Bilateral Acute Angle-Closure Glaucoma with Topiramate
Stop topiramate immediately—this is a known serious adverse effect causing acute angle-closure glaucoma that typically occurs within the first month of therapy and requires urgent ophthalmologic intervention. 1, 2
Immediate Management
Discontinue topiramate urgently as this medication causes acute myopia and secondary angle-closure glaucoma through ciliary body swelling and anterior displacement of the lens-iris diaphragm. 1, 2
- Refer emergently to ophthalmology for intraocular pressure management, which may include topical medications, systemic agents, or surgical intervention. 2
- Do not perform laser peripheral iridotomy as the mechanism differs from primary angle-closure glaucoma—topiramate causes anterior rotation of the ciliary body rather than pupillary block. 2
Clinical Context
Topiramate-induced acute angle-closure glaucoma is a well-recognized serious adverse effect that:
- Typically presents bilaterally (unlike primary angle-closure which is often unilateral initially). 1
- Usually occurs within the first 2 weeks to 1 month of starting therapy. 1
- Resolves with drug discontinuation, though acute management of elevated intraocular pressure is still required. 2
This is an absolute contraindication to future topiramate use. 2
Alternative Therapy Considerations
If topiramate was being used for idiopathic intracranial hypertension (IIH):
- Switch to acetazolamide as the first-line carbonic anhydrase inhibitor for IIH, with dose escalation as tolerated. 3, 4
- Acetazolamide does not carry the same risk of acute angle-closure glaucoma. 3
- Both medications lower intracranial pressure through different molecular mechanisms—acetazolamide primarily through carbonic anhydrase inhibition at the choroid plexus, while topiramate also affects CSF secretion through additional transporters. 5
If topiramate was being used for migraine prophylaxis:
- Consider alternative migraine preventive medications that do not carry this ocular risk. 3
- Weight management and lifestyle modifications remain important for IIH patients. 3
Key Pitfall to Avoid
Do not restart topiramate after resolution—this represents a serious drug reaction with potential for permanent vision loss if not recognized and managed promptly. 1, 2