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Aripiprazole induced transient myopia: A case report and review of literature

August 2011
Cutaneous and Ocular Toxicology 31(1):74-6

August 2011
31(1):74-6

DOI:10.3109/15569527.2011.603106

Source
PubMed

Authors:

Akshay Gopinathan Nair

Ronnie George

Sankara Nethralaya

Jyotirmay Biswas

Sankara Nethralaya

Show all 5 authorsHide

Aripiprazole is a drug belonging to the group of atypical antipsychotics. Ocular side effects of aripiprazole are rare. We report a case of transient myopia in a 33-year-old male who was being treated for schizophrenia with oral quetiapine and was recently supplemented with aripiprazole. One month after the addition of aripiprazole the patient reported sudden onset painless blurring of vision in both eyes. He was found to have myopia of-3.0 diopters in both eyes; his corrected visual acuity being 20/20. He was advised to discontinue aripiprazole. Ten days later on examination, the patient had an uncorrected visual acuity of 20/20 in both eyes. The stoppage of symptoms on stopping the drug indicates a strong correlation between the drug and the adverse effect. Ophthalmologists and psychiatrists must be aware of this reversible adverse drug reaction, so it may be treated promptly.

. Details of cases of aripiprazole induced transient myopia.

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Introduction

Aripiprazole is a new drug belonging to a class of

atypical antipsychotics. It is a quinolinone derivative

with a high affinity for dopamine D2 and D3 receptors,

and serotonin 5-HT1A, 5-HT2A and 5-HT2B receptors

(1). It is used in the treatment of schizophrenia and

schizoaffective disorders, treatment resistant depres-

sion, bipolar disorder and obsessive-compulsive

disorder (2).

Commonly reported side eects include somnolence,

headache anxiety, insomnia, nausea, and vomiting (2).

Other less frequently reported side eects include par-

oxysmal supraventricular tachycardia, Pisa syndrome,

hiccups and rabbit syndrome (3). Out of 926 subjects

who received oral arpiprazole in short-term, placebo-

controlled trials, 3 subjects reported blurred vision. e

exact cause and nature of this visual complaint, however,

was not mentioned (4). Documented ocular side eects

of arpiprazole are rare. ere have been, to the best of

our knowledge, only 2 other cases of arpiprazole induced

transient myopia

Case history

We wish to report a case of acute transient myopia

caused by the use of arpiprazole. A 33-year-old male

patient reported to our hospital with a complaint of sud-

den painless blurring of vision in both eyes. ere was

no other ocular complaint and he had no prior history

of using glasses. His uncorrected visual acuity was 20/80

in both eyes. His best-corrected visual acuity was 20/20

in both eyes with a refractive error of−3.00 diopters.

Pupillary evaluation was normal with no aerent pupil-

lary defect. Ocular motility was normal in both eyes. Slit

lamp examination revealed shallow anterior chamber

depth. Gonioscopic examination showed the angles to

be moderately narrow: 20° (Grade II− Shaer’s classi-

cation) with a convex iris conguation. ere was no

evidence of pupillary block. Dilated fundus examination

was normal in both eyes. Intraocular pressure in both

eyes was 14 mm Hg. Systemically; the patient was not

a hypertensive or a diabetic and did not have a history

of substance abuse. He had, however been diagnosed

with schizophrenia and was being treated with tablet

CASE REPORT

Aripiprazole induced transient myopia: A case report and

review of literature

Akshay Gopinathan Nair1, Aditya Gopinathan Nair2, Ronnie Jacob George1, Jyotirmay Biswas1, and

Rashmin Anilkumar Gandhi1

1Sankara Nethralaya, A Unit of Medical Research Foundation, Nungambakkam, Chennai, India and 2Disha Psychiatric

Clinic, Chembur, National Burns Centre, Airoli, Mumbai, India

Abstract

Aripiprazole is a drug belonging to the group of atypical antipsychotics. Ocular side eects of aripiprazole are rare. We

report a case of transient myopia in a 33-year-old male who was being treated for schizophrenia with oral quetiapine

and was recently supplemented with aripiprazole. One month after the addition of aripiprazole the patient reported

sudden onset painless blurring of vision in both eyes. He was found to have myopia of−3.0 diopters in both eyes; his

corrected visual acuity being 20/20. He was advised to discontinue aripiprazole. Ten days later on examination, the

patient had an uncorrected visual acuity of 20/20 in both eyes. The stoppage of symptoms on stopping the drug

indicates a strong correlation between the drug and the adverse eect. Ophthalmologists and psychiatrists must be

aware of this reversible adverse drug reaction, so it may be treated promptly.

