Acute angle closure glaucoma precipitated by homeopathic eyedrops containing Atropa belladonna.

Acute angle closure glaucoma is a sight-threatening condition that may lead to blindness. This is a case report of a woman who presented to the emergency department (ED) with acute angle closure glaucoma following use of an over-the-counter (OTC) homeopathic eye drop containing atropa belladonna (deadly nightshade). A 55-year-old woman presented to the ED with a 5-day history of left eye redness, swelling, tearing, and foreign-body sensation that had acutely worsened in the last two days. Her exam revealed mild left conjunctival injection with watery tearing and a hazy appearance of her left cornea. Fluorescein staining was negative, while tonometry revealed elevated intraocular pressure on the left, suggestive of acute angle closure glaucoma. She was urgently referred to ophthalmology. The etiology of the acute angle closure glaucoma was initially unclear however, with additional prompting, she revealed that two days prior she had started using homeopathic OTC eye drops. Inspection of the eyedrop's ingredients revealed that atropa belladonna was the primary ingredient and likely precipitated her isolated episode of acute angle closure glaucoma. A high level of clinical suspicion and focused ophthalmic exam including tonometry is essential to identify acute angle closure glaucoma in the ED. We present a case report of acute angle closure glaucoma associated with the use of homeopathic belladonna-containing eyedrops. Our report reinforces the necessity to perform thorough medication and supplement history given the prevalence of physiologically active substances available in OTC medications.

Acute exposure to air pollutants increase the risk of acute glaucoma.

BACKGROUND: Ambient air pollution is related to the onset and progression of ocular disease. However, the effect of air pollutants on the acute glaucoma remains unclear. OBJECTIVE: To investigate the effect of air pollutants on the incidence of acute glaucoma (acute angle closure glaucoma and glaucomatocyclitic crisis) among adults. METHODS: We conducted a time-stratified case-crossover study based on the data of glaucoma outpatients from January, 2015 to Dec, 2021 in Shanghai, China. A conditional logistic regression model combined with a polynomial distributed lag model was applied for the statistical analysis. Each case serves as its own referent by comparing exposures on the day of the outpatient visit to the exposures on the other 3-4 control days on the same week, month and year. To fully capture the delayed effect of air pollution, we used a maximum lag of 7 days in main model. RESULTS: A total of 14,385 acute glaucoma outpatients were included in this study. We found exposure to PM2.5, PM10, nitrogen dioxide (NO2) and carbon monoxide (CO) significantly increased the odds of outpatient visit for acute glaucoma. Wherein the odds of acute glaucoma related to PM2.5 and NO2 were higher and more sustained, with OR of 1.07 (95%CI: 1.03-1.11) and 1.12 (95% CI: 1.08-1.17) for an IQR increase over lag 0-3 days, than PM10 and CO over lag 0-1 days (OR:1.03; 95% CI: 1.01-1.05; OR: 1.04; 95% CI: 1.01-1.07). CONCLUSIONS: This case-crossover study provided first-hand evidence that air pollutants, especially PM2.5 and NO2, significantly increased risk of acute glaucoma.

[Drug-induced acute angle closure glaucoma]. / Quels sont les médicaments à risque de précipiter un glaucome aigu par fermeture de l'angle ?

Acute angle closure glaucoma is an ophthalmic emergency that can lead to blindness in some cases. The presenting signs are often suggestive, like ocular pain and blurred vision accompanied by headache, nausea and vomiting. These symptoms must be recognized as soon as possible, and the patient must be addressed, urgently, to an ophthalmologist for treatment. Many drugs may lead to an acute angle closure glaucoma in patients with risk factors. This article aims to remind the anatomical risk factors as well as the drugs that may induce an acute angle closure glaucoma. For a better understanding, this article will provide a brief reminder of the pathophysiological mechanism of acute angle closure glaucoma.

