Sumatriptan

Abstract

Bilateral acute angle closure glaucoma: case report A 52-year-old woman developed bilateral acute angle closure (AAC) glaucoma during treatment with sumatriptan for migraines. The woman presented to the emergency department with a history of severe headache, nausea, vomiting and loss of vision. She had a history of hypertension and migraine and was treated with sumatriptan 100mg [route not stated] as required for migraines with good response. Over the past 3 days, her migraine severity increased. Hence, she had to double her regular dose of sumatriptan to 200 mg/24h to achieve adequate control of pain. At the presentation, she was orientated and alert. She was also hypertensive, tachycardic and apyrexial with a pain score of 10/10. Her pupils were moderately dilated, while other neurological investigations were normal. Sumatriptan was immediately discontinued, and the woman started receiving treatment with intravenous fluids and unspecified analgesia under close observation. On the next day, her vision remained poor. She had an ocular history of mild myopia, which was corrected with spectacles for distance. Ocular examination showed bilaterally decreased best-corrected visual acuity and increased intraocular pressure (IOP). Slit-lamp examination showed marked bilateral conjunctival hyperaemia, fixed mid-dilated pupils, corneal oedema with Descemet’s folds, early nuclear sclerosis and a uniformly shallow anterior chamber. Gonioscopy showed bilateral appositional angle closure of 360°. The B-scan ultrasonography showed an intact flat retina. The anterior segment optical coherence tomography scan revealed anterior chamber angle closure. Based on findings, a diagnosis of simultaneous bilateral AAC secondary to sumatriptan was made. After ophthalmology examination, she was treated with morphine and ketamine. She also received treatment with acetazolamide, apraclonidine, timolol, pilocarpine and dexamethasone. Subsequently, her IOP was reduced, which allowed bilateral peripheral iridotomies. Her pain also improved. On further follow-up, her visual acuity improved, while IOP became normal. Initially, she also experienced some photophobia with a misshapen pupil in her right eye. Further review of initial CT scan findings indicated glaucoma. Therefore, a diagnosis of bilateral acute angle-closure (AAC) glaucoma was made. No recurrence of AAC was observed. Her treatment with topical hypertensives was slowly weaned off with no further complications. No signs of optic neuropathy were observed. She remained symptom-free with no long-term visual side-effects. Afterwards, she had cataract surgery, which resulted in significant improvement of her vision.