Probable Association of an Attack of Bilateral Acute Angle-Closure Glaucoma With Duloxetine

Blind Spots in Therapy: Unveiling Drug-Induced Angle-Closure Glaucoma Through a National Analysis

OBJECTIVE

To identify and quantify medications causing angle-closure glaucoma through the FDA Adverse Event Reporting System (FAERS).

DESIGN

National retrospective database analysis.

SUBJECTS

There were 11 737 133 total adverse event reports from the FDA Federal Adverse Event Reporting System (FAERS) database 2004 to third quarter of 2023 (2023Q3), which included 1629 reports of angle-closure glaucoma.

METHODS

Drugs associated with reports of angle-closure glaucoma were identified in FAERS through disproportionality analysis MAIN OUTCOME MEASURES: To ascertain if these reports yielded statistically significant signals, we used the proportional reporting ratio (PRR), reporting odds ratio (ROR), empirical Bayes geometric mean (EBGM), and information component (IC). We considered a signal to be detected when all 4 disproportionality analysis metrics were positive.

RESULTS

We identified a total of 1629 adverse event reports linked to 611 suspected drugs over the course of 20 years (2004-2023Q3). Frequently reported drugs included topiramate (520 reports) and citalopram (69 reports), amongst many others. Eighteen medications yielded a positive signal, including lesser-known medications like olanzapine, phentermine, and ranibizumab. Tropicamide exhibited the most robust statistical significance (n = 18; PRR: 164.263; ROR [95% confidence interval {CI}]: 167.95 [104.994-268.655]; EBGM [EBGM05]: 162.421 [109.5]; IC [IC05]: 7.344 [4.591]), while acetazolamide was the second strongest (n = 51; PRR: 113.088; ROR 95% CI: 114.782 [86.665-152.021]; EBGM [EBGM05]: 109.506 [86.501]; IC [IC05]: 6.775 [5.115]).

CONCLUSIONS

Drug-induced glaucoma included both well-known medications such as topiramate as well as lesser-known medications such as olanzapine, phentermine, and ranibizumab. Clinician awareness of these findings is important.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Evaluation of the effects of duloxetine treatment on anterior segment parameters by optical coherence tomography

PURPOSE

To evaluate the effects of Duloxetine on anterior segment parameters and intraocular pressure (IOP) in open angle eyes.

METHODS

38 eyes of 38 patients with fibromyalgia who had open or wide open angles according to the Shaffer classification. Anterior segment optic coherence tomography was performed before and after (month 3) Duloxetine treatment. IOP, central corneal thickness (CCT), corneal endothelial cell density (CECD) and anterior chamber depth (ACD) were also recorded and evaluated.

RESULTS

No statistically significant difference was determined in IOP, CCT and CECD (p > 0.05). However, a statistically significant decrease was determined in both the temporal and nasal anterior chamber angle, angle opening distance, nasal trabecular-iris space area and ACD values between the baseline and month 3 (p < 0.001).

DISCUSSION

We think that the short term use of Duloxetine does not lead to clinically significant changes despite their statistically significant effects on the anterior chamber parameters.

Association of Drugs With Acute Angle Closure

Importance

Acute angle-closure (AAC) glaucoma is a sight-threatening disease and can reportedly occur in association with various drugs.

Objective

To identify drugs that are associated with AAC glaucoma occurrence and evaluate the risk of AAC associated with each drug.

Design, Setting, and Participants

A case-crossover study was conducted using the Health Insurance Review and Assessment Service database, which contains medical information of the entire Korean population. Patients who were first diagnosed with AAC and treated between 2013 and 2019 were identified using diagnostic and procedure codes. All drugs that the study participants were prescribed as well as prescription dates during the period of 1 to 180 days before the onset of AAC were extracted from the database. For each patient, 1 to 30 days before onset was considered the hazard period, and 91 to 180 days before AAC onset was considered the control period.

Main Outcomes and Measures

Drugs associated with AAC and odds (calculated as odds ratios [ORs] with 95% CIs) of AAC development associated with each identified drug.

