Acetazolamide-induced bilateral choroidal effusion with shallow anterior chamber following uncomplicated cataract surgery

Swati Singh; Kanika Bhardwaj; Obuli Ramachandran

doi:10.4103/IJO.IJO_2711_22

CASE REPORT

Year : 2023 | Volume : 3 | Issue : 2 | Page : 384-387

Acetazolamide-induced bilateral choroidal effusion with shallow anterior chamber following uncomplicated cataract surgery

Swati Singh¹, Kanika Bhardwaj², Obuli Ramachandran³
¹ Cataract and Glaucoma Services, Centre for Sight, New Delhi, India
² Cataract and Refractive Surgery, Centre for Sight Eye Institute, New Delhi, India
³ Vitreo-Retina Services, Centre for Sight Eye Institute, New Delhi, India

Date of Submission	16-Oct-2022
Date of Acceptance	08-Dec-2022
Date of Web Publication	28-Apr-2023

Correspondence Address:
Swati Singh
Cataract and Glaucoma Services, Centre for Sight, B-5/24, Safdarjung Enclave, New Delhi - 110 029
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_2711_22

Abstract

Choroidal effusion is a collection of fluid in the suprachoroidal space, which may be rarely seen after few surgical procedures or in unoperated eyes, especially in the settings of hypotony, inflammation, or both. Certain systemic medications such as sulfonamides have been identified to induce sudden myopic shift and acute angle closure glaucoma with ciliochoroidal effusion. We report a case of a 78-year-old man who developed bilateral choroidal effusion on the first postoperative day after an uncomplicated cataract surgery in one eye. The most probable cause was identified to be the consumption of carbonic anhydrase inhibitor in both pre- and postoperative periods, and there was a complete resolution of choroidal detachment after discontinuation of the drug.

Keywords: Bilateral choroidal effusion, cataract surgery complications, choroidal detachment post phacoemulsification, induced myopia, idiosyncratic drug reaction, secondary angle closure glaucoma

How to cite this article:
Singh S, Bhardwaj K, Ramachandran O. Acetazolamide-induced bilateral choroidal effusion with shallow anterior chamber following uncomplicated cataract surgery. Indian J Ophthalmol Case Rep 2023;3:384-7

How to cite this URL:
Singh S, Bhardwaj K, Ramachandran O. Acetazolamide-induced bilateral choroidal effusion with shallow anterior chamber following uncomplicated cataract surgery. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:384-7. Available from: https://www.ijoreports.in/text.asp?2023/3/2/384/374976

Acute transient myopia and bilateral secondary angle-closure glaucoma after systemic administration of certain drugs is not an unknown entity.^[1] The exact pathophysiology is unknown, and different mechanisms have been proposed to explain this phenomenon. Many psychotropics and antihistaminic drugs by their anticholinergic or sympathomimetic effect may precipitate acute angle-closure attack with a pupillary block by causing mydriasis in anatomically susceptible eyes.^[1] Drugs belonging to sulfonamide group are known to induce an idiosyncratic ciliary body edema and ciliochoroidal effusion causing an anterior shift of lens iris diaphragm and acute myopia along with a nonpupillary block secondary angle-closure glaucoma, which is not amenable to laser treatment.^[2],[3] The most notorious agent in this group is topiramate, an anticonvulsant with maximum cases of induced myopia and angle closure reported after its usage.^[2] Acetazolamide, another sulfa derivative which is frequently prescribed in the peri-operative period to prevent the postoperative intraocular pressure (IOP) spikes, is also reported to cause ciliochoroidal effusion and acute secondary angle-closure glaucoma.^{[3],[4],[5],[6],[7],[8],[9]} We present the case of a 78-year-old man who developed acetazolamide-induced bilateral serous choroidal effusion with shallow anterior chamber (AC) without an acute elevation of IOP on the first postoperative day after uncomplicated cataract surgery in his right eye.

Case Report

A 78-year-old man, a known hypertensive on tab. bisoprolol 2.5 mg and amlodipine 5 mg, underwent uneventful phacoemulsification with posterior chamber intraocular lens implantation in his right eye. He was given one tablet of acetazolamide 250 mg pre-surgery and then one tablet in the evening after surgery to prevent a postoperative IOP spike, along with routine pre- and postoperative medication. On the first postoperative day, patient was asymptomatic with an unaided vision of 20/40 in RE and 20/60 in LE. AC was diffusely shallow in both eyes without any significant AC reaction. A small air bubble was present in RE, with a well-centered IOL and round pupil [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. The entry wound was well apposed with a clear cornea and no wound leak [Figure 1]a. AC depth (IOL Master 700) in RE was 2.27 mm (2.93 mm preop) and in LE was 1.78 mm (2.67 mm preop). In the phakic fellow eye, the lens thickness had increased from 5.28 mm pre-op to 5.53 mm [Table 1]. The IOP was 16 and 18 mm in the right and left eyes, respectively. Fundus examination showed 360° serous choroidal detachment (CD) in RE and inferonasal and superior CDs in LE, which was confirmed on ultrasound B-scan [Figure 2]a and [Figure 2]b. The patient was diagnosed as having bilateral choroidal effusion, and acetazolamide was immediately discontinued. He was started on oral steroid (prednisolone 1 mg/kg body weight), eyedrops prednisolone 1% one hourly, atropine 1% three times a day, and brimonidine 0.15%, 12 hourly. After 1 week, deepening of AC was observed in both eyes [Figure 3]a and [Figure 3]b. AC depth on IOL Master increased to 4.11mm (RE) and 2.74mm (LE), lens thickness in LE reduced to 5.32 mm [Table 2], and unaided vision improved to 20/30 in both eyes (BE). Oral and topical steroids were slowly tapered over the next few weeks, and patient was doing well until the last visit.

