Is it safe to prescribe Zoloft (sertraline) to a patient with a family history of glaucoma?

Zoloft and Family History of Glaucoma

Zoloft (sertraline) can be prescribed to patients with a family history of glaucoma, but requires careful risk assessment and patient counseling about angle-closure glaucoma risk, particularly in those with anatomic predisposition.

Key Safety Considerations

Family History Risk Does Not Contraindicate SSRIs

• A family history of glaucoma alone is not a contraindication to sertraline use 1
• Family history increases the odds of developing primary open-angle glaucoma (POAG) by 1.92 to 9.2-fold depending on the number of affected relatives, but this relates to chronic open-angle disease, not acute medication-induced angle closure 1
• Open-angle glaucoma is NOT a risk factor for angle-closure glaucoma 2

The Real Concern: Angle-Closure Glaucoma

The FDA label specifically warns that sertraline can cause mild pupillary dilation, which in susceptible individuals can trigger an episode of angle-closure glaucoma 2. This is the critical safety issue, not family history per se.

Mechanism of SSRI-Induced Angle Closure

• SSRIs including sertraline can precipitate acute angle-closure glaucoma through mydriasis caused by adrenergic effects, weak anticholinergic activity, or increased serotonin levels 3
• Multiple case reports document acute angle-closure glaucoma with SSRIs including sertraline, citalopram, escitalopram, fluoxetine, paroxetine, and fluvoxamine 3
• The risk is specifically in patients with narrow anterior chamber angles, not those with open-angle glaucoma 2, 4

Clinical Algorithm for Safe Prescribing

Step 1: Determine Glaucoma Type in Family Members

• Ask specifically whether affected relatives have open-angle or angle-closure glaucoma 5
• If family history is of open-angle glaucoma (most common type), this does NOT increase risk of medication-induced angle closure 2

Step 2: Assess Patient's Anatomic Risk Factors

High-risk anatomic features for angle closure include: 5

• Hyperopia (farsightedness), especially in older patients
• Shallow anterior chamber depth on examination
• Narrow angles on gonioscopy
• Asian ethnicity (higher prevalence of narrow angles)
• Age >40 years (lens thickening narrows angles)

Step 3: Risk Stratification and Management

Low Risk (Proceed with sertraline):

• Family history of open-angle glaucoma only
• No hyperopia
• Normal anterior chamber depth
• Patient counseling about symptoms of angle closure 2

Moderate Risk (Ophthalmology consultation before prescribing):

• Hyperopic refraction
• Age >60 years
• Unknown type of glaucoma in family members
• Consider gonioscopy to assess angle anatomy 5

High Risk (Ophthalmology evaluation mandatory):

• Known narrow angles
• Previous angle-closure attack in fellow eye
• Shallow anterior chamber on slit-lamp examination
• May require prophylactic laser iridotomy before starting sertraline 2

Patient Counseling Requirements

The FDA label mandates advising patients that: 2

• Sertraline can cause mild pupillary dilation
• Susceptible individuals may experience angle-closure glaucoma
• Patients may wish to be examined to determine susceptibility
• Prophylactic iridectomy can be performed if susceptible

Warn patients to seek immediate care for: 5

• Sudden eye pain
• Headache
• Blurred vision or halos around lights
• Eye redness
• Nausea/vomiting with eye symptoms

Common Pitfalls to Avoid

• Do not confuse open-angle and angle-closure glaucoma - they have completely different risk profiles with SSRIs 2
• Do not assume all glaucoma is a contraindication - pre-existing open-angle glaucoma is almost always safe, as it can be managed with standard treatments 2
• Do not rely on family history reporting alone - approximately 75% of glaucoma cases remain undiagnosed, so family members may have unrecognized disease 1
• Do not skip the anatomic assessment - hyperopia and shallow anterior chambers are more predictive of angle-closure risk than family history alone 5

Monitoring Recommendations

• Patients with any glaucoma risk factors should have baseline IOP measurement and optic disc examination 5
• Those with family history should begin comprehensive ophthalmologic screening by age 40 (earlier for African Americans or Latinos) 1
• If angle-closure symptoms develop, discontinue sertraline immediately and refer emergently to ophthalmology 5