Results

A total of 949 drugs that were prescribed to 13 531 patients with AAC (mean [SD] age, 66.8 [10.6] years; 9585 [70.8%] female) during the period of 1 to 180 days before the onset of AAC were analyzed. A total of 61 drugs were found to be associated with AAC, among which sumatriptan (OR, 12.60 [95% CI, 4.13-38.44]) was associated with the highest odds of AAC development, followed by topiramate (OR, 5.10 [95% CI, 2.22-11.70]) and duloxetine (OR, 4.04 [95% CI, 2.95-5.54]). The median (IQR) period from prescription of the drug to the onset of AAC for the 61 drugs was 11.9 days (10.9-12.8). A number of drugs not previously considered to be associated with AAC, including lactulose (OR, 2.81 [95% CI, 1.72-4.61]) and metoclopramide (OR, 2.52 [95% CI, 1.95-3.25]), were identified.

Conclusions and Relevance

Results of this case-crossover study suggest a need to consider AAC risk in patients taking any of the 61 drugs found to be associated with AAC.

A Review of Ocular Complications Associated with Medications Used for Anxiety, Depression, and Stress

This review of commonly prescribed psychotropic drugs aims to update the clinician on possible ophthalmic side effects that may include dry eye, diplopia, mydriasis, and cataracts. This review summarizes our current knowledge of known ocular side effects of psychotropic drugs based on reviews, case reports, case-control studies, a case series, and cross-sectional observational studies reported in the recent literature. The review covers disorders related to depression, anxiety, and stress which are commonly encountered within society and can have debilitating impacts on an individual's quality of life that may require chronic therapeutic management. The main medications used in the treatment and management of these conditions typically target receptors, metabolic enzymes, or transport pumps that alter the pre- and/or post-synaptic levels of neurotransmitters such as serotonin, norepinephrine, dopamine, gamma-aminobutyric acid, and opioids to improve mood and/or relieve pain and anxiety. Novel non-therapeutic options are undergoing clinical trials, and some patients may seek alternative therapies or have associated substance abuse issues to alleviate their symptoms. This review summarizes some of the clinical signs of depression and the main therapeutic options and their reported ocular side effects which may be pertinent today given the rise in use of psychotropic medications used to manage depression, anxiety, and stress.

Psychopharmacological Treatment, Intraocular Pressure and the Risk of Glaucoma: A Review of Literature

Through the years, the available psychopharmacological treatments have expanded with numerous new drugs. Besides weight gain, gastro-intestinal problems or Parkinson-like symptoms, ocular adverse effects of psychiatric drugs have been reported. These adverse effects are not common, but can be dangerous for the patient. This review summarises the current knowledge on the risk of raised intraocular pressure and glaucoma entailed by psychopharmacological treatment. Also, it provides updated data for clinicians involved in the treatment of patients with glaucoma or glaucoma risk factors. For this purpose, we performed an extensive literature search in the PubMed database using specific terms. Selective serotonin and noradrenaline reuptake inhibitors are the best evidenced as having no association with glaucoma. Antipsychotics, and especially first generation, seem to have no correlation with an increased intraocular pressure and therefore possibly with a risk of glaucoma, although a special attention should be paid when using ziprasidone. Tricyclic antidepressants, benzodiazepines and topiramate should be avoided in patients diagnosed with glaucoma or at risk. Clinicians should be aware of the possible psychotropic drug induced glaucoma and monitor at risk patients closely in order to prevent this condition. Irrespective of the psychopharmacological regimen taken into consideration, the glaucoma patient should be under the strict supervision of the ophthalmologist.

Psychotropic Drug-Induced Glaucoma: A Practical Guide to Diagnosis and Management

This article provides a practical review of the diagnosis and management of angle closure induced by psychotropic agents, including tricyclic antidepressants, antipsychotics and anticonvulsants. Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, monoamine oxidase inhibitors and antipsychotics may trigger angle closure by influencing pupil configuration through adrenergic, anticholinergic, serotonergic or dopaminergic mechanisms. Patients with narrow iridocorneal angles are at risk, and these are more common in people with hypermetropia (near-sightedness), older people and individuals with an Asian background. These patients may benefit from a laser peripheral iridotomy, either prophylactically or to relieve an acute angle-closure episode. An idiosyncratic reaction to medications such as topiramate may lead to angle closure through an alternate mechanism, leading to a uveal effusion. Ophthalmological review may be considered prior to commencing medications in high-risk patients.

