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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 501-502

Escitalopram-induced bilateral secondary angle-closure with uncommon associations


Department of Ophthalmology, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India

Date of Submission17-Sep-2020
Date of Acceptance27-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Rajwinder Kaur
Department of Ophthalmology, Adesh Institute of Medical Sciences and Research, Barnala Road, Bathinda, Punjab - 151 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2925_20

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  Abstract 


Acute angle closure is a rare complication in patients receiving antidepressant treatment. We report two uncommon associations of acute-onset myopia with internal limiting membrane folds and soft exudates following the use of escitalopram. A 28-year-old woman, with no prior history of glasses, taking escitalopram for depression, presented with decreased vision. On examination, she was found to have myopic shift in both eyes and intraocular pressure of 38 mm Hg and 40 mm Hg in the right and left eye, respectively. She had closed angles on gonioscopy; anterior displacement of the iris-lens diaphragm on B-scan and undilated fundus examination revealed soft exudates and inner limiting membrane folds at the macula in both eyes. It is highly important that clinicians be made aware of the risk factors associated with drug-induced secondary acute angle closure with an antidepressant. History taking plays a significant role play in view of any hepatic and renal dysfunction.

Keywords: Acute angle-closure glaucoma, depression, escitalopram


How to cite this article:
Kaur R, Gupta E, Aggarwal A. Escitalopram-induced bilateral secondary angle-closure with uncommon associations. Indian J Ophthalmol Case Rep 2021;1:501-2

How to cite this URL:
Kaur R, Gupta E, Aggarwal A. Escitalopram-induced bilateral secondary angle-closure with uncommon associations. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:501-2. Available from: https://www.ijoreports.in/text.asp?2021/1/3/501/320026



Depression is the most common psychological disorder globally including in India. Many large population-based studies in India reported the prevalence to be as high as 73.97 cases per 1000 population.[1] SSRIs (Selective Serotonin Receptor Inhibitors) are the first choice of drugs in the medical management of depression as they are well tolerated, efficacious, and have a better safety profile. Examples include escitalopram and fluoxetine.[2] Human ocular tissues differentiately express mRNA for various serotonin (five- hydroxytryptamine) receptor subtypes.[3] Chidlow G found that serotonin is involved in aqueous humor dynamics and may have a potential role in IOP regulation.[4] Drug-induced bilateral secondary acute angle closure (2° AAC) is an ophthalmic emergency. 2° AAC is caused by abnormal accumulation of fluid into structures behind the iris that causes forward rotation of the ciliary body, iris-lens diaphragm causing myopic shift, shallow anterior chamber, and elevated intraocular pressure (IOP). Withdrawal of the offending agent is central for the successful and timely treatment to prevent visual loss.[5]

This is the first reported case in relation to escitalopram-induced acute angle closure in this region and is an alert for clinicians and nonophthalmologists to be mindful of medications that can potentially precipitate acute angle closure.


  Case Report Top


Here, we describe a case of 28-year-old woman who presented with the complaint of a sudden decrease in vision along with redness, pain and chemosis and lid edema since 8 days. Five months before presentation, she was started on escitalopram 20 mg/day for depressive psychosis. At the time of presentation, she was admitted in the surgery ward for treatment of viral hepatitis and kidney dysfunction. The patient also had a history of fever, loss of appetite, weakness, and loose stools for eight days. Viral markers including Hepatitis B, HCV, and HIV were negative. On general physical examination, the patient was febrile and pallor was seen. Laboratory investigations revealed deranged liver function tests and renal function tests. On ocular examination, uncorrected visual acuity (UCVA) was <20/400 in both eyes. Best-corrected visual acuity of 20/40 in both eyes with correction of –4.25/–0.75 *70° in the right eye and –4.50/–0.5*80° in the left eye. Slit-lamp examination revealed circumcorneal congestion, mild corneal edema, mid-dilated pupil, and shallow anterior chamber both central and peripheral with forward convexity of the iris-lens diaphragm. IOP with standard Goldmann Applanation tonometer was 38 mm Hg and 40 mm Hg in the right and left eye, respectively. Central Corneal thickness was 546 μm in both eyes. On gonioscopy, angles were closed 360° in both eyes. B-scans revealed anterior displacement of iris-lens diaphragm, choroidal thickening and choroidal effusion [Figure 1]. IOL master 700 was used to document axial length which was 22.46 mm in the right eye and 22.48 mm in the left eye and anterior chamber depth which was OD 2.38 mm and OS 2.33 mm. Fundus examination (mid-dilated) showed internal limiting membrane (ILM) folds and soft exudates in both eyes. Optic nerve head evaluation showed cup: disc ratio of 0.3 in both eyes [Figure 2]. Spectral-domain optical coherence tomography (Spectralis; Heidelberg Engineering, Germany) revealed ILM folds at the macula and infarcts of nerve fiber layer [Figure 3].
Figure 1: (a) B-scan showed choroidal thickening and choroidal effusion in right and left eye. (b) Showed anterior displacement of the iris-lens diaphragm

