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Psychotropic medications and screening IOL surgery candidates
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What you should know to provide the best outcomes for the patient and your practice.
Question: I recently was at a meeting where a case was presented of a patient unhappy with their premium IOL outcome despite excellent visual exam results. The surgeon mentioned that perhaps he shouldn’t have performed the surgery since the patient was on three psychotropic medications. Everyone offered different opinions as to who should be screened out as non-candidates based on taking psychiatric medications. Do you have some guidance?
Answer: This is a topic I often hear about at ophthalmology meetings, and I am happy to offer advice based on my experience as a medical-surgical consult-liaison psychiatrist who has screened patients with psychiatric diagnoses for cataract and refractive surgery.
It is true that some antidepressants, antipsychotics, mood stabilizers, anxiolytics and stimulant medications can cause varying degrees of dry eye and/or blurred vision. So, a review of a prospective surgical candidate’s medication list is always necessary to correlate with their preoperative symptom review and exam. Given the large number of people taking a psychotropic medication of some kind for a wide variety of reasons, it is important for eye surgeons to understand the issues involved so they don’t unnecessarily screen out an otherwise excellent candidate for a premium IOL or other procedure.
The myth of numbers
Surgeons frequently tell me at meetings that they screen out anyone who is on two or three psychotropic medications as candidates for refractive surgery and premium IOLs, but they do it based simply by reviewing the medication list. Yet, the issue is not really one of numbers – it’s whether they were prescribed for psychiatric symptoms, and the level of acuteness and severity of those symptoms.
Talk to the patient. You must sit down and ask the patient a few simple questions about his/her psychotropic medications. First, for what conditions was he/she prescribed drug 1, 2 and 3? Let’s say the patient is taking amitriptyline, clonazepam and bupropion. You can’t simply assume your patient is taking these for psychiatric problems, but you certainly need to ask. They may be taking amitriptyline for migraine prophylaxis, clonazepam for restless legs syndrome and bupropion to help them stop smoking. The tricyclic antidepressants, such as amitriptyline and nortriptyline, aren’t as commonly used anymore for depression, but are used for chronic pain, insomnia and migraine prophylaxis treatment.
In terms of possible visual side effects, some of the more concerning medications on a screening exam, or if new at follow-up exams, would be tricyclic antidepressants, topiramate, stimulants, and older antipsychotics. It may be helpful to see if these can be temporarily decreased, or if another medication without visual effects can be substituted.
Keep it simple. Although I used to tell surgeons to ask their patients taking multiple psychotropics a list of questions, I now try to keep it simple. If the patient says that he/she was prescribed psychotropic medications for psychiatric conditions, my guidance is to ask for permission to speak to the prescribing provider to discuss the medications and the surgery, and of course keep that information confidential. I’ve had many patients on psychotropic combinations who I considered stable for elective surgery procedures, and others who I would not have recommended had anyone bothered to ask. They didn’t, but I’m sure after patients’ tearful, angry post-op visits to their offices, they wish they had.
Communicate your request to the patient without making it sound pejorative or judgmental. Instead, let them know how important it is for you to know as much as possible about them, their medical history and their medications so you can determine the best treatment options available that will provide the most superior outcome. If the patient gets upset about this request (which is in their best interest), that raises a red flag. However, it may simply be their concern for their confidentiality and autonomy. From the moment you ask about their medications to asking about contacting their provider, consistently reassure them of confidentiality. Remember – if you practice in a small town, that means that you need to make the call to the provider, not your nurse or office manager. Only document the absolute minimum psychiatric information you require to make your decision.
Antidepressants: Everyone takes them! So why ask?
Indeed, as of 2005, antidepressants surpassed antihypertensives as the most-prescribed medications in the U.S. At least half were prescribed for reasons other than a depressive disorder. But that still leaves the other 50% for you to consider. I’ve had surgeons tell me they don’t even bother to ask the patient when they started the medication or why because “It’s no big deal — everyone is on one of those meds.”
I disagree. You do need to ask about that one antidepressant. Why? Say your 60-year-old male candidate’s medication list includes a selective serotonin reuptake inhibitor (SSRI) like sertraline. Given that it is an SSRI, it’s highly likely it was prescribed for an anxiety or depressive disorder. You don’t ask about it, and the patient receives a premium IOL in a procedure without complications. However, on follow-up, he tearfully tells everyone in your reception area that he regrets ever having the surgery, and he felt overwhelmed and couldn’t even concentrate when you were counseling him preoperatively. In your office, you are surprised to learn he has been significantly depressed, and the SSRI that you didn’t bother to ask about 3 weeks ago in consultation was only prescribed 6 weeks ago when the patient was admitted to a psychiatric unit because of suicidal ideation and depression. Remember that it takes 4 to 6 weeks for the antidepressant groups of medications to begin to reduce anxiety or mood symptoms.
It’s far better to have simply asked why and when it was prescribed at initial evaluation and delayed the scheduling of surgery temporarily until his depression had sufficiently improved than to assume that being on an antidepressant these days is never a big deal.
Summary
The presence of psychotropic medications doesn’t automatically mean that a premium IOL candidate should be screened out, but neither should it be ignored. Doctor-patient communication is crucial to determine why the patient is taking the medication(s). Communication with the prescribing provider is optimal to help determine the candidate’s surgical suitability and timing of the surgery, as well as to discuss temporary reductions in (or substitutions for) medications with visual effects. Many patients on psychotropic medications will turn out to be excellent candidates, and following these steps will provide the best outcome for the patient and your practice.
Jennifer S. Morse, MD, is in private practice as a consultant for medical and surgical psychiatry in San Diego, Calif. She can be reached at 619-405-5919; e-mail: jmorsemd@aol.com.