New article
We are pleased to announce the publication of a new peer-reviewed article based on data from RxISK: “Serotonin reuptake inhibiting antidepressants: A trigger for visual snow syndrome?”
It can be freely viewed and downloaded. We would be grateful if you could share it as widely as possible.
To our knowledge, it is the biggest series of visual snow cases linked to a particular drug group. But of further interest is the evidence that visual snow and visual snow syndrome can endure for months or years after serotonin reuptake inhibiting antidepressants are stopped.
We have previously mentioned a link between visual snow and antidepressants in several blog posts, going all the way back to Keeping an Eye on the Ball in December 2013.
Then, in 2022, we published a peer-reviewed article about a range of different visual problems linked to serotonin reuptake inhibiting antidepressants. This included several reports of visual snow.
Almost as soon as that article was published, there were discussions about the possibility of writing one specifically for visual snow. Despite a significant number of publications about this condition in the academic literature, very little has been written about a link with antidepressants, so there seemed to be a gap in the knowledge base that our data could help to fill.
Not all cases of visual snow are linked to antidepressants, but the data suggests that the use of certain types of antidepressants may be responsible for the condition in some people.
Through a long and fruitful collaboration with Jonathan Lochhead and Hannaa Bobat over some years now, we and they have come to realise that most ophthalmologists examining the eyes of people with visual snow syndrome, and failing to see visible damage, assume the effect is in the brain or the mind – an assumption that may be reinforced if the person is on or has been on an SSRI.
There is, however, comparatively more serotonin in our eyes relative to their size than in our brain, and those of us linked to the new article are beginning to consider the idea that we may well be dealing with something in the eyes. The implication of this, as with PSSD, is that it does people complaining about real difficulties a disservice to suggest they have a mental problem.
Road to publication
The article has had an interesting road to publication.
An earlier version of the manuscript was submitted to a journal in mid-2024 who replied saying “your manuscript did not receive a high enough priority score to be sent out for external review”. It was rejected without review.
We then sent the manuscript to another journal on 9 December 2024. Based on previous experience with that journal, we suspected they might also reject it. They did – without review.
We then submitted it to BMC Ophthalmology on 19 December 2024. This seemed like a better fit for the article, and we hoped that inclusion in this journal would increase awareness of Visual Snow linked to antidepressants among the ophthalmology community.
On 23 December 2024, we received a response from the journal asking for a small change to our ethics statement. We made the adjustment and resubmitted it a few days later. Then we heard nothing.
We still hadn’t heard anything by the middle of March 2025. This was very unusual, and we wondered if we had missed an email or had done something wrong during the submission process. We contacted them to see what was happening.
On 18 March 2025, we received an email from Dr Sushila Kamble, assistant editor at BMC, apologising for the delay. She explained:
“We have unfortunately been having problems obtaining sufficient reviewer reports as requested by the handling Editor and as such, your manuscript is still going through the peer review process.”
This seemed a little unusual. If our article had been about an unknown condition that was on the edge of the journal’s scope, it might make sense that they were having difficulty finding reviewers. But this was an ophthalmology journal, and the article was about a well-documented visual problem. We also noticed that the journal was publishing a high number of new articles every week and didn’t seem to be having difficulty finding reviewers for those.
We thanked Dr Kamble for the note and, as an aside, we informed her that the World Health Organization (WHO) had announced that visual snow syndrome now features in ICD 11, the most recent edition of the International Classification of Diseases.
Things went quiet again.
A colleague
By the end of April 2025, we hadn’t heard anything further. But coincidentally, one of us heard from a colleague who recently had a strange experience with another BMC journal.
He had submitted a meta-analysis involving adverse effects of a medication – nothing to do with visual problems or antidepressants. A meta-analysis is a type of study that brings together the results of existing studies into one larger study, thereby helping to build a bigger picture.
After several months of reviews and revisions, and with three peer reviewers seemingly happy with the article but one with quibbles, it was rejected by the journal. The person appealed and was apparently told:
“There is no advance presenting or analysing the updated/existing evidence in a valid manner such as meta-analysis.”
It went on to say that the drug regulator should be left to decide whether or not there is a problem.
Meta-analyses are a common type of research in the academic literature, so this is a new reason for an article to be rejected. It made us wonder whether this was indicative of BMC’s position on adverse drug effects and might explain their reluctance to accept our paper.
Another note to BMC
On 1 May 2025, we emailed Dr Kamble at BMC Ophthalmology to ask for an update. We explained the importance of the research, offered to provide the details of a possible reviewer if they were still having difficulty finding someone, and also asked whether the fact that our article involved adverse drug effects was causing difficulty. There was no response.
