Benzodiazepine Tapering and Withdrawal: The Impact on Eye Health

Can tapering off a benzodiazepine affect your eyes?

Yes. Blurred vision, double vision, sore or dry eyes, and sensitivity to light are documented symptoms of benzodiazepine withdrawal, and they can appear during a slow taper as well as after a sudden stop. In most cases, they are temporary.

Neither the Ashton Manual nor the drug labels describe these symptoms as damage to the eye. They describe a nervous system that is readjusting.

Patients who taper with Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, tend to arrive at the same question. Is this the taper, or is something wrong with the eyes themselves?

Usually, it is the taper. However, there is one eye emergency that every person who takes a benzodiazepine should recognize, and it is named on the drug label. So, which symptoms are withdrawal, which are the medication, and which need an eye doctor today?

Which eye symptoms are documented in benzodiazepine withdrawal?

Professor C. Heather Ashton listed “blurred/double vision, sore or dry eyes” among the physical symptoms in Table 1 of Chapter III of the Ashton Manual. The same table lists hypersensitivity to light.

The drug labels agree. The label for clonazepam (Klonopin), approved by the United States Food and Drug Administration (FDA), lists blurred vision and photophobia, the medical word for light sensitivity, among the acute withdrawal signs associated with benzodiazepines. The diazepam (Valium) label carries the same sentence.

The day-to-day experience is covered in a separate article on benzo eyes. This one is about the health of the eye itself.

Why would a medication for anxiety or sleep change how the eyes work?

Benzodiazepines strengthen the effect of gamma-aminobutyric acid (GABA), the brain’s main calming signal, and with steady use the nervous system adapts to the drug. When the dose comes down, Chapter III explains, nearly all of the excitatory mechanisms in the nervous system go into overdrive until new adaptations develop.

Professor Ashton traced the blur to muscle. In withdrawal, she wrote, “the muscles, especially the small muscles of the eye, are not well co-ordinated, which may lead to blurred or double vision or even eyelid spasms (blepharospasm).”

Think of a pair of binoculars knocked slightly out of line. Each barrel still gives a sharp picture, but the two pictures no longer land in the same place, so the view doubles or smears. The glass is fine. The alignment is off, and alignment can come back.

Light sensitivity comes from the same overdrive. The Manual describes a heightened sensitivity to every sense, sight included, and notes that the same sensations occur in anxiety states with no benzodiazepine involved.

Chapter III also notes that some long-term users have withdrawal symptoms while still taking the drug, because of tolerance. So, eye symptoms can appear before the first dose reduction, as part of tolerance withdrawal.

The medication itself can blur vision, too.

The clonazepam label lists blurred vision, double vision, and abnormal eye movements among the adverse reactions reported with the drug, and the diazepam label lists blurred vision and double vision. Eye irritation and dry eye appear on the clonazepam label only as infrequent events that were not necessarily caused by the medication.

The timing is the clue. A symptom that began when the medication was started or raised points toward the drug. A symptom that follows a dose reduction, or arrives as a dose wears off, points toward withdrawal, and either one is worth writing down for the prescriber.

Do the eye symptoms go away?

In most cases, yes. Of the heightened senses, Professor Ashton wrote that these sensations “return towards normal as withdrawal progresses.” In the same section that describes the eye muscles, she wrote, “None of these symptoms is harmful, and they need not be a cause of worry once they are understood.”

That reassurance is about withdrawal. It does not cover every eye problem.

Unfortunately, no one can promise a date. For a minority of people, symptoms outlast the taper, and the clonazepam label says that protracted withdrawal symptoms may last weeks to more than 12 months.

Vision that stays blurred for months can feel permanent. In most cases, it is not.

What should happen to the taper when the eyes flare?

Fortunately, the main tool is the pace. Chapter III stresses that withdrawal symptoms can be minimized and largely avoided by slow tapering, tailored to the individual. When blur or light sensitivity surges after a reduction, the usual answer is a smaller next step or a hold at the current dose, and the patient decides, with the prescriber.

