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Acute narrow-angle glaucoma induced by topiramate with acute myopia and macular striae: A case report
Glaucoma agudo de ángulo cerrado inducido por topiramato con miopización aguda y estrías maculares: a propósito de un caso
M.A. Sierra-Rodríguez
, L. Rodríguez-Vicente, J.J. Chavarri-García, J.L. del Río-Mayor
Corresponding author
Servicio de Oftalmología, Hospital San Pedro, Logroño, La Rioja, Spain
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"apellidos" => "Landa Alvarado" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669118302430" "doi" => "10.1016/j.oftal.2018.07.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669118302430?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579419300180?idApp=UINPBA00004N" "url" => "/21735794/0000009400000003/v1_201903010631/S2173579419300180/v1_201903010631/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Short communication</span>" "titulo" => "Acute narrow-angle glaucoma induced by topiramate with acute myopia and macular striae: A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "130" "paginaFinal" => "133" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M.A. Sierra-Rodríguez, L. Rodríguez-Vicente, J.J. Chavarri-García, J.L. del Río-Mayor" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M.A." "apellidos" => "Sierra-Rodríguez" "email" => array:1 [ 0 => "sffera@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Rodríguez-Vicente" ] 2 => array:2 [ "nombre" => "J.J." "apellidos" => "Chavarri-García" ] 3 => array:2 [ "nombre" => "J.L." "apellidos" => "del Río-Mayor" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmología, Hospital San Pedro, Logroño, La Rioja, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Glaucoma agudo de ángulo cerrado inducido por topiramato con miopización aguda y estrías maculares: a propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1573 "Ancho" => 2167 "Tamanyo" => 325975 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Anterior pole image showing slight conjunctival injection, conjunctival chemosis and narrow anterior chamber in BE. (B) Resolution of the condition.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinic case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">Patient, 29, who visited the Emergencies Dept. due to diminished visual acuity in both eyes (BE) with 24<span class="elsevierStyleHsp" style=""></span>h evolution. Personal history included generalized epilepsia with myoclonic and generalized crises in treatment with topiramate starting 9 days prior to debut of the condition, at an initial dose of 25<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h during 7 days and dosage increase to 50<span class="elsevierStyleHsp" style=""></span>mg/day the past 2 days. Ophthalmological characteristics include use of spectacles with −1.00; −0.50 at 60° in the right eye (RE) and −1.50; −0.75 at 100° in the left eye (LE), with best corrected visual acuity (BCVA) of 1 in BE at the latest checkup 6 months before.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Ophthalmological examination produced finger counting VA at 3<span class="elsevierStyleHsp" style=""></span>m in BE with usual spectacles. Refractometry showed myopization of −13 diopters in BE with respect to the previous grade. Anterior pole exhibited slight conjunctival injection, conjunctival chemosis, narrow anterior chambers without cell reaction (negative Tyndall) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) and bilateral angle closure evidenced with gonioscopy. Intraocular pressure (IOP) was 38<span class="elsevierStyleHsp" style=""></span>mmHg in BE and ocular fundus exhibited macular striae (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) in BE, confirmed with macular optical coherence tomography (OCT) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). Considering bilateral compromise and topiramate treatment history, the diagnostic of angle closure acute glaucoma (ACAG) secondary to topiramate was concluded. Systemic treatment was administered with 250<span class="elsevierStyleHsp" style=""></span>cc of 20% mannitol, topical treatment with timolol and brinzolamide, forcing midriasis with cycloplegic, suspending treatment in agreement with the prescribing physician. A few hours after beginning treatment, anterior chambers gained depth, myopization diminished in 4 diopters and IOP was 16<span class="elsevierStyleHsp" style=""></span>mmHg in BE. Three days after the first visit, VA had improved to 1 in BE with usual spectacles, IOP was 14<span class="elsevierStyleHsp" style=""></span>mmHg in BE and anterior and posterior pole ophthalmological examination (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) was completely normal. An additional macular OCT was taken, evidencing the disappearance of macular striae (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B). Three months after onset of the disorder, the patient remains stable.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Topiramate is an anti-convulsive used mainly for treating epilepsy and as prophylactic treatment for migraine.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Most frequent adverse reactions include nervous disorders and weight loss, with ocular compromise being infrequent. Of described ocular adverse effects of topiramate,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> ACAG is the most frequent (58.3–74.8% of cases). It arises approximately between 7 and 12.8 days of administration. Myopization occurs in 14.8–20.2% of cases and appears at 8.59 days, prior to ACAG.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Other effects such as choroidal effusion, visual field defects, scleritis, maculopathy, retinal striae, diplopia and nystagmus have been described.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Approximately 85% of patients (generally females) exhibit symptoms such as blurred vision due to myopization and headaches caused by sharp IOP increase within 2 weeks from beginning treatment or when changing dose.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,4</span></a> In the present case, symptoms appeared 2 days after increasing the dose and 9 days of treatment.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Angle closure induced by topiramate is usually bilateral and occurs in the absence of pupil blockage, as a consequence of ciliochoroidal effusion and ciliary body edema which give rise to anterior ciliary body rotation, anterior displacement of iris lens diaphragm and lens curving due to relaxation of the zonule, in turn giving rise to anterior chamber narrowing and increased distance between the lens and the retina, which accounts for the myopization and angle closure.