A Curious Case of Bilateral Optic Disc Edema Brittney Dautremont, DO, MPH
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1 A Curious Case of Bilateral Optic Disc Edema Brittney Dautremont, DO, MPH PGY2 Ophthalmology Resident Grandview Medical Center Dayton, OH
2 CASE PRESENTATION 51 year old white female presenting with blurred vision
3 Case Presentation 51 yo white female c/o cloudy vision OU upon waking this morning Like looking through dirty glasses Eyes feel tired, strained, and sore
4 History of Present Illness Denies any previous episodes Denies frequent headaches (admits to occasional stress related headaches responsive to OTC NSAIDs) Denies pulsatile tinnitus Anything else you would like to ask regarding her initial presentation?
5 Medical History Past Ocular History: presbyopia Past Medical History: hypertension Past Surgical History: none Family History: heart disease, diabetes Social History: denies using tobacco products, admits to occasional alcohol, denies any recreational drug use ROS: recent significant weight loss, otherwise non contributory
6 Medical History Meds: Tribenzor 40/5/12.5mg 1 tab PO daily Phentermine HCl 37.5mg ½ tab PO daily Topamax 25mg 2 tabs PO daily Allergies: Penicillin
7 Medical History Upon further questioning Participating in a medical weight loss program Lost approximately 30 pounds over the last 3 months Used Phentermine for 12 weeks, and then discontinued it Started taking Topamax 1 week prior during the transition off of the Phentermine
8 Physical Exam General Alert and oriented x 4, pleasant affect Visual Acuity (UCVA) OD: 20/30, pinholes to 20/25 OS: 20/25, pinholes to 20/20 IOP OD: 38 OS: 40 External unremarkable Anterior Segment 1+ cell and flare OU Gonioscopy Angles closed OU
9 Physical Exam DFE was attempted but patient was too photosensitive to cooperate with exam
10 Diagnosis & Treatment Diagnosis Acute Angle Closure OU, secondary to Topamax Acute Anterior Uveitis OU, secondary to Topamax Blurred vision OU Management Stop Topamax Simbrinza (brinzolamide/brimonidine) 1%/0.2% gtts bid OU Prednisolone acetate 1% gtts qid OU Atropine sulfate 1% gtts bid OU Follow up RTC in 1 2 days for IOP check
11 Day #3 Patient presents complaining of continued blurred vision, increased pain and redness, and dryness OU Visual Acuity (UCVA) OD: 20/40+, pinholes to 20/20 OS: 20/30, no improvement with pinhole IOP OD: 8 OS: 9 External Pupils dilated with Atropine Anterior Segment Conjunctival chemosis OU Trace cell and flare OU
12 Day #3 Posterior Segment Vitreous: clear OU Cup to disc ratio: <0.1 OU Optic disc edema OU disc elevation, chronic in appearance no disc hemorrhages relatively sharp margins Macula: flat, attached OU Vessels: normal caliber OU Periphery: intact 360 and unremarkable OU
13 Diagnosis & Management Allergic reaction to Atropine sulfate gtts Instructed patient to d/c Atropine gtts Acute Angle Closure OU, secondary to Topamax Improved, IOP WNL Continue Simbrinza gtts Acute Anterior Uveitis OU, secondary to Topamax Improved Continue prednisolone acetate gtts Disc edema OU Unknown etiology Return for further diagnostic testing: OCT optic nerve Humphrey Visual Field 24 2
14 1 Week Patient states her eyes feel sore and ache toward the end of the day. She feels that her vision OD is not as bright and clear as OS. She noticed some gray spots in her vision OD, but notes that they don t move around like a normal floater. The redness and irritation stopped soon after she d/c Atropine gtts a few days ago.