Le glaucome aigu par fermeture de l'angle, appelé communément crise de glaucome, est une urgence ophtalmologique pouvant potentiellement conduire à la cécité. Les symptômes sont assez bruyants, les manifestations les plus fréquentes sont une douleur oculaire et une vision floue accompagnées de céphalées, de nausées et de vomissements. Ces symptômes doivent être reconnus le plus rapidement possible afin de référer le patient chez un ophtalmologue pour une prise en charge urgente. Plusieurs médicaments peuvent précipiter la survenue d'une crise chez un patient prédisposé. Il convient donc de rappeler les facteurs de risque anatomiques ainsi que les médicaments pouvant précipiter un glaucome aigu par fermeture de l'angle. Pour une meilleure compréhension, cet article fait un rappel succinct des mécanismes physiopathologiques impliqués dans la survenue d'un glaucome aigu par fermeture de l'angle.

A case series of topiramate-induced angle closure crisis - an ophthalmic emergency.

BACKGROUND: Topiramate is a drug commonly used by physicians. However, it has various systemic and ocular adverse effects. Bilateral angle closure crisis is a potentially blinding adverse reaction that is seldom reported in non-ophthalmic journals. OBJECTIVE: This article aims to report a case series of topiramate-induced angle closure crisis in the eyes. METHODS AND MATERIAL: Most patients presented to us with blurred vision and high intra-ocular pressure within days of starting topiramate tablet for headache. However, the attack resolved in those who presented early with prompt treatment, which included stopping topiramate. CONCLUSIONS: Physicians prescribing topiramate must be well aware of this potentially blinding adverse effect. Educating the patient about this possible side effect is important. Timely referral and treatment can prevent blindness in these individuals.

Angiographic features of drug-induced bilateral angle closure and transient myopia with Ciliochoroidal effusion.

BACKGROUND: To report five cases of acute drug-induced angle closure and transient myopia with ciliochoroidal effusion and to analyze angiographic findings of these cases. METHODS: This study is an observational case series. Five patients with acute drug-induced angle closure and transient myopia with ciliochoroidal effusion were examined by fluorescein angiography, indocyanine green angiography (ICGA) and ultrasound biomicroscopy (UBM). RESULTS: Five patients presented with bilateral visual loss and ocular pain after intake of topiramate, methazolamide, phendimetrazine tartrate or mefenamic acid. All patients showed elevated intraocular pressure (IOP) with shallow anterior chamber and myopic shift from - 0.5 to - 17.0 diopters (D). UBM showed ciliochoroidal effusions with diffuse thickening of the ciliary body in all cases. Rapid normalization of IOP and decrease of myopic shift occurred in all patients after discontinuing the suspected drugs. We classified the ICGA findings into 2 major signs (hypofluorescent dark spots, hyperfluorescent pinpoints) and 3 minor signs (diffuse choroidal hyperfluorescence, early hyperfluorescence of choroidal stromal vessel, and leakage and dilated retinal vessels). CONCLUSIONS: The pathogenesis of acute drug-induced angle closure and transient myopia with ciliochoroidal effusion may be idiosyncratic reaction of uveal tissue to systemic drugs. Accumulation of extravascular fluid in the ciliochoroidal layer had a major role in the pathogenesis. ICGA could be a useful method to examine the pathophysiology of this condition by imaging of the choroidal layer.

Bilateral acute angle-closure glaucoma following tramadol subcutaneous administration.

BACKGROUND: To report a case of bilateral acute angle closure-glaucoma following the use of subcutaneous Tramadol. CASE PRESENTATION: A 42-year-old healthy man with unremarkable past medical and ocular history, was admitted to the Orthopedic Department for surgical treatment of a bilateral open fracture of the femur following a road accident. Three hoursafterTramadolsubcutaneous injection, the patient complained of a bilateral acute painful visual loss with persistent vomiting. An ocular examination showed bilateral acute angle-closure-glaucoma. The patient was treated with topical anti-glaucoma therapy and intravenous Mannitol 20%.After resolution of ocular hypertension attack, NdYag laser peripheral iridotomy was performed on both eyes. After a follow-up period of 7 days visual acuity improved to 20/20 in both eyes and intraocular pressure returned to normal levels. CONCLUSIONS: This case highlights the risk of developing bilateral acute angle-closure glaucoma after Tramadol administration.

