What antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs), do not affect intraocular pressure in patients with glaucoma?

Antidepressants for Patients with Glaucoma

For patients with glaucoma requiring antidepressant therapy, selective serotonin and norepinephrine reuptake inhibitors (SSNRIs) are the safest option with the least risk of increasing intraocular pressure. 1

Understanding the Risk

Antidepressants can affect intraocular pressure (IOP) through various mechanisms:

• Some antidepressants cause mydriasis (pupil dilation) through adrenergic or anticholinergic effects
• Serotonergic mechanisms may influence IOP in susceptible individuals
• Risk is highest in patients with anatomically narrow angles or undiagnosed angle-closure glaucoma

Antidepressant Classes and Glaucoma Risk

Safe Options (First-Line)

• SSNRIs (Selective Serotonin and Norepinephrine Reuptake Inhibitors)
  • Best evidenced as having no association with glaucoma 1
  • Should still be monitored in patients with pre-existing glaucoma

Use with Caution (Second-Line)

• SSRIs (Selective Serotonin Reuptake Inhibitors)
  • Generally safer than older antidepressants but not without risk
  • Long-term use (>365 days) and higher doses associated with increased glaucoma risk 2
  • Case reports link fluoxetine and fluvoxamine to IOP increases 3, 4
  • Higher risk in patients younger than 65 without diabetes, hypertension, or hypercholesterolemia 2

Avoid (High Risk)

• Tricyclic Antidepressants (TCAs)
  • Should be avoided in glaucoma patients due to anticholinergic effects 1
  • Well-documented association with angle-closure glaucoma
• SNRIs like Duloxetine
  • Case reports of bilateral acute angle-closure glaucoma 5
  • Mechanism likely related to mydriasis from adrenergic effects

Monitoring Recommendations

For patients with glaucoma requiring antidepressant therapy:

1. Baseline ophthalmologic examination before starting therapy
2. Regular IOP monitoring during treatment (especially during dose adjustments)
3. Patient education about symptoms of acute angle-closure (eye pain, blurred vision, halos around lights, headache, nausea)
4. Lower threshold for ophthalmology referral if ocular symptoms develop
5. Consider lower starting doses with gradual titration

Special Considerations

• Angle-Closure Risk: Patients with anatomically narrow angles are at highest risk for medication-induced angle closure
• Pre-existing Glaucoma: All antidepressants should be used with caution and close monitoring
• Elderly Patients: May have undiagnosed narrow angles; consider ophthalmologic screening before initiating therapy

Clinical Pitfalls to Avoid

• Assuming all SSRIs are equally safe in glaucoma patients
• Failing to recognize early symptoms of IOP elevation
• Not considering the additive effects of multiple medications with mydriatic properties
• Overlooking the need for regular ophthalmologic monitoring in high-risk patients

The American Academy of Ophthalmology recognizes prostaglandin analogs as first-line therapy for glaucoma 6, but does not specifically address antidepressant selection in glaucoma patients. When antidepressant therapy is necessary, the choice should be made with careful consideration of the patient's glaucoma status and risk factors, with SSNRIs generally representing the safest option.