Anxiolytics and psychotropic medications in central serous chorioretinopathy: Caveats and concerns

Dear Editor,

I read with interest the letter by Dudani et al.[1] in continuation with their previous article on the psychiatric evaluation of patients with central serous chorioretinopathy (CSCR). Treating CSCR with anxiolytics and antidepressants appears an obvious choice. I would like to share some concerns, caveats, my limited experience, and suggestions regarding this approach. Between 2015 and 17, two of seven CSCR patients treated with escitalopram (6), clonazepam (1), and bromazepam (1), discontinued their medication due to intolerable headache and somnolence respectively; the CSCR in four others resolved between 5–14 weeks, an effect that could be based on the natural history of CSCR. The day time somnolence was thought to be a result of altered sleep cycle and nocturnal insomnia.

Psychotropic medications are risk factors for CSCR. Although the causal mechanisms remain elusive, these drugs commonly employ serotonergic and dopaminergic pathways. The adverse events such as postural hypotension, tinnitus, flushing, headache, erectile dysfunction, ataxia, and visual disturbances reflect their vasoactive properties that can potentially modulate the choroidal blood flow, a factor that determines susceptibility to CSCR. Thus, the anxiety-induced vasomotor instability cited by authors could also be an outcome or regulatory response to psychotropic drugs. Hayreh demonstrated an adrenergic surge following nocturnal hypotension induced by phosphodiesterase inhibitors.[2]

Further, many psychotropic drugs exhibit dose-related (sometimes opposite as in the case of a and b adrenergic responses) effects or operate through more than one neurotransmitters;[3] the underlying risk factors such as anxiety, insomnia, or circadian rhythm disturbance too involve multiple neurotransmitters/neuromodulators, making the predictions of therapeutic outcome difficult.[4]

With these caveats, a pragmatic approach to proceed should involve a checklist of comorbidities and a routine evaluation of autonomic functions to determine suitable candidates and to avoid adverse events.[5] This will ensure a customized solution after a holistic evaluation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.