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Lorazepam-induced diplopia

Article  in  Indian Journal of Pharmacology · March 2014

DOI: 10.4103/0253-7613.129328 · Source: PubMed

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Jisha Lucca Ramesh Madhan

Imam Abdul Rahman bin Faisal University JSS University
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Botswana Medicines Regulatory Authority Shaqra University
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Lorazepam-induced diplopia
Jisha M. Lucca, Madhan Ramesh, Gurumurthy Parthasarathi, Dushad Ram1

ABSTRACT
Department Pharmacy Practice, JSS
College of Pharmacy, JSS University, Diplopia – seeing double – is a symptom with many potential causes, both neurological
1
Department of Psychiatry, JSS and ophthalmological. Benzodiazepine induced ocular side‑effects are rarely reported.
Hospital, Mysore, Karnataka, India Lorazepam is one of the commonly used benzodiazepine in psychiatric practice. Visual
problems associated with administration of lorazepam are rarely reported and the
Received: 17‑08‑2013 frequency of occurrence is not established. We report a rare case of lorazepam‑induced
Revised: 07‑11‑2013 diplopia in a newly diagnosed case of obsessive compulsive disorder.
Accepted: 18‑01‑2014
KEY WORDS: Adverse drug event, diplopia, lorazepam
Correspondence to:
Dr. Madhan Ramesh,
E‑mail: madhanramesh@hotmail.com

Introduction with obsessive compulsive disorder (OCD) was made and

subsequently patient was diagnosed as suffering from OCD.
Lorazepam is a high‑potency, short‑to intermediate‑acting,
Patient was prescribed lorazepam 4 mg intravenous (IV) stat
3‑hydroxy benzodiazepine indicated for the management of
and later as required for the severe anxiety symptoms. Tablet
anxiety disorders, convulsion disorders and as a skeletal muscle
clomipramine 25 mg at night and tablet sertraline 50 mg were
relaxant.[1,2] It is used widely in medical practice since it was first
prescribed in the morning to treat OCD. The patient received
marketed in 1977. Its adverse effects are well‑established. Most
lorazepam 4 mg IV and clomipramine 25 mg at 9 pm on day 1
common adverse effects observed with the drug are sedation
and woke up next morning at 6 am complaining of giddiness,
and drowsiness soon after the initiation of therapy. Impaired
diplopia and unstable gait. Patient was receiving no other
concentration and memory, feelings of dissociation are other
medication, including over the counter medications. He had
undesirable effects associated with the use of lorazepam and
never experienced similar complaints before. As diplopia
are dose dependent.[1‑3] Lorazepam is also reported to increase
was a new symptom the mental health team requested for a
intraocular pressure[4,5] and visual disturbances including
neurological and ophthalmic consultation to determine the
diplopia.[1,2] However, the frequency of occurrence of diplopia
possible underlying causes. However, diplopia resolved at 12 h
was not established due to insufficient data.
of onset. Ophthalmologic and neurologic observations were
Case Report insignificant. Meanwhile based on literature search and detailed
review of the patient’s medical history, lorazepam was suspected
The present case is about a 21‑year‑old male patient who
to be the causal agent for this adverse reaction and discontinued.
was admitted to the psychiatry unit of a tertiary care teaching
However, patient continued to receive clomipramine and
hospital in South India. He had no history of similar condition or
sertraline during the remaining 4 days of his hospital stay without
any significant past medical or family history. Patient presented
reoccurrence of diplopia or any other visual problems.
with the complaints of persistent pre‑occupation with sexual
A causal association between diplopia and lorazepam was
and contamination thoughts, insomnia, increased fearfulness,
assessed by World Health Organization probability scale and
memory impairment and anxiety and repeated hand washing.
Naranjo’s algorithm it showed “probable” association between
Based on the symptoms a provisional diagnosis of depression
the adverse reaction and lorazepam.
Access this article online Discussion
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Website: www.ijp‑online.com
A literature search was conducted using the databases.
DOI: 10.4103/0253-7613.129328 PubMed and Ovid did not identify lorazepam induced diplopia.
To the best of our knowledge, this is the first report of
lorazepam‑induced diplopia from India.
Diplopia, commonly known as double vision, is the
simultaneous perception of two images of a single object that

