Transient Intraocular Pressure Elevation During Modified Electroconvulsive Therapy in an Elderly Patient with Schizophrenia and Primary Open-Angle Glaucoma: a case report

Transient Intraocular Pressure Elevation During Modified Electroconvulsive Therapy in an Elderly Patient with Schizophrenia and Primary Open-Angle Glaucoma: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Transient Intraocular Pressure Elevation During Modified Electroconvulsive Therapy in an Elderly Patient with Schizophrenia and Primary Open-Angle Glaucoma: a case report Qing li, Yiwen Yuan, Zhixiong Li, Ying Ou, Zhe Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9236369/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Modified electroconvulsive therapy (MECT) is a widely used treatment for schizophrenia. Glaucoma, a common ophthalmic condition, is characterized by elevated intraocular pressure (IOP). Although MECT has no absolute contraindications, its safety in patients with comorbid glaucoma is not well established, and reports of IOP changes during MECT in such patients are scarce. Case Presentation: We report the case of a 75-year-old woman of Han Chinese ethnicity with a 13-year history of emotional instability and a 3-year diagnosis of schizophrenia. She was admitted due to a relapse of psychotic symptoms. After the third session of MECT, she developed elevated IOP (right eye 12.1 mmHg, left eye 26.8 mmHg). An ophthalmology consultation diagnosed primary open-angle glaucoma (POAG). IOP was monitored during subsequent MECT sessions and gradually normalized (right eye 10.2 mmHg, left eye 11.5 mmHg after the eighth session) despite continued treatment. The patient’s psychiatric symptoms improved markedly. Conclusion: MECT may be safely administered to elderly patients with schizophrenia and comorbid POAG under close ophthalmologic monitoring. Transient IOP elevation can occur but does not necessarily warrant treatment discontinuation. Baseline IOP measurement and monitoring during the course are recommended to mitigate the risk of acute glaucomatous complications. Modified electroconvulsive therapy schizophrenia glaucoma intraocular pressure case report Background Electroconvulsive therapy (ECT) is a physical treatment for psychiatric disorders involving the passage of a controlled electrical current through the brain to induce therapeutic seizures [ 1 ]. To improve safety and tolerability, it is now commonly performed under intravenous anesthesia and muscle relaxation, a practice known as modified electroconvulsive therapy (MECT) [ 1 ]. Primary open-angle glaucoma (POAG) is a prevalent eye disease characterized by elevated intraocular pressure (IOP), leading to optic nerve damage and visual field defects [ 2 ]. While traditional ECT considered glaucoma a contraindication, MECT has no absolute contraindications, though it may pose relative risks for patients with certain comorbidities [ 3 ]. Anesthetics used in MECT, such as atropine, succinylcholine, and propofol, can influence IOP [ 4 – 6 ]. However, reports on the use of MECT in patients with schizophrenia and POAG are rare. Here, we present a case of transient IOP elevation during the initial phase of MECT in an elderly patient with schizophrenia and previously undiagnosed POAG, highlighting the importance of IOP monitoring in this population and contributing to the limited evidence on the safety of MECT in patients with glaucoma. Case presentation Medical history A 75-year-old woman of Han Chinese ethnicity was admitted to our hospital due to a 3-day recurrence of abnormal behavior and speech. Her psychiatric history began 13 years ago following her mother’s death, with episodes of excessive talking, incoherent speech, aimless wandering, and irritability, each lasting 3–5 days and resolving spontaneously. Three years prior to this admission, she developed auditory hallucinations and persecutory delusions, leading to a diagnosis of schizophrenia at a local psychiatric hospital, where she was treated with clozapine (dose unknown) and electroconvulsive therapy (ECT). Due to poor response, she was transferred to our hospital. During that admission, she was diagnosed with comorbid hyperthyroidism (TSH <0.005 mU/L, elevated FT3, FT4, and thyroid antibodies). Her psychiatric symptoms improved with risperidone 5 mg/day and clozapine 100 mg/day, and she was discharged on levothyroxine 12.5 μg/day and methimazole 2.5 mg/day for hyperthyroidism. Three days before the current admission, after attending a class reunion, she exhibited similar abnormal behaviors: she became unresponsive, spoke incoherently with themes of guilt ("I deserve to die") and catastrophe ("The earth is destroyed"), experienced auditory hallucinations, and had insomnia. Her family brought her to our hospital for further management. Past medical history: