Question from a Member:
I have a patient with a history of major depression who has early-stage narrow-angle glaucoma. I have her on fluoxetine (OK’d by her ophthalmologist). However, when I added bupropion for adjunctive treatment of her depression, the ophthalmologist cautioned against using this as it further increases the risk of glaucoma. This is unfortunate since bupropion was extremely helpful for her [in the past] for treating residual depression and addressing anergia.
I am encouraging her strongly to go forward with the laser procedure both for her visual health and to allow for appropriate psychiatric treatment.
Many psychotropic medications, including antidepressants, antipsychotics, topiramate, etc., can precipitate an acute attack of angle-closure glaucoma in persons with a narrow angle in the anterior chamber of the eye. For more on this, please see the following article on this website:
Narrow-angle glaucoma (also called angle-closure glaucoma) can be treated with medications or surgery. Our Member’s question is one that comes up regularly in these patients—what about AFTER surgery? Can psychiatric medications then be prescribed to these patients without much concern? This is, obviously, of the greatest clinical significance in treating these patients with psychiatric medications.
We don’t need to go into too many details but to understand the discussion on this page, we need to first understand just a little bit about how narrow-angle glaucoma can be precipitated by psychiatric medications and why using a laser to make a hole in the iris (laser iridotomy) relieves the problem. Bear with me for just a moment.
The term “angle” in “narrow angle” refers to the angle between the cornea and the iris. The obliquely placed red arrow in the image below points to the angle of the eye. OK?
The reason this angle very important is because the aqueous humor that fills the anterior chamber of the eye (shown in light grey color in the image below and labeled “camera anterior”, its Latin name) drains at that angle.
But, some people have an angle that is structurally narrower than usual. These people are at risk of angle becoming completely blocked if some factor further blocks the angle. They are prone to developing angle-closure glaucoma.
Many psychotropic medications can make the pupils dilate. When that happens in a person who already has a narrow angle, the angle of the eye gets blocked. This stops drainage of the aqueous humor leading to a sharp increase in pressure inside the eye, which is called angle-closure glaucoma. Note: dilation of the pupil is only one of the ways in which medications can precipitate an attack of narrow-angle glaucoma, but it is the one that is of most concern for mental health clinicians.
To treat this problem, the most commonly used surgery is laser iridotomy. This involves using a laser to make a tiny hole in the peripheral part of the iris. In the image above, the approximate location of where the hole would be made is shown by the horizontal red arrow. This allows the aqueous humor to go THROUGH the hole in the iris to drain into the angle.
Now, let’s use this basic understanding to answer our Member’s question.
Psychotropic medications after laser iridotomy
The question we are addressing on this page is—what about after the patient with a narrow-angle has had laser iridotomy? Are psychotropic medications now safe to prescribe?
As of September 2020, I could not find any published study or even a case series of the use of psychotropic medications after surgery for narrow-angle glaucoma.
But, two review articles that I looked up agree on this point. Here is what they say:
1. “In fact, people with narrow anterior chambers but who are adequately treated by antiglaucoma agents (or who have undergone laser iridectomy) and patients with safely wide anterior chambers can receive almost any psychotropic treatment without restriction, provided they are being followed up” (Richa and Yazbek, 2010—quoting Oshika, 1995)
2. “Patients with a narrow anterior chamber angle who are receiving antiglaucoma treatment or have undergone laser treatment, as well as those with open angles, can receive antidepressant medication without restrictions” (Oshika, 1995).
So, psychotropic medications that cause pupillary dilatation can usually be used in patients with narrow-angle glaucoma if the patient is on effective medication or has had laser surgery.
But, even in such circumstances, it is a good idea to:
1. Have the ophthalmologist approve the use of the specific psychotropic medication being planned.
2. Make sure the patient is evaluated by the ophthalmologist after the psychotropic medication is started
3. Make sure the patient regularly follows up with the ophthalmologist over time as advised.
Oshika T. Ocular adverse effects of neuropsychiatric agents. Incidence and management. Drug Saf. 1995 Apr;12(4):256-63. doi: 10.2165/00002018-199512040-00005. PMID: 7646824.
Quigley HA. Glaucoma. Lancet. 2011 Apr 16;377(9774):1367-77. doi: 10.1016/S0140-6736(10)61423-7. Epub 2011 Mar 30. PMID: 21453963.
Richa S, Yazbek JC. Ocular adverse effects of common psychotropic agents: a review. CNS Drugs. 2010 Jun;24(6):501-26. doi: 10.2165/11533180-000000000-00000. PMID: 20443647.
Copyright © 2020, Simple and Practical Medical Education, LLC. All rights reserved. May not be reproduced in any form without express written permission.
Disclaimer: The content on this website is provided as general education for medical professionals. It is not intended or recommended for patients or other laypersons or as a substitute for medical advice, diagnosis, or treatment. Patients must always consult a qualified health care professional regarding their diagnosis and treatment. Healthcare professionals should always check this website for the most recently updated information.