In the academic world, having articles rejected isn’t unusual, but it’s unusual for a journal to put an article out for peer review and then simply stop communicating with the authors. Even when reviewers don’t like an article, they are often still happy to review it, even just to reject it.
Our article wasn’t introducing a new concept. There were already two publications linking serotonin reuptake inhibiting antidepressants to the onset of visual snow.
Was there internal disagreement about whether or not it should be accepted? Did the journal not want to accept the article, but also not want to be seen rejecting it?
Checking the online status showed that it was still apparently in the peer review process.
Switch to IJRSM
By the middle of June 2025, there had been no response. We decided it wasn’t worth pursuing BMC Ophthalmology any further, so we submitted the manuscript to the International Journal of Risk and Safety in Medicine.
After a few weeks, we heard back. The article had been peer reviewed and was being considered for publication pending some minor revisions. We were a little surprised to find that the reviewers had raised 66 different points.
Keeping track of all the comments, making the changes, and typing up the responses to the reviewers was quite a task. But we responded to the points, made 32 minor changes to the manuscript, and resubmitted it.
On 8 August 2025, we were informed that the article would now be accepted for publication pending some further small revisions. We addressed the reviewers comments and attempted to submit our second revision on 12 August 2025. Unfortunately, the journal had changed to a new system and it wasn’t letting us upload the documents. Journals are increasingly relying on automated systems rather than interacting with people.
After numerous emails back and forth over the next few weeks, the journal eventually agreed to accept the documents by email, and they would upload them at their end.
It was now the beginning of September 2025, and we assumed that everything was now resolved. We hoped to hear from the publisher shortly with a draft article for proof reading. But we heard nothing.
After chasing the journal a couple of times, it was discovered that the article had fallen through the cracks and nothing was happening with it. We were told that the peer reviewers hadn’t actually signed it off, so it would have to be sent to them for further review.
On 22 October 2025, we were informed that the article was now accepted (again).
A week later, the publisher had prepared our article for publication and provided us with a link to their online proofing system for checking. We got part of the way through and their system stopped working. Despite continued attempts, we couldn’t access it. We informed the publisher and waited for them to fix it. In the meantime, we received an automated email chasing us to complete the proof reading.
The system was eventually fixed, and the article was published online on 7 November 2025.
Another colleague
While trying to get the visual snow article published, another colleague was having an interesting experience with his own ophthalmology articles.
A few months ago, he completed a study suggesting that SSRIs may reduce the risk of a particular eye condition. The manuscript was accepted and published in a popular and highly regarded ophthalmology journal without any difficulty.
He has just completed another study of similar size and quality, but for a different eye issue. This study found an association between SSRIs and negative structural changes to the eye. So far, he can’t get it published. Journals are rejecting it as being unsuitable without even sending it out for peer review.
Journals often receive significant advertising revenue from pharmaceutical companies, so perhaps anything that mentions adverse effects is seen as bad for business.
Whatever the reason, the reality is that it’s becoming increasingly difficult to get any article published about serious adverse drug effects. The increasing use of automated systems is also not helping.
Reporting
It would be great to get reports from anyone with both visual snow syndrome and post-SSRI sexual dysfunction (PSSD). It would also be great to get reports from people who have persistent postural-perceptual dizziness (PPPD) after stopping a medication, or what you perceive as enduring or recurrent akathisia – these may be the same thing.
Dr. David Healy says
Within minutes of sending an email around about this post, we had a response from a UK doctor saying:
Thank you for sharing this with me
I have personally seen quite a few cases where VSS symptoms have appeared or worsened following treatment with SSRIs in particular. So much so that I routinely warn patients about this possibility.
There are as you point out a number of potential mechanisms that might account for this
Best wishes
Dr. David Healy says
One of our VSS cohort emailed to say:
“… I just wanted to thank you for your efforts. They’re deeply, deeply appreciated.”
D
Dr. David Healy says
We emailed a group of doctors on a Visual Snow list and had this response from one of them
Hello all,
I appreciate you reaching out to me! While I am already aware that SSRIs (and serotonergic drugs in general) can cause VSS, it is helpful to have peer-reviewed literature to cite. I have a fair number of patients who experienced VSS after taking these medications and were not aware that this was a potential side effect. Thank you for your work.
Sincerely,
Dr. DeStefano
David Healy says
We’ve had two more people get in touch from the VS Initiative saying thanks for the article.
