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Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 17-18

Acute psychosis after refractive surgery

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission07-Jul-2021
Date of Acceptance23-Aug-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Manpreet Kaur
Assistant Professor, Cornea, Lens and Refractive Surgery Services, R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1816_21

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A 20-year-old male with no previous history of systemic or mental illness underwent femtosecond laser-assisted in situ keratomileusis (LASIK) in both eyes. A suction loss was experienced during surgery in the left eye. Repeat docking was performed, and subsequent surgery was uneventful. In the postoperative period, the uncorrected distance visual acuity (UDVA) was 20/20 in both eyes; however, the patient developed behavioral changes and acute psychotic symptoms, which subsided with anti-psychotics over 3 weeks. Acute psychosis following ocular surgeries is rare; however, a strong suspicion should be kept if any behavioral changes are noted in the postoperative period. Timely psychiatric referral and adequate management are essential to achieve optimal outcomes.

Keywords: Acute psychosis, LASIK, post-surgical psychosis

How to cite this article:
Asif MI, Meena SK, Titiyal JS, Kaur M. Acute psychosis after refractive surgery. Indian J Ophthalmol Case Rep 2022;2:17-8

How to cite this URL:
Asif MI, Meena SK, Titiyal JS, Kaur M. Acute psychosis after refractive surgery. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:17-8. Available from: https://www.ijoreports.in/text.asp?2022/2/1/17/334912

Acute onset of psychotic symptoms in the postoperative period has been reported following complex surgical procedures; however, it is rare following ocular surgeries. The onset of symptoms may be precipitated by stress, anxiety-inducing factors, or postoperative medications. Systemic medications have been implicated in postoperative acute psychosis; however, topical use may rarely result in these symptoms. Herein, we report a case of acute psychosis in a patient following refractive surgery.

  Case Report Top

A 20-year-old male patient with no previous history of systemic or mental illness presented for laser refractive correction. He had no history of any drug use for therapeutic or recreational purposes. There was no history of smoking or alcohol intake. On examination, the ocular surface and anterior and posterior segments were unremarkable. His refractive error was − 4.50DS/−0.50DC @ 180 in both eyes with normal topography. Written informed consent was obtained and was adhered to the tenets of the Declaration of Helsinki. He underwent femtosecond laser-assisted in situ keratomileusis (LASIK) using a WaveLight FS200 laser system (Alcon Laboratories Inc., Fort Worth, TX) in both eyes. Suction loss was experienced before the delivery of the femtosecond laser in the left eye resulting in restlessness of the patient. Following counseling, the patient was less anxious and repeat docking was performed, and the subsequent surgery was uneventful. In the postoperative period, the patient was started on topical moxifloxacin hydrochloride 0.5%, prednisolone sodium phosphate 1%, and carboxymethylcellulose 0.5% four times per day.

On postoperative day one, parents noticed some behavioral changes such as repeated and irrelevant questioning. On ocular examination, UDVA was 20/20 in both eyes and an IOP of 14 mm Hg. On day 2, parents noticed increased behavioral changes such as complaining/asking “if someone is conspiring against him” or “if someone is following him.” There were bouts of sudden crying, visual hallucinations, and insomnia. Topical antibiotics and steroids were stopped, and immediate psychiatric assessment was advised. Blood investigations, including complete blood count, serum electrolytes, liver enzymes, blood urea nitrogen, and creatinine, were normal. The chest x-ray was unremarkable. The patient was started on Tab Diazepam by the psychiatrist. At 1 week, parents did not observe any improvement in symptoms. On psychiatric reevaluation, a blood sample was taken to rule out withdrawal symptoms of any substance abuse, which revealed presence of diazepam (prescribed by psychiatrist) and negative for others (morphine, cocaine, heroin, ketamine, nicotine, and other antipsychotic drugs). A diagnosis of acute psychosis was made, and the patient was started on tab clonazepam and tab olanzapine. The patient's symptoms eventually improved within a week and he was completely asymptomatic at the end of the third week.

Differential diagnosis to be considered in our case include post-surgical acute psychosis, topical steroid-induced or fluoroquinolones-induced acute psychosis, and withdrawal symptoms following drug abuse.