Keywords: Adverse drug reactions, drug induced myopia, aripiprazole

Address for Correspondence: Akshay Gopinathan Nair, Sankara Nethralaya, A Unit of Medical Research Foundation, Nungambakkam,

Chennai, 600006, India. E-mail: akshaygn@gmail.com

(Received 04 June 2011; revised 22 June 2011; accepted 01 July 2011)

Cutaneous and Ocular Toxicology, 2012; 31(1): 74–76

ISSN 1556-9527 print/ISSN 1556-9535 online

DOI: 10.3109/15569527.2011.603106

Cutaneous and Ocular Toxicology

2012

04 June 2011

22 June 2011

01 July 2011

1556-9527

1556-9535

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603106

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Aripiprazole induced transient myopia 75

quetiapine fumarate (Psynil, Crescent erapeutics,

Hyderabad, India) which had been titrated to daily

25 mg dose over three years. He was subsequently sup-

plemented with a daily dosing of 15 mg of arpiprazole

(Arpit, Crescent erapeutics, Hyderabad, India), 30

days prior to the onset of the ocular symptoms. Given

the clinical history, the normal intraocular pressures

and the open angles on gonioscopy, there was a high

degree of suspicion that the myopic shift was drug

induced. e patient was therefore not investigated. A

psychiatric referral was sought and subsequently oral

arpiprazole was stopped with the patient being under

close follow-up. e patient was re-examined 10 days

later and was found to have an uncorrected visual acu-

ity of 20/20. e anterior chamber was of normal depth

and the intraocular pressures were 14 mm Hg in both

eyes. Gonioscopy of both eyes showed the angles to be

widely open: 45° (grade IV) Dilated funduscopy was

normal.

Discussion

Acute, transient myopia may be caused by many drugs

(Table 1). e various mechanisms of drug-induced

myopia reported in literature are accommodation

spasm, ciliary body eusion, the eect of ocular sero-

tonergic, interneuronal bers, ciliary spasm, increase

in thickness of the lens and peripheral uveal eusion

(3,5). Ciliary body rotation and edema resulting in

forward movement of iris lens diaphragm has been

reported as another possiblility leading to acute myo-

pia (6).

Selvi et al. described a case of a 19-year-old female

who was treated with oral arpiprazole for obsessive-com-

pulsive symptoms (3). Fifteen days after the initiation

of 10 mg daily dose of aripiprazole therapy, the patient

developed myopia and diplopia, which resolved when

aripiprazole was stopped. Our case had no complaints of

diplopia. Kaya et al. have reported a case of a 21-year-old

female, diagnosed to have bipolar aective disorder on

sodium valproate (5). Oral aripiprazole 15 mg was added

when she presented with manic symptoms. Seven days

after the introduction of aripiprazole, she developed

myopia in both eyes, which disappeared 10 days after

stopping the drug (Table 2). It is also interesting to note

that the duration between the initiation of oral aripipra-

zole and the ocular symptoms in our case was substan-

tially longer than the other two case reports (30 days vs.

7 and 15 days).

We report this case of transient myopia, attributable

to the use of aripiprazole. e resolution of symptoms

on discontinuing the drug points to a strong co-relation

between the symptoms and the medication. Adverse

drug reactions such as sudden onset, transient myopia

can be distressing for patients. erefore, we believe that

clinicians prescribing aripiprazole must inform and edu-

cate the patients regarding this possible ocular adverse

eect. Ophthalmologists must be aware of this ocular

adverse eect, which may occur well after therapy is initi-

ated; promptly recognize it and stop the drug in order to

reverse the symptoms.

Table 1. List of drugs reported to have caused acute onset

myopia (not exhausative).

Acetazolamide (7)

Anti-lymphocytic globulins (8)

Aripiprazole (3,5)

Chlorthalidone (9)

Dapsone (10)

Disothiazide (11)

Hydrochlorthiazide (12)

Indapamide (13)

Levomepromazine (14)

Mefenamic Acid (15)

Metronidazole (11)

Sulfasalazine (16)

Topiramate (17)

Triamterene (12)

Table 2. Details of cases of aripiprazole induced transient myopia.

