What anti-anxiety medications are safe to prescribe to a patient with closed angle glaucoma?

Anti-Anxiety Medications in Closed-Angle Glaucoma

Benzodiazepines (such as lorazepam, clonazepam, and diazepam) and SSRIs (such as sertraline, escitalopram, and fluoxetine) are generally safe for patients with closed-angle glaucoma, while medications with significant anticholinergic properties must be avoided.

Medications to AVOID

Absolutely contraindicated anti-anxiety medications include:

• Tricyclic antidepressants (TCAs) - These have strong anticholinergic effects that can precipitate acute angle-closure attacks 1, 2
• Tetracyclic antidepressants (such as maprotiline) - Case reports document bilateral angle closure with visual loss to no light perception when combined with benzodiazepines 3
• Anticholinergic agents - Any medication with anticholinergic properties can cause pupillary dilation and precipitate acute angle closure 2, 4

Critical Warning Signs

The evidence shows that anticholinergic medications can cause catastrophic outcomes. One documented case involved a 71-year-old woman treated with maprotiline (tetracyclic antidepressant) combined with clotiazepam and alprazolam who developed bilateral angle closure resulting in complete bilateral blindness (no light perception in both eyes) 3.

SAFE Medication Options

First-Line Choices

SSRIs without significant anticholinergic activity are the safest anti-anxiety options 1, 2:

• Sertraline
• Escitalopram
• Fluoxetine
• Citalopram

Important caveat: Paroxetine should be used with extreme caution or avoided, as it has been associated with chronic angle-closure glaucoma in a 33-year-old patient, with IOP rising from 10 mmHg to 42 mmHg when the medication was resumed 5.

Benzodiazepines

Pure benzodiazepines are generally safe when used alone 2, 3:

• Lorazepam
• Clonazepam
• Diazepam
• Alprazolam (when used without anticholinergic co-medications)

The key distinction is that benzodiazepines themselves do not have anticholinergic properties, though the case report showing harm involved their combination with anticholinergic antidepressants 3.

Medications Requiring Special Consideration

Naltrexone/bupropion combination carries a specific warning for acute angle-closure glaucoma and is contraindicated in patients with narrow-angle glaucoma 6.

Essential Clinical Algorithm

Before Prescribing ANY Anti-Anxiety Medication:

1. Verify the type of glaucoma - The question specifies "closed-angle" glaucoma, which is the high-risk population for drug-induced acute attacks 2

2. Assess current glaucoma status:

   • Has the patient undergone laser peripheral iridotomy? (This significantly reduces but does not eliminate risk) 2
   • What is the current IOP control status?
   • Is the patient under active ophthalmologic care?

3. Screen the medication for anticholinergic properties - Use the Anticholinergic Drug Scale to quantify burden 4

4. Coordinate with ophthalmology - Studies show 32.4% of closed-angle glaucoma patients receive potentially inappropriate anticholinergic prescriptions 4

Monitoring Protocol

For any patient with closed-angle glaucoma starting anti-anxiety medication 5, 2:

• Educate patients to immediately report: eye pain, blurred vision, halos around lights, headache, or nausea
• Schedule ophthalmology follow-up within 2-4 weeks of medication initiation
• Check IOP if any ocular symptoms develop
• Document baseline IOP before starting medication when possible

If Acute Symptoms Develop

The paroxetine case demonstrated that IOP normalized from 42 mmHg to 10 mmHg within 48 hours of medication discontinuation 5. Therefore:

• Immediately discontinue the suspected medication
• Emergency ophthalmology referral same day
• Do not wait for scheduled appointments - acute angle closure is an ophthalmologic emergency

Common Pitfalls to Avoid

1. Assuming all antidepressants are equivalent - The anticholinergic burden varies dramatically between classes 1, 2

2. Overlooking medication combinations - Studies identified anticholinergic drug interactions in 32.1% of glaucoma patients, with females having higher odds (OR 1.54) of receiving high anticholinergic burden 4

3. Failing to specify glaucoma type - Package inserts often list "glaucoma" as a contraindication without distinguishing open-angle from closed-angle 1

4. Not recognizing age-related risk - Patients aged 75-84 years (OR 2.35) and ≥85 years (OR 3.40) have significantly higher probability of receiving inappropriate anticholinergic medications 4

5. Resuming medications without ophthalmology clearance - The documented case showed IOP spiked again when the patient independently resumed paroxetine 5