Dupilumab Use in Patients with Glaucoma
Dupilumab can be safely used in patients with glaucoma, as the drug's ocular adverse effects are limited to the ocular surface (conjunctiva, cornea, eyelids) and do not affect intraocular structures like the trabecular meshwork or optic nerve. 1
Key Safety Distinction
- Dupilumab-related ocular surface disorders (DROSD) exclusively affect the external eye structures including the conjunctiva, cornea, tear film, and eyelids—not the internal eye structures involved in glaucoma 1
- The cases reported to date are "almost exclusively constrained to the surface of the eye" with "no definitive evidence of a novel disease induced by dupilumab" affecting deeper ocular structures 1
- Glaucoma itself is not listed as a contraindication or significant concern in expert consensus guidelines on dupilumab use 1
Important Monitoring Considerations
However, if topical corticosteroid eyedrops are required to manage DROSD in your glaucoma patient, this creates a significant risk that requires careful ophthalmologic monitoring:
- Topical corticosteroids used to treat moderate-to-severe DROSD can increase intraocular pressure and worsen glaucoma 1
- The consensus recommendation is that topical corticosteroids should be limited to a maximum of 8 weeks, with corticosteroid-sparing agents (tacrolimus ointment or ciclosporin drops) started early to facilitate tapering 1
- Monitoring for corticosteroid eyedrop adverse events should include intraocular pressure measurements and retinal nerve fiber layer optical coherence tomography 1
Pre-Treatment Assessment and Planning
Before initiating dupilumab in a glaucoma patient, establish clear ophthalmology coordination:
- Patients with "significant current or chronic corneal or conjunctival eye disease" should have standard/routine ophthalmology referral prior to starting dupilumab 1
- While glaucoma itself doesn't affect the ocular surface, many glaucoma patients use topical medications that can predispose to medication-induced keratoconjunctivitis, which is a risk factor for DROSD 1
- Offer prophylactic preservative-free ocular lubricants to patients with any pre-existing ocular surface disease managed by ophthalmology 1, 2
Risk Stratification for DROSD Development
Your glaucoma patient's risk of developing DROSD depends on other factors:
- History of atopic eye disease (allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis) is the strongest risk factor for developing DROSD 1
- DROSD occurs in approximately 26% of patients in real-world data, with only 4.2% discontinuing dupilumab due to ocular complications 1, 2
- Most cases present as mild irritation and redness that settle with simple interventions like ocular lubricants 1
When to Urgently Refer During Treatment
Use the RAPID acronym to identify severe DROSD requiring urgent ophthalmology referral within 24 hours 1:
- Redness plus any of the following:
- Acuity loss or worsening
- Pain (ocular pain, moderate or severe of new onset)
- Intolerance of light (photophobia)
- Damaged cornea visible or opacity
Critical Pitfall to Avoid
The major concern is not dupilumab's direct effect on glaucoma, but rather the potential need for prolonged topical corticosteroids to manage DROSD, which can elevate intraocular pressure. 1 If corticosteroids are needed beyond 8 weeks, this should prompt discussion about switching to alternative systemic therapies like JAK inhibitors, which carry lower risk of ocular complications 1, 2
Indications for Considering Alternative Therapy
Dupilumab withdrawal or switching should be discussed if: 1
- Significant risk of serious ocular adverse effects from requirement for prolonged ocular topical corticosteroid therapy (>8 weeks) 1
- Significant risk that visual acuity may be reduced because DROSD inflammation is not responding to treatment 1
- Progressive conjunctival cicatrization despite treatment 1