Age/Sex Diagnosis

Pre-existing

refractive error

Presenting

ocular

conditions

Myopia, in

diopters Medication in addition to Aripiprazole

Kaya et al(5). 21/F Bipolar aective

disorder

Nil Myopia OD: - 7

OS: - 8

Sodium Valproate

Selvi et al(3). 19/F Obsessive

Compulsive

symptoms

Nil Myopia,

Diplopia

OD: - 4.0

OS: - 4.5

Sertraline

Our Case 33/M Schizophrenia Nil Myopia OD: - 3.0

OS: - 3.0

Quetiapine

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76 A.G. Nair et al.

Cutaneous and Ocular Toxicology

Declaration of interest

e authors report no conict of interest. e authors

alone are responsible for the content and writing of

this paper.

References

1. Swainston Harrison T, Perr y CM. Aripiprazole: a review of its use

in schizophrenia and schizoaective disorder. Drugs 2004;64:

1715–1736.

2. Gupta S, Masand P. Aripiprazole: review of its pharmacology and

therapeutic use in psychiatric disorders. Ann Clin Psychiatry

2004;16:155–166.

3. Selvi Y, Atli A, Aydin A, Yener HI. Aripiprazole-related acute transient

myopia and diplopia: a case report. J Clin Psychopharmacol

2011;31:249–250.

4. McQuade RD, Burris KD, and Jordan S., et al. Aripiprazole:

a dopamine-serotonin system stabilizer. Int J Neuropsycho-

pharmacol 2002;5(Suppl 1):S176.

5. Kaya H, Yilbasi B, Dilbaz N, et al. Aripiprazole induced acute

myopia: a case report. Bull Clin Psychopharmacol 2009;19:Suppl

1:S147–S148.

6. Krieg PH, Schipper I. Drug-induced ciliary body oedema: a new

theory. Eye (Lond) 1996;10 (Pt 1):121–126.

7. Szawarski P, Hall-ompson B. Acetazolamide-induced myopia at

altitude. Wilderness Environ Med 2009;20:300–301.

8. Milea D, Zech C, Dumontet C, Coier B, Trepsat C. Transient acute

myopia induced by antilymphocyte globulins. Ophthalmologica

1999;213:133–134.

9. Mahesh G, Giridhar A, Saikumar SJ, Fegde S. Drug-induced acute

myopia following chlorthalidone treatment. Indian J Ophthalmol

2007;55:386–388.

10. Gopalani VV, More AS. Dapsone-induced acute myopia. Indian J

Dermatol Venereol Leprol 2006;72:455–456.

11. Grinbaum A, Ashkenazi I, Avni I. Drug induced myopia associated

with treatment for gynecological problems. Eur J Ophthalmol

1995;5:136–138.

12. Söylev MF, Green RL, Feldon SE. Choroidal eusion as a

mechanism for transient myopia induced by hydrochlorothiazide

and triamterene. Am J Ophthalmol 1995;120:395–397.

13. Blain P, Paques M, Massin P, Erginay A, Santiago P, Gaudric A.

Acute transient myopia induced by indapamide. Am J Ophthalmol

2000;129:538–540.

14. Kashani S, Barclay D, Lee E, Hollick E. A case of transient myopia in

a patient with multiple myeloma secondary to levomepromazine.

Palliat Med 2005;19:261–262.

15. Vishwakarma P, Raman GV, Sathyan P. Mefenamic acid-induced

bilateral transient myopia, secondary angle closure glaucoma and

choroidal detachment. Indian J Ophthalmol 2009;57:398–400.

16. Santodomingo-Rubido J, Gilmartin B, Wolsohn JS. Drug-induced

bilateral transient myopia with the sulphonamide sulphasalazine.

Ophthalmic Physiol Opt 2003;23:567–570.

17. Gubbay SS. e occurrence of drug-induced myopia as a transient

side eect of topiramate. Epilepsia 1998;39:451.