D
Dr. David Healy says
We’ve just had a nice note from a US colleague who also has links to the Visual Snow Initiative thanking us for the article and willing to help with the ’cause’.
It probably should not be a surprise but I didn’t expect so much support from this quarter. It’s gratifying to think that maybe our effort and the efforts of all those filing RxISK reports might gain some traction.
One of the key elements of this paper is the fact that like PSSD, VSS is a problem that persists after treatment stops. This is potentially a big step forward, There are a lot of PIEZO proteins in the eye – both in the cornea and the retina.
Another interesting development is seeing some ophthalmologists stop thinking the problem is in the brain and start thinking it might be something to do with the serotonin in the eyes they are looking at.
D
.
Jonathan Lochhead says
VSS has always been considered to have a central neurological origin but recently, I have started to think that the retina may also play a part in this ( at least with SRIs ).
This resulted from recent data we collected on Optical Coherence Tomography changes secondary to SRIs and also some previous studies reporting abnormal Electroretinogram (ERG).
Since 5-Ht has a clear role in retinal amacrine / bipolar cell regulation there may be a physiological case for this.
VSS patients should enquire about electrophysiology investigations (ERG) as part of an Ophthalmic assessment. I think this could help increase the diagnostic potential and also advance our knowledge.
Hannaa Bobat says
Agreed, it is definitely worth asking about this.
My neuro-ophthalmology colleagues where I currently work generally do request electrodiagnostic tests as part of routine investigations for VSS, but this is not always the case, and it is more with a view to ruling out other causes than expecting to find a specific abnormality pointing to VSS.
Dr. David Healy says
Hannaa and Jonathan
Should people specifically request tests of retinal bipolar cell function – as was reported in our very first Visual Snow post on RxISK – over a decade ago?
David
Hannaa says
Hi David,
Retinal bipolar cell function is tested in an electroretinogram which is part of the standard electrodiagnostic tests we would request.
Specifically, the a wave and the d wave of the ERG reflect bipolar cell function.
Becky Huxley says
I have developed visual snow since ssris that I started over 20 years ago. Had a severe (pretty much as bad as it gets ssri withdrawal from 2018-2022) . I have permanent visual snow and light sensitivity. I have me CFS and other symptoms.
Dr. David Healy says
B
If you haven’t already, great if you could file a RxISK report and especially add in any other post SSRI problems – like PSSD or PPPD (persistent postural perceptual dizziness).
D
Becky Huxley says
Ooh – do you think glutamate is a factor – I have pondered this. Also high concentrations in eyes- glutamate is high in mania and icd I believe – haven’t looked into apathetic and glutamate but could be? I had apathetic for a year or so in ssri withdrawal .
Dr. David Healy says
B
I think the obvious thing to look at first is serotonin in the eye. The problem for all of us is that ophthalmologists and neuro-ophthalmologists right up to now figure that unless they can see a problem in the eye it must be somewhere else. It is made easier for them to point to the brain if we have been on SSRIs. We need to get them to get more curious about our eyes – and possible links between enduring problems there that also happen to our eroticism and endure and to our balance and endure leading to panic attacks.
It is going to take a lot to open the eyes of the ophthalmological community. Getting the tests that Jonathan Lochhead mentions in the comment above is one step everyone with Visual Snow can take.
David
Harriet Vogt says
Your paper stimulated quite a few patients with VS/VSS on X to put their hands up:
‘Is there any treatment for it? I have VSS with tinnitus and was on SSRIs for 3 decades. Been off them for 10 years now but this exact symptoms just won’t stop and it’s maddening’
@kassoekitson
‘I have PSSD and VSS (not very pronounced). Why are these studies being conducted 40 years after the drug was released?’
@DzhafD8899
And of course rx harm and particularly the PSSD community were fascinated by the notion you floated:
‘It is conceivable that in patients taking SRIs, the symptoms of VSS (Visual Snow Syndrome) reflect an analogous process to PSSD and PGAD occurring within the visual system.”
As a sad aside, Roy posted that he had now suffered with PSSD for 18 years, 11 of those being gaslit and even mocked. Tonight the dinosaurs are still in denial on X, asteroids on go slow.
‘We need good quality and credible research. I only treat older people, many have active sex lives (which, to my shame, surprised me when I started out), and I have never seen problems that haven’t resolved when the patient was well enough for the antidepressant to be stopped’. @ProfrobHoward
‘Agree and the research is poor in quality in that it does not look at confounders – even the obvious ones. It is only looking at SSRIs as the cause. @dawson007 (Name is Bond – surely not).