Hyperthyroidism diagnosed 3 years ago, treated with levothyroxine and methimazole. No other significant medical history. Family history: Unremarkable for psychiatric disorders. No history of alcohol or substance abuse. Diagnosis relevant On admission, physical and neurological examinations were unremarkable. Mental status examination revealed that she was voluntarily admitted, appeared anxious, maintained self-care, but had limited attention, poor insight, and passive contact. Positive symptoms included auditory hallucinations and delusions (guilt, catastrophic). Sleep disturbance and impaired social functioning were noted. Laboratory tests on admission showed elevated thyroid function: TSH <0.005 mU/L (reference: 0.27–4.2), FT3 22.85 pmol/L (3.6–7.5), FT4 77.56 pmol/L (12.0–22.0), T3 6.17 nmol/L (1.3–3.1), T4 296 nmol/L (52–164). Thyroid antibodies were markedly elevated: anti-thyroglobulin antibody 2989.00 IU/mL (<115), anti-thyroid peroxidase antibody 338.50 IU/mL (<34), thyrotropin receptor antibody 28.17 IU/L (<3). Thyroid ultrasound revealed a hypoechoic nodule in the right lower lobe and a possible parathyroid mass. Routine blood work, MRI brain, and EEG were normal. The diagnosis of schizophrenia was confirmed according to DSM-5 criteria. Treatment Upon admission, the patient was started on risperidone 5 mg/day and clozapine 150 mg/day. An endocrinology consultation adjusted methimazole to 10 mg twice daily. A course of eight MECT sessions was planned. Anesthesia for MECT included atropine, propofol, succinylcholine, lidocaine, and epinephrine. After the third consecutive daily MECT session, the patient developed bilateral conjunctival injection and edema. An ophthalmology consultation was obtained. IOP was measured at 12.1 mmHg in the right eye (RE) and 26.8 mmHg in the left eye (LE) (normal range 8–21 mmHg). Visual evoked potentials showed delayed P100 latency bilaterally. A diagnosis of bilateral primary open-angle glaucoma (POAG) was made, and observation without specific intervention was recommended. Given the persistence of severe psychiatric symptoms, MECT was continued with close IOP monitoring. IOP measurements after subsequent sessions are summarized in Table 1. MECT session Interval since previous IOP (RE/LE, mmHg) Clinical notes After 3rd – 12.1 / 26.8 Conjunctival injection After 4th 1 day 12.0 / 26.0 Psychiatric symptoms unchanged After 5th 2 days – / 20.0 After 6th 2 days 11.0 / 16.0 After 7th 2 days 10.0 / 11.7 Auditory hallucinations resolved, more responsive After 8th 2 days 10.2 / 11.5 Psychotic symptoms remitted, discharged Table 1. Intraocular pressure during MECT course After the seventh session, the patient’s auditory hallucinations disappeared, and she became more interactive. By the eighth session, persecutory delusions had resolved, and communication improved. She was discharged in stable condition. Follow-up Three months after discharge, the patient remained stable without psychotic symptoms. The patient expressed gratitude for the treatment.Follow-up IOP was 11.0 mmHg in the RE and 12.8 mmHg in the LE. Discussion This case describes an elderly patient with schizophrenia and previously undiagnosed POAG who experienced transient IOP elevation during the initial phase of an MECT course. Despite continued treatment, IOP normalized, suggesting that MECT can be safely administered in such patients with appropriate monitoring. The transient nature of the IOP rise and its resolution without sequelae highlight the importance of close observation rather than automatic treatment cessation. Several factors may have contributed to the observed IOP changes. First, the patient’s age and gender could be predisposing factors. Although the relationship between age, gender, and IOP is complex, some studies suggest that IOP may be higher in women, potentially due to hormonal influences [ 8 , 9 , 11 , 12 ]. However, the IOP elevation in this case was likely multifactorial. Second, the anesthetic agents used in MECT have known effects on IOP. Succinylcholine can cause a transient IOP increase of 4–7 mmHg [ 13 ], while propofol may lower IOP by reducing blood pressure [ 6 , 13 , 15 , 16 ]. Atropine, an anticholinergic agent, can elevate IOP by inducing mydriasis and impairing aqueous outflow, particularly in patients with narrow angles [ 5 , 17 , 18 ]. In our patient, the opposing effects of these drugs might have contributed to the transient and ultimately reversible IOP elevation. The roles of lidocaine and epinephrine, also used in this case, warrant further investigation, as their effects on IOP during MECT are not well documented. Third, the initial frequency of MECT sessions—three consecutive daily sessions—may have been a contributing factor. While expert consensus recommends 8–12 sessions administered every other day [ 1 ], the decision