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Acute acquired myopia is a rare condition in psychiatry and ophthalmology practice. Several drugs have been reported, produce blurring, decrease accommodation and cause diplopia. To our knowledge there is no report of ariprazole that caused ophalthalmologic side effects. In this report we will discuss a case of aripirazole induced myopia. 21-year-old woman, with known case of bipolar affective disorder with 2 previous manic episodes in 2004 and 2006. She was under the treatment with reguler mood stabilizer sodium valproat 1000 mg/day. She presented with manic symptoms for 10 days. Aripiprazole 15 mg/day was added. The patient who had no refraction error before, reported blurring of distance vision in the seventh day of treatment. She consulted an ophthalmologist, who confirmed binocular myopia of - 7 diopters in the right eye and - 8 diopters in the left eye. Ten days after discontinuation of aripiprazole, . Her visual acuity was 20/20 without correction. Because of the disappearance of transient myopia following discontinuation of the drug we diagnosed the case as drug-induced myopia due to aripirazole. In cases with drug induced acute myopia the discussions of the mechanisms include accomodation spasm, ciliary body effusion, ciliary spasm and peripheral uveal effusion. Drug induced myopia is one of the most common causes of transient myopia. Aripiprazol is a second generation antipsychotic with a novel pharmacological profile which exhibits a partial agonistic effect on dopamin D2, D3 and serotonin 5HT1a receptors and antagonistic effect on serotonin 5HT2a receptors. This side effect due to aripiprazole, improved to normal without any intervention. The case report indicates that clinicians need to take account of the possibility that myopic shifts may be associated with new drugs.

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Abstract Aripiprazole, a quinolinone derivative, is an atypical antipsychotic drug indicated for the treatment of adult patients with schizophrenia. Aripiprazole 10 or 15mg once daily is effective and well tolerated in patients with schizophrenia or schizoaffective disorder. Although aripiprazole has only been directly compared with haloperidol and olanzapine in treatment-responsive patients to date, current data generally indicate that aripiprazole has a beneficial profile in terms of a low potential for bodyweight gain. Dosage titration is not necessary and the drug is effective in the first few weeks of treatment. Head-to-head comparative trials with atypical antipsychotic agents are required, as are long-term (≥1 year) studies, to fully define the position of aripiprazole in relation to other antipsychotic drugs. Aripiprazole is a valuable new therapeutic option in the management of patients with schizophrenia. Pharmacological Properties Aripiprazole is a quinolinone derivative with a high affinity for dopamine D2 and D3 receptors, and serotonin 5-HT1a, 5-HT2A and 5-HT2B receptors. The mechanism of action of aripiprazole is not yet known, but evidence suggests that its efficacy in the treatment of the positive and negative symptoms of schizophrenia and its lower propensity for extrapyramidal symptoms (EPS) may be attributable to aripiprazole’s partial agonist activity at dopamine D2 receptors. At serotonin 5-HT1a receptors, in vitro studies have shown that aripiprazole acts as a partial agonist whereas at serotonin 5-HT2A receptors aripiprazole is an antagonist. The main active metabolite, dehydro-aripiprazole, has affinity for dopamine D2 receptors and thus has some pharmacological activity similar to that of the parent compound. Aripiprazole is rapidly absorbed after oral administration. The mean time to peak plasma concentration is 3 hours following multiple-dose administration of aripiprazole 10 or 15mg and the absolute oral bioavailability of the drug is 87%. Steady-state plasma drug concentrations are achieved by 14 days; however, the drug appears to accumulate over this period, since mean peak plasma concentration and mean area under the plasma concentration-time curve values of aripiprazole 10 or 15 mg/day are 4-fold greater on day 14 than on day 1. This accumulation may be expected, since the mean elimination half-life of a single dose of aripiprazole is about 75 hours. Aripiprazole has extensive extravascular distribution and more than 99% of aripiprazole and dehydro-aripiprazole (the main active metabolite of aripiprazole) is bound to plasma protein. Elimination of the drug is primarily hepatic; the cytochrome P450 (CYP) 3A4 and CYP2D6 enzyme systems transform aripiprazole to dehydro-aripiprazole, with the latter enzyme system subject to genetic polymorphism. Thus, dosage adjustment of aripiprazole is necessary when it is coadministered with CYP3A4 and CYP2D6 inhibitors (since aripiprazole concentration is increased) and with inducers of CYP3A4 (since aripiprazole concentration is decreased). Therapeutic Efficacy The efficacy of aripiprazole has been demonstrated in patients with schizophrenia or schizoaffective disorder. In general, significant reductions from baseline in mean Positive and Negative Syndrome Scale total, positive and negative symptom scores, and Clinical Global Impression Severity of Illness scores were observed in patients with acute relapse of chronic schizophrenia or schizoaffective disorder receiving recommended (10 or 15 mg/day) or higher-than-recommended (20 or 30 mg/day) dosages of aripiprazole versus those receiving placebo in three well controlled, short-term trials. No additional therapeutic benefit was observed at the higher-than-recommended dosages. The drug is effective as early as the first or second week of treatment. The efficacy of aripiprazole was maintained for up to 52 weeks. The drug was significantly more effective than placebo in preventing relapse in patients with stable chronic schizophrenia in a 26-week, randomised trial. In a 52-week trial in patients with acute relapse of schizophrenia, the percentage of responders maintaining a response at study end was 77% of aripiprazole versus 73% of haloperidol recipients. Aripiprazole may improve cognitive function. In a nonblind, 26-week trial, patients with chronic schizophrenia receiving aripiprazole 30 mg/day experienced similar (general cognitive function) or better (verbal learning) changes from baseline in the neurocognitive parameters evaluated compared with recipients of olanzapine 10–15 mg/day. Tolerability Aripiprazole 10–30 mg/day was generally well tolerated. The tolerability profile of aripiprazole was broadly similar to that observed with placebo in a meta-analysis of short-term trials in patients with acute relapse of schizophrenia or schizoaffective disorder and in a 26-week trial in patients with chronic stable schizophrenia. The most frequent treatment-emergent adverse events included insomnia and anxiety, and additionally, headache and agitation (in short-term trials) or akathisia and psychosis (in a 52-week trial). In general, the drug was associated with a placebo-level incidence of EPS and EPS-related adverse events. Significantly fewer aripiprazole recipients experienced EPS-related adverse events than haloperidol recipients in a 52-week trial. Changes in severity of EPS were minimal and usually no different from those observed with placebo. Moreover, there was less severe EPS in the aripiprazole group than the haloperidol group in a long-term trial. Treatment-emergent tardive dyskinesia was reported in only 0.2% of patients receiving aripiprazole (short-term trials), an incidence similar to that seen in placebo recipients (0.2%). Aripiprazole has a low propensity to cause clinically significant bodyweight gain, hyperprolactinaemia or corrected QT interval prolongation in patients with schizophrenia or schizoaffective disorder. In addition, there were no clinically relevant differences in mean changes from baseline in measures of diabetes and dyslipidaemia between the aripiprazole or placebo groups in a 26-week, placebo-controlled trial.

