Safest Antidepressants for Patients with Glaucoma
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the safest antidepressant options for patients with glaucoma, as they have not been associated with increased intraocular pressure or glaucoma risk. 1
First-Line Options
- SSRIs have been shown in meta-analysis to have no association with higher risk of glaucoma (pooled adjusted odds ratio = 0.956) 1
- SNRIs similarly demonstrate no significant correlation with increased intraocular pressure and are considered safe options for patients with glaucoma 1
- Studies indicate that serotonergic antidepressants may actually be associated with lower intraocular pressure (IOP) compared to controls, suggesting a potentially beneficial effect 1
Medications to Use with Caution
- Bupropion carries a warning about angle-closure glaucoma in its FDA label, noting that pupillary dilation following use may trigger an angle-closure attack in anatomically predisposed patients 2
- Mirtazapine also has an FDA warning regarding angle-closure glaucoma, similar to other antidepressants that can cause pupillary dilation 3
- Tricyclic antidepressants should be avoided or used with extreme caution in glaucoma patients, particularly those with narrow angles, due to their anticholinergic effects 4, 5
Monitoring Recommendations
- All patients with glaucoma who are prescribed antidepressants should remain under rigorous supervision of an ophthalmologist with regular monitoring of intraocular pressure 6
- For patients with anatomically narrow angles who do not have a patent iridectomy, extra caution is warranted when prescribing any antidepressant that may cause pupillary dilation 2, 3
- Target intraocular pressure should be maintained at approximately 20% lower than baseline measurements to prevent glaucomatous damage 7
Special Considerations
- First-generation antipsychotics might have a smaller impact on intraocular pressure than second-generation antipsychotics if additional psychiatric medications are needed 5
- Benzodiazepines should be used with caution in patients predisposed to glaucoma 5
- The risk of drug-induced glaucoma is higher in patients with anatomically narrow angles, making pre-treatment ophthalmologic evaluation important 8
Clinical Approach
- Before initiating antidepressant therapy in glaucoma patients, a baseline ophthalmologic examination is recommended to document optic nerve status and visual field 7
- If a patient develops signs of acute angle-closure glaucoma while on antidepressants (eye pain, blurred vision, halos around lights, nausea), immediate ophthalmologic evaluation is required 8
- For patients with severe or unstable glaucoma, consultation between psychiatry and ophthalmology is advisable before initiating antidepressant therapy 6
Remember that while SSRIs and SNRIs appear to be the safest options, individual patient factors including the type of glaucoma (open-angle vs. angle-closure), severity of depression, and comorbidities should guide the final medication selection.