Corneal Endothelial and Anterior Lenticular Deposits Due to Clozapine Nathaniel Nataneli, MD Pearl S. Rosenbaum, MD Jos

1. Corneal Endothelial and Anterior Lenticular Deposits Due to Clozapine Nathaniel Nataneli, MD Pearl S. Rosenbaum, MD Jose Cardona, MS IV Martin Mayers, MD Authors have no financial interest.

2. Purpose: To provide the first clinical case report in the American literature of ocular complications of clozapine therapy.Methods: Clinical case report of a 56-year-old man with schizophrenia treated with clozapine for nine years prior to presentation. Complete ophthalmologic examination and slit-lamp photography was performed.

3. Results • Complete ophthalmologic evaluation revealed best corrected distance acuities of OD 20/25+2; OS 20/20-1. • Slit lamp examination was significant for diffuse deposition of tan-colored, reticular deposits along the corneal endothelium bilaterally. Similar deposits were noted along both anterior lens capsules, centrally, in a stellate configuration.

4. Results (cont.) • The remainder of the ophthalmologic and external examinations (including skin) were unremarkable. • POH: The patient was initially examined in 2000 at which time he was on clozapine; there was no past history of phenothiazine (thioridazine, chlorpromazine) treatment. At that time, only lenticular crystalline deposits were noted; these were attributed to “cataractous changes.”

5. Tan-colored deposits along the corneal endothelium (OD)

6. Deposits along the anterior lens in a stellate configuration OD

7. Pigmentary deposits in a stellate configuration along the anterior lens capsule, OS

8. Results (cont.) • The pupils were miotic and dilated poorly upon instillation of tropicamide 1% and phenylephrine 2.5%. • The fundus revealed no abnormalities; specifically, no pigmentary changes were observed.

9. Conclusion • This is the first case reported in the American literature of clozapine-related corneal and lenticular deposits. In the world literature (Australia) only one case of clozapine-related ocular deposits has previously been reported, involving the cornea, lens and retina; that patient had an associated decrease in visual acuity. • While ocular deposits have been previously described with phenothiazine use, this is the first case reported in the United States where the patient was on clozapine, but had no known history of thioridazine use.

10. Conclusion (cont.) • In 2000, deposits were noted on our patients lenses and were attributed to “cataractous changes.” In 2007, corneal deposits were noted and attributed to “guttatta.” The progressive involvement of the ocular tissues with these pigmentary deposits suggests that accumulation of pigment in the anterior chamber occurred with chronic clozapine use. • Psychiatrists and ophthalmologists should be aware of clozapine-related ocular deposits and to include it in the differential diagnosis of pigmented, crystalline deposits involving the cornea, lens and retina.

11. Bibliography • Borovik AM, Bosch MM, Watson SL.Ocular pigmentation associated with clozapine.Medical Journal of Australia. 2009 Feb 16;190(4):210-1. • Bock E, Swain J. Ophthalmologic findings in patients on long-term chlorpromazine therapy. American Journal of Ophthalmology 1963; 56: 808-810.