Sir,

Acetazolamide, a sulphonamide-derived medication, frequently used in glaucoma and after cataract surgery, can very rarely cause idiosyncratic reaction, and few reports are present in literature.1, 2, 3

We report ocular coherence tomography (OCT) scans of the posterior pole in a case of ciliary body oedema after the drug administration causing bilateral angle-closure glaucoma (ACG). In our case we found a massive choroidal effusion with posterior retinal folds and papillary oedema, never described before in literature.

Case report

The drug reaction occurred in a 71-year-old white man who was prescribed a single oral dose of acetazolamide (250 mg) after cataract surgery and IOL implantation under local anesthesia.

On examination, both eyes showed congestion and oedema of the inferior bulbar conjunctiva, heavy cloudy cornea, very shallow anterior chamber. IOL was shifted forward. Intra ocular pressure was 52 mm Hg in right eye and 60 mm Hg in left eye. A diagnosis of ACG was made. Fundus examination was characterized by bilateral peripheral choroidal detachment and papillary swelling (Figure 1). Posterior OCT scans confirmed papillary oedema together with retinal folds (Figure 2) and nerve fiber layer thickening.

Figure 1
figure 1

Fundus photo showing evident disc swelling and retinal folds.

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Figure 2
figure 2

High-resolution OCT images of the posterior pole during acetazolamide administration with retinal folds (a) and after the resolution of the effusion (b). High-resolution OCT images of the posterior pole during acetazolamide administration with papillary oedema (c) and after the resolution of the effusion (d).

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Acetazolamide has been suspected to be the cause of the secondary ACG, and after it was discontinued the effusion receded rapidly.

Comment

Few cases of acute secondary ACG with choroidal effusion and anterior shift of the iris-lens diaphragm have been associated with acetazolamide compared with other sulphonamides.1, 2, 3

With regard to the posterior involvement there are only few reports of retinal folds attributed to topiramate and hydrochlorothiazide.4, 5

Papillary oedema has never been associated with sulpha drugs. Posterior involvement with retinal folds and papillary oedema due to acetazolamide has never been described before.

OCT was able to document this effusion caused by the absence of any barrier in the prelaminar region that could inhibit the diffusion of fluid from the choroid into the papilla and peripapillary region.

Retinal folds were caused by the choroidal effusion contained by the barrier of retinal pigment epithelium and the inextensible scleral coat.

OCT shows the extensive posterior pole involvement and the resolution of the rare adverse reaction manifestations after the drug administration was discontinued.