15 1 Week Visual Acuity (UCVA) OD: 20/40, no improvement with pinhole OS: 20/20 Manifest Refraction OD: x 090, corrects to 20/25 IOP OD: 11 OS: 10 Anterior Segment Chemosis resolved OU Trace AC cell and flare OU Posterior Segment Chronic appearing optic disc elevation OU
16 OCT Optic Nerve at 1 week
17 Visual Field Testing at 12 days OD OS
18 2 Weeks Patient still complains of blurred vision OD Using Simbrinza and prednisolone acetate gtts as directed
19 2 Weeks Visual Acuity (UCVA) OD: 20/40+, pinholes to 20/30+ OS: 20/20 Manifest Refraction OD: x 090, corrects to 20/25 OS: plano IOP OD: 12 OS: 12 Ishihara Color Plates OD: 5.5/7 OS: 6/7 Anterior Segment Unremarkable Posterior Segment Chronic appearing optic disc elevation OU
20 OCT Optic Nerve at 2 weeks
21 Further Testing MRI brain and orbits, with and without contrast, was performed and was unremarkable
22 Diagnosis & Management Acute Angle Closure OU, secondary to Topamax Resolved, IOP WNL D/C Simbrinza gtts Acute Anterior Uveitis OU, secondary to Topamax Resolved Taper and D/C prednisolone acetate gtts Blurred Vision OD Refractive Error: myopia, astigmatism Disc edema OU Unknown etiology MRI unremarkable Repeat diagnostic testing: OCT optic nerve
23 25 Days Patient still complains of blurred vision OD No longer using Simbrinza or prednisolone acetate gtts
24 25 Days Visual Acuity (UCVA) OD: 20/40+, pinholes to 20/25 OS: 20/25, pinholes to 20/25+ Manifest Refraction OD: x 105, corrects to 20/20 OS: plano IOP OD: 12 OS: 12 Anterior Segment Unremarkable Posterior Segment Chronic appearing optic disc elevation, resolving
25 OCT Optic Nerve at 25 days
26 OCT Macula at 25 days
27 2 Months Patient still complains of blurred vision OD
28 2 Months Visual Acuity (UCVA) OD: 20/40+, pinholes to 20/30+ OS: 20/20 Manifest Refraction OD: x 100, corrects to 20/20 OS: plano IOP OD: 10 OS: 10 Anterior Segment Unremarkable Posterior Segment Optic disc elevation resolved OU
29 OCT Optic Nerve at 2 months
30 OCT Macula at 2 months
31 Visual Field Testing at 6 months OD
32 Visual Field Testing at 6 months OS
33 OCT Optic Nerve at 9 months
34 Visual Field Testing at 9 months OD
35 Visual Field Testing at 9 months OS
36 Diagnoses Acute Angle Closure OU, secondary to Topamax Acute Anterior Uveitis OU, secondary to Topamax Optic Disc Edema OU Upon resolution, Optic Atrophy OU, which has progressively worsened over 9 months Persistent Visual Field Defects OU, which have slightly improved and stabilized over 9 months Persistent Myopia and Astigmatism OD
37 Discussion Acute bilateral angle closure is a well documented adverse effect related to Topamax (as well as other sulfa derivative drugs) 1,2 Mechanism: Ciliochoroidal effusion syndrome Ciliary body swelling causes anterior rotation of the ciliary bodylens iris diaphragm, and occlusion of the AC angle Likely inflammatory component as cases of uveitis and vitritis have been reported Usually occurs days to weeks after drug administration Prevalence: 3 per 100,000 (more common in females) Also induces myopia due to anterior lens position, or possibly lens thickening with zonular relaxation Paradoxical Effect: cycloplegia allows resolution of the angle occlusion by relaxing the ciliary body Resolves with discontinuation of Topamax
38 Discussion Optic Disc Edema has NOT been previously reported in association with Topamax, nor Phentermine Cases of visual field defects and pigmentary retinopathy have been reported, usually in patients taking higher doses over longer periods of time 2 VFD occurred in between 1:100 and 1:1000 cases during manufacturer s clinical trials (the nature of these defects was not reported) 2 A Turkish study (2011) revealed statistically significant changes in RNFL thickness using OCT 4 Baseline was ± µm Increased to ±8.41 µm at 30 days (p = 0.01), and ± µm at 90 days (p = 0.004)
39 Discussion Reported adverse ocular effects associated with Topamax administration: Acute bilateral angle closure Choroidal effusion syndrome Uveitis Macular striae Pigmentary retinopathy Visual field defects Myopia Neuroophthalmologic manifestations (palinopsia, Alice in Wonderland syndrome) Optic Disc Edema?
40 Recommendations In evaluation of a patient with concurrent blurred vision and history of Topamax administration, consider the following as important parts of the initial examination: SLE IOP measurement Gonioscopy DFE Refraction Visual field testing OCT optic nerve?
41 References 1. Grewal DS, Goldstein DA, Khatana AK, Tanna AP. Bilateral angle closure following use of a weight loss combination agent containing topiramate. Journal of Glaucoma Oct Abtahi MA, Abtahi SH, Fazel F, Roomizadeh P, Etemadifar M, Jenab K, Akbari M. Topiramate and the vision: a systematic review. Clinical Ophthalmology. 2012; 6: Gualtieri W, Janula J. Topiramate Maculopathy. International Ophthalmology Feb. 4. Ozturk BT, Genc E, Tokgoz M, Kerimoglu H, Genc BO. Ocular changes associated with topiramate. Current Eye Research Jan; 36:47 52.
42 Thank You! Special thanks to Dr. Robert Peets, DO Questions?
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