¹Chulalongkorn University, Medical Sciences, Bangkok, Thailand, ²Mahidol University, Ophthalmology, Bangkok, Thailand, ³Chulalongkorn University, Psychiatry, Bangkok, Thailand

Background: Antipsychotic medications are widely prescribed across psychiatric conditions, yet ocular adverse reactions are documented inconsistently. Their actual frequency remains unknown, and there is still no clear guidance on whether routine ophthalmic screening is warranted.

Aims & Objectives: This study aimed to systematically review the literature on antipsychotic-related ocular complications and to quantify their occurrence using pooled prevalence and incidence estimates. The primary outcome was the pooled prevalence and incidence of ocular adverse effects in patients receiving antipsychotic medications. The secondary outcome was the site-specific ocular adverse effects.

Method: A systematic search of MEDLINE, SCOPUS, and PsycINFO was conducted from database inception to August 9th, 2025. Eligible studies were studies reporting the incidence or prevalence of ophthalmologic complications among users of psychotropic medications. Pooled estimates were calculated using fixed-effects or random-effects models, depending on the degree of heterogeneity. Subgroup analyses were conducted by specific ocular sites. Publication bias was assessed visually using a funnel plot and statistically using Egger’s and Begg’s tests. Sensitivity analysis was performed using a leave-one-out meta-analysis. Meta-regression was conducted to evaluate the association between publication year and proportion. PROSPERO registration number CRD420251106667.

Results: Twenty-seven studies were included, comprising 7,024 patients exposed to antipsychotics who underwent ophthalmologic assessment. Most studies reported typical antipsychotics, particularly phenothiazines, with less frequent reporting of atypical antipsychotics. The pooled prevalence of any ocular adverse effect was 32.4% (95% CI 21.4-44.5%, p < 0.001), with high heterogeneity (I² = 98.87%). When stratified by study design, incidence-based studies yielded lower pooled estimates (12.8%, 95% CI 0.01-37.9%) compared with prevalence-based studies (36.3%, 95% CI 24.3-49.3%); however, this difference was not statistically significant (Qb = 2.77, p = 0.10). The reported complications were lens changes (24.1%, 95% CI 13.5-36.4%, p < 0.001), corneal or lens pigmentation (32.6%, 95% CI 14.0-54.5%, p < 0.001), corneal lesions (14.5%, 95% CI 7.4-23.4%, p < 0.001), retinopathy (14.9%, 95% CI 1.3-38.8%, p = 0.01), conjunctival change (7.7%, 95% CI 2.7-14.4, p < 0.001), optic neuropathy (8.3%, 95% CI 0.2-25.1%, p = 0.03), and increased intraocular pressure or glaucoma (0.01%, 95% CI 0.00-0.47%, p > 0.05). Oculogyric crises were rare (1.64%, 95% CI 1.2-2.1%, p < 0.001). Meta-regression analysis demonstrated an inverse association between publication year and proportion.

Discussion & Conclusions: Ophthalmologic adverse effects associated with antipsychotic medications are relatively common but are predominantly mild or subclinical, particularly involving the lens and cornea. Potentially vision-threatening complications, such as retinal or optic nerve involvement and sustained elevation of intraocular pressure, were infrequent and inconsistently reported. The observed decline in reported incidence over time may reflect reduced screening practices or lower ocular toxicity associated with newer antipsychotic agents. These findings indicate that while routine ophthalmic screening by ophthalmologists for all patients with psychotropic drugs may not be warranted, targeted assessment for those receiving long-term treatment or having visual symptoms is appropriate.