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BRIEF COMMUNICATION
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 46-48

Topiramate-induced hypertensive uveitis and evolving Fuchs' uveitis: A case report


1 Department of Uvea, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India
2 Department of General Ophthalmology, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India
3 Department of Glaucoma, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India

Date of Submission10-Jul-2014
Date of Acceptance16-Mar-2015
Date of Web Publication19-Jan-2016

Correspondence Address:
Ankush Kawali
Department of Uveitis and Ocular Immunology, Narayana Nethralaya, Chord Road, Bangalore - 560 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.174426

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  Abstract 

We intend to report an interesting case of topiramate-induced bilateral uveitis (TIU) and angle closure glaucoma that gradually developed signs of Fuchs' uveitis (FU) in right eye after resolution of the attack. A 41-year-old female was started on oral topiramate for migraine following which she developed bilateral acute angle closure glaucoma and uveitis. She improved with topical and systemic steroids. As the attack resolved, her right eye started developing classical features of FU which were initially confused with viral uveitis. Patient was followed-up without steroids for 2 years. She remained asymptomatic in right eye and healthy systemically proving diagnosis of FU. We recommend high index of suspicion for FU in an asymptomatic low-grade uveitis even though typical features of FU are absent initially. Few weeks of observation may allow FU to manifest on its own, which will prevent unnecessary investigations and treatment.

Keywords: Angle closure glaucoma, diagnostic delay, evolving Fuchs′ uveitis, topiramate-induced uveitis, viral uveitis


How to cite this article:
Kawali A, Ayyar A, Ahuja A, Abdul KM. Topiramate-induced hypertensive uveitis and evolving Fuchs' uveitis: A case report. J Clin Ophthalmol Res 2016;4:46-8

How to cite this URL:
Kawali A, Ayyar A, Ahuja A, Abdul KM. Topiramate-induced hypertensive uveitis and evolving Fuchs' uveitis: A case report. J Clin Ophthalmol Res [serial online] 2016 [cited 2022 Jul 4];4:46-8. Available from: https://www.jcor.in/text.asp?2016/4/1/46/174426

Topiramate-induced myopia, angle closure glaucoma, and uveitis is well reported in the literature. [1],[2],[3] We intend to report an interesting case of topiramate-induced bilateral uveitis (TIU) and angle closure glaucoma, which after resolution left behind subtle inflammation in the right eye and created confusion in diagnosis until it developed classical signs of Fuchs' uveitis (FU). The purpose of this report is to appreciate hidden FU.


  Case Report Top


A 41-year-old lady presented to us with complaints of sudden onset of redness and watering in both the eyes since 3 days. She had no ocular history prior to this episode. Patient had shown to a local ophthalmologist who noted high intraocular pressure (IOP; right eye: 35 mmHg and left eye: 40 mmHg) and put her on topical steroids, timolol, and pilocarpine. At presentation, her best corrected visual acuity (BCVA) was 20/60 in both the eyes. IOP was 20 mmHg in right eye and 14 mmHg in left eye. Slit-lamp examination of both eyes showed corneal edema with descemet membrane folds, constricted pupil, shallow anterior chambers, fibrinous membranes, and 3+ cells in the anterior chamber. Posterior segment evaluation of the both eyes showed hyperemic discs and choroidal folds. There was evidence of choroidal thickening in both eyes on B-scan, but no subretinal fluid was detected. Gonioscopy was deferred as patient had pain. A diagnosis of bilateral angle closure glaucoma with panuveitis was made. A detailed probe into history revealed that the patient was also on treatment for her migraine with tab. topiramate 25 mg since 1 week. With the knowledge that topiramate may cause uveitis and glaucoma, the drug was discontinued immediately. Investigations revealed normal blood counts and normal erythrocyte sedimentation rate (ESR). The patient received intravenous dexamethasone 8 mg twice a day for 3 days followed by oral prednisolone 40 mg tapered over 4 weeks along with topical dexamethasone qid tapered over a month. Within days uveitis started resolving, anterior chamber started forming but left behind posterior synechiae in the left eye. On subsequent visits, periodic gonioscopic examination revealed development of peripheral anterior synechiae in both the eyes. Hence, prophylactic peripheral iridotomy was performed in both the eyes. The patient presented 2 months later with pain in her left eye and no complaints for the right eye. Right eye showed diffuse white keratic precipitates, 1 + cells and flare, Koeppe nodules, and patent iridotomy; while vitreous was clear [Figure 1]a and b. Left eye was congested with subepithelial opacities in the cornea, anterior chamber was quiet, 270° posterior synechiae, a patent iridotomy, glaukomaflecken, and immature cataract was noted in that eye. Fundus examination was normal in both the eyes. She was diagnosed as nummular keratitis in the left eye and probable viral anterior uveitis in the right eye. The patient was treated with lubricating eye drops (polyvinyl alcohol 1.4% and povidone 0.6%) and topical prednisolone acetate qid tapered over 1 month. She improved, but in the next follow-up visit though patient was asymptomatic, right eye vitritis was noted along with previous findings in the right eye and no active inflammation was observed in left eye. With the fear that the probable viral anterior uveitis in the right eye is now involving posterior segment, she was put on oral acyclovir 400 mg five times per day along with oral prednisolone 40 mg in a tapering dose. A month after stopping steroids, inflammation in right eye was same and patient remained asymptomatic in the right eye. At this time FU was suspected in right eye. During further follow-up of 2 years, patient remained asymptomatic in right eye and healthy systemically. BCVA at final follow-up was 20/20 in right eye and 20/60 in left eye attributed to the cataract.
Figure 1: (a) Right eye with Fuchs' uveitis showing diffuse keratic precipitates. (b) Koeppe nodules along papillary border (black arrow), absence of posterior synechiae, and neodymium: Yttrium-aluminumgarnet (Nd:YAG)-peripheral iridectomy (PI)

