Primary angle closure is usually unilateral at first presentation. Simultaneous bilateral closure, especially in a younger patient or with myopic shift, should prompt a search for a secondary cause: drug-induced ciliochoroidal effusion (topiramate and sulfonamide-containing drugs are classic), uveal effusion, or inflammatory disease.
In drug-induced effusion the mechanism is not pupil block, so laser iridotomy does not help and miotics can worsen it. Stop the drug, use aqueous suppressants and cycloplegia, and image the posterior segment.
- Take a drug history - topiramate and sulfonamide-containing drugs - in every bilateral angle closure
- Suspect ciliochoroidal effusion when both eyes close with a myopic shift
- Image the posterior segment with B-scan or ultrasound biomicroscopy
- Avoid miotics and do not rely on iridotomy when effusion is the cause
Why it matters
Treating a secondary closure as primary can delay the right treatment and worsen the eye.
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