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Clinical<br />

Doina Gherghel MD, FRCOphth<br />

The eye and <strong>the</strong> mind<br />

Psychiatric encounters in optometric practice<br />

In <strong>the</strong>ir day-to-day professional lives, optometrists and<br />

ophthalmologists come into contact with various kinds of<br />

ophthalmic disorders. However, many of our patients may also<br />

experience psychological or psychiatric problems as a result of<br />

<strong>the</strong>ir eye diseases, and so practitioners should be prepared to<br />

recognise <strong>the</strong>se and follow <strong>the</strong> appropriate course of action. This<br />

article introduces this often overlooked aspect of optometric practice.<br />

Effects of low vision<br />

Visual loss is a common problem<br />

encountered in optometric practice and it<br />

affects patients of different ages and<br />

backgrounds. It is estimated that in <strong>the</strong><br />

USA, around 12% of <strong>the</strong> population aged<br />

65 years or older is legally blind, and an<br />

additional 8% have chronic vision<br />

impairments 1 .<br />

There are a large number of ocular<br />

diseases causing low vision, however, agerelated<br />

macular degeneration (AMD),<br />

glaucoma and diabetic retinopathy are <strong>the</strong><br />

most common causes of visual loss seen by<br />

<strong>the</strong> optometrist. Besides <strong>the</strong>ir ocular<br />

consequences, <strong>the</strong>se diseases may also affect<br />

<strong>the</strong> patient’s well-being, causing<br />

psychological and psychiatric disturbances.<br />

Low vision patients often suffer from<br />

o<strong>the</strong>r systemic diseases, which toge<strong>the</strong>r with<br />

<strong>the</strong> visual impairment, may lead to a large<br />

variety of social problems, such as physical<br />

dependency, loneliness, social isolation and<br />

often poverty. Sadly, elderly people usually<br />

accept all of <strong>the</strong>se as part of <strong>the</strong> natural part<br />

of ageing, assuming that nothing can be<br />

done 2 .<br />

It has been demonstrated that a large<br />

number of patients affected by AMD suffer a<br />

very significant degree of psychological<br />

distress. In a recent study, Brody et al 3 found<br />

that 32.5% of patients with advanced AMD<br />

met specific criteria for depressive disorders.<br />

This percentage was twice <strong>the</strong> rate observed<br />

in <strong>the</strong> general population of elderly adults<br />

and similar to that found in patients<br />

suffering from cancer and cardiovascular<br />

diseases. Interestingly, depression scores for<br />

glaucoma patients seem to be similar to<br />

those of control patients 4 .<br />

Although depression is often seen<br />

among patients with visual loss, a<br />

differentiation between major depression<br />

and normal grief should be considered<br />

before referring <strong>the</strong>se patients to <strong>the</strong>ir GP.<br />

In clinical depression, mood changes are<br />

associated with neurovegetative symptoms<br />

such as loss of sleep, energy, appetite and<br />

concentration. The patient could be also<br />

agitated and may be suicidal 5 . Whenever<br />

such symptoms are detected, <strong>the</strong> patient<br />

should be immediately referred for fur<strong>the</strong>r<br />

evaluation.<br />

Visual hallucinations are ano<strong>the</strong>r<br />

common complaint reported by visually<br />

impaired patients. In 1769, Charles Bonnet,<br />

a Swiss scientist, described <strong>the</strong> case of his<br />

grandfa<strong>the</strong>r who had his cataract removed at<br />

<strong>the</strong> age of 78. Subsequently, at <strong>the</strong> age of 89,<br />

