What ophthalmic side effects can aripiprazole cause and how should they be managed?

Ophthalmic Side Effects of Aripiprazole

Aripiprazole can cause acute transient myopia and, less commonly, acute angle-closure glaucoma, both of which typically resolve within days to weeks after discontinuation of the medication.

Primary Ocular Side Effects

Acute Transient Myopia

• Aripiprazole-induced myopia is the most commonly reported ophthalmic adverse effect, presenting as sudden-onset bilateral painless blurred vision 1, 2, 3.
• The myopic shift typically ranges from -3.0 to -3.5 diopters in both eyes 1, 2.
• Onset occurs rapidly, within 3 to 30 days of initiating aripiprazole therapy 3.
• This effect appears not to be dose-dependent, as cases have been reported with dosages ranging from 3 mg to 20 mg daily 3.
• Resolution occurs within 3 to 14 days after discontinuation of aripiprazole 3.

Acute Angle-Closure Glaucoma

• Aripiprazole can induce angle-closure glaucoma, particularly in patients with predisposing anatomical features such as plateau iris configuration 4.
• The mechanism is hypothesized to involve mydriasis and/or supraciliary effusion mediated by serotoninergic effects on the iris and ciliary body complex 4.
• Patients may present with elevated intraocular pressure (IOP as high as 44 mm Hg) and angle closure on gonioscopy 4.
• This complication can occur months after initiating therapy and may worsen with dose escalation 4.

Clinical Recognition and Diagnosis

Key Presenting Features

• Sudden bilateral painless blurred vision is the hallmark presentation of aripiprazole-induced myopia 1, 2.
• Patients maintain normal corrected visual acuity (typically 20/20) with appropriate myopic correction 1, 2.
• Uncorrected visual acuity is significantly reduced (often 2/10 or 20/200) 1.
• For angle-closure, patients may present with eye pain, elevated IOP, and narrow or closed angles on gonioscopy 4.

Diagnostic Workup

• Perform refraction testing to document the degree of myopic shift 1, 2.
• Conduct gonioscopy to evaluate angle anatomy and rule out angle-closure, especially in patients with eye pain or elevated IOP 4.
• Measure intraocular pressure in all patients presenting with visual symptoms on aripiprazole 4.
• Obtain a detailed medication history, specifically asking about recent initiation or dose changes of aripiprazole 1, 3.

Management Algorithm

For Acute Transient Myopia

1. Immediately consult the prescribing psychiatrist to discuss discontinuation of aripiprazole 1.
2. Discontinue aripiprazole as the primary intervention 2, 3.
3. Cross-switch to an alternative antipsychotic such as paliperidone or quetiapine 1, 3.
4. If immediate discontinuation is not feasible, consider adding biperiden 2 mg daily, which may temporarily reduce symptoms 1.
5. Re-examine the patient 7-14 days after discontinuation to confirm resolution 2, 3.
6. Avoid prescribing corrective lenses during the acute phase, as the condition is reversible 1, 2.

For Angle-Closure Glaucoma

1. Initiate IOP-lowering therapy immediately with topical medications 4.
2. Perform laser peripheral iridotomy as initial intervention 4.
3. Strongly recommend discontinuation of aripiprazole to the prescribing psychiatrist 4.
4. If aripiprazole cannot be discontinued due to psychiatric necessity, perform iridoplasty to reduce angle-closure risk 4.
5. Monitor IOP and angle anatomy closely (weekly initially) if the medication must be continued 4.
6. Expect angle widening within 1 week of aripiprazole cessation 4.

Important Clinical Caveats

Timing and Reversibility

• All reported cases have been completely reversible upon discontinuation of aripiprazole 1, 2, 3.
• The rapid onset (within days to weeks) distinguishes this from other drug-induced ocular effects 3.
• Do not delay discontinuation while awaiting ophthalmologic consultation, as the condition is medication-induced and reversible 1.

Risk Factors

• Patients with plateau iris configuration or narrow angles are at higher risk for angle-closure complications 4.
• There is no clear correlation with dose or duration of therapy for myopia 3.
• Prior tolerance does not predict future tolerance; angle-closure can occur months after stable dosing 4.

Monitoring Considerations

• While the American Academy of Child and Adolescent Psychiatry recommends baseline and 6-month follow-up eye examinations for quetiapine due to cataract concerns in animal studies 5, similar formal monitoring guidelines do not exist specifically for aripiprazole.
• However, given the documented risk of acute myopia and angle-closure, educate all patients starting aripiprazole to report any visual changes immediately 1, 3.
• Ophthalmologists should maintain a high index of suspicion for aripiprazole-induced ocular effects when evaluating patients with acute visual changes 1, 2.

Interdisciplinary Communication

• Immediate communication between ophthalmologist and psychiatrist is essential when this adverse effect is identified 1.
• Document the temporal relationship between aripiprazole initiation/dose change and symptom onset to establish causality 2, 3.
• Alternative antipsychotics should be readily available for cross-switching to avoid psychiatric decompensation 1, 3.