Zonisamide
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Choroidal effusion and off-label use: case report A 72-year-old woman developed choroidal effusion during off-label treatment with zonisamide for essential tremor. The woman presented to a hospital with a 4-day history of bilateral blurred vision and a drop of water sensation in the peripheral temporal field of both eyes. She also reported bilateral periocular pain and eyelid swelling, which substantially improved by the time of presentation. Ten days prior to the presentation, she received off-label treatment with oral zonisamide 25mg daily for essential tremor. Three days before the onset of symptoms, the dose had been increased to 50mg. The woman discontinued the medication after onset of visual symptoms. She had neither systemic or ophthalmological medical history nor any previous ocular surgeries. She also had a normal globe size. Ophthalmological examination revealed best-corrected visual acuity was 20/25 in the left eye (OS) and 20/40 in the right eye (OD). Extraocular motility and periorbital examination showed no significant findings. The pupils were slightly hyporeactive to light, symmetric and without any pupillary afferent defect. Slit-lamp examination showed the corneas were transparent, there was no conjunctival injection and the anterior chamber in both eyes was deep, both peripherally and centrally (grade 3 to 4, Van Herick grading system). Gonioscopy confirmed the angle to be open. On applanation tonometry, intraocular pressure was 13 mm Hg OS and 18 mm Hg OD. Dilated fundus examination showed normal maculas and optic discs. In the right eye, the presence of small choroidal folds located temporal to the macula was noted. Subsequently, a peripheral annular choroidal detachment involving all 4 quadrants were found. The left eye showed only some patches of temporal peripheral choroidal and nasal detachment, which were flatter than the choroidal detachment in the right eye. Ultrasound of the right eye showed a bullous peripheral choroidal detachment. The choroidal detachment in the left eye was more extensive than it had appeared on the fundoscopic examination, with fluid present posterior to the equator. Ultrasound biomicroscopy of both eyes showed the presence of suprachoroidal effusion with no anterior chamber narrowing and no anterior rotation of the ciliary body. A diagnosis of zonisamide-induced choroidal effusion was made. She was instructed to avoid zonisamide and referred to her neurologist for a different prescription. As her intraocular pressure was found to be normal, she was discharged with no ophthalmological treatment. On a follow-up after 1 month, no pathologic findings were observed on fundoscopy or ultrasound, and her best-corrected visual acuity was found to be 20/20 in both eyes. Final follow-up examination after 6 months was normal, with no systemic or ocular abnormalities. Baradad Jurjo MC, et al. Zonisamide-induced Choroidal Effusion: A Case Report. Journal of Glaucoma 29: E100-E102, No. 9, Sep 2020. Available from: URL: http:// 803517619 doi.org/10.1097/IJG.0000000000001596
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