to treat consecutively was made to rapidly control severe psychotic symptoms. Some studies indicate that although IOP may rise after ECT, it often remains within a manageable range and is transient [ 6 ]. In our patient, after extending the interval to 2 days, IOP gradually returned to normal, supporting the role of treatment frequency in IOP dynamics. Fourth, the patient’s comorbid hyperthyroidism and long-term use of antipsychotics should be considered. Hyperthyroidism can influence IOP, but the patient had no signs of thyroid eye disease, making it an unlikely primary cause [ 22 ]. Antipsychotics such as risperidone and clozapine can elevate IOP, possibly due to their anticholinergic properties [ 24 , 25 ]. However, the patient had been on stable doses for years without prior ocular symptoms, and IOP normalized during continued antipsychotic treatment, suggesting that these medications were not the main drivers of the acute IOP rise. Nonetheless, this case underscores the importance of baseline IOP screening in patients on long-term antipsychotic therapy, as early POAG can be asymptomatic [ 26 ]. This case has limitations. IOP was not measured before MECT, so pre-existing elevated IOP cannot be ruled out. Additionally, the contribution of individual anesthetic agents cannot be isolated due to the combination used. In conclusion, MECT appears to be safe in elderly patients with schizophrenia and comorbid POAG under close ophthalmologic monitoring. Transient IOP elevation may occur, particularly with frequent initial sessions, but does not necessarily require treatment interruption. We recommend baseline IOP measurement before initiating MECT and regular monitoring during the course, especially if ocular symptoms develop, with prompt ophthalmology consultation to rule out acute angle-closure glaucoma. Abbreviations MECT:modified electroconvulsive therapy IOP:elevated intraocular pressure POAG:primary open-angle glaucoma ECT:electroconvulsive therapy DSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition CT: Computed Tomography MRI: Magnetic Resonance Imaging RE:right eye LE:left eye Declarations Ethics approval and consent to participate Our manuscript does not report or involve the use of any animal or human data or tissue Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal Availability of data and materials Our manuscript does not contain any data.The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author. Competing interests The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding This study was supported by grants to ZeL from the Applied Psychology Research Center of Sichuan Province (CSXL-202A08), Special Project for Strategic Cooperation between Sichuan University and Dazhou Municipal People’s Government (2022CDDZ-17), and Science and Technology Department of Sichuan Province (2022YFS0349). The funders had no role in study design, data collection, analysis, interpretation, or manuscript writing. Authors' contributions QL and YY: writing – original draft preparation, writing – review and editing. ZXL and YO: clinical management, writing – review and editing. ZeL: conceptualization, supervision, writing – review and editing, funding acquisition. All authors approved the final version of the manuscript. Acknowledgements We thank the patient for her cooperation and consent to publish this case report. References Electroconvulsive and Nerve Stimulation Group of Neuroregulation Committee of Chinese Medical Doctor Association, Psychopsychological Group of Sleep Committee of Chinese Medical Doctor Association, Anesthesiologist Branch of Chinese Medical Doctor Association. Expert consensus on modified electroconvulsive therapy (2019 edition). Journal of Translational Medicine. 2019;8(3):129-134. Wang XQ, Li WP, Li J. Research progress in the treatment of primary open angle glaucoma. Gansu Medicine. 2017;36(1):20-22. Zhou XD, et al. Expert consensus on electroconvulsive therapy (2017 edition). Clinical Meta. 2017;32(10):837-840. Jiang W, et al. Types and dosages of anesthetics and muscle relaxants used in modified electroconvulsive therapy. Chin J Mental Health. 2011;25(11):835-839. Cheng XL, Dai B. Paroxetine combined with modified electroconvulsive therapy induced acute attack of glaucoma: a case report. J Clinical Psychiatry. 2019;29(1):22. Boroojeny SB, et al. The effect of electroconvulsive therapy using propofol and succinylcholine on the intraocular pressure. Middle East J Anaesthesiol. 2012;21(5):713-717. Zhao JP. Clinical efficacy and safety of modified modified electroconvulsive therapy in elderly patients with mental disorders. J Med. 2023;44(8):2167-2170. Han X, et al. Age-Related Changes of Intraocular Pressure in Elderly People in Southern China: Lingtou Eye Cohort Study. PLoS One. 2016;11(3):e0151766. Bhandari G, et al. Relationship Between Intraocular Pressure and Age: A Population-Based Study in Nepal. J Glaucoma. 