Vigabatrin-associated visual field defects in children

Vigabatrin (Sabril), a drug that blocks GABA transaminase, has been used in the treatment of epilepsy since 1989. There have been reports of irreversible constriction of the visual field in adult patients related to vigabatrin (VGB) therapy, resulting in reduced VGB usage in adults. Although used as a second or third line agent in adults, in children it is often considered as a first line treatment for several subgroups of seizures in spite of there being no way, in the majority of cases, to monitor visual fields. Some of these children have a pre-existing visual field defect as part of their primary disorder. We aimed to identify whether visual field loss due to VGB was occurring in our hospital.

We have studied the results of ophthalmic examination in 14 children on VGB at Great Ormond Street Hospital who were able to perform Goldmann visual fields.

Ten of the 14 patients had constriction of their visual fields attributed to VGB. In addition there were 2 patients with suspicious visual field defects thought to be due to VGB. There was pre-existing visual pathway damage in 4 cases and in 2 of these optic disc pallor increased in association with constricted visual fields. However, the optic discs were normal in 7 patients in spite of visual field constriction. Visual acuity was generally normal in spite of gross visual field constriction.

We believe that VGB should be used with great caution where there is pre-existing visual pathway damage. In other cases the benefits should be considered in relation to the risks, which include irreversible visual field damage. At present visual fields can only be monitored by perimetry, which is often not possible in children with epilepsy.