he started having visual hallucinations<br />

consisting of different coloured and dynamic<br />

objects and people. Moreover, Charles<br />

Bonnet himself experienced <strong>the</strong> same<br />

phenomena towards <strong>the</strong> end of his life 6 .<br />

These symptoms are now termed Charles<br />

Bonnet syndrome. It is estimated that<br />

approximately 10% of all visually impaired<br />

patients will experience visual hallucinations<br />

as long as <strong>the</strong>y have a best-corrected visual<br />

acuity (BCVA) of 6/36 or less. Charles<br />

Bonnet syndrome is characterised by <strong>the</strong><br />

following clinical features 7 :<br />

• Variable onset of highly organised visual<br />

hallucinations<br />

• The visual hallucinations are initially<br />

simple and elementary and <strong>the</strong>n progress<br />

to more complex images. They tend to<br />

occur periodically or almost continuously<br />

• The hallucinations appear in <strong>the</strong> real<br />

world, are bright, coloured (as in AMD)<br />

or black and white (as in glaucoma or<br />

diabetic retinopathy), are usually<br />

animated and are outside of <strong>the</strong> patient’s<br />

control<br />

The explanation for <strong>the</strong> occurrence of<br />

Charles Bonnet syndrome in low vision<br />

patients is still under investigation. It seems<br />

that an interruption on <strong>the</strong> normal visual<br />

pathway results in an increase in <strong>the</strong><br />

spontaneous neural activity. Moreover, as<br />

part of <strong>the</strong> normal ageing process, <strong>the</strong><br />

cortical inhibition decreases. Visual<br />

hallucinations may be <strong>the</strong> result of <strong>the</strong><br />

complex interaction between increased<br />

spontaneous neural activity and loss of<br />

cortical inhibition. The visual cortex also has<br />

complex interconnections and a pathological<br />

increase in activity is widespread. It could be<br />

that visual hallucinations reflect <strong>the</strong><br />

anatomical connection between different<br />

visual areas 8 .<br />

Loneliness, shyness and use of betablockers,<br />

have also been implicated in <strong>the</strong><br />

aetiology of this syndrome.<br />

The first psychological reaction to visual<br />

hallucinations is complex and usually<br />

positive. The patients report surprise,<br />

38 | March 21 | 2003 OT

Clinical<br />

curiosity and amazement and only very<br />

rarely, fear. Later, however, <strong>the</strong><br />

embarrassment and fear that <strong>the</strong>y may be<br />

losing <strong>the</strong>ir sanity make <strong>the</strong>se patients very<br />