A review of systemic medications that may modulate the risk of glaucoma

With increasing longevity, patients are developing more and more chronic diseases that require treatment with medications. Yet, it is not fully understood the extent by which these systemic medications affect ocular structures and whether they may increase or decrease the risk of sight-threatening ocular diseases. This review provides a summary of reported associations between different systemic medications and the risk of developing glaucoma or experiencing disease progression. Medication classes covered in this review that are known to or may modulate the risk of open-angle glaucoma include corticosteroids, beta blockers, calcium channel blockers, metformin, statins, selective serotonin reuptake inhibitors, bupropion, postmenopausal hormones, and cannabinoids. Medication classes addressed in this review that may increase the risk of angle closure glaucoma include anticholinergics, adrenergic agonists, certain classes of antidepressants, sulfonamides, and topiramate.

Acute Angle-closure Glaucoma Associated With Aripiprazole in the Setting of Plateau Iris Configuration

PURPOSE OF THE STUDY

The purpose of this study was to report a novel case of drug-induced angle-closure from aripiprazole (Abilify), an atypical antipsychotic, and propose a mechanism for this association.

METHODS/RESULTS

We report a case of a 45-year-old white woman who presented in subacute angle closure 2 months after initiating aripiprazole 5 mg daily for depression. This patient reported no prior ocular history and had been on longstanding duloxetine (Cymbalta) 60 mg daily for over 10 years before starting aripiprazole. Examination at initial presentation revealed an intraocular pressure (IOP) of 16 mm Hg in the right eye and an elevated IOP of 44 mm Hg in the left eye. Gonioscopy demonstrated a plateau iris configuration in the right eye and angle closure with a plateau iris configuration in the left eye. She was started on IOP-lowering therapy and underwent a laser peripheral iridotomy. Despite recommendation to discontinue aripiprazole, duloxetine was discontinued; aripiprazole was maintained and later increased to 10 mg daily for worsening depression. Three months after the dosage increase, the patient was found to have an elevated IOP of 32 mm Hg and angle-closure with a plateau iris configuration in the left eye. Iridoplasty was performed in the left eye with subsequent opening of the angle and improvement in IOP. The second attack of angle-closure led to the discontinuation of aripiprazole and a corresponding widening of the angles in both eyes 1 week after cessation.

CONCLUSIONS

This is the first report to describe drug-induced angle-closure glaucoma associated with aripiprazole use. The mechanism of angle closure, we hypothesize, is from mydriasis and/or supraciliary effusion mediated by the serotoninergic effect on the iris and ciliary body complex. Treatment is preferably cessation of the medication. However, in cases where the medication is necessary for management of major depression, iridoplasty should be performed to reduce the risk of angle closure.

SIMULTANEOUS BILATERAL ACUTE ANGLE-CLOSURE GLAUCOMA IN MILLER FISHER SYNDROME

PURPOSE

To report a case of patient with Miller Fisher syndrome, complicated by simultaneous bilateral acute angle-closure glaucoma in her slightly (+1.5) hyperopic eyes.

METHODS

We present a case report of a 71-year-old female patient presenting with total ophthalmoplegia, areflexia, ataxia and bilateral acute angle-closure glaucoma.

RESULTS

The initial ocular examination revealed hand motion in the both eyes and oedematic corneas. Initial intraocular pressure was immeasurable high (measurment by Tonopen Avia). Measurement was possible after intravenous Mannitol 20 % infusion on both eyes as 54 and 56 mm Hg, respectively. Local medical therapy of pilocarpine, timolol, dorsolamide and dexamethasone improve intraocular pressure into normal limits within several hours. Prophylactic peripheral Nd-YAG laser iridotomy was performed on a both eyes two days later. Systemic treatment involved plasma exchange and rehabilitation program. Subsequent cataract surgery on both eyes with posterior capsule lens implantation improve the best corrected visual acuity on right eye from 0.5 to 1.0 and the left eye from 0.5 to 0.8, respectively. Intraocular pressure is within normal limits without any glaucoma therapy. Follow up period is three years.

CONCLUSIONS

This is the second reported case of patient with Miller Fisher syndrome and simultaneous bilateral acute angle-closure glaucoma and the fifth reported case of Miller Fisher syndrome and acute angle-closure glaucoma. Treatment for both conditions made a very good recovery.

Drug-induced Acute Angle-closure Glaucoma: A Review

Aim

Our goal is to review current literature regarding drug-induced acute angle-closure glaucoma (AACG) and provide ophthalmologists and general practitioners with a thorough understanding of inciting medications and treatment pitfalls to be avoided.

