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Year : 2019  |  Volume : 57  |  Issue : 3  |  Page : 240-242

Aftermath of topiramate: An interesting case report and literature review

Department of Glaucoma Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India

Date of Submission18-Aug-2019
Date of Acceptance17-Sep-2019
Date of Web Publication11-Nov-2019

Correspondence Address:
Dr. Vijayalakshmi A Senthilkumar
Department of Glaucoma, Aravind Eye Hospital, Madurai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_73_19

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We report an interesting case report on idiosyncratic reaction of topiramate causing bilateral secondary acute angle-closure glaucoma with glaukomflecken, which mimicked acute primary angle closure (APAC) with nongranulomatous uveitis and choroidal effusions. After conservative management, signs and symptoms stabilized within 72 h, but the patient developed posterior synechiae with intermittent peripheral anterior synechiae (PAS) in BE, which was more prominent in LE. Here we report this case because presentation of topiramate-induced idiosyncratic reaction with glaukomflecken and subsequent resolution with posterior synechiae and PAS were rarely documented in literature. A detailed history taking and meticulous clinical evaluation helped us differentiate from APAC.

Keywords: Acute angle-closure glaucoma, choroidal effusion, glaukomflecken

How to cite this article:
Senthilkumar VA, Rajendrababu S. Aftermath of topiramate: An interesting case report and literature review. TNOA J Ophthalmic Sci Res 2019;57:240-2

How to cite this URL:
Senthilkumar VA, Rajendrababu S. Aftermath of topiramate: An interesting case report and literature review. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2020 Jul 12];57:240-2. Available from: http://www.tnoajosr.com/text.asp?2019/57/3/240/270698

  Introduction Top

Topiramate is a sulfamate-substituted monosaccharide used in the treatment of seizure, migraine, bipolar disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and weight reduction. Since the introduction of topiramate in 1995, several cases of transient myopia, uveal effusions, bilateral angle-closure glaucoma (ACG), and rarely uveitis and macular striae have been published.[1] Even though there have been case reports of topiramate-induced acute ACG (AACG) and panuveitis in the past, to the best of our knowledge, no published Indian case reports have documented bilateral glaukomflecken as presentation of topiramate-induced idiosyncratic reaction as well as resolution with posterior synechiae and peripheral anterior synechiae (PAS).

  Case Report Top

A 42-year-old female was referred as a case of bilateral AACG with a documented intraocular pressure (IOP) of 60 mmHg in RE and 64 mmHg in LE, 2 days back. The patient presented with sudden-onset pain, watering, eyelid swelling, photophobia, and defective vision associated with severe frontal headache and nausea and vomiting for 2 days, for which she consulted a local ophthalmologist and treated with fixed combination of timolol 0.5% + pilocarpine 2% BD in both eyes and oral Diamox 250 mg BD for 3 days. She had no significant ocular history before the presentation.

At presentation, her best-corrected visual acuity (BCVA) was RE 6/24 and LE 6/36. IOP by applanation tonometry was 28 mmHg in RE and 34 mmHg in LE. Slit-lamp examination revealed bilateral eyelid edema, circumcorneal congestion (CCC), mild corneal edema with few fine keratic precipitates on endothelium, shallow anterior chamber (AC) of Van Herick grading 1 both peripherally and centrally with 2+ flare and 2+ cells, 5 mm mid-dilated, nonreacting pupil, and glaukomflecken [Figure 1]. Fundus evaluation showed hyperemic disc in both eyes. Refraction, gonioscopy, and fundus photo were deferred as the patient had severe pain and headache. B-scan ultrasonography (USG) of BE showed 360° shallow choroidal detachment [Figure 2].
Figure 1: Slit lamp examination at presentation showing CCC, corneal edema with few keratic precipitates, shallow AC, mid-dilated pupil, and glaukomflecken

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Figure 2: B-scan showing bilateral 360° shallow choroidal detachment

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Because bilateral AACG is a rare entity, with panuveitis, an idiosyncratic reaction related to systemic drug intake was kept in mind. A detailed probe into the history revealed that she is a known case of migraine on flunarizine tablet since 5 years. She had an episode of severe headache 10 days back, for which a magnetic resonance imaging brain was done and was found to be normal. Neurologist's opinion was sought and diagnosed as a case of vascular headache and treated with tablet topiramate 50 mg/day for 1 week.


Based on the history and clinical findings, probable diagnosis of bilateral secondary AACG and panuveitis due to topiramate was made. She was managed with topical (timolol 0.5% + dorzolamide 2% e/d BD) and systemic (capsule acetazolamide 250 mg TID) antiglaucoma medications, topical steroids, and cycloplegics. With the knowledge that topiramate can cause secondary ACG and panuveitis, the drug was discontinued immediately. Furthermore, pilocarpine eye drops was stopped as the drug can aggravate the anterior shift of the lens–iris diaphragm. Her symptoms subsided dramatically within 48 h.


