Do antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), cause worsening eye fluttering or blepharospasm?

Antidepressants and Eye Fluttering/Blepharospasm

Antidepressants, particularly SSRIs and atypical antipsychotics, can cause or worsen blepharospasm (eye fluttering), though this is an uncommon adverse effect that typically improves within 2 months of medication cessation. 1, 2

Evidence for Drug-Induced Blepharospasm

SSRIs and Ocular Dystonias

• SSRIs can rarely cause ocular dystonias, including blepharospasm, as part of their extrapyramidal side effect profile 1
• In a case series of 12 patients with drug-induced blepharospasm from psychotropic medications, all patients showed improvement within 2 months (average 3.9 weeks) after cessation of the offending agent 2
• The severity at presentation was typically moderate to severe (Jankovic rating scale 2-3 out of 4), but improved by at least 2 points on the scale after drug withdrawal 2

Specific Antidepressants Implicated

• Tricyclic antidepressants (TCAs) are associated with uveal tract problems and can cause mydriasis and ocular dystonias 1
• SSRIs (including fluoxetine, sertraline) have documented cases of causing ocular dystonias and blepharospasm, though this is rare 1, 3
• Atypical antipsychotics (olanzapine, quetiapine) when combined with antidepressants can cause blepharospasm—one case report documented complete resolution within 2 months of switching from olanzapine to quetiapine 3

Clinical Recognition and Pitfalls

Key Distinguishing Features

• Drug-induced blepharospasm typically develops after weeks to months of psychotropic exposure (mean 47.3 months in one series, range 3-120 months) 2
• Patients present with inability to keep eyes open, excessive blinking, eye irritation, watery discharge, and photophobia 3
• Routine neurological imaging (MRI, EEG) and ocular examination are typically normal, helping distinguish this from structural causes 3

Common Pitfall

• Do not assume blepharospasm is always due to typical antipsychotics alone—atypical antipsychotics and SSRIs should be considered as potential culprits, especially in patients on polypharmacy for mood disorders 1, 3, 2

Management Algorithm

Step 1: Identify the Offending Agent

• Review all psychotropic medications, particularly SSRIs, TCAs, and atypical antipsychotics 1, 2
• Consider the temporal relationship between medication initiation/dose escalation and symptom onset 2

Step 2: Medication Adjustment

• Reduce or discontinue the suspected psychotropic agent as far as clinically safe 2
• If complete cessation is not feasible, switch to an alternative agent with lower risk of extrapyramidal effects (e.g., replacing olanzapine with quetiapine) 3
• Expect improvement within 2-8 weeks after cessation, with most patients showing initial improvement around 3.9 weeks 2

Step 3: Symptomatic Treatment (If Needed)

• Most patients improve with medication cessation alone and do not require botulinum toxin injections 2
• Only 3 of 12 patients in one series required a single botulinum toxin injection, and all were able to discontinue this therapy after psychotropic cessation 2
• Botulinum toxin type A provides rapid relief lasting weeks to months with minimal side effects if medication adjustment is insufficient 4

Additional Ocular Considerations

Other SSRI-Related Eye Effects

• SSRIs can cause IOP modifications and have been associated with acute angle-closure glaucoma attacks in susceptible patients 5
• Fluoxetine has been shown to increase IOP in clinical studies, though often asymptomatic 5
• Consider ophthalmological consultation before starting SSRIs in elderly patients or those with glaucomatous risk factors 5

Broader Ocular Adverse Effects

• Benzodiazepines, antiepileptic drugs (carbamazepine, topiramate), and lithium can cause disturbances in eye movements but are less commonly associated with blepharospasm specifically 1
• Topiramate has been frequently associated with acquired myopia and angle-closure glaucoma through a different mechanism (allergic-type reaction affecting lens and ciliary body) 1