shy in reporting such symptoms. Only a<br />

very open and strong relationship with <strong>the</strong>ir<br />

doctor helps <strong>the</strong>m overcome this inhibition.<br />

Patients suffering from visual<br />

hallucinations require a speedy intervention.<br />

Measures can include 9 :<br />

• Improving <strong>the</strong> patient’s visual acuity and<br />

his or her physical condition<br />

• Replacing medication, such as betablockers,<br />

if necessary<br />

• Psycho-education – patients should be<br />

reassured that <strong>the</strong>y are not losing <strong>the</strong>ir<br />

sanity and taught how to cope<br />

emotionally with <strong>the</strong> hallucinations<br />

• Helping patients to decrease <strong>the</strong>ir social<br />

isolation<br />

• Explaining different techniques of<br />

relaxation<br />

• Teaching <strong>the</strong> patient techniques to stop<br />

hallucinations, such as closing and<br />

opening <strong>the</strong>ir eyes, looking or walking<br />

away, approaching <strong>the</strong> hallucination,<br />

visual fixation on <strong>the</strong> hallucination,<br />

increasing <strong>the</strong> light, concentrating on<br />

something else, trying to hit <strong>the</strong><br />

hallucination, shouting at <strong>the</strong><br />

hallucination, etc<br />

Ocular diseases associated<br />

with psychosis<br />

Usher’s syndrome<br />

Retinitis pigmentosa (RP) represents a group<br />

of hereditary diseases characterised by<br />

degeneration of photoreceptor cells and<br />

progressive loss of visual function. The<br />

general prevalence of <strong>the</strong> disease is one in<br />

4,000 people worldwide and it is an<br />

important cause of low vision and blindness<br />

by <strong>the</strong> age of 60. A number of inherited<br />

conditions are associated with RP, including<br />

abetalipoproteinemia, Refsum’s disease,<br />

Friedreich-like ataxia, Laurence-Moon-<br />

Bardet-Biedl syndrome and Usher’s<br />

syndrome. Almost all <strong>the</strong>se diseases include<br />

some degree of neurological implications or<br />

mental retardation. However, this chapter<br />

will focus on <strong>the</strong> psychiatric changes which<br />

occur in Usher’s syndrome.<br />

Usher’s syndrome is characterised by <strong>the</strong><br />

co-existence of progressive pigmentary<br />

retinopathy, congenital sensorineural<br />

hearing loss and vestibular dysfunction.<br />

There are three types of Usher’s syndrome –<br />

type 1 which is characterised by profound<br />

congenital deafness and vestibular ataxia,<br />

type 2 in which <strong>the</strong> hearing loss is mild and<br />

non-progressive and type 3, with progressive<br />

hearing loss.<br />

Patients suffering from Usher’s syndrome<br />

sometimes exhibit psychotic symptoms.<br />

Links between <strong>the</strong> genes responsible for<br />

schizophrenia and those for Usher’s<br />

syndrome have been implicated as possible<br />

causes for this association 10 ; it seems,<br />

however, that <strong>the</strong> genetic <strong>the</strong>ory is still in<br />

doubt. It has also been suggested that <strong>the</strong><br />

psychotic breakdown in patients suffering<br />

from Usher’s syndrome could be related to<br />

stress induced by <strong>the</strong> physical and social<br />

handicaps 11 . O<strong>the</strong>r researchers have<br />

purposed a neuropathological explanation<br />

for <strong>the</strong> co-existence of Usher’s syndrome<br />

and schizophrenia. According to this <strong>the</strong>ory,<br />

it seems that patients with Usher’s<br />

syndrome have global anatomical cerebral<br />

and cerebellar degenerations which could<br />

lead to <strong>the</strong> observed psychotic changes 12 .<br />

It is well known that vitamin A plays an<br />

important role in <strong>the</strong> pathogenesis of RP. In<br />

addition, vitamin A metabolism is also<br />

associated with schizophrenia. Whe<strong>the</strong>r<br />

<strong>the</strong>re is any metabolic link between <strong>the</strong> two<br />

disorders is still a matter of debate.<br />

Behçet’s disease<br />

Behçet’s disease is an immune complex<br />

disease with occlusive vasculitis. It was first<br />

described by <strong>the</strong> Turkish dermatologist,<br />

Hulusi Behçet, in 1937. It occurs worldwide,<br />

but is found more often in <strong>the</strong> Middle and<br />

Far East. Diagnosis of Behçet’s disease is<br />

based on clinical findings and, although<br />

<strong>the</strong>re is a large variety of clinical<br />

manifestations, <strong>the</strong> most characteristic triad<br />

of symptoms are recurrent hypopyon uveitis<br />

associated with oral and genital ulcerations.<br />

This disease may also affect <strong>the</strong> central<br />

nervous system (neuro-Behçet) where<br />

patients complain of altered mental status<br />

and headaches. Arai et al 13 have suggested<br />

that patients with neuro-Behçet suffer from<br />

secondary dysfunction of <strong>the</strong> frontal cortex<br />

due to anatomical damage of <strong>the</strong> brain stem<br />

and pons. These pathological changes might<br />

be responsible for <strong>the</strong> changes in personality<br />

and dementia observed in <strong>the</strong>se patients.<br />

Ocular and facial<br />

disfigurement<br />

Ocular tumours and trauma often result in<br />

facial disfigurement and can cause<br />

psychological disorders in those who have<br />

suffered <strong>the</strong>m. Disfigurement affects not<br />

only <strong>the</strong> patient’s self-image and sense of<br />

attractiveness, but also his or her social and<br />

occupational roles and interactions 14 . The<br />

most common reactions are depression,<br />

acute stress reactions, anxiety and<br />

personality changes. When <strong>the</strong> facial<br />

disfigurement is <strong>the</strong> result of a trauma, <strong>the</strong><br />

patient may experience <strong>the</strong> so-called ‘posttraumatic<br />

stress disorder’ (PTSD), a<br />

neurophysiological disease which occurs in<br />

20-30% of people exposed to traumatic<br />

stress 15 . People suffering from PTSD initially<br />

respond with shock, disbelief and denial,<br />

which can last hours, days or weeks. After<br />

this period, <strong>the</strong> emotional response<br />

becomes more complex and <strong>the</strong> patient<br />

experiences feelings of anxiety, rage,<br />

sadness, vulnerability and confusion 16 .<br />

The ophthalmologist and optometrist<br />

have an important role in <strong>the</strong> physical but<br />

and psychological recovery of <strong>the</strong>se<br />

individuals. Whenever it is suspected that a<br />

patient might be suffering from PTSD or<br />

o<strong>the</strong>r forms of psychological distress, <strong>the</strong><br />

