Alternative Antidepressants for Patients with Mydriasis (Increased Pupil Size)
For patients with mydriasis (increased pupil size), selective serotonin reuptake inhibitors (SSRIs) like sertraline should be avoided, and bupropion is the preferred alternative antidepressant as it does not cause mydriasis or other significant ocular side effects at therapeutic doses. 1
Understanding Mydriasis and Antidepressant Effects on Pupil Size
- Mydriasis (pupillary dilation) can be problematic in patients with anatomically narrow angles who don't have a patent iridectomy, as it may trigger an angle-closure glaucoma attack 2
- Several classes of antidepressants can cause or worsen mydriasis:
- Tricyclic antidepressants (TCAs) frequently cause mydriasis and accommodation problems, with up to one-third of patients experiencing blurred vision 3
- SSRIs like sertraline can cause pupillary dilation that may trigger angle-closure attacks in susceptible patients 2
- Typical antipsychotics can also cause mydriasis that is often transient but potentially problematic in predisposed patients 3
Recommended Alternative: Bupropion
- Bupropion does not cause mydriasis at therapeutic doses, making it an excellent choice for patients with increased pupil size 1
- In comparative studies, bupropion (50mg and 100mg) did not affect pupil size, while other psychotropic medications like dexamphetamine caused significant mydriasis 1
- Bupropion also lacks the anticholinergic effects seen with many other antidepressants, which further reduces the risk of ocular complications 1
Cautions and Considerations
- Patients with untreated angle-closure glaucoma should avoid medications with anticholinergic effects that might cause mydriasis 4
- The FDA label for bupropion notes angle-closure glaucoma as a potential adverse effect, but this is much less common than with TCAs or SSRIs 4
- For patients with both mydriasis and angle-closure concerns, careful monitoring of intraocular pressure and pupil size is recommended when starting any antidepressant 5
Management of Medication-Induced Mydriasis
- If a patient develops problematic mydriasis while on an antidepressant:
- Consider switching to bupropion as it does not affect pupil size at therapeutic doses 1
- In emergency situations where mydriasis must be reversed quickly, topical pilocarpine can be used, though this may induce substantial pseudo-myopia in young adults 6
- Monitor for signs of angle-closure glaucoma, including eye pain, blurred vision, and halos around lights 5
Special Populations and Considerations
- Patients with a history of narrow angles or glaucoma require particular caution when prescribing any psychotropic medication 5
- Those with Waardenburg syndrome or other conditions affecting pupillary responses may have unpredictable reactions to medications affecting pupil size 7
- In patients with depression who also have ocular conditions requiring mydriatic agents (like tropicamide for eye examinations), careful coordination between psychiatric and ophthalmologic care is essential 6
Remember that early prevention and intervention can avoid most serious and potentially irreversible ocular toxicities from psychotropic medications 3.