The shape matters as much as the speed. The Maudsley Deprescribing Guidelines describe hyperbolic tapering, in which each reduction is smaller than the one before.

For a person on a short-acting benzodiazepine, the Ashton Manual describes a crossover taper to diazepam, where it helps. A taper like this runs for months, sometimes longer.

What the eyes never justify is a sudden stop. The boxed warning that the FDA required on every benzodiazepine label in 2020 says that abrupt discontinuation or rapid dosage reduction may precipitate acute withdrawal reactions, which can be life-threatening, and the label names seizures as the example. Call emergency services for a seizure or any other medical emergency.

What does the label say about glaucoma?

The clonazepam label lists acute narrow angle glaucoma as a contraindication, and adds that the drug “may be used in patients with open angle glaucoma who are receiving appropriate therapy.” The diazepam label says the same, which matters because many tapers run on diazepam. Labels differ by drug, so a pharmacist can check the wording for any other benzodiazepine.

Glaucoma is not on the Manual’s list of withdrawal symptoms, or on the labels’, and the two conditions the label names are not alike. Open-angle glaucoma is the common, slow form, managed over years with drops, laser, or surgery.

Acute narrow-angle glaucoma, also called acute angle closure, is sudden. The drainage angle at the front of the eye closes, the pressure inside the eye rises within hours, and vision can be lost for good without fast treatment.

For a person whose open-angle glaucoma is being treated, the label does not forbid the medication, and nothing in it calls for a hurried taper. For a person told that the angles in their eyes are narrow, the questions for the eye doctor are whether that has been treated and whether any medication is a concern.

A contraindication is a reason for the prescriber and the eye doctor to talk promptly. It is never a reason to stop a benzodiazepine suddenly at home.

Which eye symptoms need emergency care?

The trouble is that the first signs of acute angle closure, a blurred eye, a headache, and nausea, can look like a hard day of withdrawal. No one can sort that out at home. Go to an emergency department or an emergency eye clinic right away, or call emergency services if there is no safe way to get there, for any of the following:

• sudden, severe pain in or around an eye
• halos or rainbow-colored rings around lights
• sudden loss of vision, in part or all of the field of view
• a red, painful eye, especially with headache, nausea, or vomiting

A sudden shower of floaters or flashes of light needs the same urgency, and so does sudden double vision with weakness, numbness, a drooping face, or trouble speaking. Tell the emergency team which benzodiazepine is being taken and at what dose.

An exam that finds nothing wrong is not a wasted trip. It lets the patient and the prescriber treat the symptom as a taper problem.

Keep the eye exams, and tell the eye doctor about the taper.

A taper is no reason to postpone routine eye care. Keep the regular exams, keep using any prescribed glaucoma drops, and tell the eye doctor which benzodiazepine is being tapered and how vision has changed since the last reduction. The prescriber, in turn, should hear about any eye diagnosis, glaucoma and narrow angles above all.

Unfortunately, some patients leave the taper out of that conversation, because the word withdrawal has gotten them treated like a person with a drug problem before. A patient who took a benzodiazepine as prescribed and has symptoms while reducing it has physical dependence, and dependence is not addiction. In fact, the clonazepam label defines physical dependence as a state that develops from physiological adaptation to repeated use of a drug.

Smaller questions belong in the same visit, such as whether blur that comes and goes is worth new glasses now, and whether lubricating drops make sense for sore, dry eyes. Evidence that any comfort measure changes the course of withdrawal is limited, responses vary, and none replaces a gradual taper. And, on a day of double vision, the driving belongs to someone else.

How does Dr. Leeds respond to eye symptoms during a taper?

In Dr. Leeds’ practice, once an eye emergency has been ruled out, an eye symptom during a taper is information about the pace. He reviews the size and timing of the last reductions with the patient, and the patient decides whether to hold, take a smaller step, or continue.

Dr. Leeds’ practice in Fort Lauderdale focuses on medically supervised benzodiazepine and z-drug tapering, for patients in Florida. While no one can say when the eyes will settle, a taper with room to slow down gives them the time. Contact the office to ask about a gradual, supervised taper.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.