What is the link between glaucoma and depression?
There is a circular link. Patients with glaucoma have higher risk of becoming depressed, and being exposed to antidepressants; some antidepressants can precipitate acute angle closure glaucoma (1).
Why is this important for a psychiatrist?
It is easy to miss a history of glaucoma in a psychiatric assessment. Acute angle closure glaucoma, when occurs, is an ophthalmic emergency that can result in blindness if left unattended. Acute onset of ocular pain, headache, blurred vision, nausea and vomiting should prompt immediate attention.
Who is at risk?
The most common type of glaucoma is open-angle type. This usually does not result in an ophthalmic emergency. So psychotropics have no effect on open-angle glaucoma. Psychotropics can precipitate narrow angle glaucoma especially in female patients, those of advanced age, patients with a family history of narrow angle glaucoma, being far-sighted and being of Asian, Hispanic or Inuit ethnicity.
What antidepressant drugs can worsen angle closure glaucoma?
Medications with anticholinergic properties or adrenergic agonist effects can precipitate acute angle closure. Serotonergic agents are also increasingly reported to be associated with glaucoma.
What antidepressant drugs should I avoid in a patient known to have glaucoma?
- Beware of clomipramine, imipramine, amitryptyline
- Caution is needed with SSRIs such as citalopram, escitalopram, fluoxetine and paroxetine as well as the SNRI venlafaxine. SSRI treatment >365 days and the use of higher doses of SSRIs (≥1 defined daily dose) are associated with greater risk of glaucoma incidence (3).
- Caution is warranted for using MAO inhibitors such as tranylcypromine or phenelzine as well.
- Interestingly, bupropion reduces intraocular pressure in open angle glaucoma, but like SSRIs, worsens narrow-angle glaucoma.
Can I use antipsychotics in a patient with glaucoma?
Certain antipsychotics, though weaker anticholinergics than tricyclics, can induce glaucoma. These include trifluoperazine, perphenazine, fluphenazine, zuclopenthixol as well as olanzapine and quetiapine.
What other drugs in my practice should I be wary of?
Benzodiazepines (diazepam and alprazolam) can induce relaxation of the sphincter muscle of the iris and precipitate angle closure in patients who are at risk. Topiramate is also associated with angle closure risk. Not to forget that some patients may also be using ecstasy, marijuana or cocaine, all of which may also precipitate angle closure.
Is there any antidepressant that I can safely use in angle-closure glaucoma?
While no single drug can be confidently recommended (all of them urge caution for glaucoma in their monographs), it is prudent to:
- Elicit history and clarify the type of glaucoma
- Request ophthalmic evaluation before treatment onset
- Start medications with least anticholinergic propensity and avoid polypharmacy
- Educate the patient on symptoms of acute worsening (pain, headache, halos and blurred eye-sight, red eye, excess lacrimation)
- Arrange for regular intraocular pressure monitoring while taking treatment
Where can I read more?
- Chen YY, et al. The association between glaucoma and risk of depression: a nationwide population-based cohort study. BMC ophthalmology. 2018 Dec 1;18(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6013853/
- Yang MC, Lin KY. Drug-induced Acute Angle-closure Glaucoma: A Review. Journal of Current Glaucoma Practice. 2019 Sep;13(3):104. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7221246/
- Chen VC, et al. Effects of selective serotonin reuptake inhibitors on glaucoma: A nationwide population-based study. PLOS one. 2017 Mar 3;12(3):e0173005. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5336262/
- Symes RJ, Etminan M, Mikelberg FS. Risk of angle-closure glaucoma with bupropion and topiramate. JAMA ophthalmology. 2015 Oct 1;133(10):1187-9. https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2381574