Supplementary Material for: Episodic Angle Closure After Visian™ Implantable Collamer Lens Implantation in a Patient using Adderall®

Introduction: Amphetamine-based medications such as Adderall®, used for the treatment of Attention deficit-hyperactivity disorder (ADHD), may theoretically elicit angle-closure glaucoma through their adrenergic mechanisms. The relationship between the use of Implantable Collamer Lenses (ICL) and angle-closure glaucoma has been extensively investigated based on appropriate vault and lens sizing and postoperative changes in the anterior chamber angle (ACA) and corneal morphology. This case reflects a synergistic impact from both Adderall® use and ICL implantation for the proposed mechanism of angle closure. Case Presentation: A 36-year-old myopic female with ADHD controlled with Adderall® underwent toric ICL implantation in the right eye after undergoing preoperative laser peripheral iridotomy (LPI). Shortly after, the patient developed episodic angle closure in the right eye, with episodes mainly occurring after taking an additional dose of Adderall® in a dimly lit environment. The patient later had an ICL exchange with a smaller-sized EVO+ toric ICL in the right eye and remained asymptomatic after. Conclusion: Additive mechanisms from both the ICL and Adderall® were present in our patient. The ICL caused crowding of the ACA through a pseudophacomorphic mechanism, and the Adderall® caused increased iridotrabecular contact secondary to pharmacologic mydriasis. This resulted in episodic angle closure with subsequent spikes in the intraocular pressure (IOP). There are no current reports or studies in the current literature describing the combined mechanisms of ICL implantation and Adderall® use in the potential development of angle closure. Further studies may be done to assess interactions of such medications in patients after ICL implantation.