Abstract
Purpose
We present a case of acute onset of bilateral choroidal effusions leading to angle closure glaucoma attributed to multiple mechanism of actions causing ciliary body and aqueous flow disruption in the setting of topical glaucoma therapy with latanoprost, brimonidine 0.2%, and Brinzolamide 0.1%.
Observation
The patient presented with ocular hypertension in the setting of bilateral choroidal effusions, leading to angle closure without pupillary block. After cessation of the glaucoma drops and starting steroids and cycloplegics, the patient’s symptoms resolved.
Conclusions and importance
This case report highlights the various physiological mechanisms of action that can induce angle closure glaucoma from commonly used topical medications for glaucoma treatment. Thus, a keen awareness is warranted of this idiosyncratic reaction in order to avoid morbidity and long term vision loss.
Abbreviations
IOP
Intraocular Pressure
OU
Oculus Uterque – Both eyes
QHS
Quaque hora somni – Every night
COPD
Chronic Obstructive Pulmonary Disease
OD
Oculus Dexter
OS
Oculus Sinister
UBM
Ultrasound biomicroscopy
Va
Visual Acuity
CF
Count Fingers
QID
Four times a day
TID
Three times a day
BID
Two times a day
VKH
Vogt-Koyanagi-Harada Disease
1
Introduction
Drug induced bilateral angle closure is a well reported phenomenon, especially with sulphamate-substituted compounds, such as topiramate, hydrochlorothiazide, and acetazolamide . Topical brinzolamide, a carbonic anhydrase inhibitor, brimonidine, alpha 2 adrenergic receptor agonist, and latanaprost, a prostaglandin analog, are routinely used to for the treatment of glaucoma. This case presents a patient with bilateral angle closure, who improves rapidly after cessation of all glaucoma drop therapy. We seek to identify various mechanisms of action of each glaucoma drug taken by our patient that may have lead and compounded to the development of angle closure.
2
Case presentation
A 78 year old female presented to the ophthalmology clinic with acute vision loss and headache. Her past ocular history was significant for pseudophakia OU, dry macular degeneration and open angle glaucoma, for which she had chronically used latanaprost 0.005% QHS OU, and recently prescribed Simbrinza™ (Brimonidine 0.1%/Brinzolamide 0.1%) BID OU. Her medical history was significant for COPD. On examination, her visual acuity was 20/400 OD and 20/200 OS. Pupils were equally reactive and without a relative afferent pupillary defect. Her IOP was 24 OD and 23 OS. Slit lamp exam showed a quiet anterior chamber but shallow peripherally. Indentation gonioscopy revealed closed angles OU. UBM demonstrated irido-corneal apposition in the setting of 360° choroidal effusions OU ( Fig. 1 ). A manifest refraction revealed a 3 diopter myopic shift. The diagnosis of bilateral secondary acute angle closure secondary to choroidal effusions from brinzolamide was made. As a result, Simbrinza™ was discontinued and brimonidine 0.15% TID OU was added to control her IOP, as well as topical homatropine BID OU.