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> The authors were not able to confirm the existence of ciliochoroidal effusion due to the unavailability of ultrasound biomicroscopy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the present case, in addition to ACAG and myopization, macular striae were observed in OCT. Even though these have been described in other cases, very few reports include retinography and OCT Images.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> Guier<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> suggests that the striae are caused by folds in the internal limiting membrane (ILM) due to the volume effect of choroidal effusion, causing redundancy of the overlying retina.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Oral or intravenous acetazolamide and topical hypotensors can be used for treating ACAG after suspending topiramate. However, prostaglandin analogs and miotics (pilocarpine) should be avoided because topiramate-induced ACAG comprises an underlying inflammatory component.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The present case did not exhibit cellular reaction in the anterior chamber, although cases of uveitis<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> and vitritis<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> have been reported in patients with topiramate-induced ACAG, in which case the use of topical steroids is recommended. Miotics could even worsen angle closure by producing relative pupil blockage and anterior displacement of the iris lens diaphragm. In contrast, cycloplegics diminish IOP by producing a retraction of ciliary processes and deepening the anterior chamber due to posterior displacement of the iris lens diaphragm.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Laser iridotomy is not recommended in these patients because the main mechanism is not pupil blockage, although some authors suggest that it could be useful in refractory cases.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The present case responded positively to treatment with intravenous mannitol, topical hypotensors and cycloplegic after suspending topiramate. VA, IOP, the refractive condition, the angle and anterior chamber recovered their original condition, while ciliochoroidal effusion and macula striae resolved in a few days.</p><p id="par0040" class="elsevierStylePara elsevierViewall">It is important to differentiate a case of topiramate-induced ACAG from a primary ACAG case because clinic presentation, action mechanism and treatment are all different. Inadequate management could involve potentially severe consequences leading to blindness due to persistent high IOP.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflict of interests</span><p id="par0045" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres1157249" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1084470" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1157248" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1084469" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinic case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interests" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-08-12" "fechaAceptado" => "2018-11-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1084470" "palabras" => array:5 [ 0 => "Topiramate" 1 => "Ciliochoroidal effusion" 2 => "Acute angle closure glaucoma" 3 => "Myopic shift" 4 => "Macular striae" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1084469" "palabras" => array:5 [ 0 => "Topiramato" 1 => "Efusión ciliocoroidea" 2 => "Glaucoma agudo de ángulo cerrado" 3 => "Miopización" 4 => "Estrías maculares" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 29-year-old epileptic woman who had been on treatment with topiramate 25<span class="elsevierStyleHsp" style=""></span>mg/day for 9 days. She was referred to the Emergency Department due to reduction in far visual acuity (VA) after increasing the dose to 50<span class="elsevierStyleHsp" style=""></span>mg/day two days before. The ocular examination showed bilateral acute angle closure glaucoma (AACG) and macular striae in both eyes (AO) observed by Retinography and Optical Coherence Tomography (OCT). The AACG is a well-known side effect of topiramate, but the macular striae rarely accompanies it. Although macular striae have been previously described in other cases, very few document those using retinography and OCT images. Therefore, it is important to differentiate a case of AACG induced by topiramate from a case of primary AACG, since they differ in their clinical presentation, mechanism of action, and treatment. Mismanagement can have potentially serious consequences.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso clínico de una mujer epiléptica de 29 años en tratamiento con topiramato 25<span class="elsevierStyleHsp" style=""></span>mg/día desde 9 días previos a la presentación del cuadro, que acude a urgencias por disminución de la agudeza visual (AV) tras incrementar la dosis a 50<span class="elsevierStyleHsp" style=""></span>mg/día 2 días antes. En la exploración presenta un glaucoma agudo de ángulo cerrado (GAAC) bilateral y estrías maculares en ambos ojos (AO) objetivadas mediante retinografía y tomografía de coherencia óptica (OCT). El GAAC es un efecto secundario conocido y ampliamente descrito del topiramato, sin embargo, las estrías maculares que ocasionalmente acompañan al GAAC, aunque se han descrito anteriormente en otros casos, muy pocos las documentan mediante imágenes de retinografía y OCT. Es importante diferenciar un caso de GAAC inducido por topiramato de un caso de GAAC primario ya que difieren en su presentación clínica, mecanismo de acción y tratamiento. Su manejo inadecuado puede tener consecuencias potencialmente graves.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sierra-Rodríguez MA, Rodríguez-Vicente L, Chavarri-García JJ, del Río-Mayor JL. Glaucoma agudo de ángulo cerrado inducido por topiramato con miopización aguda y estrías maculares: a propósito de un caso. Arch Soc Esp Oftalmol. 2019;94:130–133.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1573 "Ancho" => 2167 "Tamanyo" => 325975 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Anterior pole image showing slight conjunctival injection, conjunctival chemosis and narrow anterior chamber in BE. (B) Resolution of the condition.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 503 "Ancho" => 1300 "Tamanyo" => 87454 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Retinal striae in the macula.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1598 "Ancho" => 2917 "Tamanyo" => 872268 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) F in the internal limiting membrane of the macular (macular striae). 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