Posters

Sumatriptan-induced bilateral acute angle closure glaucoma: a rare association

Poster Details

First Author: S.Zormpas UK

Co Author(s): A. Matsou   C. Panos                 

Abstract Details

Purpose:

Simultaneous bilateral acute angle closure glaucoma is a rare ophthalmic emergency that requires prompt recognition and treatment to prevent permanent optic nerve damage. Several topical and systemic medications have been implicated in precipitating bilateral drug-induced acute angle closure, with the most commonly reported systemic ones being sulfa-based drugs, antidepressants (such as amitryptilline), antipsychotics, benzodiazepines, anti-parkinsonians, anticonvulsants (topiramate being the most common) and antiinflammatory agents. Sumatriptan is a triptan class drug used for migraine and cluster headaches. We present a case of bilateral simultaneous acute angle closure in a female patient following recent increase of the sumatriptan dose for migraine treatment

Setting:

Epsom & St Helier University Hospitals, NHS Trust, London, UK

Methods:

A 54 year-old female patient who had recently her sumatriptan dose increased due to persistent migraines, presented to the emergency department with acute onset headache, nausea and vomiting. She was initially considered to develop serotonin syndrome until she also admitted bilateral blurry vision and was subsequently seen by the on call ophthalmologist. Examination revealed bilaterally reduced visual acuity (OD 3/60, OS 2/60), marked bilateral conjunctival hyperaemia, severe corneal oedema with Descemet’s folds, fixed mid-dilated pupils, shallow anterior chamber with closed angles and raised intraocular pressure (IOP: OD 55mmHg, OS 58mmHg). A diagnosis of bilateral acute angle closure was made.

Results:

The patient was managed with intravenous acetazolamide and topical apraclonidine, pilocarpine, timolol and dexamethasone drops with a drastic reduction in intraocular pressure which allowed for bilateral peripheral iridotomies to be performed. The possible association with sumatriptan intake was considered and therefore immediate discontinuation was advised. On further follow up, IOP normalized and anterior chamber deepened bilaterally with no further angle closure episodes or other sequelae. The patient was successfully weaned off topical hypertensive agents and remained symptom-free on subsequent visits.

Conclusions:

Sumatriptan is a selective vascular 5-hydroxytryptamine 1 receptor subtype agonist mediating vasoconstriction. Both patients and treating physicians should be aware of the potential side-effect of this drug to cause acute angle closure, especially since acute angle closure symptoms may be mistaken for systemic side effects of serotonergic drugs. In our case, the symptoms developed after an increase in the usual sumatriptan dose, falsely raising initially an alarm for serotonin syndrome. Careful history taking and appropriate ophthalmological referral contributed to timely management of this patient with no detrimental visual consequences.

Financial Disclosure:

None