following procedures should be used 16 :<br />

• Create a calm and quiet atmosphere in<br />

<strong>the</strong> consulting room; by this method <strong>the</strong><br />

patient is more likely to open up and<br />

gain a sense of control over his or her<br />

emotions and reactions<br />

• Try to establish a friendly relationship<br />

and show interest in what <strong>the</strong> patient has<br />

to say about him or herself<br />

• Be equal to <strong>the</strong> patient; <strong>the</strong>re is no need<br />

for words of wisdom, sometimes <strong>the</strong><br />

patient just needs somebody to talk to<br />

• Encourage <strong>the</strong> presence of family<br />

members during discussion and analyse<br />

how <strong>the</strong>y cope with <strong>the</strong> situation. These<br />

people often need reassurance so use <strong>the</strong><br />

opportunity to emphasise that <strong>the</strong>y need<br />

to take care of <strong>the</strong>mselves in order to<br />

better help <strong>the</strong> patient<br />

• Assure a multidisciplinary approach of<br />

<strong>the</strong> case. Work in collaboration with<br />

psychologists and social workers in order<br />

to establish good care for <strong>the</strong> patient<br />

• Introduce <strong>the</strong> patient to local support<br />

groups<br />

No drugs are currently designated for <strong>the</strong><br />

treatment of PTSD.<br />

Malingering<br />

Optometrists and ophthalmologists are<br />

often confronted with patients whose<br />

clinical examination does not coincide with<br />

<strong>the</strong> actual complaints. In malingering, <strong>the</strong><br />

patient intentionally complains of false or<br />

grossly exaggerated symptoms, motivated by<br />

external incentives such as avoiding school,<br />

work, criminal prosecution or obtaining<br />

financial compensation or drugs<br />

(Diagnostic and Statistical Manual of<br />

Mental Disorders, DSM-IV, 2000).<br />

There are four general indications that a<br />

patient could be malingering (from: “The<br />

defence analysis of symptoms manipulation<br />

and malingering”):<br />

• The existence of a medico-legal context<br />

(check if <strong>the</strong> patient has been referred by<br />

a solicitor)<br />

• The patient may complain of symptoms<br />

which are far beyond any objective<br />

findings<br />

• The patient does not co-operate with<br />

medical examination and treatment<br />

• The patient has a personality disorder<br />

When facing a possible malingerer, <strong>the</strong><br />

optometrist should handle <strong>the</strong> patient with<br />

patience and to perform some simple tests<br />

to help discover <strong>the</strong> real nature of <strong>the</strong><br />

‘disease’ (Table 1).<br />

Hysteria<br />

Conversion disorder (hysteria) represents a<br />

polysymptomatic disorder which occurs<br />

from early childhood, usually before 35<br />

years of age. It is characterised by different<br />

pseudoneurological symptoms such<br />

weakness, aphonia, paralysis, urinary<br />

retention, seizures and convulsions 17 . The<br />

symptoms are not intentionally produced to<br />

obtain benefits (differentiate conversion<br />

39 | March 21 | 2003 OT

Clinical<br />

Doina Gherghel MD<br />

Table 1<br />

Tests to perform in case of ocular malingering<br />

1. If <strong>the</strong> patient claims to be totally blind:<br />

- Initiate a blink by approaching an object or threatening <strong>the</strong> patient’s eye; <strong>the</strong> malingering<br />

patient will blink, while a true blind person will not<br />

- Test <strong>the</strong> optokinetic nystagmus<br />

- Rotate a mirror in front of <strong>the</strong> patient; a malingering patient will involuntarily rotate his or<br />

her eyes<br />

2. If <strong>the</strong> patient has ‘lost’ <strong>the</strong>ir vision in one eye:<br />

- Check for <strong>the</strong> presence of a relative afferent pupillary defect (RAPD); a normal eye has<br />

normal pupillary reflexes<br />

- Use stereoscopic or duochrome testing<br />

3. O<strong>the</strong>r tests and manoeuvres:<br />

- Perform a visual field test<br />

- Electroretinogram, visually evoked cortical potentials<br />

- Change <strong>the</strong> distance at which you test <strong>the</strong> visual acuity, use fogging, etc<br />

