visual test

Visual Problems with Psych Meds

Harm & Safety
Psych Team

I’ve discussed the importance of monitoring side effects and adverse/complicated reactions. The body acts strange in psych, I had a patient on bupropion who said her urine turned brown. Patients will stop taking their medications because of these effects (and my patient did) to mainly not risk causing permanent damage such as Tardive Dyskinesia.

I simply make a note of it and move on to the next medication so it won’t turn into drama or a complication. Visual side-effects/adverse reactions are no exception. Anything that risks blindness is considered serious and sometimes an emergency.  Thankfully, the patient’s issue was resolved but what if it wasn’t and I kept prescribing the same medication? I only ask this question because many times, providers will continue to prescribe a medication that’s causing damage.

SSRIs take 4-6 weeks to achieve full efficacy, but not if the person is experiencing major side effects beforehand like vision loss. I usually ask patients to just call if there’s a problem and not wait weeks or until the next follow-up. I want to catch the problem early. In general, with SSRIs, I discussed GI effects/take with food, increased SI thoughts…etc. -but never discussed visual problems because it’s rare or the ophthalmologist’s job…

What Medications?

However, I’ll probably just start mentioning how visual issues may occur with many of these psych meds. Mainly because it’s not in the inserts and can be vague, confusing, or easily overlooked. Not to mention the exact mechanisms, plan of care, and the prognosis is basically unknown or not good. Here are some key medications associated with vision problems:

  • SSRIs have been shown to have a higher prevalence for dry eye than SNRIs.
  • TCAs, SSRIs, and SNRIs have all been reported to precipitate acute angle-closure glaucoma.
  • SSRIs and SNRIs may cause mydriasis by noradrenergic effects or anticholinergic effects or by 5-HT7 effects which can cause relaxation of the sphincter muscle of the pupil.
  • Mirtazapine, moclobemide and trazodone have been reported to cause mydriasis.
  • TCAs and Antipsychotics have been reported to cause accommodation interference by anticholinergic effects
  • Reports of SSRI-induced EPSEs can, rarely, affect ocular muscles and lead to visual symptoms.
  • SSRIs have been linked to optic neuropathy, possibly via multiple transient vasospasms in the optic nerve which could progressively induce ischemic optic neuropathy.

– North Metropolitan Health Service 

Psychiatric Medications and their Ocular Complications

  • Refractive error: Topamax
  • Increased intraocular pressure: Topamax, antidepressants (TCAs/SSRIs/SNRIs)
  • Accommodative interference: Topamax, antidepressants (TCAs/SSRIs)
  • Ocular motor disturbances: Anticonvulsants, Topamax, anxiolytics, lithium
  • Oculogyric crisis: Typical antipsychotics, atypical antipsychotics, Topamax, anticonvulsants
  • Tear film changes: Lithium, antidepressants
  • Corneal or lenticular opacities: Typical antipsychotics, rarely atypical antipsychotics
  • Pigmentary retinopathy: Typical antipsychotics, rarely anticonvulsants and anxiolytics

–Review of Optometry

visual snow example
An example of “Visual Snow” –Monash University 

Plan of Care 

  1. PREVENT THIS: the Review of Optometry explained that early detection and intervention can prevent permanent visual consequences.
  2. Take precautions: If a person has an autoimmune disorder, metabolic issues, diabetes, endocrine, one kidney, etc. -don’t go into cowboy mode. I start dosages low to get some kind of green light to increase or change/add a medication. Yes, add one medication at a time to catch any issues and weigh the risks vs benefits…
  3. Be empathetic: some of the comments on these articles are disheartening and people are getting written off like it’s all in their heads. I don’t argue, just say let’s try something else. Quick side-note, even going to the ophthalmologist and getting tests done -there’s no specific testing for “visual snow”, dry eye, photosensitivity, etc. even if the vision is or isn’t 20/20…so sometimes things have to be based on the subjective view whether it’s true or not.
  4. Collaborate: talk with the eye doctor or PCP, get a 2nd opinion, and review the plan of care when things are getting complicated. Don’t go at critical situations like the lone ranger… I’ve had patients where another provider would change or d/c my medications based on certain conditions like seizures. Don’t get upset, maybe the patient got a complication, didn’t tell you additional issues, new problems occurred, etc. I don’t undermine other services or simply call to express concerns, which I did when another physician was prescribing BZD’s. He was calm and nice because he appreciated me taking over the person’s scheduled meds so these interactions don’t have to get rough.
  5. Document: this is a part of the ROS (HEENT) and MED/SURG HX, it should be noted if there are any visual problems, a history, or if it’s simply negative. I’m not doing eye exams, just noting if there’s blurred vision, dry eyes, frequent tearing, etc… and assessing if the medications are inducing this reaction or if they truly need to f/u with a doctor. However, it’s overall another green light, to help when starting and changing medications i.e. if the person has persistent eye dryness, TCAs probably wouldn’t be the first line. Documentation overall is also important if there’s a possibility of going to court for damages.

Additional References and Information 

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