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  Discussion Top


Our patient had many confusing findings at the presentation as well as throughout the follow-up. Her bilateral panuveitis at presentation was confused with Vogt-Koyanagi-Harada syndrome. Absence of serous retinal detachments, significant anterior inflammation with history of high IOP made us to keep this possibility low in the list. Sectoral iris atrophy in the left eye [Figure 2] was another confusing finding when it was seen along with subepithelial punctate keratitis suggesting a viral etiology. But its peripupillary location rather than midperipheral along with glaukomaflecken prompted changes post angle closure glaucoma. Interestingly, similar iris changes were not observed in the right eye even though IOP in right eye was just 5 mmHg lower than that of left eye during the attack. We believe this disparity might be because of preexisting subtle stromal iris changes due to FU in the right eye. The most interesting finding was evolving FU in the right eye which was mistaken and treated as viral uveitis. Patient's FU was initially masked under the aggressive presentation of TIU and remained undiscovered due to high dose steroid treatment given for the same.
Figure 2: Note the 360° posterior synechia, patent PI, and sectoral iris atrophy in left eye

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Diagnosis of FU has always been challenging when heterochromia iridis is less pronounced, especially in pigmented races and as in our case. [4] In our case patient initially received unnecessary antiviral and steroid treatment. Mere observation without steroids allowed FU to develop its typical features. White eye, diffuse white keratic precipitates, 0.5 cells in anterior chamber, Koeppe's nodules, slightly altered iris pattern without posterior synechia and vitritis without any fundus lesions remained unchanged and the patient remained asymptomatic in right eye as well as systemically when followed-up for more than 2 years without steroids. This confirmed diagnosis of FU in the right eye. To best of our knowledge overlap of FU and TIU has not been reported. This report also shows that FU resumes its classical pattern when the inflammation due to other etiology resolves completely and influence of high dose steroids recedes. This is then a confusing situation when FU has not been documented earlier. We recommend high index of suspicion for FU in an asymptomatic low-grade uveitis, even though typical features of FU are absent initially. Few weeks of observation may allow FU to manifest on its own, which will prevent unnecessary investigations and treatment.

 
  References Top

1.
Thambi L, Karcala 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. 1
    
2.
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.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Senthil S, Garudadri C, Rao HB, Maheshwari R. Bilateral simultaneous acute angle closure caused by sulphonamide derivatives: A case series. Indian J Ophthalmol 2010;58:248-52.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Bouchenaki N, Herbort CP. Fuchs' Uveitis: Failure to associate vitritis and disc hyperfluorescence with the disease is the major factor for misdiagnosis and diagnostic delay. Middle East Afr J Ophthalmol 2009;16:239-44.  Back to cited text no. 4
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 Topiramate-induced acute angle closure with severe panuveitis: A challenging case report
Padmamalini Mahendradas, Snehanka Parab, Rajesh Sasikumar, Ankush Kawali, BhujangK Shetty
Indian Journal of Ophthalmology. 2018; 66(9): 1342
[Pubmed] | [DOI]



 

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