NOT APPLICABLE

A 14-young female was admitted to the emergency department after three days of progressive, severe frontoparietal headache (10/10), photophobia, constant tearing, and blurred vision. Neurological examination was unremarkable, but mild bilateral periorbital edema and intense epiphora were noted. She had initiated topiramate combined with metformin eight days earlier for weight loss. Ophthalmologic evaluation revealed elevated intraocular pressure with narrow angle behavior but minimal conjunctival hyperemia. Brain MRI demonstrated an extra-axial enhancing lesion suggestive of periosteal fibroma, without intracranial hypertension. Fundoscopic images revealed subtle cortical retinal changes. Laboratory results were within normal limits. Topiramate was discontinued immediately, and conservative treatment with systemic analgesia, hydration, and anxiolytic support was initiated.

This case highlights dual mechanisms of topiramate-induced ocular injury: ciliochoroidal effusion causing secondary angle narrowing, and possible cortical retinal involvement from altered vascular permeability or transient bloodVretina barrier disruption. Lack of pain or redness delayed recognition, emphasizing the need for clinical suspicion even in mild presentations. Topiramate can cause multifocal ocular damage beyond the anterior segment. Early recognition and prompt discontinuation are essential to prevent irreversible cortical retinal injury. Clinicians should remain vigilant when prescribing topiramate for off-label indications, particularly in young women.