Can Lexapro Cause Increased Eye Pressure?
Yes, Lexapro (escitalopram) can cause increased intraocular pressure and precipitate acute angle-closure glaucoma, though this is a rare adverse effect that occurs primarily in patients with anatomically narrow angles. 1
Mechanism of Action
Escitalopram can increase intraocular pressure through multiple pathways:
Uveal effusion mechanism: The most well-documented mechanism involves ciliochoroidal effusions with ciliary body detachments that cause forward rotation of the lens-iris diaphragm, leading to angle closure 1
Adrenergic effects: SSRIs including escitalopram have weak adrenergic properties that can cause mydriasis (pupil dilation), which bunches peripheral iris tissue into the drainage angle in susceptible patients 2, 3
Serotonergic pathway: Elevated serotonin levels from SSRI therapy may directly affect intraocular pressure regulation, though the exact mechanism remains incompletely understood 2
Clinical Evidence
A documented case report demonstrates the causal relationship:
A 41-year-old woman developed bilateral acute angle-closure glaucoma within days of starting escitalopram 1
High-frequency ultrasonography confirmed bilateral choroidal effusions with ciliary body detachments 1
Standard treatments (topical antihypertensives and laser peripheral iridotomy) failed to control the pressure 1
Discontinuation of escitalopram plus topical cycloplegics and corticosteroids resulted in complete resolution within 4 days, with normalization of intraocular pressures and resolution of uveal effusions 1
Risk Factors for SSRI-Induced Angle Closure
Patients at highest risk include those with:
Anatomically narrow anterior chamber angles (the primary risk factor) 4, 3
Hyperopia (farsightedness), especially older patients with natural lenses 4
Family history of glaucoma 5
Advanced age (angle becomes progressively narrower with aging) 3
Clinical Recommendations
Before starting Lexapro:
Ophthalmologic evaluation with gonioscopy should be performed in patients with known narrow angles or risk factors for angle closure 4
Consider prophylactic laser peripheral iridotomy if narrow angles are confirmed and escitalopram is deemed necessary 4
During treatment:
Monitor for acute angle-closure symptoms: sudden eye pain, redness, blurred vision, halos around lights, headache, and nausea 4, 1
Ophthalmological consultations should be considered during treatment with any SSRI in patients with glaucomatous risk factors, especially elderly patients 2
If angle closure occurs:
Immediately discontinue escitalopram 1
Initiate topical cycloplegics and corticosteroids 1
Standard glaucoma medications may be ineffective until the underlying uveal effusion resolves 1
Laser peripheral iridotomy is typically ineffective for drug-induced uveal effusion-type angle closure (unlike pupillary block mechanisms) 1
Important Caveats
The incidence of SSRI-related intraocular pressure modifications is likely underestimated because:
Most cases are asymptomatic or cause only vague visual disturbances that patients may not report 2
Progressive or intermittent angle closure may develop slowly without dramatic symptoms 2
Visual disturbances are often dismissed as unrelated to medication 2
This is NOT a contraindication to using Lexapro in patients with well-controlled open-angle glaucoma, as the mechanism differs entirely from the uveal effusion/angle closure mechanism described above 6, 7.