2023;32(11):983-988. Lu HL. Analysis of intraocular pressure and systemic influencing factors in routine physical examination population in the Yangtze River Delta region [master’s thesis]. Anhui Medical University; 2014. p. 47. Astrom S, Stenlund H, Linden C. Intraocular pressure changes over 21 years - a longitudinal age-cohort study in northern Sweden. Acta Ophthalmol. 2014;92(5):417-420. Tehrani S. Gender difference in the pathophysiology and treatment of glaucoma. Curr Eye Res. 2015;40(2):191-200. Amritwar A, et al. Electroconvulsive therapy in a patient with glaucoma. Natl Med J India. 2016;29(2):85-86. Sienaert PA, Vanholst C. Electroconvulsive Therapy After Eye Surgery. J ECT. 2013;29(2):139-141. Yin H, Luo ZZ. Research progress of modified electroconvulsive therapy anesthetic drugs. West China Med. 2014;29(10):1983-1985. Rasmussen KG. Propofol for ECT Anesthesia a Review of the Literature. J ECT. 2014;30(3):210-215. Yang MC, Lin KY. Drug-induced Acute Angle-closure Glaucoma: A Review. J Curr Glaucoma Pract. 2019;13(3):104-109. He ZQ, et al. Expert consensus on the use of anticholinergic drugs before anesthesia. Guangdong Med. 2016;37(17):2533-2535. Feng AT. The effect of different frequency of MECT combined with second-generation antipsychotic drugs in the treatment of hospitalized patients with schizophrenia. Chinese Medical Innovation. 2023;20(32):155-159. Moulier V, et al. A prospective multicenter assessor-blinded randomized controlled study to compare the efficacy of short versus long protocols of electroconvulsive therapy as an augmentation strategy to clozapine in patients with ultra-resistant schizophrenia (SURECT study). Trials. 2021;22(1):284. Plakiotis C, George K, O’Connor DW. Is electroconvulsive therapy use among young-old and old-old adults comparable? A 10-year population-level analysis of service provision. J ECT. 2014;30(3):232-241. Betzler BK, Young SM, Sundar G. Intraocular Pressure and Glaucoma in Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg. 2022;38(3):219-225. Chinese Society of Endocrinology, Chinese Medical Association, et al. Chinese Guidelines for the diagnosis and treatment of hyperthyroidism and other causes of thyrotoxicosis. Int J Endocrinol Metabolism. 2022;42(5):401-450. Ciobanu AM, et al. Psychopharmacological Treatment, Intraocular Pressure and the Risk of Glaucoma: A Review of Literature. J Clin Med. 2021;10(13):1-18. Jain NS, et al. Psychotropic Drug-Induced Glaucoma: A Practical Guide to Diagnosis and Management. CNS Drugs. 2021;35(3):283-289. Liu XL, Liu DY, Liang S. An updated interpretation of primary glaucoma diagnosis and treatment. Journal of Hebei Medical University. 2020;41(5):497-500,505. Additional Declarations No competing interests reported. Supplementary Files CAREchecklist0325.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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To improve safety and tolerability, it is now commonly performed under intravenous anesthesia and muscle relaxation, a practice known as modified electroconvulsive therapy (MECT) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Primary open-angle glaucoma (POAG) is a prevalent eye disease characterized by elevated intraocular pressure (IOP), leading to optic nerve damage and visual field defects [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While traditional ECT considered glaucoma a contraindication, MECT has no absolute contraindications, though it may pose relative risks for patients with certain comorbidities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Anesthetics used in MECT, such as atropine, succinylcholine, and propofol, can influence IOP [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, reports on the use of MECT in patients with schizophrenia and POAG are rare. Here, we present a case of transient IOP elevation during the initial phase of MECT in an elderly patient with schizophrenia and previously undiagnosed POAG, highlighting the importance of IOP monitoring in this population and contributing to the limited evidence on the safety of MECT in patients with glaucoma.