CASE REPORT
Acute Transient Myopia With Shallowing of the Anterior Chamber Induced by Sulfamethoxazole in a Patient With Pseudoxanthoma Elasticum Joana R. Arau´jo, MD,* Se´rgio E. Silva, MD,* Francisco Cruz, MD,* and Fernando Falca˜o-Reis, PhD*w
Purpose: To report a case of acute transient myopia with anterior chamber shallowing induced by sulfamethoxazole in a patient with pseudoxanthoma elasticum (PXE). Design: Observational case report. Methods: A case report of a 45-year-old woman who presented with bilateral acute myopia, anterior chamber shallowing, and intraocular hypertension induced by sulfamethoxazole and was found to have PXE. Initial and follow-up examination findings were reviewed. Results: On first examination, bilateral myopic shift of 4.25 D, bilateral narrowed angles, and ocular hypertension (36 mm Hg right eye and 38 mm Hg left eye) were found. Pentacam images documented the anterior displacement of the iris-lens diaphragm. Undilated fundus examination disclosed bilateral angioid streaks radiating from the papilla. Several redundant skin folds on the neck and axillae were found on external examination. With sulfamethoxazole discontinuation and administration of topical intraocular pressure–lowering drops, there was complete clinical resolution within 1 week. The diagnosis of PXE was confirmed by biopsy of the skin lesions. Conclusions: Acute myopia with angle narrowing is an extremely rare sulfamethoxazole side effect, and its relationship, if any, with PXE is unknown. As far as we know, this is the first reported case of PXE presenting with bilateral angle narrowing induced by sulfamethoxazole. Key Words: bilateral angle closure glaucoma, transient myopia, sulfonamides, pseudoxanthoma elasticum
(J Glaucoma 2014;23:415–417)
F
orward rotation of the iris-lens diaphragm with acute transient myopia and ocular hypertension secondary to angle closure is a known but rare idiosyncratic effect of sulfonamides. Sulfamethoxazole + trimethoprim (cotrimoxazole) is an antibiotic combination and despite its widespread use, there are few case reports of this extremely rare side effect.1–3 The degree of myopia induced by sulfonamides ranges from 0.754 to 8.00 D.5 In addition to acute myopia, the anterior chamber may become markedly shallower with a consequent risk of acute angle closure
Received for publication May 28, 2013; accepted March 14, 2014. From the *Ophthalmology Department, S. Joa˜o Hospital; and wDepartment of Sense Organs, University of Porto, Porto, Portugal. Disclosure: The authors declare no conflict of interest. Reprints: Joana R. Arau´jo, MD, Avenida Prof. Hernaˆni Monteiro, 4202–451, Porto, Portugal (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins DOI: 10.1097/IJG.0000000000000074
J Glaucoma
Volume 23, Number 6, August 2014
glaucoma.1 We report a case of a well-documented anterior displacement of the iris-lens diaphragm with secondary transient myopic shift, angle narrowing, and ocular hypertension induced by sulfamethoxazole. Its relationship, if any, with pseudoxanthoma elasticum (PXE) is unknown. There is 1 case reported about transient myopia and angle closure glaucoma induced by cotrimoxazole in a patient with few bilateral retinal stria radiating from the macula.1 This is the first reported case of PXE presenting with bilateral acute myopia and angle narrowing induced by sulfamethoxazole.