  Discussion Top

Behavioral changes such as depression, hallucinations, mania, or true psychosis following surgery have been well documented in the literature. Cognitive changes have also been reported after surgical interventions.[1] These changes have been reported following pelvic surgeries, oophorectomy, abortion, renal transplantation, and other complex surgeries.[2],[3] Rarely, psychiatric complications have been reported following ocular surgeries.[4]

Sekimoto et al.[4] reported a series of three patients who developed delirium following ocular surgery; one had cataract surgery and the other two had cryoretinopexy with segmental buckling for retinal detachment. The patients who underwent retinal surgeries were kept in the prone position for a week due to intravitreal gas injection. The symptoms started 1-week post-surgery and improved within a month with treatment. They concluded that this behavioral change could be attributed to the environmental change, which could have been stressful and anxiety-inducing. Apart from this, the prone position may have partly contributed to the precipitation of these symptoms. The patient who underwent cataract surgery was disappointed with postoperative visual acuity, which could have precipitated delirium. All three patients had their operated eye occluded following surgery. Nan et al.[5] reported a case of Charles Bonnet syndrome following occlusion of the vitrectomized eye. This patient had acute onset visual hallucinations (within 30 min of patching) and disappeared after 2 days of removal of the patch. Weissman and Hackett documented delirium following bilateral occlusion (known as black-patch delirium).[6]

There are few reports of topical medication use resulting in acute psychosis. Systemic absorption of topical medications can happen through the conjunctival route or highly vascular nasal mucosa. They could be absorbed by the capillaries and reach the brain through the angulus venosus of the deep cerebral veins and cavernous sinuses.

Tripathi et al.[7] reported dizziness, lightheadedness, visual hallucinations, and irrational conversation on day 1 of the use of topical ciprofloxacin for conjunctivitis. When the drug was stopped, the symptoms improved after 12–24 hours. Similarly, use of tropicamide 1% has been associated with abnormal behavioral status such as abnormal flow of speech, complex visual hallucinations, impaired judgement, and lack of insight.[8] Acute psychosis has also been reported following cyclopentolate use following cataract surgery. The patient developed irritability, disruptive and wandering behavior, irrelevant talking, and disturbed sleep, which reverted in 48 hours following the stoppage of the drug.[9] Systemic corticosteroids are notorious for causing psychotic symptoms; however, they are rare following topical use. Upadhyaya et al.[10] reported tactile hallucinations following topical triamcinolone in a retropositive patient with chronic eczema.

In our patient, the symptoms developed from the first postoperative day; the time to onset of symptoms was in accord with previously described cases of topical medication-induced acute psychosis. However, symptoms persisted up to 3 weeks despite stopping the medications on day 2. Most of the previous reports observed rapid improvement in symptoms within 24–48 hours of discontinuing topical medications. LASIK was performed on a daycare basis as per our protocol. The entire hospital stay duration of the patient was less than 2 hours and no eye patching was done following surgery. There were no described risk factors in our patient that could induce acute psychosis following surgery. The cause for acute psychosis in our patient is still debatable; however, suction loss during surgery could have been a contributing stress factor that might result in acute psychosis in a previously anxious patient. There are no previously reported cases of acute psychosis following any refractive procedures.

  Conclusion Top

Acute psychosis following ocular surgeries is rare. However, a strong suspicion should be kept if any behavioral changes are noted in the postoperative period. Optimal outcomes and desirable patient satisfaction may be achieved with timely diagnosis and prompt intervention.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Anderson KE, Mullins J. Behavioral changes associated with deep brain stimulation surgery for Parkinson's disease. Curr Neurol Neurosci Rep 2003;3:306-13.  Back to cited text no. 1
Chandra PS. Post-ovariectomy and oestrogen therapy related recurrence of oestrogen withdrawal associated psychosis. Acta Psychiatrica Scandinavica 2002;106:76.  Back to cited text no. 2
Davidson K, Clare AW. Psychotic illness following termination of pregnancy. Br J Psychiatry 1989;154:559-60.  Back to cited text no. 3
Sekimoto M, Hayasaka S, Noda S, Iijima M, Setogawa T. Psychiatric complications after ocular surgery. Ophthalmologica 1993;206:113-4.  Back to cited text no. 4
Nan L, Yanbin H, Jingping Z. Acute reversible Charles Bonnet syndrome following eye patch placement. Neuroophthalmology 2013;37:35-7.  Back to cited text no. 5
Weisman AD, Hackett TP. Psychosis after eye surgery: Establishment of a specific doctor-patient relation in the prevention and treatment of black-patch delirium. N Engl J Med 1958;258:1284-9.  Back to cited text no. 6
Tripathi A, Chen SI, O'Sullivan S. Acute psychosis following the use of topical ciprofloxacin. Arch Ophthalmol 2002;120:665-6.  Back to cited text no. 7
Munhoz RP, Moscovich MM, Filla L, Carneiro MC. Topical tropicamide induced delirium and psychosis: case report. Jornal Brasileiro de Psiquiatria 2010;59:74-6.  Back to cited text no. 8
Rajappa N, Patra S, Bhalsing S, Lune AA. A case of acute psychosis induced by topical cyclopentolate eye drops in an elderly patient. Medical Journal of Dr. DY Patil University 2014;7:68.  Back to cited text no. 9
Upadhyaya M, James M. Topical triamcinolone-induced psychosis. Am J Psychiatry Resid J 2019;14:4-5.  Back to cited text no. 10


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