCVA was 20/20 and N 6 in both eyes with -3.00 DSph and -1.00 DCyl at 160 degrees in the right eye and -3.50 DSph and -0.75 DCyl at 20 degrees in the left eye. The rest of the parameters remained unchanged. By 6.00 pm, the BCVA was 20/20 and N 6 in both eyes with -4.00 DSph and -1.00 DCyl at 160 degrees in right eye and -5.00 DSph and -0.75 DCyl at 20 degrees in left eye.

On slit lamp examination, her pupils and lens were normal and anterior chambers were shallow. Her intraocular pressures were 19 and 20 mm of Hg in right and left eyes respectively, by applanation. Gonioscopy showed an occludable angle in the right eye. No angle structures could be seen beyond the Schwalbes line, even on indentation. However, there were no goniosynechia, as there was dipping of beam in the angle recess. The left eye also had a similar appearance. Undilated fundus was normal. There was no serous elevation of the retina or choroidal folds. Ultrasonography (USG) B Scan with a 10 MHZ probe showed slight thickening of the choroid in the periphery, with slight suprachoroidal separation in the left eye [Figure - 2]. The USG of the other eye was normal. No features of posterior scleritis were seen.

She was asked to stop topiramate. Her pressures and anterior chamber depth were monitored every hour, except during the night. The next day, the status of the anterior chambers, intraocular pressures and refraction remained unchanged. By the third day, her anterior chambers had deepened [Figure - 3] and refraction was back to her original prescription. Gonioscopy showed angles open up to the ciliary body band in both the eyes.

  Discussion Top

In this case, the various parameters were monitored on hourly basis. Hence, the progression in myopia could be documented. Due to timely stoppage of medications, the progression to angle closure glaucoma was prevented.

The differential diagnoses considered, were accommodative spasm, primary angle closure, posterior scleritis and drug- induced shallowing of the anterior chamber.

Accommodative spasm occurs as a result of some drugs, as discussed later or in true spasm of the ciliary body.[6] True spasm occurs in patients who are neurotically inclined, trigeminal neuralgia or some dental lesion. The angles are not narrow in these cases and glaucoma has not been reported. The diagnosis can be confirmed by doing a cycloplegic (atropine) retinoscopy. This was not possible in our case, as the pupils could not be dilated to prevent further angle closure and possible rise in pressure.

A few factors such as younger age and myopic refractive status ruled out the possibility of primary angle closure. Also the progressive myopia could not be explained solely by narrow angles.

Posterior scleritis can give rise to angle closure glaucoma[7] without pupillary block, due to choroidal effusion. Posterior scleritis is painful and may be associated with choroidal folds and serous elevation of the retina. Bilateral posterior scleritis can occur, but is rare. USG B scan is quite characteristic due to presence of the T sign, which occurs due to collection of fluid in the Subtenon's space

Topiramate is an oral sulfamate medication, used primarily for seizure treatment. It has also been found useful in conditions like migraine, bipolar and post-traumatic stress disorders, post-herpetic neuropathy and other neuralgic conditions as well. Topiramate has multiple mechanisms of action.[8] Although the mechanism for topiramate-induced myopia is unknown, it may partly be from the topiramate weak carbonic anhydrase inhibitor activity or a prostaglandin mediated effect. Uveal effusions with ciliary body swelling cause forward rotation of the iris-lens diaphragm, causing myopia and angle closure glaucoma. Although peripheral iridotomy may relieve some pupillary block, most glaucoma cases resolve without miotics or iridotomy.

Many drugs have been reported to cause a forward shift of the iris-lens diaphragm, the most important being sulfa derivatives.[9] But topiramate assumes importance, since it is being used to improve the quality of life of patients suffering from migraine.[2] Topiramate - 100 mg/day has been shown to be effective in the prevention of migraine headache in adults. Henceforth, it is likely to be prescribed more frequently. Ophthalmologists will have to be aware of this potential complication, since they may be the first ones to see patients with these symptoms. There is a chance that these may be misdiagnosed to be accommodative spasm or more importantly, angle closure glaucoma. If that happens, these patients will be subjected to peripheral iridotomy or at least dilatation, to detect accommodative spasm. The knowledge of this complication and usage of USG and ultra-biomicroscopy would help arriving at the diagnosis and averting inadvertent treatment for glaucoma.

Whenever a case of bilateral acute angle-closure glaucoma associated with myopia and a shallow anterior chamber is encountered, ciliochoroidal effusion syndrome induced by drugs should be considered in the differential diagnosis.[9] Symptoms include blurred vision and are reported as early as 3-21 days after commencement of treatment for migraine. Fortunately, discontinuation of the drug leads to resolution of symptoms. Fraunfelder also noted that "iridotomy does not help, since the event is not due to pupillary block."[10] Patients who develop blurred vision should promptly discontinue topiramate to prevent progression to angle closure glaucoma. Pediatric and developmentally delayed mile stones patients on topiramate should be closely monitored during the first 2 weeks of treatment. Patient education is essential while prescribing the drug, so as to be able to intervene before progression to angle closure glaucoma and its sequel.

  References Top

Lipton RB, Stewart WF. Prevalence and impact of migraine. Neurol Clin 1997;15:1-13.  Back to cited text no. 1
Diamond M, Dahl φf C, Papadopoulos G, Neto W, Wu SC. Topiramate Improves Health-Related Quality of Life When Used to Prevent Migraine. Headache. J Head Face Pain 2005;45:1023-30.  Back to cited text no. 2
Chen TC, Chao CW, Sorkin JA. Topiramate induced myopic shift and angle closure glaucoma. Br J Ophthalmol 2003;87:648-9.  Back to cited text no. 3
Rhee DJ, Goldberg MJ, Parrish RK. Bilateral angle-closure glaucoma and ciliary body swelling from topiramate. Arch Ophthalmol 2001;119:1721-3.   Back to cited text no. 4
Sachi D, Vijaya L. Topiramate induced secondary angle closure glaucoma. J Postgrad Med 2006;52:72-3.  Back to cited text no. 5
Abrams D. Anamolies of Accommodation In : David Abrams, Editor. Duke -Elder s Practice of Refraction. 10th ed. B.I Churchill Livingstone Pvt Ltd: 1995. p. 96.  Back to cited text no. 6
Quinlan MP, Hitchings RA. Angle closure glaucoma secondary to posterior scleritis. Br J Ophthalmol 1978;62:330-5.  Back to cited text no. 7
Ikeda N, Ikeda T, Nagata M, Mimura O, Ciliochoroidal Effusion Syndrome Induced by Sulfa Derivatives. Arch Ophthalmol 2002;120:1775.   Back to cited text no. 8
Sankar PS, Pasquale LR, Grosskreutz CL. Uveal effusion and secondary angle-closure glaucoma associated with topiramate use. Arch Ophthalmol 2001;119:1210-1.  Back to cited text no. 9
Fraunfelder FW, Fraunfelder FT, Keates EU. Topiramate-associated acute, bilateral, secondary angle-closure glaucoma. Ophthalmology 2004;111:109-11.  Back to cited text no. 10


  [Figure - 1], [Figure - 2], [Figure - 3]

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