Bilateral simultaneous acute angle closure attack triggered by an over-the-counter flu medication.

Most of the rare bilateral acute angle closure (AAC) cases are precipitated by systemic factors, such as drug intake, snake bite or general anaesthesia. We present a case of simultaneous bilateral AAC in a middle-aged male, precipitated by the use of medication for flu, containing an alpha-1 adrenergic receptor agonist and an anticholinergic agent. In our case, axial length was shorter, anterior chamber depth was narrower, and the lens was thicker than normal, including the patient within the risk group for AAC. In this circumstance, drugs acted as triggers. Case description and evolution following treatment are completed with the discussion of mechanisms involved in triggering bilateral AAC in predisposed patients, as emerging from literature. This case report brings up the risk of bilateral AAC in patients at risk, of which ophthalmologists, physicians of other specialties and patients should be aware of.

Bilateral acute angle closure glaucoma and myopic shift by topiramate-induced ciliochoroidal effusion: case report and literature review.

PURPOSE: To report two cases of ciliochoroidal effusion after the usage of topiramate. CASES: Two middle-aged women experienced sudden onset of acute glaucoma and acquired myopia after taking topiramate. Ultrasound biomicroscopy demonstrated bilateral ciliochoroidal effusion and angle closure. The A-scan ultrasonography revealed shallow anterior chamber and thick lens. After the treatment and drug withdrawal, intraocular pressure, refractive status and angle anatomy returned to normal and there was resolution of ciliochoroidal effusion. During the clinical course, the anterior chamber depth (ACD) increased from 2.02 to 3.30 mm (1.28 mm of changes) OD and from 1.94 to 3.36 mm (1.42 mm of changes) OS. The lens thickness (LT) became thinner from 4.53 to 4.31 mm (0.22 mm of changes) OD and from 4.59 to 4.30 mm (0.29 mm of changes) OS in the first case. In the second case, the ACD increased from 2.33 to 3.07 mm (0.74 mm of changes) OD and from 2.30 to 3.05 mm (0.75 mm of changes) OS. The LT became thinner from 4.42 to 4.27 mm (0.15 mm of changes) OD and from 4.38 to 4.26 mm (0.12 mm of changes) OS. The forward displacement of the lens-iris diaphragm contributed more to the shallowness of the anterior chamber than the thickening of the lens itself (only accounting for 20%). CONCLUSION: Topiramate-induced bilateral acute angle closure glaucoma and myopic shift was due to ciliochoroidal effusion which resulted in thicker lens and shallow anterior chamber. The later was mainly due to anterior displacement of the lens-iris diaphragm.

Bilateral acute angle closure developing due to use of ipratropium bromide and salbutamol.

Acute angle closure can be seen as a side effect of some medications that can be used systemically. In this article, clinical characteristics of 54-year-old female patient who applied to our clinic with bilateral acute angle closure and has been received nebulized form of salbutamol and ipratropium bromide due to asthma for 4 days was evaluated. Right and left eye IOP were measured as 50 and 48 mmHg. IOP was reduced with anti-glaucomatous treatment. and peripheral iridectomy was done, and then the patient was discharged. It is necessary to be careful to prevent contact with the eye of nebulized form of these drugs which may result in angle closure glaucoma when used systemically.

Acute angle closure following hemodialysis in a 34-year-old Nigerian female.