After 2 weeks of treatment with topical steroids and cycloplegics, her BCVA was 6/6 in RE and 6/9 in LE with IOP of 14 mmHg in RE and 16 mmHg in LE. Slit-lamp examination of BE showed clear corneas, with pigments on endothelium and anterior lens capsule, quiet AC, deep anterior chamber with glaukomflecken and posterior synechiae, which was more severe in LE than RE [Figure 3]. Gonioscopy using Goldmann 4 mirror showed open angles with few intermittent PAS in both eyes. Both optic discs had a cup disc ratio of 0.3 with healthy neuroretinal rim. B-scan USG revealed totally resolved Choroidal detachment [Figure 4]. She was advised to continue tapering doses of steroids and antiglaucoma drops for 1 month.
Figure 3: After 2 weeks of conservative treatment, resolving corneal edema with deepening of anterior chamber seen

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Figure 4: B-scan showing resolved choroidal detachment

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After 1 month of follow-up, anterior and posterior segment findings remained the same. All topical medications were stopped, the patient reassured and advised to follow up once every 6 months.

  Discussion Top

Topiramate-induced myopia, ACG, and uveitis can be considered as an idiosyncratic reaction to the sulfonamide group of drugs. Topiramate causing bilateral AACG was first reported by Banta et al. in 2001.[2] A largest case series was published in 2004 by Fraunfelder et al. of 83 bilateral and 3 unilateral cases.[1] Eighty-five percent of these cases occurred within first 2 weeks of initiating therapy. The overall mean of onset of angle closure in their series was 7 days. However, five cases developed ACG within few hours. The severity of this idiosyncratic reaction is dose independent and differs for each individuals.[3],[4],[5] The most postulated hypothesis is hapten hypothesis, which postulates that the reactive drug metabolites bind to proteins forming altered proteins which are recognized as foreign substances and incite an immune reaction. Risk of developing acute angle closure due to topiramate may not be related to biometric factors such as shallow anterior chamber, crowded angle structures, and short axial length unlike drugs such as serotonin which causes angle closure in anatomically predisposed eyes.

Treatment of topiramate-induced ACG includes immediate discontinuation of the drug, lowering IOP with aqueous suppressants, topical beta blockers, and IV mannitol if necessary. Topical cycloplegics are helpful to push back the anteriorly displaced lens–iris diaphragm. Topical or systemic steroids or both may be needed to reduce the inflammation depending on the severity. Use of pilocarpine and sulfonamides such as acetazolamide should be avoided as they can aggravate the forward shift of lens–iris diaphragm. Several case reports have claimed the cross sensitivity between sulfonamide drugs and worsening of secondary ACG in patients using topiramate.[6] Other sulfa-containing drugs known to cause angle closure are antibiotics (trimethoprim–sulfamethoxazole), diuretics (hydrochlorothiazide, acetazolamide, and furosemide), rheumatologic drugs (sulfasalazine), and other drugs such as chlorpropamide and sumatriptan. Acute angle closure usually resolves within 24–48 h of stopping the drug and myopic shift resolves within 1–2 weeks and uveitis resolves within 4–6 wks.[7] Topiramate-induced idiosyncratic reactions settle down completely in majority of the patients on discontinuing the drug. However, Aminlari et al. reported a similar clinical condition where resolution of topiramate induced angle closure with bilateral peripheral anterior synechiae was documented as seen in our patient.[8]

  Conclusion Top

Outcomes of patients with properly treated topiramate-induced AACG and uveitis are usually good and resolves without residual changes. However, our patient had posterior synechiae and gonioscopically intermittent PAS in BE. Furthermore, the presence of bilateral glaukomflecken confirms high rise in IOP within a short span of time which can lead to sight-threatening complications, if not treated immediately. Physicians prescribing topiramate need to be aware and alert patients of this potential sight-threatening idiosyncratic reaction in initial 2 weeks. Early diagnosis and timely intervention avoids irreversible vision loss. In this case report, we also highlight the fact that a careful history with a meticulous clinical approach can prevent ambiguity in diagnosis and differentiation from APAC.

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


Conflicts of interest

There are no conflicts of interest.

  References Top

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
Banta JT, Hoffman K, Budenz DL, Ceballos E, Greenfield DS. Presumed topiramate-induced bilateral acute angle-closure glaucoma. Am J Ophthalmol 2001;132:112-4.  Back to cited text no. 2
Lan YW, Hsieh JW. Bilateral acute angle closure glaucoma and myopic shift by topiramate-induced ciliochoroidal effusion: Case report and literature review. Int Ophthalmol 2018;38:2639-48.  Back to cited text no. 3
Jabbarpoor Bonyadi MH, Soheilian R, Soheilian M. Topiramate-induced bilateral anterior uveitis associated with hypopyon formation. Ocul Immunol Inflamm 2011;19:86-8.  Back to cited text no. 4
Craig JE, Ong TJ, Louis DL, Wells JM. Mechanism of topiramate-induced acute-onset myopia and angle closure glaucoma. Am J Ophthalmol 2004;137:193-5.  Back to cited text no. 5
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. 6
Thambi L, Kapcala LP, Chambers W, Nourjah P, Beitz J, Chen M, et al. Topiramate-associated secondary angle-closure glaucoma: A case series. Arch Ophthalmol 2002;120:1108.  Back to cited text no. 7
Aminlari A, East M, Wei W, Quillen D. Topiramate induced acute angle closure glaucoma. Open Ophthalmol J 2008;2:46-7.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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