a 45-year - old woman presented with acute bilateral visual deterioration with duration of one day .
she had been taking fluoxetine , magnesium hydroxide , and hctz for one month to reduce her weight .
she had visited another local ophthalmic clinic on the day of symptom onset , and had been told that the iops of the right and left eyes were 37 and 41 mmhg , respectively .
she was prescribed topical iop - lowering drugs , namely , cosopt ( dorzolamide hydrochloride - timolol maleate ) and xalatan ( latanoprost ) , and oral diamox ( acetazolamide ) .
her uncorrected visual acuities ( ucvas ) were 0.15 ( 20 / 150 ) , oculus dexter ( od ) and 0.1 ( 20 / 200 ) , oculus sinister ( os ) . automated refraction revealed bilateral myopia with spherical equivalents of -3.0 diopters ( d ) , od and -3.6 d , os .
after correcting measured refractive errors , she could see 1.0 ( 20 / 20 ) with either eye .
her iops were 12 mmhg , od and 14 mmhg os by goldmann applanation tonometry .
an anterior segment examination revealed conjunctival chemosis and injection , shallow anterior chambers , and narrow angles in both eyes ( fig .
1a and 1b ) , and a funduscopic examination revealed bilateral choroidal effusions in the 360o periphery ( fig .
she was diagnosed as having drug - induced myopia and asked to discontinue drugs including hctz .
ten days later , she reported that her vision had recovered and that all ocular changes had disappeared ( fig .
2 ) . at this time , her ucvas were 0.8 ( 20 / 25 ) , od and 0.6 ( 20 / 33 ) , os and she had a best - corrected visual acuity ( bcva ) of 1.0 ( 20 / 20 ) in both eyes .
myopia had been reduced to the prior refractive state ( spherical equivalent of -0.75d , oculi unitas ) . a 40-year - old woman presented with bilateral visual acuity deterioration , which had started 9 hours before presentation .
she had been prescribed ginexin , spironolactone , and hctz at the local clinic of internal medicine to cure edematous changes of the lower extremities .
her ucvas were 0.08 ( 20 / 250 ) , od and 0.06 ( 20 / 300 ) , os .
automated refraction revealed bilateral myopia with spherical equivalents of -4.5 d , od and -5.25 d , os and degree of myopia was unchanged by cycloplegic refraction ( table 1 ) . after correcting measured refractive errors
, she could see 1.2 ( 20 / 16 ) , od and 1.0 ( 20 / 20 ) , os .
her iops were 15 mmhg , od and 16 mmhg , os by goldmann applanation tonometry .
anterior segment examinations revealed conjunctival chemosis , shallow anterior chambers , and narrow angles in both eyes .
she was also diagnosed as having drug - induced myopia and recommended to discontinue all three drugs .
nine days after the discontinuance of medications , her ucvas were 0.8 ( 20 / 25 ) , od and 0.6 ( 20 / 30 ) , os and myopia had been reduced to the prior refractive state ( spherical equivalent of -0.75 d , od and -1.25 d , os ) .
an anterior segment examination revealed that the conjunctival chemosis had disappeared and that the anterior chambers were of normal depth .
a 45-year - old woman presented with acute bilateral visual deterioration with duration of one day .
she had been taking fluoxetine , magnesium hydroxide , and hctz for one month to reduce her weight .
she had visited another local ophthalmic clinic on the day of symptom onset , and had been told that the iops of the right and left eyes were 37 and 41 mmhg , respectively .
she was prescribed topical iop - lowering drugs , namely , cosopt ( dorzolamide hydrochloride - timolol maleate ) and xalatan ( latanoprost ) , and oral diamox ( acetazolamide ) .
her uncorrected visual acuities ( ucvas ) were 0.15 ( 20 / 150 ) , oculus dexter ( od ) and 0.1 ( 20 / 200 ) , oculus sinister ( os ) . automated refraction revealed bilateral myopia with spherical equivalents of -3.0 diopters ( d ) , od and -3.6 d , os .
after correcting measured refractive errors , she could see 1.0 ( 20 / 20 ) with either eye .
her iops were 12 mmhg , od and 14 mmhg os by goldmann applanation tonometry .
an anterior segment examination revealed conjunctival chemosis and injection , shallow anterior chambers , and narrow angles in both eyes ( fig .
1a and 1b ) , and a funduscopic examination revealed bilateral choroidal effusions in the 360o periphery ( fig .
she was diagnosed as having drug - induced myopia and asked to discontinue drugs including hctz .
ten days later , she reported that her vision had recovered and that all ocular changes had disappeared ( fig .
