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Abstract
Purpose
This study reports a case of bilateral acute angle-closure crisis induced by two kinds of serotonin-norepinephrine reuptake inhibitors (SNRIs), duloxetine and tramadol.
Case summary
A 55-year-old female visited our clinic, complaining of bilateral visual impairment, ocular pain, and headache, which began 2 days after taking several drugs including duloxetine and tramadol for the purpose of back pain relief. On the day of the first visit, her uncorrected visual acuity was 0.04 in the right eye and 0.02 in the left eye, and the intraocular pressure (IOP) was 45 mmHg in the right eye and 51 mmHg in the left eye. The anterior chamber was shallow and the anterior chamber-angle was closed in both eyes on gonioscopy. There was mild nuclear sclerosis of both lenses. Assuming drug-induced bilateral acute angle-closure crisis, all medications were discontinued, and IOP-lowering agents were prescribed. The symptoms, visual acuity, and IOP improved; however, both anterior chambers were still shallow and the iridocorneal angle was still closed in both eyes. Laser iridotomy was tried in the right eye but failed because the pupils were not completely constricted, and iris bleeding occurred. Phacoemulsification and posterior chamber lens insertion were conducted in both eyes, and her visual acuity, IOP, anterior chamber depth, and iridocorneal angle have been stable at 9 months since her first visit.
Figures and Tables
 | Figure 1Anterior segment photographs of the first visit. Right eye (A) and left eye (B) showed conjunctival injection and dilated pupils. Right eye (C) and left eye (D) showed shallow anterior chamber and mild nuclear sclerosis with anterior bowing of the iris.
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 | Figure 2Anterior segment optical coherence tomography (AS-OCT) on the 5 days after the first visit. AS-OCT of the right eye (A) and the left eye (B). The scleral spurs are noted (arrows).
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 | Figure 3Images of ultrasound biomicroscopy of the right (A) and the left (B) eye on the 5 days after the first visit. The magnified view of the nasal side of the right eye (C) and the nasal side of the left eye (D). Crystalline lens moved anteriorly and anterior chamber depth and iridocorneal angle were decreased in both eyes. Ciliary effusion is observed in the left eye (yellow asterisk and arrow), while it is not obvious in the right eye.
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Table 1
Summary of case reports of AACC induced by SNRIs
AACC = acute angle closure crisis; SNRIs = serotonin-norepinephrine reuptake inhibitors; IOP = intraocular pressure; F = female; OD = right eye; LI = laser iridotomy; OS = left eye; IV = intravenous; OU = both eyes; M = male; ACG = angle closure glaucoma; N-C = not checkable.
*Time intervals between the first drug intake and symptom onset; †other than age and sex; ‡angle closure crisis associated with venlafaxine treatment; only presented as a poster at 10th European Glaucoma Society Congress; §acute angle closure crisis induced by duloxetine, only presented as a poster at 2012 European Association for Vision and Eye Research Conference.
Notes
This study was presented as a poster at the 120th Annual Meeting of the Korean Ophthalmological Society 2018.
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