CASE REPORT A 45-year-old white woman with no previously known ocular disease presented to the emergency department with complaints of acute bilateral visual loss, headache, and generalized itching. Patient medical history was remarkable for hypertension and recent cystitis. Cystitis was being treated with oral sulfamethoxazole (800 mg) + trimethoprim (160 mg) and trospium chloride (20 mg), initiated 5 days earlier. On first examination, the best corrected visual acuity was 6/10 ( 3.50 to 1.50 100 degrees) for the right eye (RE) and 9/10 ( 4.00 to 0.75 70 degrees) for the left eye (LE). Anterior segment examination disclosed bilateral shallow anterior chambers. Intraocular pressures (IOP) by Goldmann applanation tonometry were 36 mm Hg RE and 38 mm Hg LE. Slit-lamp gonioscopy revealed bilateral narrow angles (grade II according to the Schaffer Classification). Indentation gonioscopy opened the angles and no peripheral anterior synechiae could be observed. The remaining anterior segment examination of both eyes was unremarkable. Undilated fundus examination disclosed few angioid streaks radiating from the papilla (Fig. 1). External examination showed several redundant skin folds on the neck and axillae. Pentacam confirmed the presence of shallow anterior chambers with narrow angles (19.4 degrees RE/19.2 degrees LE) in both eyes (Figs. 2A, C). The patient was treated with oral acetazolamide (500 mg), topical timolol (0.5%), and brimonidine (0.15%) and the IOP decreased to 22 mm Hg RE and to 20 mm Hg LE. Cotrimoxazole and trospium chloride were discontinued and topical timolol (0.5%, twice daily) and brimonidine (0.15%, 3 times daily) were started. The myopic shift decreased over the following days and a progressive deepening of the anterior chamber was observed. After 1 week of follow-up, the patient’s bilateral uncorrected visual acuity was 10/10 with deep angles open to the scleral spur (Shaffer grade III) and her IOP was 12 mm Hg in both eyes. Pentacam confirmed complete resolution of the iris-lens diaphragm anterior displacement (Figs. 2B, D). Central anterior chamber depth and angle opening measured by ultrasound biomicroscopy were, respectively, 2.77 mm RE and 2.73 mm LE and 30.7 degrees RE and 32.1 degrees LE. The automated static whiteon-white computerized perimetry (program 24-2, SITA standard; Humphrey Instruments, Dublin, CA) disclosed no significant visual field changes. The diagnosis of PXE was confirmed by skin biopsies, and for further systemic workup the patient was evaluated by a cardiologist.
www.glaucomajournal.com |
415
Arau´jo et al
J Glaucoma
Volume 23, Number 6, August 2014
FIGURE 1. Color fundus photograph of right eye (A) and left eye (B). Bilateral angioid streaks (arrowheads) and peau d’orange pigmentary pattern of the retina (stars).
DISCUSSION Transient myopia is a rare idiosyncratic reaction to systemic administration of sulfonamides. The myopic shift is usually bilateral and is completely reversible after discontinuation of the sulfonamide therapy. Various degrees of anterior chamber shallowing and angle narrowing have been reported. Controversy still exists regarding the exact mechanism by which sulfonamides induce forward rotation of the iris-lens diaphragm. Choroidal effusion with ciliary body edema and anterior rotation has been implicated. Because of relaxation of the zonules, the edema would lead to a thickening of the lens as well as the displacement of the iris-lens diaphragm and the consequent shallowing of the anterior chamber and angle closure glaucoma.6–8 Convincing explanations for the etiology of edema of the ciliary body are lacking, but it has been suggested that this is related with the inhibition of carbonic anhydrase or with an effect mediated by prostaglandins.9 In this case, forward rotation of the iris-lens diaphragm with narrow angles induced by cotrimoxazole was documented. This patient was also taking trospium chloride which is a parasympatholytic drug that may dilate the pupil and place the susceptible patient at risk of an attack of angle-closure
glaucoma. However, the possible parasympatholytic effect of this drug in the eye does not explain the acute myopia and the anterior displacement of the iris-lens diaphragm. PXE is a multisystemic heritable disorder with ectopic mineralization, and is characterized by progressive calcification and fragmentation of elastic fibers.10 PXE manifests with characteristic skin findings, and ocular and cardiovascular involvement. The characteristic ocular sign, angioid streaks, results from degeneration and calcification of the elastic fibers leading to breaks in Bruch’s membrane.10 As a systemic disease and although unlikely, the relationship between PXE and the development of acute myopia and angle narrowing cannot be completely ruled out. In contrast, a possible predisposition in patients with PXE for ocular side effects of sulfonamides cannot be excluded. Recently, Trelohana et al11 have found that PXE may be associated with mild myopia, not due to axial length, keratometry, or lens power differences. As cornea and lens have no elastic fibers, the authors suggest that the elastic zonular fibers may be affected in PXE, and that this could predispose to an anterior displacement of the lens. PXE and Marfan syndrome are 2 different diseases, affecting both the elastic tissue. Previous histologic studies
FIGURE 2. PENTACAM images of right eye (A, B) and left eye (C, D) of the anterior chamber and angle during the acute phase and during the convalescent phase.
