A patient on aripiprazole (e.g., 2 mg daily for 2–4 weeks or 10 mg daily) develops new painless blurred vision and diplopia—what ocular side effects are associated with aripiprazole and how should they be managed?

Aripiprazole-Induced Ocular Side Effects and Management

Direct Answer

Aripiprazole causes acute transient myopia and diplopia through ciliary body effects, typically within 3-30 days of initiation; immediate discontinuation of the drug reverses symptoms within 3-14 days. 1, 2, 3

Recognized Ocular Side Effects

Acute Transient Myopia

• Myopic shift of -3.0 to -3.5 diopters occurs most commonly, presenting as painless bilateral blurred vision 1, 2, 3
• Onset typically occurs within 3-30 days of starting aripiprazole, regardless of dose (reported at doses ranging from 2-20 mg daily) 3
• The mechanism involves ciliary body spasm or supraciliary effusion affecting accommodation 4
• Anterior chamber shallowing and narrow angles may be observed on examination 5

Diplopia

• Diplopia has been reported in conjunction with myopia in several cases 1
• The diplopia appears to be secondary to the accommodative dysfunction rather than extraocular muscle involvement 1

Angle-Closure Glaucoma (Rare but Serious)

• Acute angle-closure can occur, particularly in patients with plateau iris configuration 4
• The mechanism is hypothesized to involve mydriasis and/or supraciliary effusion mediated by serotonergic effects on the iris-ciliary body complex 4
• Intraocular pressure elevation may be significant (up to 44 mm Hg reported) 4

Clinical Presentation Pattern

Timeline

• Symptoms begin 3 days to 1 month after aripiprazole initiation 1, 3, 5
• Resolution occurs 3-14 days after drug discontinuation 3
• The effect is not dose-dependent (occurs at 2-20 mg daily) 3

Examination Findings

• Uncorrected visual acuity typically reduced to 2/10 to counting fingers 1, 2
• Best-corrected visual acuity returns to 20/20 with approximately -3.0 diopter correction 1, 2
• Shallow anterior chamber and narrow angles on slit-lamp examination 5
• Normal intraocular pressure in uncomplicated myopia cases 5

Management Algorithm

Immediate Actions

1. Discontinue aripiprazole immediately upon recognition of visual symptoms 1, 2, 3, 5
2. Measure intraocular pressure to rule out angle-closure glaucoma 4, 5
3. Perform gonioscopy if IOP is elevated or anterior chamber is shallow 4
4. Contact the prescribing psychiatrist to arrange medication substitution 1, 5

Temporary Symptomatic Relief (While Awaiting Resolution)

• Prescribe temporary myopic correction (-3.0 diopters typically) if patient requires immediate visual function 1, 2
• Consider adding biperiden 2 mg daily as an anticholinergic agent, which may reduce symptoms while transitioning medications 1

Medication Substitution

• Switch to alternative antipsychotic such as paliperidone palmitate (75 mg/month) or quetiapine 1, 3
• Resolution of symptoms should occur within 10-14 days of aripiprazole cessation 2, 3
• Verify resolution at 2-week follow-up with uncorrected visual acuity testing 5

If Angle-Closure Develops

• Initiate IOP-lowering therapy immediately 4
• Perform laser peripheral iridotomy as first-line intervention 4
• Consider iridoplasty if angle closure persists despite iridotomy 4
• Aripiprazole discontinuation remains essential even after laser procedures 4

Critical Pitfalls to Avoid

Do Not Continue Aripiprazole

• Never continue aripiprazole hoping symptoms will resolve spontaneously—they will not 1, 2, 3
• Increasing the dose will worsen or precipitate angle-closure 4

Do Not Prescribe Permanent Glasses

• Avoid prescribing permanent spectacle correction, as the myopia is completely reversible within 2 weeks of drug cessation 2, 3, 5

Do Not Miss Angle-Closure Risk

• Always check IOP and anterior chamber depth—angle-closure glaucoma is a vision-threatening complication that requires urgent intervention 4, 5
• Patients with plateau iris configuration are at particularly high risk 4

Communication Failure

• Ophthalmologists must immediately contact the psychiatrist—patients may be reluctant to stop psychiatric medications without physician guidance 1, 5
• Document the adverse reaction clearly to prevent re-challenge 3

Follow-Up Protocol

Short-Term (2 Weeks Post-Discontinuation)

• Recheck uncorrected visual acuity—should return to baseline 2, 5
• Verify anterior chamber depth normalization 5
• Confirm IOP remains normal 4

Long-Term (6 Months)

• Verify no recurrence with alternative antipsychotic 1
• Document that the adverse effect is specific to aripiprazole 3

Prognosis

• Complete resolution is expected in all cases with drug discontinuation 1, 2, 3, 5
• No permanent ocular damage occurs if recognized and managed promptly 2, 3
• The same side effect does not recur with alternative antipsychotics 1, 3