- Ask <strong>the</strong> patient to come for ano<strong>the</strong>r examination. Malingering patients usually do not come<br />

back<br />

Table 2<br />

Ocular signs and symptoms in hysteria<br />

• Binocular or monocular blindness<br />

• Fluctuating visual acuity<br />

• Different visual field defects, such as<br />

tubular fields, ring scotoma, hemianopias<br />

• Diplopia<br />

• Blepharospasm<br />

• Ocular pain<br />

• Problems with reading and writing<br />

• Colour blindness<br />

• Ocular paralysis<br />

• Convergence spasm<br />

disorder from malingering and factitious<br />

disorders) and do not conform to <strong>the</strong><br />

‘classical’ clinical picture and physiological<br />

mechanisms of <strong>the</strong> presumed disease, but<br />

instead follow <strong>the</strong> patient’s idea about <strong>the</strong><br />

condition. Ocular hysteria may present with<br />

a large variety of signs and symptoms<br />

(Table 2).<br />

Usually <strong>the</strong>se symptoms are a<br />

consequence of an emotional stress which<br />

<strong>the</strong> patient represses into <strong>the</strong>ir unconscious.<br />

It seems that many of <strong>the</strong>se patients<br />

subsequently develop different neurological<br />

diseases. They should be referred for<br />

psychological counselling and treatment.<br />

Factitious disorders<br />

(Münchausen’s syndrome)<br />

According to <strong>the</strong> Diagnostic and Statistical<br />

Manual of Mental Disorders (DSM-IV,<br />

2000), “Factitious disorders are<br />

characterised by physical or psychological<br />

symptoms that are intentionally produced<br />

or feigned in order to assume <strong>the</strong> sick role”.<br />

“Fever of unknown aetiology” is <strong>the</strong> most<br />

common medical example of a factitious<br />

disorder. The difference between factitious<br />

disorders and malingering is that in <strong>the</strong><br />

former, <strong>the</strong> patient seeks a psychological<br />

benefit, while in <strong>the</strong> latter <strong>the</strong> benefit is<br />

more material.<br />

Münchausen’s syndrome is a more<br />

chronic and severe form of factitious<br />

disorder. It is characterised by a triad of<br />

features 18 – simulated illness, ‘pseudologia<br />

fantastica’ (pathological lying), and<br />

‘peregrination’ (<strong>the</strong> patient has a huge<br />

medical history and wanders from hospital<br />

to hospital and from doctor to doctor). The<br />

syndrome was named after <strong>the</strong> fictional Karl<br />

Friedrich Hieronymous Baron von<br />

Münchausen, known for his fabulous<br />

anecdotes about his life published in 1786<br />

by Rudolf Erich Raspe in “Baron<br />

Münchausen’s narrative of his marvellous<br />

travels and campaigns in Russia”. The name<br />

was used for <strong>the</strong> first time in medicine by<br />

Richard Asher in 1951 19 .<br />

Münchausen’s syndrome is often<br />

confused with hypochondria and, as such,<br />

can be overlooked and minimised by<br />

doctors. While in hypochondria <strong>the</strong> patient<br />

actually believes that he or she is really ill,<br />

in Münchausen’s syndrome, <strong>the</strong> patient<br />

knows <strong>the</strong> unrealistic nature of <strong>the</strong><br />

complaint but is determined to get<br />

attention at all costs. Some patients even<br />

self-mutilate <strong>the</strong>mselves to <strong>the</strong> extent of<br />

self-enucleation. A more severe form of<br />

Münchausen’s syndrome is <strong>the</strong> so-called<br />

‘Münchausen’s by proxy’ in which a person<br />

makes someone else sick in order to get<br />

attention. A good example is when a parent<br />

intentionally creates symptoms in a child to<br />

get sympathy.<br />

These patients should be managed with<br />

increased care and continuously monitored<br />

in how <strong>the</strong>y handle <strong>the</strong>ir own bodies<br />

because, in <strong>the</strong> effort to gain attention, <strong>the</strong><br />