I guess what you’re talking about are effectively tardive syndromes – and it sounds like you and your ophthalmology colleagues have a lot of the jigsaw pieces. Ditto for ototoxicity https://pmc.ncbi.nlm.nih.gov/articles/PMC3138949/#Bib1
.As you may recall, I asked an opthalmologist whose work and intellect I greatly respect about the effects of SSRIs on the vision system and he was pretty well in the dark.
‘I haven’t seen many patients over the past 25 years with significant side effects from SSRIs. I am not aware of SSRIs having any negative effects on corneal transplants, but that’s not my area really. Yes, they might reduce blink rate which can exacerbate dry eyes a bit but that can be managed by drops or other interventions to enable the cornea to be better lubricated. I am not aware of having seen anyone with raised IOP secondary to SSRIs alone, however, in truth I have not searched the evidence base about it’
That’s partialism for you. I plan on sending him your paper.
Richard says
David, thank you so much to you and your team for your persistence with this.
It gives those of us suffering a ray of hope.
It´s incredible that the journals treated your submission this way but this is inline with the attitudes that I have found from ophthalmologists as well sadly.
As ever, I´m interested to here of any possible new treatment options.
Dr. David Healy says
R
There will be a further VS post next week that will include a link to tests worth doing and possible treatments – and some other interesting angles on points in your comment
D
chris says
“with both visual snow syndrome and post-SSRI sexual dysfunction (PSSD). It would also be great to get reports from people who have persistent postural-perceptual dizziness (PPPD) after stopping a medication, or what you perceive as enduring or recurrent akathisia – these may be the same thing.”
Are you linking this with Carbonic Anhydrase being activated where it should not be activating. This enzyme is so incredibly important am thinking that any drug interfering with its function – what ever the isoform – is a dangerous matter.
Dr. David Healy says
A note from Sui Wong at Moorfields Eye Hospital
Hi there, many congratulations on your article publication, and it’s good to see this work. Thank you for sharing! All the best, Sui Wong
D
Hannaa Bobat says
It’s great to see such a positive response and some excellent points raised for further research.
When I shared our article with a fellow ophthalmologist, his immediate response was to send a video clip implying that VSS is not real. It was meant as a joke (and he even apologised later!) but it illustrates that we still have work to do to change commonly held perspectives.
Thinking about how patients can get doctors to take their symptoms seriously, it is helpful if they are able to accurately describe their problems. In my experience, many patients find visual disturbances difficult to articulate, which unfortunately takes up precious NHS appointment time and they risk being misdiagnosed or not properly investigated. So it important for a patient to have a clear idea of what they are experiencing – this can really help someone like me!
annie says
What a very bizarre comment, we have here.
It is not difficult to articulate Visual Snow. It is quite obvious to a patient who has Visual Snow that it is like snow in the visuals. If you visit many eye specialists, which I have done many times, as I have macular degeneration, I can articulate what is happening to my eyes. We are not daft, most of us say it as we see it.
Visual Snow is a calamitous condition to live with. If you don’t see it, your job is not done..
Dr. David Healy says
Annie
You may be missing the point. You don’t have VSS and I don’t either. A colleague who now has VS now wonders if his mother had VS as she often seemed to think it was raining when it wasn’t. Apparently thinking it’s raining when it’s not is a common thing for people to say.
D
Hannaa says
Hi Annie,
I agree, visual snow may indeed be obvious to the patient – but it’s not always easy to describe to someone else and thus it is not always obvious to the doctor!
There are many different eye conditions which cause overlapping visual symptoms, so a patient saying they see ‘snow in the visuals’ or they think it’s raining (when it’s not) could indicate a wide range of possible causes – some completely unrelated to VS. Yes it is up to the doctor to diagnose the problem but the more information they have from the patient, the easier this becomes and the more quickly they can get the best treatment.
annie says
Yes, it must be frustrating for you not to quite understand what your patients are saying. This is a universal problem, as we learnt to our cost with SSRI adverse effects. However, you are different as you want to understand what the patient is saying. I don’t doubt that you use probing questions to try to get to the bottom of it, unlike doctors not listening with SSRIs.
If a patient thinks it’s raining, when it’s not, I wonder how often an eye doctor thinks it is psychological. Like my mum who kept saying, can you hear that train, when she had tinnitus.
I hope with probing and deep questioning, you can at least eliminate some other eye conditions which you say overlap. In the SSRI world, doctors most times have no interest in listening or learning from patients. So good for you for sharing and for your published paper.
https://journals.sagepub.com/doi/10.1177/09246479251394585
With thanks for the eye-opening