Studies have reported that intraocular pressure (IOP) might change markedly during hemodialysis. We report the case of a 34-year-old Nigerian female with a 3-year history of chronic kidney disease secondary to chronic glomerulonephritis who presented with acute symptomatic elevation of IOPs following hemodialysis. She had no ocular complaints immediately before undergoing hemodialysis. She presented with a history of pain, redness, and mild blurring of vision in the left eye about 15 min after hemodialysis. Examination revealed circumciliary injection, shallow anterior chambers, and closed angles on gonioscopy in both the eyes. She was treated with pilocarpine (4%) four times daily and dorzolamide/timolol (2%/0.5%) twice daily combination eye drops with subsequent relief of symptoms and IOP reduction from an initial 48 and 74 mmHg to 10 and 12 mmHg for the right and left eyes, respectively. This case highlights the need for sensitization and awareness among renal physicians and ophthalmologists of the possibility of extremely high IOP during or immediately following hemodialysis. It also emphasizes the importance of gonioscopy and treatment of at-risk patients with narrow angles before hemodialysis.

Acute angle closure attack after an intravitreal bevacizumab injection for branch retinal vein occlusion: a case report.

BACKGROUND: Intravitreal injection is widely used to treat retinal vein occlusion, and acute angle closure (AAC) is an exceptional complication of intravitreal injection. The authors report a case of AAC that occurred immediately after administering intravitreal bevacizumab to treat branch retinal vein occlusion (BRVO). CASE PRESENTATION: A 65-year-old woman was referred to the retina clinic of a tertiary referral center for the treatment of macular edema secondary to BRVO. On slit lamp examination, anterior chamber (AC) depth was shallow (3 corneal thicknesses centrally, 1/4 corneal thicknesses peripherally) in both eyes. Intraocular pressure (IOP) was 19 mmHg in both eyes, and refractive error was +1.00 diopter sphere in both eyes. A gonioscopy exam demonstrated narrow angle of over 180° in both eyes. To treat the macular edema, bevacizumab was injected into her right eye intravitreally. After two bevacizumab injections, the macular edema regressed but recurred 5 months later, and thus, a third injection was performed. The next day, she visited our emergency department complaining of persistent ocular pain in her right eye. The right pupil had dilated to 6 mm diameter and was fixed. Slit lamp exam revealed diffuse corneal edema in her right eye, which had an IOP of 56 mmHg. After administration of intravenous mannitol, the IOP fell to 14 mmHg and the corneal edema disappeared. Subsequently, a glaucoma specialist performed laser iridotomy on the right eye. CONCLUSIONS: Although AAC is a rare complication of intravitreal injection, it can occur in a patient with risk factors such as hyperopic eye or narrow angle.

Acute angle-closure glaucoma in retinopathy of prematurity following pupil dilation.

BACKGROUND: Pupil dilation is a known risk factor for acute angle-closure glaucoma. Regular retinal evaluation is necessary for retinopathy of prematurity (ROP) cases. An acute attack of angle-closure glaucoma following pupil dilation in regressed ROP has never been reported. CASE PRESENTATION: A five-year-old girl presented to the hospital for a routine retina check-up. The patient was born prematurely with a gestation age of 27 weeks and a body weight of 980 grams. She had a history of stage 4A ROP in the right eye and received scleral buckling. After pupil dilation with 1 % tropicamide and 10 % phenylephrine for retinal examination, acute elevation of intraocular pressure (IOP) was observed in the right eye. Her IOP remained over 50 mmHg in the right eye even under treatment with oral acetazolamide and maximal tolerated doses of topical anti-glaucoma medications. Ultrasound biomicroscopy (UBM) showed that the angle in the right eye was closed 360 degrees circumferentially. In order to lower IOP, trabeculectomy with mitomycin C (0.2 mg/cc) was performed under general anesthesia. Postoperatively, the cornea became clear, the filtering bleb functioned well, and IOP returned to normal values. In the two-year follow-up, IOP was kept around 15 mmHg without anti-glaucoma medications. Although mild lens opacity was noted, her postoperative VA remained 20/200 in the right eye. CONCLUSION: Regular retinal evaluation will be necessary for the increasing number of ROP cases to be seen in the future. Ophthalmologists should bear in mind that pupil dilation for a retina check-up could result in acute angle-closure glaucoma in ROP patients.

