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Acute Onset of Blurry Vision in a Young Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 25-year-old man presented to an ophthalmologist outside the authors’ department with acutely decreased visual acuity in both eyes. He had woken up earlier that morning with normal visual acuity, but his visual acuity had progressively worsened to the point that he was unable to work. He denied additional symptoms, other than mild tearing. Per his ophthalmologist, his visual acuity improved with a −10 diopter lens, but his intraocular pressure was elevated to between 30 and 40 mm Hg OU. The patient was sent to the emergency department, where the authors’ consultation team evaluated him. The patient’s medical history was remarkable for hypertension and asthma. He denied smoking, drinking alcohol, and using recreational drugs. A review of symptoms was otherwise negative. His medications included losartan, albuterol, and fluticasone. On examination, his visual acuity was 20/400 OU (while wearing prescription lenses, −2.75 + 1.00 × 090 OD and −2.50 + 1.00 × 081 OS). His best-corrected visual acuity was 20/25 OU (manifest refraction, −12.00 + 1.75 × 097 OD and −10.75 + 0.25 × 050 OS). His intraocular pressure was 19 OU. Sensorimotor and external examination results were normal. A slitlamp examination revealed mild diffuse vasodilation and temporal chemosis, clear corneas, shallow anterior chambers, and clear lenses in both eyes. A gonioscopic examination showed no angle structures in either eye. Results of an undilated fundus examination was unremarkable. Figure 1 shows ultrasonographic images of his eyes.

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Presumed drug-induced secondary angle-closure glaucoma

D. Provide patient education and observation

On further questioning, the patient acknowledged ingesting 2 extended-release pills combining 3.75-mg phentermine and 23-mg topiramate (Qsymia), which were given by his mother 1 week prior and intended for weight loss. Because he subsequently developed elevated intraocular pressures and blurry vision, this history and clinical findings were concerning for angle-closure glaucoma, presumably induced by phentermine-topiramate. Since being approved by the Food and Drug Administration for weight loss in 2012,1 one other case of presumed phentermine-topiramate–induced glaucoma has been reported in the literature.2 Other drugs implicated in secondary angle-closure glaucoma include acetazolamide, hydrochlorothiazide, and venlafaxine,3,4 which the patient denied taking.

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Article Information

Corresponding Author: Kai B. Kang, MD, Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, 1855 W Taylor St, MC 648, Chicago, IL 60612 (kaikang@uic.edu).

Published Online: August 22, 2019. doi:10.1001/jamaophthalmol.2019.3058

Conflict of Interest Disclosures: Dr Kang reports receiving a grant from National Institutes of Health (K12EY021475) during the conduct of this study. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
US Food and Drug Administration. Highlights of prescribing information: Qsymia (phentermine and topiramate extended-release) capsules, for oral use, CIV, initial U.S. approval: 2012. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/022580s004lbl.pdf. Published April 2013. Accessed July 17, 2019.
2.
Grewal  DS, Goldstein  DA, Khatana  AK, Tanna  AP.  Bilateral angle closure following use of a weight loss combination agent containing topiramate.  J Glaucoma. 2015;24(5):e132-e136. doi:10.1097/IJG.0000000000000157PubMedGoogle ScholarCrossref
3.
Murphy  RM, Bakir  B, O’Brien  C, Wiggs  JL, Pasquale  LR.  Drug-induced bilateral secondary angle-closure glaucoma: a literature synthesis.  J Glaucoma. 2016;25(2):e99-e105. doi:10.1097/IJG.0000000000000270PubMedGoogle ScholarCrossref
4.
Parivadhini  A, Lingam  V.  Management of secondary angle closure glaucoma.  J Curr Glaucoma Pract. 2014;8(1):25-32. doi:10.5005/jp-journals-10008-1157PubMedGoogle Scholar
5.
Fraunfelder  FW, Fraunfelder  FT, Keates  EU.  Topiramate-associated acute, bilateral, secondary angle-closure glaucoma.  Ophthalmology. 2004;111(1):109-111. doi:10.1016/j.ophtha.2003.04.004PubMedGoogle ScholarCrossref
6.
Abtahi  MA, Abtahi  SH, Fazel  F,  et al.  Topiramate and the vision: a systematic review.  Clin Ophthalmol. 2012;6(January):117-131. doi:10.2147/OPTH.S27695PubMedGoogle ScholarCrossref
7.
Lai  J, Choy  BNK, Shum  JWH.  Management of primary angle-closure glaucoma.  Asia Pac J Ophthalmol (Phila). 2016;5(1):59-62. doi:10.1097/APO.0000000000000180PubMedGoogle ScholarCrossref
8.
Friedman  DS, Vedula  SS.  Lens extraction for chronic angle-closure glaucoma.  Cochrane Database Syst Rev. 2006;(3):CD005555. doi:10.1002/14651858.CD005555.pub2PubMedGoogle Scholar
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