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Apr 1995

We present three cases of women who developed acute transient myopia caused by drugs for gynecological problems. One patient was treated with disothiazide for premenstrual edema. The second had acute cystitis and was treated by sulphonamide and the third developed myopia coincident with metronidazole treatment for trichomonas vaginalis. We followed these patients by A scan ultrasonographic ocular measurements, documenting reduction of the anterior chamber depth combined with lens thickening. The ocular and myopic changes cleared up completely on discontinuation of the causative agent. The possible mechanism is thought to be an allergic reaction to the drug.

Choroidal Effusion as a Mechanism for Transient Myopia Induced by Hydrochlorothiazide and Triamterene

Article

Oct 1995
AM J OPHTHALMOL

We treated a case of transient myopia in a patient being treated with hydrochlorothiazide and triamterene for tinnitus. The patient underwent gonioscopic, ophthalmoscopic, and echographic examinations. Examination showed anterior chamber flattening and echography disclosed bilateral 360-degree shallow choroidal detachments. All of the patient's symptoms and signs resolved after the cessation of drug therapy.

Drug-induced ciliary body oedema: A new theory

Article

Feb 1996

Drug-induced oedema of the ciliary body is rare, and occurs predominantly following exposure to sulphonamides. In a 31-year-old patient in her 37th week of pregnancy, we observed reversible myopia of -4.75 dioptres following the ingestion of chlorthalidone. In a second case report we describe, in a 61-year-old patient suffering from aspirin-sensitive asthma, recurrent ciliary body oedema with a marked spastic component which was triggered by the medications acetazolamide, dipivefrine and pilocarpine. We explain oedema of the ciliary body on the basis of the eicosanoids. We believe that the oedema is caused mainly by prostaglandins and that leucotrienes are predominantly responsible for the spastic component. We postulate a drug-induced elevation in eicosanoid concentrations, as well as certain interrelationships between ciliary body oedema and aspirin-sensitive asthma.