Zonisamide-induced angle closure and myopic shift.

PURPOSE: To present a previously unreported case of angle closure secondary to the sulfonamide derivative zonisamide, to introduce eye care providers to zonisamide, and to review sulfonamide-induced angle closure. Zonisamide is a relatively new sulfonamide derivative indicated for epilepsy and used off-label for migraines. Although angle closure secondary to systemic medications such as topiramate and other sulfonamide derivatives is well documented, this is the first case of zonisamide-induced angle closure and myopic shift to be reported. CASE REPORT: A 39-year-old Hispanic woman presented with sudden vision loss OU with a concurrent bilateral frontal headache. No changes in health were reported other than initiating zonisamide for refractory migraines 2 weeks prior. Ocular history was significant only for low myopia. Entering visual acuities were 20/400 OD, OS. Manifest refraction revealed a 3-diopter myopic shift OU with best-corrected visual acuities of 20/20 OD, OS. On slit lamp examination, the anterior chamber angles were narrow OU and gonioscopy confirmed partially occluded angles OU. The intraocular pressures were elevated OU. B-scan ultrasonography exhibited peripheral choroidal effusion OU. With discontinuation of zonisamide, the patient experienced full recovery. CONCLUSIONS: With increasing use of zonisamide, practitioners should be aware of its sulfonamide derivative properties and the risk of secondary angle closure.

Acute myopia and angle closure glaucoma from topiramate in a seven-year-old: a case report and review of the literature.

BACKGROUND: A case is reported of acute bilateral myopia and angle closure glaucoma in a 7-year-old patient from topiramate toxicity. This is the second known reported case of topiramate induced acute angle closure glaucoma and third known reported case of topiramate induced acute myopia in a pediatric patient. CASE PRESENTATION: This case presents a 7-year-old who had recently begun topiramate therapy for seizures and headache. She developed painless blurred vision and acute bilateral myopia, which progressed to acute bilateral angle closure glaucoma. After a routine eye exam where myopia was diagnosed, the patient presented to the emergency room with symptoms of acute onset blurry vision, tearing, red eyes, swollen eyelids, and photophobia. The symptoms, myopia, and angle closure resolved with topical and oral intraocular pressure lowering medications, topical cyclopentolate, and discontinuation of topiramate. CONCLUSION: Acute angle closure glaucoma is a well-known side effect of topiramate, but is rarely seen in children. It cautions providers to the potential ophthalmic side effects of commonly used medications in the pediatric population. It highlights the need to keep a broad differential in mind when encountering sudden onset blurry vision in the primary care clinic, the need for careful consideration of side effects when starting topiramate therapy in a child, and the need for parental counseling of side effects.

Do we really need to panic in all acute vision loss in ICU? Acute angle-closure glaucoma.

Acute angle closure glaucoma is a sight-threatening situation characterized by a sudden and marked rise in intraocular pressure (IOP) due to obstruction of aqueous humour outflow. Many local (ocular drops, nasal and nebulized agents) and systemic drugs (e.g. atropine, adrenaline, ephedrine, some psychoactive and antiepileptic drugs) that are widely used in intensive care units have the potential to precipitate such an acute attack. In this case report, we describe progressive visual loss due to acute angle-closure glaucoma (AACG) in a 59 year old female patient followed in the ICU due to a massive pulmonary embolism.

Topiramate-induced angle-closure glaucoma: cross-sensitivity with other sulphonamide derivatives causing anterior uveitis.

Topiramate is a recognized cause of drug-induced acute angle-closure glaucoma. We describe a case presenting with bilateral acute angle-closure glaucoma caused by topiramate intake. Patient subsequently developed severe anterior uveitis caused by sulphonamide derivatives (acetazolamide and co-trimoxazole) due to cross-sensitivity, on two separate occasions. The present case also highlights the role of anterior segment optical tomography in diagnosis and follow-up. In a patient with known drug allergy to topiramate, other sulphonamide derivatives should be avoided to limit the ocular morbidity.