Download Uveitis and Topamax – Dr. Amir Hadayer

Uveitis & Phacodonesis Topamax
Ophthalmology & Visual Sciences
University of Louisville School of Medicine
February, 2016
Presentation

CC: Photopsia and blurry vision, OU, with recurrent
headaches and tinnitus, 18 months.

HPI: 20 yo while male hit his head on sand playing volley
ball 18 months ago (? concussion). Symptomatic and
diagnosed with post-traumatic stress syndrome and
pseudotumor cerebri. Started on oral Diamox; changed to
Topamax (50mg PO, b.i.d) on 8/2015; discontinued
12/2015.
History

POHx: None

PMHx: None

Meds: None

Allergies: NKDA
Ophthalmic Exam
20/60
BCVA
20/40
+1.5+0.5X180
M
+3.00+1.00X90
full
VF
full
full
EOM
full
4.5
Pupils
4.5 +APD
16
IOP
17
Alternating
horizon
nystagmus
Ophthalmic Exam
WNL
No injection
No KP
L/L
Conjunctiva
Cornea
WNL
No injection
No KP
2+ cells, 4+ flare
A/C
1.5 cells, 2+ flare
Iridophacodonesis
Iris
Iridophacodonesis
Clear
1+ vitreous cells, ON edema +
macular edema
Lens
Fundus
Clear
2+ vitreous cells, ON edema +
macular edema
Prior evaluation
0:21
1/2016
1:02
4:44
Prior work up
HVF: Enlarged blind spots ou
 OCT RNFL: Diffusedly increase RNFL
thickness
 LP: Opening pressure 280. CSF content
normal
 TSH,PTH: wnl
 Vit A: wnl

FA/ICGA at UofL
Assessment / Plan
Impression:
1. Occult multifocal choroidites OU with secondary macular
edema and optic disc edema
2. Iridiophacodenesis OU (secondary to Topamax)
3. Alternating horizontal nystagmus
 Plan:
– Further diagnostic work up of occult multifocal
choroiditis
– 40 mg prednisone po qAM

Topamax Ocular SE

Topiramate (brand name Topamax) is an anticonvulsant (antiepilepsy)
drug. In late 2012, topiramate was approved by the United States Food and
Drug Administration (FDA) in combination with phentermine for weight loss. It is
also Food and Drug Administration (FDA) approved for, and most frequently
prescribed for, the prevention of migraines

Complications: Uveal effusion syndrome
–
–
–
–
–
–
Angle Closure Glaucoma
Acute myopia
Uveitis
Ciliary body edema
Uveal effusion
Ant. rotation of the lens and iris
Pathophysiology




Idiosyncratic effect: The most prevalent hypothesis is the
hapten hypothesis. The reactive drug metabolites bind to
the proteins on the zonular fibers of the lens and these
altered proteins are perceived as foreign and induce an
immune response.
Unrelated to dosage
Sulfonamides: Indapamide, Topiramate, Acetazolamide
Side effects start within the first 2 weeks
Treatment

Stop the offending medication
– Topiramate has a number of physiologic effects,
including inhibition of voltage-gated sodium and
calcium channels, augmentation of GABA-induced
chloride flux, inhibition of glutamate-related
excitatory neurotransmission and carbonic
anhydrase
Cycloplegia
 Corticosteroids
 IOP control if acute angle closure has occurred

1/2016
References
1. Senthil S, Garudadri C, Rao HBL, Maheshwari R. Bilateral simultaneous acute angle closure caused by
2.
3.
4.
5.
6.
7.
sulphonamide derivatives: A case series. Indian Journal of Ophthalmology. 2010;58(3):248-252.
Mitra A, Ramakrishnan R, Kader MA. Anterior segment optical coherence tomography documentation of a
case of topiramate induced acute angle closure. Indian Journal of Ophthalmology. 2014;62(5):619-622.
Acharya N, Nithyanandam S, Kamat S. [Letter to the Editor] Topiramate-associated bilateral anterior
uveitis and angle closure glaucoma. Indian Journal of Ophthalmology. 2010;58(6):557-559
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 Sep;54(3):195-7.
Aminlari A, East M, Wei W, Quillen D. Topiramate Induced Acute Angle Closure Glaucoma. The Open
Ophthalmology Journal. 2008;2:46-47.
Jabbarpoor Bonyadi MH, Soheilian R, Soheilian M. Topiramate-induced bilateral anterior uveitis
associated with hypopyon formation. Ocul Immunol Inflamm. 2011 Feb;19(1):86-8.
Katsimpris JM, Katsimpris A, Theoulakis PE, Lepidas J, Petropoulos IK. Bilateral severe anterior uveitis
and acute angle-closure glaucoma following topiramate use for migraine crisis. Klin Monbl Augenheilkd.
2014 Apr;231(4):439-41.