patients can induce <strong>the</strong>mselves a real illness<br />

or even death. Whenever a child is involved,<br />

<strong>the</strong> matter should be regarded as a form of<br />

child abuse and should be reported as soon<br />

as possible. The patient should be treated by<br />

a multidisciplinary approach, and often<br />

<strong>the</strong>y require a referral for an urgent<br />

psychiatric evaluation and treatment.<br />

However, confrontation of <strong>the</strong> patient<br />

should be done carefully and in a nonpunitive<br />

way.<br />

Psychiatric side effects of<br />

ophthalmic medications<br />

The most common way to treat eye diseases<br />

is by using a large variety of topical<br />

administrated solutions, suspensions, gels<br />

or ointments. These drugs act primarily at<br />

eye level, however, drugs passing into <strong>the</strong><br />

nasolacrimal duct can enter <strong>the</strong> systemic<br />

circulation ei<strong>the</strong>r via <strong>the</strong> nasal mucosa or<br />

from <strong>the</strong> gastrointestinal tract after<br />

ingestion, and can cause a multitude of<br />

systemic side effects. Among <strong>the</strong>m,<br />

neuropsychiatric side effects are reported for<br />

various topical ophthalmic medications<br />

such as corticosteroids, beta-blockers,<br />

acetazolamide, anticholinergic and<br />

sympathomimetic eye drops.<br />

Corticosteroids<br />

Corticosteroids are possibly <strong>the</strong> most<br />

commonly prescribed drugs in medicine.<br />

They were first introduced to<br />

ophthalmology in <strong>the</strong> 1950s, first as<br />

systemic medication and <strong>the</strong>n as drops,<br />

ointments and solutions for local<br />

injections. Their main effect is antiinflammatory,<br />

accomplished via a large<br />

variety of mechanisms such as<br />

vasoconstriction and reduction of vascular<br />

permeability, membrane stabilisation and<br />

stabilisation of mast-cells and basofils,<br />

suppression of lymphocyte proliferation<br />

and mobilisation of PMNs, etc. Systemic<br />

side effects of corticosteroids have been<br />

reported with <strong>the</strong> oral and parenteral forms<br />

of administration, however, systemic<br />

absorption of topically administrated<br />

corticosteroids is important. Depression,<br />

mania, psychosis and o<strong>the</strong>r psychiatric<br />

disorders have all been reported after<br />

topical, long-term corticosteroid <strong>the</strong>rapy.<br />

Timolol<br />

Timolol was introduced for <strong>the</strong> treatment of<br />

glaucoma in 1977 and since <strong>the</strong>n, it has<br />

been an essential part of <strong>the</strong> management<br />

of <strong>the</strong> disease. Only about 1% of topically<br />

administrated timolol is absorbed into <strong>the</strong><br />

eye, leaving <strong>the</strong> o<strong>the</strong>r 99% available for<br />

systemic absorption. Because <strong>the</strong> drug is<br />

absorbed directly into <strong>the</strong> venous<br />

circulation, it bypasses <strong>the</strong> hepatic<br />

detoxifying metabolism, thus increasing <strong>the</strong><br />

risk of systemic toxicity 20 . Approximately<br />

10% of glaucoma patients treated with<br />

timolol can experience different psychiatric<br />

problems, such as fatigue, depression,<br />

dissociative behaviour, memory loss,<br />

paranoia, confusion, hallucinations and<br />

psychosis 21,22 . Psychiatric side effects<br />

following betaxolol <strong>the</strong>rapy have also been<br />

reported.<br />

CAIs<br />

Carbonic anhydrase inhibitors (CAI) are<br />

ano<strong>the</strong>r class of drugs used in<br />

ophthalmology as intraocular pressurelowering<br />

agents. Initially administrated<br />

systemically as acetazolamide, CAIs have<br />

also been developed as topically active<br />

forms under <strong>the</strong> names of dorzolamide and<br />

40 | March 21 | 2003 OT

Clinical<br />

brinzolamide. Carbonic anhydrase is a<br />

widely distributed enzyme which<br />

catalyses <strong>the</strong> production of H 2 CO 3<br />