416 | www.glaucomajournal.com
r
2014 Lippincott Williams & Wilkins
J Glaucoma
Volume 23, Number 6, August 2014
have found qualitative and quantitative changes in Marfan zonular fibers, the hypothesis that the elastic zonular fibers may also be affected in PXE patients might be therefore considered.12,13 In this case, pathologic zonular elastic fibers may predispose to the sulfamethoxazole side effect observed. Additional studies are needed to confirm these preliminary findings. REFERENCES 1. Postel EA, Assalian A, Epstein DL. Drug-induced transient myopia and angel-closure glaucoma associated with supraciliary choroidal effusion. Am J Ophthalmol. 1996;122:110–112. 2. Ramos-Esteban JC, Goldberg S, Danias J. Drug induced acute myopia with supraciliary choroidal effusion in a patient with Wegener’s granulomatosis. Br J Ophthalmol. 2002;86:594–596. 3. Spadoni VS, Pizzol MM, Muniz CH, et al. Bilateral angle-closure glaucoma induced by trimetoprim and sulfamethoxazole combination: case report. Arq Bras Oftalmol. 2007;70:517–520. 4. Boissonnot L, Boissonnot M, Charles-Gervais C, et al. Acute myopia due to Indapamide. Presse Med. 1986;15:802–803. 5. Fan JT, Johnson DH, Burk RR. Transient myopia, angleclosure glaucoma and choroidal detachment after oral acetazolamide. Am J Ophtalmol. 1993;115:813–814.
r
2014 Lippincott Williams & Wilkins
Acute Transient Myopia Induced by Sulfamethoxazole
6. Grinbaum A, Ashkenazi I, Gutman I, et al. Suggested mechanism for acute transient myopia after sulfonamide treatment. Ann Ophthalmol. 1993;25:224–226. 7. Panday VA, Rhee DJ. Review of sulfonamide-induced acute myopia and acute bilateral angle-closure glaucoma. Compr Ophthalmol Update. 2007;8:271–276. 8. Waheeb S, Feldman F, Velos P, et al. Ultrasound biomicroscopic analysis of drug-induced bilateral angle-closure glaucoma associated with supraciliary choroidal effusion. Can J Ophthalmol. 2003;38:299–302. 9. Krieg PH, Shipper I. Drug-induced ciliary body oedema: a new theory. Eye. 1996;10(pt 1):121–126. 10. Uitto J, Li Q, Jiang Q. Pseudoxanthoma elasticum—molecular genetics and putative pathomechanisms. J Invest Dermatol. 2010a;130:661–670. 11. Trelohan A, Milea D, Martin L, et al. Myopia in pseudoxanthoma elasticum. J Fr Ophtalmol. 2013;36:414–417. 12. Mir S, Wheatley HM, Hussels IE, et al. A comparative histologic study of the fibrillin microfibrillar system in the lens capsule of normal subjects and subjects with Marfan’s syndrome. Invest Ophthalmol Vis Sci. 1998;39:84–93. 13. Pavlin CJ, Buys YM, Pathmanathan T. Imaging zonular abnormalities using ultrasound biomicroscopy. Arch Ophtalmol. 1998;116:854–857.