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003e\u003cstrong\u003eMedical history\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A 75-year-old woman of Han Chinese ethnicity was admitted to our hospital due to a 3-day recurrence of abnormal behavior and speech. Her psychiatric history began 13 years ago following her mother\u0026rsquo;s death, with episodes of excessive talking, incoherent speech, aimless wandering, and irritability, each lasting 3\u0026ndash;5 days and resolving spontaneously. Three years prior to this admission, she developed auditory hallucinations and persecutory delusions, leading to a diagnosis of schizophrenia at a local psychiatric hospital, where she was treated with clozapine (dose unknown) and electroconvulsive therapy (ECT). Due to poor response, she was transferred to our hospital. During that admission, she was diagnosed with comorbid hyperthyroidism (TSH \u0026lt;0.005 mU/L, elevated FT3, FT4, and thyroid antibodies). Her psychiatric symptoms improved with risperidone 5 mg/day and clozapine 100 mg/day, and she was discharged on levothyroxine 12.5 \u0026mu;g/day and methimazole 2.5 mg/day for hyperthyroidism. Three days before the current admission, after attending a class reunion, she exhibited similar abnormal behaviors: she became unresponsive, spoke incoherently with themes of guilt (\u0026quot;I deserve to die\u0026quot;) and catastrophe (\u0026quot;The earth is destroyed\u0026quot;), experienced auditory hallucinations, and had insomnia. Her family brought her to our hospital for further management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePast medical history:\u003c/strong\u003e Hyperthyroidism diagnosed 3 years ago, treated with levothyroxine and methimazole. No other significant medical history.\u003cbr\u003e\u003cstrong\u003eFamily history:\u003c/strong\u003e Unremarkable for psychiatric disorders. No history of alcohol or substance abuse.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnosis relevant\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;On admission, physical and neurological examinations were unremarkable. Mental status examination revealed that she was voluntarily admitted, appeared anxious, maintained self-care, but had limited attention, poor insight, and passive contact. Positive symptoms included auditory hallucinations and delusions (guilt, catastrophic). Sleep disturbance and impaired social functioning were noted.\u003c/p\u003e\n\u003cp\u003eLaboratory tests on admission showed elevated thyroid function: TSH \u0026lt;0.005 mU/L (reference: 0.27\u0026ndash;4.2), FT3 22.85 pmol/L (3.6\u0026ndash;7.5), FT4 77.56 pmol/L (12.0\u0026ndash;22.0), T3 6.17 nmol/L (1.3\u0026ndash;3.1), T4 296 nmol/L (52\u0026ndash;164). Thyroid antibodies were markedly elevated: anti-thyroglobulin antibody 2989.00 IU/mL (\u0026lt;115), anti-thyroid peroxidase antibody 338.50 IU/mL (\u0026lt;34), thyrotropin receptor antibody 28.17 IU/L (\u0026lt;3). Thyroid ultrasound revealed a hypoechoic nodule in the right lower lobe and a possible parathyroid mass. Routine blood work, MRI brain, and EEG were normal.\u003c/p\u003e\n\u003cp\u003eThe diagnosis of schizophrenia was confirmed according to DSM-5 criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Upon admission, the patient was started on risperidone 5 mg/day and clozapine 150 mg/day. An endocrinology consultation adjusted methimazole to 10 mg twice daily. A course of eight MECT sessions was planned. Anesthesia for MECT included atropine, propofol, succinylcholine, lidocaine, and epinephrine.\u003c/p\u003e\n\u003cp\u003eAfter the third consecutive daily MECT session, the patient developed bilateral conjunctival injection and edema. An ophthalmology consultation was obtained. IOP was measured at 12.1 mmHg in the right eye (RE) and 26.8 mmHg in the left eye (LE) (normal range 8\u0026ndash;21 mmHg). Visual evoked potentials showed delayed P100 latency bilaterally. A diagnosis of bilateral primary open-angle glaucoma (POAG) was made, and observation without specific intervention was recommended.\u003c/p\u003e\n\u003cp\u003eGiven the persistence of severe psychiatric symptoms, MECT was continued with close IOP monitoring. IOP measurements after subsequent sessions are summarized in Table 1.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMECT session\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eInterval since previous\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIOP (RE/LE, mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eClinical notes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAfter 3rd\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.1 / 26.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eConjunctival injection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAfter 4th\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.0 / 26.