2 ) . at this time , her ucvas were 0.8 ( 20 / 25 ) , od and 0.6 ( 20 / 33 ) , os and she had a best - corrected visual acuity ( bcva ) of 1.0 ( 20 / 20 ) in both eyes .
myopia had been reduced to the prior refractive state ( spherical equivalent of -0.75d , oculi unitas ) .
a 40-year - old woman presented with bilateral visual acuity deterioration , which had started 9 hours before presentation .
she had been prescribed ginexin , spironolactone , and hctz at the local clinic of internal medicine to cure edematous changes of the lower extremities .
her ucvas were 0.08 ( 20 / 250 ) , od and 0.06 ( 20 / 300 ) , os .
automated refraction revealed bilateral myopia with spherical equivalents of -4.5 d , od and -5.25 d , os and degree of myopia was unchanged by cycloplegic refraction ( table 1 ) . after correcting measured refractive errors
, she could see 1.2 ( 20 / 16 ) , od and 1.0 ( 20 / 20 ) , os .
her iops were 15 mmhg , od and 16 mmhg , os by goldmann applanation tonometry .
anterior segment examinations revealed conjunctival chemosis , shallow anterior chambers , and narrow angles in both eyes .
she was also diagnosed as having drug - induced myopia and recommended to discontinue all three drugs .
nine days after the discontinuance of medications , her ucvas were 0.8 ( 20 / 25 ) , od and 0.6 ( 20 / 30 ) , os and myopia had been reduced to the prior refractive state ( spherical equivalent of -0.75 d , od and -1.25 d , os ) .
an anterior segment examination revealed that the conjunctival chemosis had disappeared and that the anterior chambers were of normal depth .
both of our patients showed 2 to 4 diopters of transient myopia after hctz intake ( table 1 ) . because hctz was the only drug taken by both patients and all ocular signs and symptoms disappeared after cessation of this drug
many reports [ 1 - 3,6 - 10 ] have been issued on the clinical characteristics of sulfa drug - induced acute ocular changes . in this report
, we show photographs of choroidal effusion , radiating retinal folds , and conjunctival chemosis , which have not been previously presented .
the mechanism of acute myopic shift has been suggested to involve ciliochoroidal effusion and an anterior rotation of the ciliary body .
myopic shift occurs due to the anterior migration of the iris - lens diaphragm , which increases focal length .
the resulting configuration has a significantly shallower anterior chamber and appositionally closes the angle of both eyes , which precipitates a glaucomatous crisis .
the pathophysiology of ciliochoroidal effusion is considered to be driven by an idiosyncratic reaction , and some researchers have suggested that prostaglandins are involved .
ciliary muscle spasm occurs as a manifestation of iridocyclitis , but it may also be induced by some drugs like anticholinesterase . the diagnosis of the patient can be confirmed by cycloplegic refraction . in our case studies , refractive errors , as determined by cycloplegic refraction , were similar to those detected by manifest refraction , which allowed us to rule out a ciliary muscle spasm .
furthermore , because primary angle - closure glaucoma seldom develops bilaterally , the differential diagnosis is relatively easy .
other clinical manifestations , such as choroidal effusion , retinal folds , and conjunctival chemosis can also aid in establishing the differential diagnosis .
treatment of drug - induced myopia requires the prompt withdrawal of the offending agent , though discontinuation of medication should be conducted in consultation with an internist to reduce the likelihood of systemic side effects .
a previous report also noted that laser iridotomy is not helpful , since the event is not due to a pupillary block .
whenever a case of bilateral acute myopic shift with shallow anterior chambers and iop elevation is encountered , drug - induced myopia from ciliochoroidal effusion should be suspected and treated properly .
 the authors experienced two cases of hydrochlorothiazide ( hctz)-induced acute - onset bilateral myopia and shallowing of the anterior chambers . 
 two middle - aged women taking hctz , a sulfa derivative , visited our clinic complaining of acute bilateral visual deterioration . 
 both had good visual acuity without corrective lenses before taking hctz . 
 a complete ophthalmologic examination revealed bilateral myopic shift , intraocular pressure elevation , shallowing of the anterior chambers , choroidal effusions , radiating retinal folds , and conjunctival chemosis . 
 approximately one week after hctz discontinuance , all ocular changes disappeared completely . 
 physicians should be aware of the adverse ocular effects of hctz and should manage patients accordingly . 
Case Reports
Case 1
Case 2
Discussion