How to manage increased intraocular pressure (IOP) in patients taking prednisone?

Management of Increased Intraocular Pressure in Patients Taking Prednisone

Patients taking prednisone should be closely monitored for intraocular pressure (IOP) elevation, with topical steroids limited to short-term use (≤3 months) whenever possible to minimize the risk of steroid-induced glaucoma and cataracts.

Risk Factors for Steroid-Induced IOP Elevation

• Approximately 18-36% of the general population are corticosteroid responders, with this response increasing to 46-92% in patients with primary open-angle glaucoma (POAG) 1
• Children are at substantially higher risk of developing clinically important IOP elevation with topical steroid use (adjusted hazard ratio 7.85) 2
• Concurrent use of systemic corticosteroids with topical steroids significantly increases the risk of IOP elevation (adjusted hazard ratio 5.31) 2
• Higher frequency of topical steroid administration (≥2 drops/day) is a strong risk factor for IOP elevation 3
• Longer duration of therapy increases the risk of complications 3
• Patients over 40 years of age and those with certain systemic diseases (e.g., diabetes mellitus, high myopia) are more vulnerable to corticosteroid-induced glaucoma 1
• Relatives of patients with POAG are at increased risk 1

Monitoring Recommendations

• Regular monitoring for elevated IOP is essential when using prednisolone eye drops, especially when treatment extends beyond a few weeks 3
• For patients on topical steroids, periodic examinations are necessary to monitor ocular status and check for corticosteroid-related side effects such as elevated IOP 4
• IOP should be checked at regular intervals in patients using long-term topical corticosteroids 4
• Consider baseline IOP measurement before initiating steroid therapy to identify pre-existing elevated IOP 4
• Patients with uveitis on difluprednate developed clinically important IOP elevation at a mean of 7.4±4.8 weeks, suggesting more frequent monitoring during this timeframe 2

Prevention and Management Strategies

Prevention:

• Use the minimum effective dose and duration of steroid therapy 3
• Consider alternative steroid formulations with lower IOP risk:
  • Prednisolone acetate 1% is preferred over difluprednate due to lower risk of steroid-induced IOP elevation 4
  • Corticosteroids with poor ocular penetration (e.g., fluorometholone) or site-specific corticosteroids (e.g., loteprednol) may be less likely to result in elevated IOP 4
• For conditions requiring ongoing topical glucocorticoids beyond 3 months, consider adding systemic immunomodulatory therapy to allow tapering of topical steroids 3

Management of Steroid-Induced IOP Elevation:

• For mild transient elevations of IOP, topical IOP-lowering medications can be used while continuing steroid therapy if necessary 4
• For significant IOP elevation:
  1. Taper and discontinue steroid therapy if clinically feasible 5
  2. Add topical IOP-lowering medications (see algorithm below) 4
  3. Consider switching to a steroid with lower IOP risk 4
  4. In severe cases unresponsive to medical therapy, consider surgical intervention 4

Treatment Algorithm for Steroid-Induced IOP Elevation

1. Mild elevation (IOP 21-25 mmHg):

   • Continue monitoring closely
   • Consider reducing steroid frequency if clinically appropriate 3

2. Moderate elevation (IOP 26-35 mmHg):

   • Initiate topical IOP-lowering medication (prostaglandin analogs are first-line) 4
   • Reduce steroid frequency or switch to lower-potency steroid if possible 4
   • Re-evaluate within 1-2 weeks 4

3. Severe elevation (IOP >35 mmHg):

   • Discontinue steroid if clinically feasible 5
   • Initiate multiple topical IOP-lowering medications 4
   • Consider oral carbonic anhydrase inhibitors for rapid IOP reduction 4
   • Refer urgently to glaucoma specialist 4
   • Re-evaluate within days 4

Common Pitfalls and Caveats

• Continuing topical steroids beyond 3 months without considering alternative therapies increases risk of complications 3
• Using higher doses than necessary (≥4 drops daily) significantly increases the risk of complications 3
• Failing to monitor for IOP elevation during treatment 3
• Patients with concurrent systemic corticosteroids develop clinically important IOP elevation earlier (mean 5.7±3.4 weeks vs. 10.4±5.7 weeks) and require more vigilant monitoring 2
• IOP typically normalizes after discontinuation of steroid therapy, but some patients may require ongoing IOP management 5
• Pediatric patients with inflammatory conditions receiving systemic steroids have shown a 22.2% rate of IOP ≥20 mmHg, highlighting the need for careful monitoring in this population 6