www.glaucomajournal.com |
417
Acute Transient Myopia With Shallowing of the Anterior Chamber Induced by Sulfamethoxazole in a Patient With Pseudoxanthoma Elasticum Joana R. Arau´jo, MD,* Se´rgio E. Silva, MD,* Francisco Cruz, MD,* and Fernando Falca˜o-Reis, PhD*w
Purpose: To report a case of acute transient myopia with anterior chamber shallowing induced by sulfamethoxazole in a patient with pseudoxanthoma elasticum (PXE). Design: Observational case report. Methods: A case report of a 45-year-old woman who presented with bilateral acute myopia, anterior chamber shallowing, and intraocular hypertension induced by sulfamethoxazole and was found to have PXE. Initial and follow-up examination findings were reviewed. Results: On first examination, bilateral myopic shift of 4.25 D, bilateral narrowed angles, and ocular hypertension (36 mm Hg right eye and 38 mm Hg left eye) were found. Pentacam images documented the anterior displacement of the iris-lens diaphragm. Undilated fundus examination disclosed bilateral angioid streaks radiating from the papilla. Several redundant skin folds on the neck and axillae were found on external examination. With sulfamethoxazole discontinuation and administration of topical intraocular pressure–lowering drops, there was complete clinical resolution within 1 week. The diagnosis of PXE was confirmed by biopsy of the skin lesions. Conclusions: Acute myopia with angle narrowing is an extremely rare sulfamethoxazole side effect, and its relationship, if any, with PXE is unknown. As far as we know, this is the first reported case of PXE presenting with bilateral angle narrowing induced by sulfamethoxazole. Key Words: bilateral angle closure glaucoma, transient myopia, sulfonamides, pseudoxanthoma elasticum
(J Glaucoma 2014;23:415–417)
F
orward rotation of the iris-lens diaphragm with acute transient myopia and ocular hypertension secondary to angle closure is a known but rare idiosyncratic effect of sulfonamides. Sulfamethoxazole + trimethoprim (cotrimoxazole) is an antibiotic combination and despite its widespread use, there are few case reports of this extremely rare side effect.1–3 The degree of myopia induced by sulfonamides ranges from 0.754 to 8.00 D.5 In addition to acute myopia, the anterior chamber may become markedly shallower with a consequent risk of acute angle closure
Received for publication May 28, 2013; accepted March 14, 2014. From the *Ophthalmology Department, S. Joa˜o Hospital; and wDepartment of Sense Organs, University of Porto, Porto, Portugal. Disclosure: The authors declare no conflict of interest. Reprints: Joana R. Arau´jo, MD, Avenida Prof. Hernaˆni Monteiro, 4202–451, Porto, Portugal (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins DOI: 10.1097/IJG.0000000000000074
J Glaucoma
Volume 23, Number 6, August 2014
glaucoma.1 We report a case of a well-documented anterior displacement of the iris-lens diaphragm with secondary transient myopic shift, angle narrowing, and ocular hypertension induced by sulfamethoxazole. Its relationship, if any, with pseudoxanthoma elasticum (PXE) is unknown. There is 1 case reported about transient myopia and angle closure glaucoma induced by cotrimoxazole in a patient with few bilateral retinal stria radiating from the macula.1 This is the first reported case of PXE presenting with bilateral acute myopia and angle narrowing induced by sulfamethoxazole.
