recent reports suggest that patients with glaucoma have higher prevalence of depression in contrast to the control group . taking this into consideration , it is expected that more and more patients with glaucoma require treatment for their depression and some of these patients with severe depression may require ect . hence it is important to understand the consequences of ect procedure on intraocular pressure ( iop ) . studies which have evaluated the changes in the iop during ect in patients with normal iop prior to ect have reported rise in iop during ect , although the magnitudes of this elevation is not hazardous and usually returns to the baseline iop levels after 90 min of seizure activity during the ect . one of the studies which compared the iop changes during ect in patients with glaucoma and non - glaucoma patients reported significantly higher elevation of iop in glaucoma patients . however a small case series involving two patients suggested that rise in iop is of lesser magnitude in glaucomatous patients than the non - glaucomatous patients . evidence in the form of case reports suggests that ect is usually associated with transient elevation in the iop and occasional reports suggest fall in intra - ocular pressure . in this report we present the case of a patient with open angle glaucoma ( who had undergone trabeculectomy for the same ) who was treated with ect and review the existing literature with respect to glaucoma and ect . 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 . his 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 . 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 . on 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 / m ) . 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 . the cup disc ratio was 0.6 in right eye and 0.8 in the left eye . his 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 . modified 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 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 . 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. along 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 ( table 1 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 . 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 . the electroconvulsive therapy treatment parameters prior to starting of ect , his intraocular pressure was 10 - 11 mm of hg . however , after 3 ect the iop increased to 18 mm and 20 mm of hg in the right and left eye respectively . with 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 . studies suggest that there is clinically insignificant rise in iop during ect in patients with no ocular pathologies . data in the form of case reports since early 1950s suggests that ect leads to increase in iop in patients with glaucoma . these case reports have described varied clinical situations in the form of use of ect in patients after bilateral iridectomy , bilateral iridectomy with cataract surgery in the past , and glaucoma tube implants . some of the case reports which have evaluated the changes in iop in glaucoma patients with ect have discussed the anaesthetic issues . in one of the case report this change in iop almost stabilized when the patient was administered ganglionic blocking medication trimethaphan prior to ect stimulus . two case reports described prolonged apnea as a complication of ect in glaucoma patients receiving echothiophate eye drops . prolonged apnea was attributed to the increased duration of action of succinylcholine due to low levels of serum cholinesterase caused by ecothiophate . in another case report authors described the successful use of short - acting nondepolarizing agent atracurium instead of succinylcholine for muscle relaxation . from the above literature it can be concluded that whenever patient with glaucoma are recommended to receive ect , eye drops like ecothiophate , which is a cholinesterase inhibitor should be avoided . american psychiatric association guidelines , recommend consultation liaison with an ophthalmologist , prophylactic use of medication to keep the intraocular pressure low , avoiding anti - cholinesterases as it prolongs succinylcholine induced apnea , reducing the movements of head to least during ect and attempts to reduce the hypertensive surge . in the index case a close liaison with the ophthalmologist was maintained , esmolol was used to prevent hypertensive surge and head movements were restricted . the index case was diagnosed with open angle glaucoma , had undergone bilateral trabeculectomy and cataract surgery prior to ect . in contrast to the previous reports which have reported rise in iop upto 30 mm of hg , in the index case the rise of iop was in the range of upto 10 mm of hg . in contrast to previous case reports of prolonged apnea with succinylcholine , we did not encounter the similar adverse effect . this could be possibly due to use of combination of atracurium and succinylcholine in lower doses and use of neostigmine after ect to reverse the effect . hence , the index case suggests that succinylcholine may be a safe option for ect when used in the absence of medications like ecothiophate . further the case demonstrates the safe use of medications like neostigmine to reverse the effect of muscle relaxants . like the previous reports , the present case also reflects that iridectomy may have some protective effect on rise in iop in glaucoma patients undergoing ect . previous reports have either have not mentioned the time of assessment of iop along with ect . or some have just measured the effect of ect procedure on iop immediately after the ictal activity . or after 90 min ( edwards et al . in contrast in the index case we were not able to measure the iop very close to the ect procedure , but we measured the same at a fixed time of the day prior to and after ect and found it useful in monitoring the iop . however , future studies should focus on the feasibility and usefulness aspect of measuring iop in glaucoma patients during ect .
limited data is available with respect to use of electroconvulsive therapy ( ect ) in the presence of glaucoma . 
 we present a case of severe depression with psychotic symptoms who did not respond to various antidepressant trials and required ect . 
 his medical history showed that he was diagnosed to have open angle glaucoma and cataract in both the eyes . 
 he had undergone bilateral trabeculectomy and cataract surgery for his ophthalmological aliments . 
 he was safely treated with bilateral ect , with which he achieved remission .