Is it safe to prescribe Lexapro (escitalopram) to a patient with a family history of glaucoma?

Lexapro and Family History of Glaucoma

Lexapro (escitalopram) can be safely prescribed to patients with a family history of glaucoma alone, as family history is not a contraindication to its use. 1

Understanding the Risk Context

Family history of glaucoma 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 The key distinction is that family history of open-angle glaucoma does not predict risk for angle-closure glaucoma, which is the relevant concern with SSRIs like Lexapro. 2

Critical Pre-Prescribing Assessment

Before prescribing Lexapro, you must determine the type of glaucoma in affected family members:

• Ask specifically whether affected relatives have open-angle or angle-closure glaucoma to clarify the family history. 1
• If family members have angle-closure glaucoma, proceed with heightened caution and ophthalmologic evaluation. 1

Anatomic Risk Factors That Matter More Than Family History

The FDA label explicitly warns that pupillary dilation from Lexapro may trigger angle closure in patients with anatomically narrow angles who do not have a patent iridectomy. 2 The following anatomic features are more predictive of angle-closure risk than family history alone:

• Hyperopia (farsightedness), especially in older phakic patients 3, 1
• Narrow angles on gonioscopy 1
• Asian ethnicity (higher prevalence of narrow angles) 1
• Age >40 years (lens thickening increases risk) 1
• Small corneal diameter 3
• Shallow anterior chamber depth 3, 1

Clinical Algorithm for Safe Prescribing

Step 1: Screen for High-Risk Anatomic Features

• Inquire about hyperopia, previous episodes of blurred vision with halos around lights, or eye pain. 3
• If the patient has any high-risk anatomic features listed above, ophthalmologic evaluation with gonioscopy should precede Lexapro use. 4

Step 2: Patient Counseling (Required for All Patients)

• Advise patients they may wish to be examined to determine susceptibility to angle-closure glaucoma. 1, 2
• Warn patients to seek immediate care for sudden eye pain, headache, blurred vision, or halos around lights. 1, 2
• Explain that pre-existing open-angle glaucoma is not a risk factor for angle closure because it can be treated definitively with iridectomy. 2

Step 3: Consider Prophylactic Intervention

• If narrow angles are confirmed on gonioscopy and Lexapro is necessary, consider prophylactic laser peripheral iridotomy. 4

Mechanism of SSRI-Induced Angle Closure

Lexapro causes mydriasis (pupillary dilation) through adrenergic effects, weak anticholinergic activity, or increased serotonin levels. 5 This mid-pupillary dilation bunches peripheral iris tissue into the angle, precipitating closure in anatomically susceptible patients. 4, 6 Case reports document acute angle-closure glaucoma with escitalopram and other SSRIs (fluoxetine, paroxetine, sertraline, citalopram). 5, 7

Monitoring Recommendations

• Baseline IOP measurement and optic disc examination for patients with any glaucoma risk factors. 1
• Patients with family history should begin comprehensive ophthalmologic screening by age 40. 8, 1
• If angle-closure symptoms develop, discontinue Lexapro immediately and refer emergently to ophthalmology. 1

Common Pitfalls to Avoid

• Approximately 75% of glaucoma cases remain undiagnosed, so family members may have unrecognized disease. 8, 1
• Do not assume all glaucoma is the same type—open-angle and angle-closure have completely different risk profiles with SSRIs. 2
• Hyperopia and shallow anterior chambers are more predictive of angle-closure risk than family history alone. 1
• The product insert mentions glaucoma as a contraindication but does not specify the type—only angle-closure glaucoma with narrow angles is the true concern. 9