Can bupropion (Wellbutrin) affect vision in patients, particularly those with pre-existing visual disturbances or taking high doses?

Bupropion and Vision Effects

Yes, bupropion can affect vision, most notably through acute angle-closure glaucoma, which is a serious and potentially sight-threatening complication that requires immediate discontinuation of the medication. 1, 2

Primary Vision-Related Adverse Effects

Acute Angle-Closure Glaucoma

• Bupropion (particularly in the naltrexone/bupropion combination) is specifically listed as causing acute angle-closure glaucoma in current guidelines 1
• The FDA drug label explicitly warns that bupropion can cause mild pupillary dilation, which in susceptible individuals can trigger an episode of angle-closure glaucoma 2
• Patients should be counseled that pre-existing open-angle glaucoma is NOT a risk factor for this complication, but those with anatomically narrow angles are at risk 2
• Consider prophylactic examination to determine angle susceptibility before initiating therapy, with possible prophylactic iridectomy in high-risk patients 2

Other Documented Visual Disturbances

• Diplopia (double vision) has been reported as a rare but documented adverse effect, resolving within one week of discontinuation 3
• Blurred vision and headaches can occur, though these are less common than with tricyclic antidepressants 3
• Changes in attention, memory, and perception have been documented in clinical trials, though these are more cognitive than purely visual 4
• Visual hallucinations have been reported in cases of intravenous bupropion abuse, though this is not relevant to therapeutic oral use 5

Clinical Context and Risk Stratification

High-Risk Populations

• Patients with anatomically narrow anterior chamber angles are at highest risk for angle-closure glaucoma 2
• Those taking higher doses (particularly the naltrexone/bupropion combination at 16 mg/180 mg twice daily) may have increased risk 1
• The corneal edema guideline specifically lists bupropion as a topical or systemic medication that can cause corneal edema, though this appears to be a rare complication 1

Comparison to Other Psychotropic Agents

• Bupropion's visual adverse effects are considerably less frequent and severe than those associated with tricyclic antidepressants, typical antipsychotics, or topiramate 6
• Unlike chlorpromazine or thioridazine, bupropion does not cause retinopathy, cataracts, or corneal pigmentation at therapeutic doses 6
• The angle-closure glaucoma risk appears lower than with tricyclic antidepressants, where ALL patients with narrow angles experience glaucomatous attacks 6

Clinical Management Algorithm

Before Initiating Bupropion

1. Screen for history of glaucoma or narrow angles 2
2. Consider ophthalmologic evaluation in patients over 40 years old or those with family history of angle-closure glaucoma 2
3. Document baseline visual acuity if patient reports any pre-existing visual disturbances 1

During Treatment

• Instruct patients to immediately report sudden eye pain, vision changes, seeing halos around lights, or eye redness 2
• These symptoms suggest acute angle-closure glaucoma and require emergency ophthalmologic evaluation 2
• If diplopia or persistent blurred vision develops, consider discontinuation as these symptoms typically resolve within one week of stopping the medication 3

If Visual Symptoms Occur

• Discontinue bupropion immediately if acute angle-closure glaucoma is suspected 2
• Arrange urgent ophthalmologic consultation for definitive diagnosis and treatment 2
• For less severe visual disturbances like diplopia, taper and discontinue bupropion; symptoms should resolve within 7 days 3

Important Caveats

• The overall incidence of vision-related adverse effects with bupropion is low, particularly compared to older antidepressants 6, 7
• Most visual disturbances are reversible upon discontinuation 3
• The angle-closure glaucoma risk, while serious, is primarily relevant in anatomically predisposed individuals 2
• Large clinical trials involving over 1,150 patients did not identify vision changes as a common adverse effect requiring discontinuation 7
• The favorable side effect profile of bupropion (particularly regarding sexual dysfunction and weight) often makes it preferable to alternatives, and vision problems should not preclude its use in appropriate patients with proper screening 8