CASE REPORT A 45-year-old white woman with no previously known ocular disease presented to the emergency department with complaints of acute bilateral visual loss, headache, and generalized itching. Patient medical history was remarkable for hypertension and recent cystitis. Cystitis was being treated with oral sulfamethoxazole (800 mg) + trimethoprim (160 mg) and trospium chloride (20 mg), initiated 5 days earlier. On first examination, the best corrected visual acuity was 6/10 ( 3.50 to 1.50 100 degrees) for the right eye (RE) and 9/10 ( 4.00 to 0.75 70 degrees) for the left eye (LE). Anterior segment examination disclosed bilateral shallow anterior chambers. Intraocular pressures (IOP) by Goldmann applanation tonometry were 36 mm Hg RE and 38 mm Hg LE. Slit-lamp gonioscopy revealed bilateral narrow angles (grade II according to the Schaffer Classification). Indentation gonioscopy opened the angles and no peripheral anterior synechiae could be observed. The remaining anterior segment examination of both eyes was unremarkable. Undilated fundus examination disclosed few angioid streaks radiating from the papilla (Fig. 1). External examination showed several redundant skin folds on the neck and axillae. Pentacam confirmed the presence of shallow anterior chambers with narrow angles (19.4 degrees RE/19.2 degrees LE) in both eyes (Figs. 2A, C). The patient was treated with oral acetazolamide (500 mg), topical timolol (0.5%), and brimonidine (0.15%) and the IOP decreased to 22 mm Hg RE and to 20 mm Hg LE. Cotrimoxazole and trospium chloride were discontinued and topical timolol (0.5%, twice daily) and brimonidine (0.15%, 3 times daily) were started. The myopic shift decreased over the following days and a progressive deepening of the anterior chamber was observed. After 1 week of follow-up, the patient’s bilateral uncorrected visual acuity was 10/10 with deep angles open to the scleral spur (Shaffer grade III) and her IOP was 12 mm Hg in both eyes. Pentacam confirmed complete resolution of the iris-lens diaphragm anterior displacement (Figs. 2B, D). Central anterior chamber depth and angle opening measured by ultrasound biomicroscopy were, respectively, 2.77 mm RE and 2.73 mm LE and 30.7 degrees RE and 32.1 degrees LE. The automated static whiteon-white computerized perimetry (program 24-2, SITA standard; Humphrey Instruments, Dublin, CA) disclosed no significant visual field changes. The diagnosis of PXE was confirmed by skin biopsies, and for further systemic workup the patient was evaluated by a cardiologist.
www.glaucomajournal.com |
415
Arau´jo et al
J Glaucoma
Volume 23, Number 6, August 2014
FIGURE 1. Color fundus photograph of right eye (A) and left eye (B). Bilateral angioid streaks (arrowheads) and peau d’orange pigmentary pattern of the retina (stars).
DISCUSSION Transient myopia is a rare idiosyncratic reaction to systemic administration of sulfonamides. The myopic shift is usually bilateral and is completely reversible after discontinuation of the sulfonamide therapy. Various degrees of anterior chamber shallowing and angle narrowing have been reported. Controversy still exists regarding the exact mechanism by which sulfonamides induce forward rotation of the iris-lens diaphragm. Choroidal effusion with ciliary body edema and anterior rotation has been implicated. Because of relaxation of the zonules, the edema would lead to a thickening of the lens as well as the displacement of the iris-lens diaphragm and the consequent shallowing of the anterior chamber and angle closure glaucoma.6–8 Convincing explanations for the etiology of edema of the ciliary body are lacking, but it has been suggested that this is related with the inhibition of carbonic anhydrase or with an effect mediated by prostaglandins.9 In this case, forward rotation of the iris-lens diaphragm with narrow angles induced by cotrimoxazole was documented. This patient was also taking trospium chloride which is a parasympatholytic drug that may dilate the pupil and place the susceptible patient at risk of an attack of angle-closure
glaucoma. However, the possible parasympatholytic effect of this drug in the eye does not explain the acute myopia and the anterior displacement of the iris-lens diaphragm. PXE is a multisystemic heritable disorder with ectopic mineralization, and is characterized by progressive calcification and fragmentation of elastic fibers.10 PXE manifests with characteristic skin findings, and ocular and cardiovascular involvement. The characteristic ocular sign, angioid streaks, results from degeneration and calcification of the elastic fibers leading to breaks in Bruch’s membrane.10 As a systemic disease and although unlikely, the relationship between PXE and the development of acute myopia and angle narrowing cannot be completely ruled out. In contrast, a possible predisposition in patients with PXE for ocular side effects of sulfonamides cannot be excluded. Recently, Trelohana et al11 have found that PXE may be associated with mild myopia, not due to axial length, keratometry, or lens power differences. As cornea and lens have no elastic fibers, the authors suggest that the elastic zonular fibers may be affected in PXE, and that this could predispose to an anterior displacement of the lens. PXE and Marfan syndrome are 2 different diseases, affecting both the elastic tissue. Previous histologic studies
FIGURE 2. PENTACAM images of right eye (A, B) and left eye (C, D) of the anterior chamber and angle during the acute phase and during the convalescent phase.
