Use of Electroconvulsive Therapy in the Presence of GLAUCOMA: A Case Report and Review of Literature
A 60-year-old man, who had no personal and family history of any mental disorder presented with severe depression with psychotic symptoms (as per International Classifications of Diseases - tenth revision). Exploration of the history revealed that he had been having the depressive symptoms for last 2 years. He had been treated with Tab Escitalopram upto 20 mg/day for a period of 6 months and Cap Venlafaxine 225 mg/day along with Tab Olanzapine 7.5-10 mg/day for 13 months without much appreciable improvement.\nHis medical history revealed that he had symptoms of headache and visual difficulties about 6 months back. There was no temporal relationship of the visual symptoms with increase in the dose of Venlafaxine and Olanzapine. There was no history of raised blood pressure during this period too. On evaluation by an Ophthalmologist, was diagnosed to have open angle glaucoma and cataract in both the eyes. He underwent bilateral trabeculectomy and also had undergone cataract surgery with implantation of the intraocular lens in the posterior chamber about 5 months prior to the index presentation.\nOn examination he was found to have sad affect, marked psychomotor retardation, depressive cognitions in the form of ideas of hopelessness, worthlessness and suicidal ideations and plans. His physical examination showed raised blood pressure (>130/84 mm of Hg) on many occasions along with raised body mass index (31.5 kg/m2). Ophthalmological examination revealed normal intraocular pressure (right eye: 10 mm of Hg and left eye: 11 mm of Hg), with low filtering bleb in the right eye. Visual acuity was 6/9 in the right eye and 6/18 in the left eye. Fundus was normal in both the eyes with no hypertensive changes. The cup disc ratio was 0.6 in right eye and 0.8 in the left eye.\nHis investigations in the form of heamogram, blood biochemistry, liver function test, renal function tests, thyroid function test, lipid profile, electrocardiogram, X-ray chest posterior anterior view, ultrasound abdomen and pelvis and electroencephalogram did not show any abnormality. In view of non-response to two antidepressant trials, marked psychomotor retardation, besides the change of antidepressant, option of ECT was discussed with the patient and the family. Following a written informed consent, patient was re-evaluated by the Ophthalmologist. In view of the cup disc ratio of 0.8 in left eye he was prophylactically prescribed Travaprost eye drops (which usually has effect on the IOP after 6 weeks) in the left eye to avoid further damage.\nModified Bilateral ECT was given using an indigenously manufactured brief-pulse, constant-energy machine (Medicaid Systems, India). The machine has settings for adjusting the frequency between 20 Hz and 90 Hz (settings of 20 Hz, 40 Hz, 50 Hz, 60 Hz, 70 Hz, and 90 Hz), duration of current passed (0.1-6 s with increments of 0.1 s), and adjusting the pulse width from 0.1 ms to 1.5 ms. Usually the electrical dose is varied by changing the duration of current while keeping the frequency (at 70 Hz) and pulse width constant (1 ms). ECT was administered thrice a week (Monday, Wednesday, and Saturday). During each ECT procedure electroencephalographic monitoring was done. Both the cuff method and EEG seizures were used to estimate seizure duration. Patient was ventilated with 100% oxygen and all the vitals (pulse, blood pressure, oxygen saturation and electrocardiogram) were monitored closely. After each ECT the monitoring of vitals using the cardiac monitor was continued for 1 h and after that patient's vitals were monitored every 15 min without any complications. Intraocular pressure in both eyes was monitored during the ECT. This was done at about 5 PM on the day of prior to ECT or on the day of ECT. ECT was given between 10.00 A.M. to 11.00 A.M.\nAlong with ECT, Cap Venlafaxine was tapered off and patient was started on Cap Milnacipran 25 mg/day which was gradually built-up to 125 mg/day. Tab Olanzapine was increased to 12.5 mg/day and Tab Amlodipine 10 mg/day was started for hypertension. During ECT, he was given glycopyrrolate (0.2 mg) as premedication, induction was done with thiopental sodium and in the initial few sessions atracurium was used for muscle relaxation ( for details), but it was not sufficient to provide adequate muscle relaxation. Resultantly a combination of atracurium and succinylcholine was used for muscle relaxation and after ECT patient was administered neostigmine to reverse the effect of atracurium. Prophylactic use of esmolol was done to avoid hypertensive surge during ECT. Precautions were taken to reduce head movements during ECT. For the initial two ECTs, the response was inadequate (i.e., seizure duration was less than the minimum duration required for effective ECT), hence, thiopentone was replaced with propofol. In total he received 12 ECTs.\nPrior to starting of ECT, his intraocular pressure was 10-11 mm of Hg. However, after 3rd ECT the IOP increased to 18 mm and 20 mm of Hg in the right and left eye respectively. However, later monitoring did not show much rise in IOP.\nWith ECT, Cap Milnacipran and Tab Olanzapine patient achieved remission and was discharged. Over the period of next 3 months, there was no major fluctuation in the intraocular pressure and patient had been maintaining well.