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePsychiatric symptoms unchanged\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAfter 5th\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash; / 20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAfter 6th\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.0 / 16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAfter 7th\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.0 / 11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAuditory hallucinations resolved, more responsive\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAfter 8th\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.2 / 11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePsychotic symptoms remitted, discharged\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Intraocular pressure during MECT course\u003c/p\u003e\n\u003cp\u003eAfter the seventh session, the patient\u0026rsquo;s auditory hallucinations disappeared, and she became more interactive. By the eighth session, persecutory delusions had resolved, and communication improved. She was discharged in stable condition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Three months after discharge, the patient remained stable without psychotic symptoms. The patient expressed gratitude for the treatment.Follow-up IOP was 11.0 mmHg in the RE and 12.8 mmHg in the LE.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case describes an elderly patient with schizophrenia and previously undiagnosed POAG who experienced transient IOP elevation during the initial phase of an MECT course. Despite continued treatment, IOP normalized, suggesting that MECT can be safely administered in such patients with appropriate monitoring. The transient nature of the IOP rise and its resolution without sequelae highlight the importance of close observation rather than automatic treatment cessation.\u003c/p\u003e \u003cp\u003eSeveral factors may have contributed to the observed IOP changes. First, the patient\u0026rsquo;s age and gender could be predisposing factors. Although the relationship between age, gender, and IOP is complex, some studies suggest that IOP may be higher in women, potentially due to hormonal influences [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, the IOP elevation in this case was likely multifactorial.\u003c/p\u003e \u003cp\u003eSecond, the anesthetic agents used in MECT have known effects on IOP. Succinylcholine can cause a transient IOP increase of 4\u0026ndash;7 mmHg [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], while propofol may lower IOP by reducing blood pressure [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Atropine, an anticholinergic agent, can elevate IOP by inducing mydriasis and impairing aqueous outflow, particularly in patients with narrow angles [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In our patient, the opposing effects of these drugs might have contributed to the transient and ultimately reversible IOP elevation. The roles of lidocaine and epinephrine, also used in this case, warrant further investigation, as their effects on IOP during MECT are not well documented.\u003c/p\u003e \u003cp\u003eThird, the initial frequency of MECT sessions\u0026mdash;three consecutive daily sessions\u0026mdash;may have been a contributing factor. While expert consensus recommends 8\u0026ndash;12 sessions administered every other day [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], the decision to treat consecutively was made to rapidly control severe psychotic symptoms. Some studies indicate that although IOP may rise after ECT, it often remains within a manageable range and is transient [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In our patient, after extending the interval to 2 days, IOP gradually returned to normal, supporting the role of treatment frequency in IOP dynamics.\u003c/p\u003e \u003cp\u003eFourth, the patient\u0026rsquo;s comorbid hyperthyroidism and long-term use of antipsychotics should be considered. Hyperthyroidism can influence IOP, but the patient had no signs of thyroid eye disease, making it an unlikely primary cause [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Antipsychotics such as risperidone and clozapine can elevate IOP, possibly due to their anticholinergic properties [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, the patient had been on stable doses for years without prior ocular symptoms, and IOP normalized during continued antipsychotic treatment, suggesting that these medications were not the main drivers of the acute IOP rise. Nonetheless, this case underscores the importance of baseline IOP screening in patients on long-term antipsychotic therapy, as early POAG can be asymptomatic [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis case has limitations. IOP was not measured before MECT, so pre-existing elevated IOP cannot be ruled out. Additionally, the contribution of individual anesthetic agents cannot be isolated due to the combination used.\u003c/p\u003e \u003cp\u003eIn conclusion, MECT appears to be safe in elderly patients with schizophrenia and comorbid POAG under close ophthalmologic monitoring. Transient IOP elevation may occur, particularly with frequent initial sessions, but does not necessarily require treatment interruption. We recommend baseline IOP measurement before initiating MECT and regular monitoring during the course, especially if ocular symptoms develop, with prompt ophthalmology consultation to rule out acute angle-closure glaucoma.