J Chin Med Assoc December 2006 Vol 69 No 12 589 2006 Elsevier. All rights reserved.IntroductionMethylphenidate hydrochloride (Ritalin), a short-actingcentral nervous system stimulant, is common and effi-cacious in the treatment of attention deficit hyperac-tivity disorder (ADHD) in psychiatric clinic, especiallyforchildren.1Itisasympathomimeticamineandiscontraindicatedinpatientswithglaucoma,asmen-tioned in the Physicians Desk Reference and packageinsert. Glaucoma exacerbated by oral methylphenidatehas been reported in the literature.2However, there hasbeennoreportofmethylphenidate-associatedcom-plicated cataract. We present a case of bilateral com-plicatedcataractandglaucomafollowinglarge-dosemethylphenidate use for 2 years.Case ReportA 10-year-old boy presented with progressive blurredvisioninbotheyesoverthepast1year.Hehadnohistory of systemic disease, ocular trauma or ocular dis-order except myopia before this episode. His correctedvisual acuity was 6/7.5 in both eyes 1 year previously.Decreased visual acuity was noted during routine schoolphysical check-up 3 months before this visit. Glaucomaand cataract were diagnosed at the ophthalmic clinic.Thepatientwasreferredtoourdepartmentduetopoorlycontrolledintraocularpressure(IOP)under2% carteolol eye drops twice a day. His best correctedvisualacuity(BCVA)was6/60withsph5.25cyl 1.5 160 in the right eye and 6/60 with sph 5.25cyl 0.75 40 in the left eye on presentation.Slit-lamp biomicroscopy revealed clear cornea, deepanteriorchamber,anddenseposteriorsubcapsularopacityoflensinbotheyes(Figure1).Gonioscopyshowed Grade 4 open (Shaffer system) and well devel-oped angle. Indirect ophthalmoscopy revealed pale discwith advanced glaucoma cupping (0.9 0.9) in botheyes.IOPwas26mmHginbotheyes.Automatedperimetry revealed generalized visual field constrictionin the right eye and upper arcuate scotoma in the leftCASE REPORTMethylphenidate (Ritalin)-associated Cataract and GlaucomaChao-Kung Lu1, Tung-Mei Kuang1, Joe Ching-Kuang Chou1,2*1Department of Ophthalmology, Taipei Veterans General Hospital, and 2National Yang-Ming University School of Medicine, Taipei, Taiwan, R.O.C.Methylphenidate hydrochloride (Ritalin) is the drug of choice for attention deficit hyperactivity disorder (ADHD). However, anassociation of Ritalin with glaucoma has been reported. We report a case of Ritalin-associated cataract and glaucoma.A 10-year-old boy was diagnosed with ADHD and had received methylphenidate hydrochloride, 60mg/day for 2 years. Hepresented with blurred vision. Best-corrected visual acuity was 6/60 in both eyes. Ocular examinations revealed intraoc-ular pressure (IOP) of 30mmHg under medication, dense posterior subcapsular opacity of lens, pale disc with advancedcupping, and marked constriction of visual field. Despite maximal anti-glaucomatous medication, IOP still could not becontrolled. The patient then received combined cataract and glaucoma surgery. Visual acuity improved and IOP was withinnormal limits in both eyes postoperatively. Large dose of methylphenidate may cause cataract and glaucoma. The mech-anism remains unclear. Doctors should be aware of the possible ocular side effects of methylphenidate. [J Chin MedAssoc 2006;69(12):589590]Key Words: cataract, glaucoma, methylphenidate, Ritalin*Correspondence to: Dr Joe Ching-Kuang Chou, Department of Ophthalmology, Taipei Veterans General Hospital,201, Section 2, Shih-Pai Road, Taipei 112, Taiwan, R.O.C.E-mail: ckjchou@vghtpe.gov.twReceived: October 24, 2005Accepted: October 31, 2006J Chin Med Assoc December 2006 Vol 69 No 12 590C.K. Lu, et aleye.ThepatienthadADHDandhadbeentakingmethylphenidate hydrochloride (Ritalin) 40mg/day in2 divided doses as prescribed by his psychiatrist. How-ever, his mother had increased the dose to 60mg/dayforthepast2years.Otherwise,hismotherdenied any other medication including steroid