Figure 1: Slit-lamp examination on the first postoperative day. (a) Right eye diffuse illumination picture. (b) Right eye oblique slit illumination showing shallow anterior chamber. (c) Left eye diffuse illumination picture. (d) Left eye oblique slit illumination showing diffuse shallowing of anterior chamber and forward shift of lens–iris diaphragm

Click here to view

Figure 2: B-scan ultrasonography on the first postoperative day showing serous choroidal detachment in (a) right eye and (b) left eye

Click here to view

Figure 3: Slit-lamp oblique illumination picture after 1 week of surgery showing deepened anterior chamber after withdrawal of acetazolamide: (a) right eye; (b) left eye

Click here to view

Table 1: Changes in anterior chamber depth in both eyes and lens thickness changes in phakic left eye on biometry from the preoperative period to 1 week postoperatively

Click here to view

Table 2: Compilation of published case reports of acetazolamide-induced bilateral choroidal effusion after phacoemulsification

Click here to view

Discussion

Uveal effusions are uncommon after cataract surgery, though many small effusions are self-resolving and may go unnoticed. Sabti et al.^[10] found uveal effusion on echography in 5.8% of patients. They found a significant correlation between wound leak-related hypotony and administration of oral acetazolamide and topical pilocarpine postoperatively, with occurrence of uveal effusion. However, a bilateral uveal effusion in a patient with unoperated fellow eye goes more in favor of a systemic cause such as drug-induced idiosyncratic reaction. We found six case reports of acetazolamide-induced choroidal effusion after phacoemulsification surgery.^{[4],[5],[6],[7],[8],[9]} In four cases, it was seen after the second eye surgery [Table 2].^{[5],[7],[8],[9]} Senthil et al.,^[5] in their case series, reported a case who presented with acute angle closure after 2 days of second eye cataract surgery. Malagola et al.^[6] reported a case of bilateral ciliochoroidal effusion with myopic shift and secondary angle-closure glaucoma on the same day of cataract surgery. Mancino et al.^[7] also reported a case of acetazolamide-induced bilateral acute angle closure glaucoma (ACG) and choroidal effusion on the first postoperative day. In all these reports, patients presented with bilateral acute angle closure with raised IOP, and acetazolamide was initially continued in an increased dosage to control the IOP. In all except one of these six cases, resolution occurred after discontinuation of acetazolamide [Table 2]. Unlike the previously reported cases, our patient did not present with acute angle closure, even though his chambers were significantly shallow. A concurrent ciliary body edema and inflammation causing reduced aqueous secretion may be a possible explanation in this case. A significant increase in lens thickness in phakic fellow eye also supports the possibility of idiosyncratic ciliary body swelling and zonular relaxation.^[4] An early diagnosis and prompt withdrawal of acetazolamide with initiation of intensive steroid–cycloplegic therapy in both eyes helped in quick resolution of ciliochoroidal effusion. Laser iridotomy was not performed as there was no pupillary block element. The relationship between appearance and disappearance of signs and symptoms with consumption and withdrawal of acetazolamide strongly suggests the role of the drug in causation of the disease.

Conclusion

Bilateral shallow AC in the postoperative period should raise a suspicion of drug-induced ciliochoroidal effusion. Indiscriminate use of acetazolamide should be avoided in all cases, unless specifically indicated. An early diagnosis and withdrawal of the offending drug saved our patient from severe ocular morbidity that could have been caused by a bilateral acute angle-closure crisis. Awareness about this paradoxical reaction-causing potential of acetazolamide is important as the drug may be inadvertently prescribed in even higher dosage to treat its own adverse effect, which may further worsen the situation.

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

1.	Postel EA, Assalian A, Epstein DL. Drug-induced transient myopia and angle-closure glaucoma associated with supraciliary choroidal effusion. Am J Ophthalmol 1996;122:110-2.
2.	Lan YW, Hsieh JW. Bilateral acute angle closure glaucoma and myopic shift by topiramate-induced ciliochoroidal effusion: Case report and literature review. Int Ophthalmol 2018;38:2639-48.
3.	Fan JT, Johnson DH, Burk RR. Transient myopia, angle-closure glaucoma, and choroidal detachment after oral acetazolamide. Am J Ophthalmol 1993;115:813-4.
4.	Parthasarathi S, Myint K, Singh G, Mon S, Sadasivam P, Dhillon B. Bilateral acetazolamide-induced choroidal effusion following cataract surgery. Eye (Lond) 2007;21:870-2.
5.	Senthil S, Garudadri C, Rao HB, Maheshwari R. Bilateral simultaneous acute angle closure caused by sulphonamide derivatives: A case series. Indian J Ophthalmol 2010;58:248-52. [PUBMED] [Full text]
6.	Malagola R, Arrico L, Giannotti R, Pattavina L. Acetazolamide-induced cilio-choroidal effusion after cataract surgery: Unusual posterior involvement. Drug Des Devel Ther 2013;7:33-6.
7.	Mancino R, Varesi C, Cerulli A, Aiello F, Nucci C. Acute bilateral angle-closure glaucoma and choroidal effusion associated with acetazolamide administration after cataract surgery. J Cataract Refract Surg 2011;37415-7.
8.	Hoskens K, Pinto LA, Vandewalle E, Verdonk N, Stalmans I. Bilateral acute angle-closure after intraocular surgery. J Curr Glaucoma Pract 2014;8:113-4.
9.	Anwar M, BrockmannT, Walckling M, Fuchsluger TA. Acute angle-closure glaucoma and effusion syndrome after phacoemulsification. Ophthalmologist 2021;118:838-41.
10.	Sabti K, Lindley SK, Mansour M, Discepola M. Uveal effusion after cataract surgery: An echographic study. Ophthalmology 2001;108:100-3.