228 Indian Journal of Pharmacology | April 2014 | Vol 46 | Issue 2

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Lucca, et al.: Lorazepam‑induced diplopia
may be displaced horizontally, vertically, or diagonally in relation
to each other.[6] The two most common types of diplopia are
monocular and binocular diplopia. Ocular misalignments in
patients with normal binocular vision result binocular diplopia
while monocular diplopia is the result of local ocular aberrations
of cornea lens, iris or rarely retina.[6] In this case, diplopia
resolved with occlusion of one eye suggestive that it is binocular.
The demographics, personal history, medical history, social
and family history did not suggest any underlying ophthalmic
or neurological diseases. The time sequences of start of the
suspected drug and onset of diplopia are consistent with
the diagnosis. Although no rechallenge was attempted,
the symptoms were recovered at 21 h of the intake of the
suspected drug and the patient did not develop diplopia
further owing to cessation of lorazepam which is suggestive
of possible association between lorazepam and diplopia. IV
administration of single dose lorazepam shows its action within
5‑15 min and duration of action is for 12‑24 h.[1,2] Tricyclic
antidepressants and selective serotonin reuptake inhibitors are
reported to cause diplopia and visual disturbances.[5] In this
case, involvement of clomipramine and sertraline in causing
diplopia is ruled out as the patient did not complain of diplopia
or any other visual disturbances while he continued to receive
chlomipramine and sertraline.
All psychotropic medications have the potential to induce
numerous and diverse unwanted ocular effects, but diplopia is
a rare adverse effect of the psychotropic medication use.[5,7] The
drugs that are reported to be associated with diplopia include
lamotrigine (27.6%), topiramate (6.3%), felbamate (3.4‑6.1%),
gabapentin (5.9%), pergolide (2.1%) and fluoxetine (0.1‑1%).[5,7]
Diplopia after taking high doses of antidepressants such as
bupropion and citalopram are also reported.[8,9] Fluoroquinolones
are reported to cause diplopia due to tendinitis of extra‑ocular
muscles.[10] Citalopram is expected to cause diplopia by the
involvement of ocular serotonergic interneuron fibers.[9] In this
case, the exact mechanism of lorazepam induced diplopia is not
known but there are reports on accommodation paresis after
taking lorazepam.[11] However, a study conducted to understand
the effects of lorazepam on visual acuity, binocular vision and
accommodation concluded that lorazepam had no effect on visual
acuity or accommodation.[12] Although we could not establish the
possible mechanism in this case, it may act as alerting mechanism
to the health care professionals especially psychiatrist.
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Conclusion
This documents lorazepam induced diplopia in a patient with
OCD. Psychiatrists, ophthalmologists, pharmacist and patients
need to be aware of the potential of lorazepam induced diplopia.
Acknowledgments
The authors sincerely thank Karin Nyfort‑Hanssen for her
support in drafting the manuscript.
References
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concentrated oral solution. Minneapolis, MN: Paddock Laboratories, Inc.;
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org.uk/emc/medicine/2196/SPC/ativan+injection. [Last updated 2012 Aug 08;
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3. Breggin PR. Analysis of adverse behavioral effects of benzodiazepines with a
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4. Masson GS, Mestre DR, Martineau F, Soubrouillard C, Brefel C, Rascol O,
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6. Pelak VS. Evaluation of diplopia an anatomical and systemic approach. Hosp
Physician 2004; 2004;40:15-25:
7. Richa S, Yazbek JC. Ocular adverse effects of common psychotropic agents:
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8. Fayyazi Bordbar MR, Jafarzadeh M. Bupropion‑induced diplopia in an Iranian
patient. Iran J Psychiatry Behav Sci 2011;5:136‑8.
9. Dorell K, Cohen MA, Huprikar SS, Gorman JM, Jones M. Citalopram‑induced
diplopia. Psychosomatics 2005;46:91‑3.
10. Fraunfelder FW, Fraunfelder FT. Diplopia and fluoroquinolones. Ophthalmology
2009;116:1814‑7.
11. Jung JJ, Baek SH, Kim US. A case of lorazepam (Ativan)‑induced accommodation
paresis. Eye (Lond) 2012;26:614.
12. Speeg‑Schatz C, Giersch A, Boucart M, Gottenkiene S, Tondre M,
Kauffmann‑Muller F, et al. Effects of lorazepam on vision and oculomotor balance.
Binocul Vis Strabismus Q 2001;16:99‑104.
Cite this article as: Lucca JM, Ramesh M, Parthasarathi G, Ram D.
Lorazepam-induced diplopia. Indian J Pharmacol 2014;46:228-9.
Source of Support: Nil. Conflict of Interest: No.
Indian Journal of Pharmacology | April 2014 | Vol 46 | Issue 2 229