and herbs orany ocular trauma history.Under the impression of methylphenidate-associatedcataractandglaucoma,latanoprosteverynight,2%carteolol twice a day for both eyes and oral acetazol-amide 125mg twice a day were given. Methylphenidatewas discontinued. Despite maximal antiglaucomatousmedicationsfor1month,IOPstillfluctuatedupto30mmHginbotheyes.Thepatientunderwenttra-beculectomyandphacoemulsificationwithintraocu-lar lens implantation for both eyes. IOP was maintainedaround 16mmHg in both eyes, and BCVA was 6/6in the right eye and 6/12 in the left eye at 1 year offollow-up.DiscussionWhen glaucoma is encountered in children, the usualfirst thought is congenital glaucoma. In the congeni-tal glaucomatous eye, we can see Haabs striae on thecornea and underdeveloped mesodermal tissue over thechamber angle by gonioscopy. In our patient, the corneawas clear without any striation. Gonioscopy showed awell developed wide open angle without any residuemesodermal tissue. Congenital glaucoma was thereforeruled out.In congenital cataract, one can usually see snowflakeorsclerosisofthelensnucleus.Inourpatient,onlyposterior subcapsular opacity with clear nucleus couldbe seen. If the lens displays posterior subcapsular opac-ity, our first consideration would be complicated cataractrelated to topical steroid use, diabetes, hyperthyroidism,systemicmedicationssuchasphenothiazines,amio-darone, steroid and herbs, etc.3However, none of theabove were found in our patient.A child with ADHD is prone to head trauma. Thiscouldinducetraumaticcataract.Insuchsituations,lenssubluxationornucleusmilkychangewouldbefound. None of that was found in our case, so traumaticcataract was also ruled out.Methylphenidate is a sympathomimetic amine. It hasthe potential to induce acute angle closure glaucomaorworsenchronicangleclosureglaucoma.2,4,5ThePhysicians Desk Reference indicates that the maximumdaily dosage is 60mg, and a dosage >60mg/day is notrecommended.Ourpatienttookahighdoseofthemedication for 2 years. A characteristic glaucomatousoptic neuropathy with associated visual field defect andelevatedIOP,andcomplicatedcataractinbotheyeswere noted. Since the congenital factor was not likely,and there were no other medication- or trauma-relatedfactors, the possibility of prolonged high-dose Ritalinuse-related complicated cataract and glaucoma was ourfirst consideration.Despite discontinuation of methylphenidate, densecataract and persistent high IOP caused severe visionlossinbotheyes.Onepossiblemechanismisthatmethylphenidate may cause cytoskeletal change in thechamber angle trabecular meshwork or obstruction oftrabecular meshwork. Even after the discontinuationofmethylphenidate,thefunctionofthetrabecularmeshworkdidnotrecover.Therefore,theglaucomaremained out of control. Filtering surgery for glaucomamanagement was necessary.Fromtheliterature,noreportofRitalin-relatedcataracthasbeenfound.Thisisthefirstreportofmethylphenidate-associatedcataractandglaucoma.Although the underlying mechanism is unknown, thepossibleocularsideeffectsshouldbeconsideredinpatients on methylphenidate treatment.References1. RappleyMD.Safetyissuesintheuseofmethylphenidate:anAmerican perspective. Drug Saf 1997;7:1438.2. Bartlik B, Harmon G. Use of methylphenidate in a patient withglaucoma and attention-deficit hyperactivity disorder: a clinicaldilemma. Arch Gen Psychiatry 1997;54:1889.3. ShahzadS,SulemanMI,ShahabH,MazourI,KaurA,Rudzinskiy P, Lippmann S. Cataract occurrence with antipsy-chotic drugs. Psychosomatics 2002;43:3549.4. KimkoHC,CrossJT,AbernethyDR.Pharmacokineticsandclinicaleffectivenessofmethylphenidate.ClinPharmacokinet1999;37:45770.5. Oshika T. Ocular adverse effects of neuropsychiatric agents: inci-dence and management. Drug Saf 1995;12:25663.Figure 1. Slit-lamp biomicroscopy of the patients right eye showsdense posterior subcapsular lens opacity.