416 | www.glaucomajournal.com
r
2014 Lippincott Williams & Wilkins
J Glaucoma
Volume 23, Number 6, August 2014
have found qualitative and quantitative changes in Marfan zonular fibers, the hypothesis that the elastic zonular fibers may also be affected in PXE patients might be therefore considered.12,13 In this case, pathologic zonular elastic fibers may predispose to the sulfamethoxazole side effect observed. Additional studies are needed to confirm these preliminary findings. REFERENCES 1. Postel EA, Assalian A, Epstein DL. Drug-induced transient myopia and angel-closure glaucoma associated with supraciliary choroidal effusion. Am J Ophthalmol. 1996;122:110–112. 2. Ramos-Esteban JC, Goldberg S, Danias J. Drug induced acute myopia with supraciliary choroidal effusion in a patient with Wegener’s granulomatosis. Br J Ophthalmol. 2002;86:594–596. 3. Spadoni VS, Pizzol MM, Muniz CH, et al. Bilateral angle-closure glaucoma induced by trimetoprim and sulfamethoxazole combination: case report. Arq Bras Oftalmol. 2007;70:517–520. 4. Boissonnot L, Boissonnot M, Charles-Gervais C, et al. Acute myopia due to Indapamide. Presse Med. 1986;15:802–803. 5. Fan JT, Johnson DH, Burk RR. Transient myopia, angleclosure glaucoma and choroidal detachment after oral acetazolamide. Am J Ophtalmol. 1993;115:813–814.
r
2014 Lippincott Williams & Wilkins
Acute Transient Myopia Induced by Sulfamethoxazole
6. Grinbaum A, Ashkenazi I, Gutman I, et al. Suggested mechanism for acute transient myopia after sulfonamide treatment. Ann Ophthalmol. 1993;25:224–226. 7. Panday VA, Rhee DJ. Review of sulfonamide-induced acute myopia and acute bilateral angle-closure glaucoma. Compr Ophthalmol Update. 2007;8:271–276. 8. Waheeb S, Feldman F, Velos P, et al. Ultrasound biomicroscopic analysis of drug-induced bilateral angle-closure glaucoma associated with supraciliary choroidal effusion. Can J Ophthalmol. 2003;38:299–302. 9. Krieg PH, Shipper I. Drug-induced ciliary body oedema: a new theory. Eye. 1996;10(pt 1):121–126. 10. Uitto J, Li Q, Jiang Q. Pseudoxanthoma elasticum—molecular genetics and putative pathomechanisms. J Invest Dermatol. 2010a;130:661–670. 11. Trelohan A, Milea D, Martin L, et al. Myopia in pseudoxanthoma elasticum. J Fr Ophtalmol. 2013;36:414–417. 12. Mir S, Wheatley HM, Hussels IE, et al. A comparative histologic study of the fibrillin microfibrillar system in the lens capsule of normal subjects and subjects with Marfan’s syndrome. Invest Ophthalmol Vis Sci. 1998;39:84–93. 13. Pavlin CJ, Buys YM, Pathmanathan T. Imaging zonular abnormalities using ultrasound biomicroscopy. Arch Ophtalmol. 1998;116:854–857.
www.glaucomajournal.com |
417
