1. Uveitis & Phacodonesis - Topamax
Ophthalmology & Visual Sciences
University of Louisville School of Medicine
February, 2016 1

2. 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.

3. History
POHx: None
PMHx: None
Meds: None
Allergies: NKDA

4. Alternating horizon nystagmus
Ophthalmic Exam
20/60
BCVA
20/40
X180 M
X90
full VF
EOM
Alternating horizon nystagmus
4.5
Pupils
4.5 +APD 16
IOP 17

5. Ophthalmic Exam WNL L/L No injection Conjunctiva No KP Cornea
2+ cells, 4+ flare
A/C
1.5 cells, 2+ flare
Iridophacodonesis
Iris
Clear
Lens
1+ vitreous cells, ON edema + macular edema
Fundus
2+ vitreous cells, ON edema + macular edema

6. Prior evaluation

7. 0:21
1:02
1/2016
4:44

8. 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

9. FA/ICGA at UofL

10. 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

11. Topamax Ocular SE Complications: Uveal effusion syndrome
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

12. 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

13. Treatment Stop the offending medication Cycloplegia Corticosteroids
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

14. 1/2016

16. References
1. Senthil S, Garudadri C, Rao HBL, Maheshwari R. Bilateral simultaneous acute angle closure caused by sulphonamide derivatives: A case series. Indian Journal of Ophthalmology. 2010;58(3):
2. 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):
3. 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):
4. 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 Sep;54(3):195-7.
5. Aminlari A, East M, Wei W, Quillen D. Topiramate Induced Acute Angle Closure Glaucoma. The Open Ophthalmology Journal. 2008;2:46-47.
6. Jabbarpoor Bonyadi MH, Soheilian R, Soheilian M. Topiramate-induced bilateral anterior uveitis associated with hypopyon formation. Ocul Immunol Inflamm Feb;19(1):86-8.
7. 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 Apr;231(4):