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Rifampicin/isoniazid/pyrazinamide/ethambutol Ocular toxicity due to ethambutol in the form of blindness and optic neuropathy: case report

A 23-year-old woman developed ocular toxicity due to ethambutol in the form of blindness and optic neuropathy during antitubercular treatment with rifampicin/isoniazid/pyrazinamide/ethambutol for tubercular meningitis. The woman, who presented to hospital with complaints of fever, headache and altered sensorium, was eventually diagnosed with tubercular meningitis. Thus, first line anti-tubercular treatment was initiated with rifampicin/isoniazid/pyrazinamide/ethambutol. The daily dose of ethambutol was 15 mg/kg [route not stated]. On the third day after initiation of anti-tubercular therapy, she presented again to the hospital with complaints of blurred vision. On the following day (on the fourth day), she experienced a complete loss of vision without any other symptom of focal neurological deficit. She was thus hospitalised for further evaluation and management. A clinical examination revealed complete blindness bilaterally, without perception of light. Pupils were found be dilated bilaterally, and light reflexes (both consensual and direct) were found to be absent with preservation of accommodation reflexes. Cranial nerve examinations were normal. A brain MRI revealed multiple tuberculomas with mild hydrocephalus without involvement of the optic nerve or tract. Also, there was no evidence of infarct or abscess. An ophthalmic examination revealed normal bilateral fundus. A visual evoked potential showed ’p’ values of 105 and 108. A macular optical coherence tomography suggested CMT 224um and 190um, suggestive of optic neuropathy. Based on the above-mentioned findings and since ethambutol was known to cause optic neuropathy, she was suspected to have developed ocular toxicity due to ethambutol in the form of blindness and optic neuropathy. The woman’s therapy with ethambutol was therefore withdrawn. Further, she was managed symptomatically along with antitubercular therapy with rifampicin/isoniazid/pyrazinamide. A gradual improvement in the vision was subsequently noted with projection of rays to 6/60. Manocha R, et al. Acute onset blindness in a tubercular meningitis patient on antitubercular treatment: A rare case. Journal of the Indian Academy of Clinical Medicine 21: 803502806 85-87, No. 1, Jan-Jun 2020. Available from: URL: http://www.jiacm.in/pdf2020/jan_july_20_85_87.pdf

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Reactions 26 Sep 2020 No. 1823