A 59-year-old female presents to the office with sudden onset of bilateral eye pain and loss of vision upon waking. The patient also reports some nausea and headache. On examination, the eyes appeared red, with mid-dilated pupils fixed and dilated. The patient has never experienced anything like this before. The patient was established with a new PCP 2 weeks prior and was prescribed new medications to control her seizures, depression, and osteoporosis. The patient was also prescribed a week-long supply of scopolamine for motion sickness prophylaxis for her cruise a week ago. The patient also reports using pseudoephedrine on occasion for nasal congestion, but has not used any in the past 4 days. What drug is the most likely culprit for this patient’s presentation?
A. Sertraline
B. Scopolamine
C. Alendronate
D. Topiramate
E. Pseudophedrine
The correct answer is D) Topiramate.
This patient is presenting with bilateral acute angle closure glaucoma (ACG), which is suggested by a combination of sudden onset of eye pain, sudden loss of vision, red conjunctiva, mid-dilated and fixed pupils, headache, and nausea. This ophthalmic emergency most commonly affects women and adults over 55, but it can also be triggered by specific drug therapies. Commonly associated drugs include anticholinergics, topiramate, sulfonamides, duloxetine, and over-the-counter decongestants. Due to this occurring weeks after starting these new therapies and the acute ACG being bilateral, the most likely culprit in this case would be the topiramate.
Choice A) Sertraline has weak anti-cholinergic effects that can rarely cause acute ACG subacutely after starting within the first two weeks, but less likely than Topiramate.
Choice B) Scopolamine is an anti-cholinergic that can cause acute ACG by causing mydriasis which blocks the trabecular meshwork, preventing aqueous humor outflow. However, this effect would be within minutes to hours after using. Since this patient has not been used for over a week, this is unlikely.
Choice C) Alendronate more commonly causes uveitis and scleritis and would be less likely than the other options.
Choice E) Pseudoephedrine acts as an agonist on the alpha-1 receptor, causing mydriasis, which can block the trabecular meshwork. Similar to scopolamine, acute ACG would present more immediately within minutes to hours, making this less likely.