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMECT:modified electroconvulsive therapy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIOP:elevated intraocular pressure\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePOAG:primary open-angle glaucoma\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eECT:electroconvulsive therapy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition\u003c/p\u003e\n\u003cp\u003eCT: Computed Tomography\u003c/p\u003e\n\u003cp\u003eMRI: Magnetic Resonance Imaging\u003c/p\u003e\n\u003cp\u003eRE:right eye\u003c/p\u003e\n\u003cp\u003eLE:left eye\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur manuscript does not report or involve the use of any animal or human data or tissue\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur manuscript does not contain any data.The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by grants to ZeL from the Applied Psychology Research Center of Sichuan Province (CSXL-202A08), Special Project for Strategic Cooperation between Sichuan University and Dazhou Municipal People\u0026rsquo;s Government (2022CDDZ-17), and Science and Technology Department of Sichuan Province (2022YFS0349). The funders had no role in study design, data collection, analysis, interpretation, or manuscript writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQL and YY: writing \u0026ndash; original draft preparation, writing \u0026ndash; review and editing. ZXL and YO: clinical management, writing \u0026ndash; review and editing. ZeL: conceptualization, supervision, writing \u0026ndash; review and editing, funding acquisition. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the patient for her cooperation and consent to publish this case report.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eElectroconvulsive and Nerve Stimulation Group of Neuroregulation Committee of Chinese Medical Doctor Association, Psychopsychological Group of Sleep Committee of Chinese Medical Doctor Association, Anesthesiologist Branch of Chinese Medical Doctor Association. Expert consensus on modified electroconvulsive therapy (2019 edition). Journal of Translational Medicine. 2019;8(3):129-134.\u003c/li\u003e\n\u003cli\u003eWang XQ, Li WP, Li J. Research progress in the treatment of primary open angle glaucoma. Gansu Medicine. 2017;36(1):20-22. \u003c/li\u003e\n\u003cli\u003eZhou XD, et al. Expert consensus on electroconvulsive therapy (2017 edition). Clinical Meta. 2017;32(10):837-840.\u003c/li\u003e\n\u003cli\u003eJiang W, et al. Types and dosages of anesthetics and muscle relaxants used in modified electroconvulsive therapy. Chin J Mental Health. 2011;25(11):835-839. \u003c/li\u003e\n\u003cli\u003eCheng XL, Dai B. Paroxetine combined with modified electroconvulsive therapy induced acute attack of glaucoma: a case report. J Clinical Psychiatry. 2019;29(1):22.\u003c/li\u003e\n\u003cli\u003eBoroojeny SB, et al. The effect of electroconvulsive therapy using propofol and succinylcholine on the intraocular pressure. Middle East J Anaesthesiol. 2012;21(5):713-717.\u003c/li\u003e\n\u003cli\u003eZhao JP. Clinical efficacy and safety of modified modified electroconvulsive therapy in elderly patients with mental disorders. J Med. 2023;44(8):2167-2170. \u003c/li\u003e\n\u003cli\u003eHan X, et al. Age-Related Changes of Intraocular Pressure in Elderly People in Southern China: Lingtou Eye Cohort Study. PLoS One. 2016;11(3):e0151766.\u003c/li\u003e\n\u003cli\u003eBhandari G, et al. Relationship Between Intraocular Pressure and Age: A Population-Based Study in Nepal. J Glaucoma. 2023;32(11):983-988.\u003c/li\u003e\n\u003cli\u003eLu HL. Analysis of intraocular pressure and systemic influencing factors in routine physical examination population in the Yangtze River Delta region [master\u0026rsquo;s thesis]. Anhui Medical University; 2014. p. 47.\u003c/li\u003e\n\u003cli\u003eAstrom S, Stenlund H, Linden C. Intraocular pressure changes over 21 years - a longitudinal age-cohort study in northern Sweden. Acta Ophthalmol. 2014;92(5):417-420.\u003c/li\u003e\n\u003cli\u003eTehrani S. Gender difference in the pathophysiology and treatment of glaucoma. Curr Eye Res. 2015;40(2):191-200.\u003c/li\u003e\n\u003cli\u003eAmritwar A, et al. Electroconvulsive therapy in a patient with glaucoma. Natl Med J India. 2016;29(2):85-86.\u003c/li\u003e\n\u003cli\u003eSienaert PA, Vanholst C. Electroconvulsive Therapy After Eye Surgery. J ECT. 2013;29(2):139-141.\u003c/li\u003e\n\u003cli\u003eYin H, Luo ZZ. Research progress of modified electroconvulsive therapy anesthetic drugs. West China Med. 2014;29(10):1983-1985. \u003c/li\u003e\n\u003cli\u003eRasmussen KG. Propofol for ECT Anesthesia a Review of the Literature. J ECT. 2014;30(3):210-215.