from CO 2 and H 2 O as well as <strong>the</strong><br />

degradation of H 2 CO 3 to CO 2 and<br />

H 2 O throughout <strong>the</strong> body. The<br />

inhibition of this enzyme carries<br />

potentially numerous side effects.<br />

Among <strong>the</strong>m, tiredness, lack of<br />

appetite and somnolence may be<br />

appreciated as depression; however,<br />

true depression and agitation have also<br />

been reported.<br />

Antocholinergics<br />

Anticholinergic medications, such as<br />

atropine, homatropine, scopolamine<br />

and cyclopentolate, are often used in<br />

ophthalmology as mydriatic and<br />

cycloplegic drugs. They act by blocking<br />

<strong>the</strong> cholinergic response of <strong>the</strong> iris<br />

sphincter and ciliary muscle. Most of<br />

<strong>the</strong> drug is destroyed by hepatic<br />

metabolism, however, 13-50% is<br />

excreted unchanged in <strong>the</strong> urine.<br />

Consequently, people with renal<br />

diseases may be at risk of systemic<br />

toxicity after administration of<br />

anticholinergic drops 23 . Visual and<br />

auditory hallucinations, irritability,<br />

restlessness, insomnia, confusion,<br />

memory loss, delirum and paranoia<br />

have all been reported in association<br />

with anticholinergic systemic and<br />

topical <strong>the</strong>rapies.<br />

Sympathomimetics<br />

Sympathomimetic eye drops have a<br />

large utilisation in ophthalmology.<br />

Some agents are used in <strong>the</strong> treatment<br />

of glaucoma, while o<strong>the</strong>rs are used as<br />

mydriatics, anaes<strong>the</strong>tics and<br />

vasoconstrictors. It has been reported<br />

that some of <strong>the</strong>se agents may cause<br />

anxiety, hallucinations, depression and<br />

paranoia 21 .<br />

Depression, psychosis, confusion,<br />

hallucinations and o<strong>the</strong>r complaints of<br />

psychiatric nature are sometimes<br />

simply <strong>the</strong> result of topically<br />

administered eye drops and,<br />

unfortunately, <strong>the</strong> practitioner can very<br />

often overlook <strong>the</strong> link between<br />

mental complaints and, for example,<br />

glaucoma treatment. These patients<br />

could receive unnecessary psychiatric<br />

referral and treatment, whereas simple<br />

withdrawal of <strong>the</strong> drug results in<br />

disappearance of <strong>the</strong>se effects in one<br />

to seven days 24 . To minimise<br />

psychiatric effects, advise <strong>the</strong> patient to<br />

apply a gentle pressure on <strong>the</strong><br />

canaliculi immediately after <strong>the</strong><br />

administration of <strong>the</strong> drug or to<br />

simply close <strong>the</strong>ir eye for five minutes<br />

after <strong>the</strong> instillation.<br />

Conclusion<br />

It is often easy to forget that each<br />

patient is unique, with special<br />

emotions and psychological needs. A<br />

disabling eye disease affects not only<br />

<strong>the</strong> patient’s self-image, but also his or<br />

her entire family system and social life.<br />

It may also trigger <strong>the</strong> appearance of a<br />

large variety of mental disorders. On<br />

<strong>the</strong> o<strong>the</strong>r hand, patients with preexisting<br />

psychiatric disturbances may<br />

produce physical symptoms which<br />

could mimic some ophthalmic<br />

diseases. Therefore, treatment and<br />

rehabilitation of <strong>the</strong>se patients should<br />

address equally both <strong>the</strong> disease and<br />

psychological maintenance factors 25 .<br />

About <strong>the</strong> author<br />

Doina Gherghel is an ophthalmologist<br />

at <strong>the</strong> Neuroscience Research Institute,<br />

Aston University, Birmingham.<br />

Acknowledgement<br />

Figure courtesy of <strong>the</strong> Scientist 15<br />

(12): 8 copyright 2002, <strong>the</strong> Scientist<br />

LLC. All rights reserved. Reproduced<br />

with permission.<br />

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41 | March 21 | 2003 OT

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