Background

Drug-induced AACG is an ophthalmological emergency that ophthalmologists and general practitioners should be familiar with, given its potentially blinding consequences. Common anatomical risk factors for AACG include a shallow anterior chamber depth, short axial length, plateau iris configuration, thick lens, anteriorly positioned lens, and rarely, intraocular tumor. Demographic risk factors include female sex, Asian ethnicity, family history, and advanced age. In patients with predisposing factors, acute angle closure can be triggered by various classes of medications including adrenergic agonists, anticholinergics, cholinergics, sulfonamides, supplements, and serotonergic medications. Physicians prescribing such inciting medications should be aware of their potentially sight-threatening adverse effects and to inform patients of the warning symptoms. Patients typically present with elevated intraocular pressure (IOP), headache, nausea, blurry vision, and halos around lights.

Review results

There are two main mechanisms of drug-induced AACG, both with different treatment strategies. The first mechanism of drug-induced AACG is pupillary block and iridocorneal angle closure secondary to thickening of iris base with mydriasis. The second mechanism of drug-induced AACG is anterior displacement of the lens-iris diaphragm due to mass effect (e.g., blood, misdirected aqueous humor, and tumors), uveal effusion, or weakened zonules.

Conclusion

This paper reviews drug-induced AACG, high-risk anatomical features, underlying mechanisms, inciting medications, and options for treatment and prevention.

Clinical significance

With proper understanding of the underlying mechanism of drug-induced AACG, physicians can respond promptly to save their patients' vision by employing the correct treatment strategy.

How to cite this article

Yang MC, Lin KY. Drug-induced Acute Angle-closure Glaucoma: A Review. J Curr Glaucoma Pract 2019;13(3):104-109.

Association between serotonin-norepinephrine reuptake inhibitors and acute angle closure: What is known?

Serotonin-norepinephrine reuptake inhibitors are widely used antidepressants with a relatively safe profile. One of the complications associated with this group of drugs is acute angle closure. The mechanisms linking serotonin-norepinephrine reuptake inhibitors and acute angle closure are complex and may be interlinked with the effects of the drug on the inhibition of serotonin and noradrenaline reuptake, as well as pseudo-anticholinergic effects, dopaminergic effects, and idiosyncratic reactions with the drug molecule in the eye. Individual characteristics, such as polymorphisms of the gene encoding the 2D6 subunit of cytochrome P450, may affect the metabolism of the serotonin-norepinephrine reuptake inhibitor, whereas the combination with other drugs may lead to an increased risk of iridocorneal angle closure and may further exacerbate other mechanisms. Improved knowledge of the mechanisms linking serotonin-norepinephrine reuptake inhibitors and acute angle closure and of the risk factors predisposing to patients to acute angle closure will reduce the number of patients affected by this dangerous complication.

How Does Usage of Serotonin Noradrenaline Reuptake Inhibitors Affect Intraocular Pressure in Depression Patients?

PURPOSE

To evaluate anterior segment parameters and intraocular pressure (IOP) modifications in patients using serotonin noradrenaline reuptake inhibitors (SNRIs) due to major depressive disorder.

METHODS

This cross-sectional study included 170 eyes of 85 subjects. All subjects were divided into three groups: group 1 included 44 healthy control subjects, group 2 included 22 patients receiving antidepressants for 1 week to 6 months, and group 3 included 19 patients receiving antidepressants for >6 months. All subjects underwent a detailed ophthalmologic examination, including gonioscopy. Anterior segments of all subjects were evaluated with the Scheimpflug system and pupil diameter (PD), central corneal thickness, anterior chamber depth (ACD), anterior chamber volume, and anterior chamber angle (ACA) measurements were enrolled.

RESULTS

The median IOP was significantly lower in patients using antidepressants [16.0 (11.0-21.0) mmHg] than the control group [17.5 (12.0-21.0) mmHg] (P = 0.041). The PD was significantly larger in patients using antidepressants [3.56 (2.29-5.60) mm] than the control group [2.95 (2.00-4.40) mm] (P = 0.000). In the study group, PD was also significantly larger in patients using SNRIs for ≥6 months [3.67 (2.38-5.08) mm] than <6 months [3.31 (2.29-5.60) mm] (P = 0.000). The median ACD was significantly lower in patients using antidepressants for ≥6 months [3.21 (2.52-4.06) mm] than the control group [3.44 (2.63-4.29) mm] (P = 0.000). ACAs were measured between 25° and 55° by Scheimpflug imaging.

CONCLUSIONS

Treatment of SNRIs causes mydriasis and decrease in width of ACD. These changes may not increase IOP as long as the patient has an open angle. SNRIs lead to decrease in IOP particularly in long-term usage.