\u003c/li\u003e\n\u003cli\u003eYang MC, Lin KY. Drug-induced Acute Angle-closure Glaucoma: A Review. J Curr Glaucoma Pract. 2019;13(3):104-109.\u003c/li\u003e\n\u003cli\u003eHe ZQ, et al. Expert consensus on the use of anticholinergic drugs before anesthesia. Guangdong Med. 2016;37(17):2533-2535.\u003c/li\u003e\n\u003cli\u003eFeng AT. The effect of different frequency of MECT combined with second-generation antipsychotic drugs in the treatment of hospitalized patients with schizophrenia. Chinese Medical Innovation. 2023;20(32):155-159. \u003c/li\u003e\n\u003cli\u003eMoulier V, et al. A prospective multicenter assessor-blinded randomized controlled study to compare the efficacy of short versus long protocols of electroconvulsive therapy as an augmentation strategy to clozapine in patients with ultra-resistant schizophrenia (SURECT study). Trials. 2021;22(1):284.\u003c/li\u003e\n\u003cli\u003ePlakiotis C, George K, O\u0026rsquo;Connor DW. Is electroconvulsive therapy use among young-old and old-old adults comparable? A 10-year population-level analysis of service provision. J ECT. 2014;30(3):232-241.\u003c/li\u003e\n\u003cli\u003eBetzler BK, Young SM, Sundar G. Intraocular Pressure and Glaucoma in Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg. 2022;38(3):219-225.\u003c/li\u003e\n\u003cli\u003eChinese Society of Endocrinology, Chinese Medical Association, et al. Chinese Guidelines for the diagnosis and treatment of hyperthyroidism and other causes of thyrotoxicosis. Int J Endocrinol Metabolism. 2022;42(5):401-450. \u003c/li\u003e\n\u003cli\u003eCiobanu AM, et al. Psychopharmacological Treatment, Intraocular Pressure and the Risk of Glaucoma: A Review of Literature. J Clin Med. 2021;10(13):1-18.\u003c/li\u003e\n\u003cli\u003eJain NS, et al. Psychotropic Drug-Induced Glaucoma: A Practical Guide to Diagnosis and Management. CNS Drugs. 2021;35(3):283-289.\u003c/li\u003e\n\u003cli\u003eLiu XL, Liu DY, Liang S. An updated interpretation of primary glaucoma diagnosis and treatment. Journal of Hebei Medical University. 2020;41(5):497-500,505. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Modified electroconvulsive therapy, schizophrenia, glaucoma, intraocular pressure, case report","lastPublishedDoi":"10.21203/rs.3.rs-9236369/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9236369/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Modified electroconvulsive therapy (MECT) is a widely used treatment for schizophrenia. Glaucoma, a common ophthalmic condition, is characterized by elevated intraocular pressure (IOP). Although MECT has no absolute contraindications, its safety in patients with comorbid glaucoma is not well established, and reports of IOP changes during MECT in such patients are scarce.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e We report the case of a 75-year-old woman of \u003cstrong\u003eHan Chinese ethnicity\u003c/strong\u003e with a 13-year history of emotional instability and a 3-year diagnosis of schizophrenia. She was admitted due to a relapse of psychotic symptoms. After the third session of MECT, she developed elevated IOP (right eye 12.1 mmHg, left eye 26.8 mmHg). An ophthalmology consultation diagnosed primary open-angle glaucoma (POAG). IOP was monitored during subsequent MECT sessions and gradually normalized (right eye 10.2 mmHg, left eye 11.5 mmHg after the eighth session) despite continued treatment. The patient’s psychiatric symptoms improved markedly.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e MECT may be safely administered to elderly patients with schizophrenia and comorbid POAG under close ophthalmologic monitoring. Transient IOP elevation can occur but does not necessarily warrant treatment discontinuation. Baseline IOP measurement and monitoring during the course are recommended to mitigate the risk of acute glaucomatous complications.\u003c/p\u003e","manuscriptTitle":"Transient Intraocular Pressure Elevation During Modified Electroconvulsive Therapy in an Elderly Patient with Schizophrenia and Primary Open-Angle Glaucoma: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 10:35:30","doi":"10.21203/rs.3.rs-9236369/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"23a87833-f205-4957-a697-b23ca0503633","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-08T14:33:00+00:00","index":130,"fulltext":""},{"type":"reviewerAgreed","content":"289958135537136881399099983862537170479","date":"2026-05-04T07:32:07+00:00","index":126,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T10:35:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 10:35:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9236369","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9236369","identity":"rs-9236369","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}