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Figure 2: Fundus examination (middilated) showed internal limiting membrane folds (ILM) folds and soft exudates in both eyes

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Figure 3: showed (a) and (b) soft exudates and ILM folds in the right eye .(c) and (d) soft exudates and ILM folds in the left eye

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Based on the history of the symptoms and clinical presentation, diagnosis of escitalopram induced secondary acute angle closure was made, escitalopram was discontinued. Topical treatment was started with homatropine eye drop twice daily for four days, with dorzolamide 2% plus timolol maleate 0.5% twice daily and prednisolone acetate 1% eye drops four times daily for three days, all of which were tapered gradually over 3 weeks.

On follow-up after 2 days, after stopping escitalopram and starting prescribed treatment, the conjunctival congestion reduced in both eyes, IOP was reduced to 24 mm Hg in the right eye and 28 mm Hg in the left eye. Psychiatrist was advised to shift to some other drug in view of viral hepatitis and bilateral renal parenchymal disease.


  Discussion Top


Our case describes a patient who presented with sign and symptoms of bilateral secondary acute angle closure with myopic shift with only one identifiable risk factor that is the use of tablet escitalopram for depression. There are cases reported in the literature by Croos,[6] Zelfesky JR,[7] that describe acute angle closure after the use of escitalopram. Escitalopram (75%) is metabolized by CYP hepatic enzymes[8],[9] and our patient suffered from viral hepatitis which might have led to impaired metabolism of escitalopram leading to an increase in serum concentration of the drug which led to drug toxicity. The case reported by Croos[6] also acknowledged the relationship of concentration of serum escitalopram and precipitation of an attack of AAC. The main mechanism of 2° AAC by anti-psychotic drug is ciliary body effusion leading to anterior rotation of iris–lens diaphragm causing shallow anterior chamber that precipitates AAC.[10] Folds in the inner limiting membrane might give a clue to choroidal effusion as the cause for this presentation.[10] Although cotton wool spots are not commonly associated with glaucoma, they can present in the setting of acute elevation of IOP and may be associated with infarct of nerve fiber layer.[11]

Limitation: nonavailability of anterior segment OCT and ultrasound biomicroscopy. (UBM)


  Conclusion Top


The use of SSRIs is widespread; thus, it is important for clinicians and nonophthalmologists to be mindful of medications that can potentially precipitate acute angle closure. Ophthalmologists should be consulted to identify risk factors involved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Grover S, Dutt A, Avasthi A. An overview of Indian research in depression. Indian J Psychiatry 2010;52(Suppl 1):S178-88.  Back to cited text no. 1
    
2.
Ng CW, How CH, Ng YP. Managing depression in primary care. Singapore Med J 2017;58:459-66.  Back to cited text no. 2
    
3.
Chidlow G, Hiscott PS, Osborne NN. Expression of serotonin receptor mRNAs in human ciliary body: A polymerase chain reaction study. Graefes Arch Clin Exp Ophthalmol 2004;242:259-64.  Back to cited text no. 3
    
4.
Osbourne NN. Serotonin and melatonin in the iris/ciliary processes and their involvement in intraocular presence. Acta Neurobiol Exp (Wars) 1994;54(Suppl):57-64.  Back to cited text no. 4
    
5.
Murphy RM, Bakir B, Brien CO, Wiggs JL, Pasquale LR. Drug-induced bilateral secondary angle-closure glaucoma: A literature synthesis. J Glaucoma 2016;25:e99-105.  Back to cited text no. 5
    
6.
Croos R, Thirumalai S, Hassan S, Roza Davis JD. Citalopram associated with acute angle-closure glaucoma: Case report. BMC Ophthalmol 2005;5:23.  Back to cited text no. 6
    
7.
Zelefsky JR, Fine HF, Rubinstein VJ, Hsu IS, Finger Paul T. Escitalopram-induced uveal effusions and bilateral angle closure glaucoma. Am J Ophthalmol 2006;141:1144-7.  Back to cited text no. 7
    
8.
Culpepper L. Escitalopram: A new SSRI for the treatment of depression in primary care. Prim Care Companion J Clin Psychiatry 2002;4:209-14.  Back to cited text no. 8
    
9.
Chen HY, Lin CL, Kao CH. Long-term use of selective serotonin reuptake inhibitors and risk of glaucoma in depression patients. Medicine (Baltimore) 2015;94:e2041.  Back to cited text no. 9
    
10.
Kumar M, Kesarwani S, Rao A, Garnaik A. Macular folds: An unusual association in topiramate toxicity. Clin Exp Optom 2012;95:449-52.  Back to cited text no. 10
    
11.
Bhatt A, Nguyen C, Mosaed S, Minckler D. Clinical and pathological correlation of cotton wool spots in secondary angle closure glaucoma. Am J Ophthalmol Case Rep 2018;10:192-5.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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