Which nasal sprays can be safely used by patients with glaucoma?

Intranasal Corticosteroid Sprays Are Safe for Patients with Glaucoma

Intranasal corticosteroid sprays (INCS) can be safely used in patients with glaucoma, as they do not cause clinically significant increases in intraocular pressure or development of glaucoma. 1

Evidence Supporting Safety in Glaucoma

The most robust evidence comes from a 2019 systematic review and meta-analysis of 2,226 patients that found:

• The absolute increased incidence of elevated IOP in patients using INCS compared to placebo was only 0.8% (95% CI: 0% to 1.6%)
• Zero cases of glaucoma developed in either INCS or placebo groups at 12 months 1
• The relative risk of elevated IOP was 2.24 but this was not statistically significant (95% CI: 0.68 to 7.34)
• No significant risk of posterior subcapsular cataract formation (absolute increased incidence 0.02%) 1

Additional supporting studies demonstrate:

• A 2013 randomized controlled trial specifically in patients with ocular hypertension or controlled primary open-angle glaucoma found no IOP elevation after 6 weeks of beclomethasone nasal spray, with mean IOP change of only +0.50 mm Hg in the steroid group versus +0.70 mm Hg in placebo 2
• Long-term use (6 months) of newer generation INCS (mometasone furoate and fluticasone furoate) showed no statistically significant IOP alterations 3
• High-dose topical nasal steroids (budesonide irrigations) used for up to 22 months in chronic rhinosinusitis patients did not increase IOP 4

Clinical Recommendations

First-line treatment options for patients with glaucoma include:

• Intranasal corticosteroid sprays - Most effective for nasal congestion and other allergic rhinitis symptoms 5
• Intranasal antihistamines - Can be used alone or in combination with INCS if monotherapy inadequate 5
• Oral antihistamines - Safe alternative if nasal sprays not tolerated

Important Caveats

Avoid topical nasal decongestants (oxymetazoline) in glaucoma patients:

• While combination INCS + oxymetazoline is effective for severe congestion, limit use to less than 3 days due to rebound congestion risk 5
• The concern with decongestants relates to their sympathomimetic effects, not IOP elevation from the steroid component

Use lowest effective dose:

• Newer generation INCS (fluticasone furoate, mometasone furoate) have lower systemic bioavailability than older preparations 6, 3
• Regular follow-up visits allow monitoring, though routine IOP checks are not necessary based on current evidence 6

Practical Algorithm

For patients with glaucoma needing nasal symptom relief:

1. Start with INCS spray (fluticasone, mometasone, or budesonide) - safe and most effective
2. If inadequate response: Add intranasal antihistamine (not oral antihistamine, as combination shows no added benefit) 5
3. If nasal sprays not tolerated: Use oral antihistamine ± oral decongestant combination 5
4. Avoid: Prolonged use (>3 days) of topical decongestants

The key distinction is that systemic corticosteroids (oral/injectable) carry glaucoma risk, but topical intranasal formulations do not due to minimal systemic absorption 1, 6.