Letters to the Editor
Treatment With Risperidone and Occurrence of Blurred Vision:
A Question of Higher Dosage
The more frequently encountered ophthalmologic adverse events of neuropsychiatric agents include thioridazine-induced retinopathy, tricyclic antidepressant-induced accommodation interference and glaucoma, and lithium carbonate-induced exophthalmos and papilloedema. Clozapine may produce blurred vision, but this side effect is usually time-limited (1). According to available evidence, episodes of transient visual disturbances appear during treatment with risperidone but disappear when medication with risperidone is reduced to a lower daily dosage (2,3).
Methods
We assessed clinical somatic state, using laboratory values, ophtalmoscopy, biomicroscopy, EEG, and brain magnetic resonance imaging (MRI). We assessed psychic profiles, using the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) and the Clinical Global Impressions (CGI). We assessed side effects, using the SimpsonAngus Rating Scale for Extrapyramidal Syndrome, the Barnes Akathisia Scale (BAS), and the Extrapyramidal Symptom Rating Scale (ESRS).
Case Report
In June 2002, because of psychotic symptoms, the patient (aged 36 years, single, with no children, and an economist) was hospitalized in our clinic with a discharge diagnosis of psychosis schizoaffectiva according to DSM-IV (4). After admission to our clinic, we continued therapy with promazine 400 mg daily, along with alprazolam 0.75 mg daily, zolpidem 10 mg daily, and fluoxetine 20 mg daily, and we started therapy with risperidone 2 mg daily. At baseline visit (that is, the first day of therapy with risperidone), we performed the PANSS, CGI, SimpsonAngus Rating Scale for Extrapyramidal Syndrome, BAS, and ESRS. The patients total PANSS score was 86, and the CGI score was markedly ill. The values of hematology, biochemistry, and urinalysis were in referent range. EEG was normal. Because of persisting positive symptoms, we increased the dosage of risperidone to 12 mg daily. Promazine was discontinued from therapy. The patient became fully remitted after 4 weeks and was discharged. After 6 weeks of risperidone therapy (4 weeks as an inpatient and 2 weeks as an outpatient), the patient reported blurred vision. To clarify the origin of blurred vision, we assessed clinical somatic state. The values of hematology, biochemistry, and urinalysis were in referent range. The results of the neuropsychological assessment excluded lesions caused by cranial trauma, diffuse brain damage, or lesions caused with slow progressive process. The patients brain MRI was normal, and the biomicroscopy results revealed no abnormalities. Ophtalmoscopy showed no pigment mottling or disturbances in the macular regions. Subsequently, the dosage of risperidone was reduced to 4 mg daily, and 2 weeks later, the patient reported full recovery of vision without worsening her mental condition. The diagnostic procedure showed no organic cause of the blurred vision. Also, blurred vision was not related to concomitant therapy.
Conclusion
Blurred vision is a side effect associated with treatment with risperidone in higher dosages, which may disappear, without worsening of symptoms, after decreasing the daily dosage of risperidone. Further observation is necessary for more precise understanding of these conditions, which is essential for diagnosis and appropriate treatment.
References
1. Folnegović-malc V, Jukić V, Kozumplik O, Uzun S, Mimica N. Side effect profile of atypical antipsychotic agents and comparison to conventional antipsycotics. Socijalna psihijatrija 2003;31:1924.
2. Lerner AG, Shufman E, Kodesh A, Rudinski D, Kretzmer G, Sigal M. Risperidone-associated, benign transient visual disturbances in schizophrenic patients with a past history of LSD abuse. Isr J Psychiatry Relat Sci 2002;39:5760.
3. Thomas CS, Lewis S. Which atypical antypsichotic? Br J Psychiatry 1998;172:1069.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington (DC): APA; 1994.
Suzana Uzun, D Sc, MD
Oliver Kozumplik, MD
Vera Folnegović-malc, D Sc, MD
Vlado Jukić, D Sc, MD
Jelena Petrinović-Doreić, MD
Ljubica Dorn, MD
Danijela Zakić Milas
Ninoslav Mimica, D Sc, MD
Zagreb, Croatia
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