Ciliochoroidal effusion in topiramate-induced bilateral acute angle closure glaucoma.

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/m2. 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.[12] 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 [Fig. 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 [Fig. 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

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.

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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.

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