Is there a contraindication for starting Sertraline (Selective Serotonin Reuptake Inhibitor) in patients with glaucoma?

SSRIs and Sertraline Are Not Contraindicated in Glaucoma, But Require Monitoring

Sertraline and other SSRIs are not absolutely contraindicated in patients with glaucoma, but they carry a specific warning for angle-closure glaucoma risk and require ophthalmologic monitoring. 1

Key Clinical Distinction: Type of Glaucoma Matters

The FDA label for sertraline explicitly states that pupillary dilation from SSRIs may trigger an angle-closure attack in patients with anatomically narrow angles who do not have a patent iridectomy 1. This is fundamentally different from open-angle glaucoma:

• Open-angle glaucoma is NOT a risk factor for angle closure glaucoma 1
• Pre-existing glaucoma is almost always open-angle glaucoma because angle-closure glaucoma, when diagnosed, can be treated definitively with iridectomy 1
• The concern is specifically for undiagnosed narrow angles, not diagnosed and treated glaucoma 1

Clinical Approach Before Starting Sertraline

Patients should be advised that sertraline can cause mild pupillary dilation, which in susceptible individuals can lead to an episode of angle-closure glaucoma 1. The FDA recommends:

• Patients may wish to be examined to determine whether they are susceptible to angle closure 1
• If susceptible, a prophylactic procedure (e.g., iridectomy) should be considered 1
• This screening is particularly important for patients who have never had their anterior chamber angles evaluated 1

Monitoring Requirements for Glaucoma Patients on SSRIs

All patients with glaucoma who are prescribed antidepressants should remain under rigorous supervision of an ophthalmologist with regular monitoring of intraocular pressure 2. Specifically:

• Target intraocular pressure should be maintained at approximately 20% lower than baseline measurements 2
• Before initiating antidepressant therapy, a baseline ophthalmologic examination is recommended to document optic nerve status and visual field 2
• For patients with severe or unstable glaucoma, consultation between psychiatry and ophthalmology is advisable before initiating therapy 2

Evidence on SSRI Effects on Intraocular Pressure

The relationship between SSRIs and glaucoma is nuanced:

• A large population-based study found that SSRI treatment of longer duration (>365 days) and higher doses (≥1 defined daily dose) were associated with greater risk of glaucoma incidence (adjusted OR = 1.36; 95% CI = 1.08-1.71) 3
• However, this increased risk was primarily in younger patients (<65 years) without diabetes, hypertension, or hypercholesterolemia 3
• The overall adjusted odds ratio after controlling for confounders was modest (aOR = 1.09; 95% CI = 1.00-1.18) 3
• Clinical studies show fluoxetine can increase IOP, though the effect was asymptomatic in most patients 4

Common Pitfalls to Avoid

Do not confuse the contraindication for anticholinergic medications (like atropine) in narrow-angle glaucoma with SSRIs 5. While both can cause pupillary changes, the mechanisms and risk profiles differ:

• Atropine is specifically contraindicated in narrow-angle glaucoma due to strong mydriatic effects 5
• SSRIs cause mild pupillary dilation and carry a warning, not an absolute contraindication 1
• The incidence of SSRI-related IOP modifications is likely underestimated because most cases are asymptomatic 4

Practical Algorithm

1. Assess glaucoma type: If open-angle glaucoma with patent iridectomy → proceed with caution and monitoring 1
2. Screen for narrow angles: If angles never evaluated → consider ophthalmology referral for gonioscopy before starting SSRI 1
3. Establish baseline: Document current IOP, optic nerve status, and visual field 2
4. Initiate therapy: Start sertraline at standard dosing with patient education about visual symptoms 1
5. Monitor regularly: Coordinate with ophthalmology for IOP checks, especially in first year and with dose escalations 2
6. Watch for symptoms: Educate patients to report eye pain, vision changes, halos around lights, or headache immediately 1