More Than Meets the Eye: Topiramate-Induced Bilateral Secondary Angle Closure Unmasking Secondary Antiphospholipid...

To describe a diagnostic challenge in a case of bilateral topiramate-induced secondary angle closure which led to unmasking of systemic lupus erythematosus (SLE) and secondary antiphospholipid syndrome (APS) highlighting the importance of recognizing posterior segment findings that are disproportionate to the expected manifestations of drug-induced angle closure.

A 21-year-old female presenting with acute diminution of vision in both eyes, following initiation of oral topiramate for migraine was evaluated.

Anterior segment examination, gonioscopy, and ultrasound biomicroscopy were performed to assess angle status. Findings were consistent with bilateral topiramate-induced secondary angle closure. Following intraocular pressure reduction, posterior segment evaluation revealed findings suggestive of retinal vascular occlusive disease and vasculitis in RE and choroidal ischemia in LE. Progressive ischemic changes were noted on serial examinations over the course of the next few days. Systemic workup for autoimmune and hypercoagulable states was added based on fundus findings which were atypical for a case of drug-induced angle closure. The patient tested positive for antinuclear antibody, anti- double stranded DNA antibody, persistent triple-positive antiphospholipid antibodies, leading to a diagnosis of SLE with secondary APS. Despite aggressive immunosuppressive and anticoagulant therapy, RE had poor visual recovery, whereas timely intervention led to visual improvement in LE.

The case illustrates that posterior segment findings that are disproportionate to the expected manifestations of topiramate-induced angle closure should prompt urgent evaluation for an underlying systemic autoimmune or hypercoagulable disorder. Careful posterior segment evaluation following normalization of intraocular pressure may reveal vision-threatening pathology and facilitate early multidisciplinary management.