What are the preferred antidepressants for patients with open-angle glaucoma (OAG) versus closed-angle glaucoma (CAG)?

Antidepressant Selection for Patients with Open-Angle vs. Closed-Angle Glaucoma

For patients with open-angle glaucoma, SSRIs are generally preferred but should be used with caution at lower doses, while patients with closed-angle glaucoma should avoid tricyclic antidepressants and use SSRIs only with extreme caution and ophthalmological monitoring. 1, 2, 3

General Considerations for All Glaucoma Patients

• All patients with glaucoma who are prescribed antidepressants should remain under rigorous supervision of an ophthalmologist with regular monitoring of intraocular pressure 4, 5
• A baseline ophthalmologic examination is recommended before initiating antidepressant therapy to document optic nerve status and visual field 4
• Target intraocular pressure should be maintained at approximately 20% lower than baseline measurements to prevent glaucomatous damage 4
• For patients with severe or unstable glaucoma, consultation between psychiatry and ophthalmology is advisable before initiating antidepressant therapy 4

Recommendations for Open-Angle Glaucoma

• SSRIs are generally preferred for patients with open-angle glaucoma, but should be used with caution as they may increase the risk of glaucoma, particularly with longer duration (>365 days) and higher doses 6
• The effect of SSRIs on glaucoma risk appears more pronounced in patients younger than 65 years of age, and in those without diabetes, hypertension, or hypercholesterolemia 6
• Lower doses of SSRIs should be considered when treating patients with open-angle glaucoma to minimize risk 6
• Regular monitoring of intraocular pressure is essential, especially when using SSRIs for extended periods 5, 6

Recommendations for Closed-Angle Glaucoma

• Tricyclic antidepressants should be avoided in patients with closed-angle glaucoma or those predisposed to it (with narrow iridocorneal angles) due to their anticholinergic effects that can precipitate acute angle closure 2, 3
• SSRIs may also increase the risk of angle-closure glaucoma in predisposed individuals, though the evidence is less clear than for tricyclics 3, 7
• Case reports have documented acute angle-closure glaucoma associated with citalopram (an SSRI), suggesting a possible direct action on the iris or ciliary body muscle through serotonergic or anticholinergic mechanisms 7
• If SSRIs must be used in patients with or at risk for closed-angle glaucoma, start with the lowest effective dose and ensure close ophthalmological monitoring 2, 3

Important Clinical Considerations

• Patients with undiagnosed narrow angles are at particular risk when starting antidepressants with anticholinergic properties 2
• Symptoms of acute angle closure (severe eye pain, blurred vision, halos around lights, nausea, vomiting) require immediate medical attention 1, 2
• For patients with closed-angle glaucoma who have already undergone peripheral iridotomy, the risk of medication-induced angle closure is significantly reduced 2
• First-generation antipsychotics might have a smaller impact on intraocular pressure than second-generation antipsychotics if additional psychiatric medications are needed 3

Monitoring Protocol

• Baseline eye examination before starting antidepressant therapy 4
• More frequent monitoring of intraocular pressure during the initial weeks of therapy 4, 5
• Regular follow-up with ophthalmology, with frequency determined by glaucoma severity and stability 4
• Patient education regarding symptoms of worsening glaucoma that warrant immediate attention 1