How to manage open angle glaucoma in patients requiring steroid therapy?

Managing Open Angle Glaucoma in Patients Requiring Steroid Therapy

Patients with open angle glaucoma requiring steroid therapy need immediate discontinuation or minimization of steroids whenever medically feasible, with aggressive IOP monitoring and preemptive glaucoma treatment intensification, as corticosteroid use represents a major risk factor for glaucoma development and progression. 1

Risk Stratification Before Steroid Initiation

Identify high-risk patients before starting steroids:

• Personal or family history of primary open-angle glaucoma is the most significant risk factor for steroid responsiveness 2, 3, 4
• Approximately 5% of the general population are high steroid responders, developing IOP elevation >15 mmHg above baseline 5
• Baseline IOP and cup-to-disc ratio correlate with likelihood of requiring surgical intervention if steroid-induced glaucoma develops 6

Route and Formulation Selection

Choose the lowest-risk steroid preparation and route when steroids are unavoidable:

• Dexamethasone and betamethasone (both topical and systemic) are more potent in producing glaucoma than medrysone and prednisolone 7
• Mode of administration significantly affects risk of IOP elevation 2
• Topical steroid use accounts for 73.5% of steroid-induced glaucoma cases 6
• Intravitreal triamcinolone causes IOP elevation in 20-65% of patients, occurring as early as 1 day to as late as 12 weeks after injection 5
• Steroid implants require IOP-lowering therapy in approximately 75% of eyes within 3 years 5

Monitoring Protocol

Implement intensive IOP surveillance during steroid therapy:

• Baseline IOP must be documented before initiating any steroid therapy 3
• Monitor IOP closely during steroid use, with frequency based on route and duration 2, 4
• IOP elevation may occur from 1 day to 12 weeks after steroid exposure, requiring vigilant monitoring throughout this window 5
• Educate patients about symptoms of worsening glaucoma: eye pain, blurred vision, halos around lights 3

Management Algorithm When IOP Elevation Occurs

Step 1: Discontinue or Minimize Steroids

• Immediate discontinuation of steroids is the primary treatment 6, 8
• IOP usually returns to normal within 2-4 weeks after stopping steroids 5
• Consider steroid-sparing agents or lower-potency steroids if systemic therapy cannot be stopped 5, 4
• Removal of residual sub-Tenon or intravitreal steroids may hasten resolution of steroid response 5

Step 2: Medical Management

• 73.5% of steroid-induced glaucoma cases can be controlled with topical medications alone 6
• Initiate standard glaucoma medications while discontinuing steroids 6, 8
• At 6,12, and 18 months after steroid cessation, 64.7%, 97.1%, and 100% of patients respectively were off glaucoma treatment 6
• The condition is reversible without permanent damage when duration of steroid therapy is short 7

Step 3: Surgical Intervention

Surgery is required in specific high-risk scenarios:

• 26.5% of patients require surgery, specifically those with baseline IOP ≥49.67 mmHg 6
• Patients ≤20 years old with higher IOP and greater glaucomatous optic neuropathy are more likely to need surgery 6
• Vertical cup-to-disc ratio ≥0.87:1 predicts need for surgical intervention 6
• Only 1-5% of patients fail to respond to medical therapy after steroid discontinuation and require surgery 5

Surgical options include:

• Trabeculectomy 5
• Trabeculotomy 5
• Shunt surgery 5
• Cyclodestructive procedures 5
• Removal of residual steroid deposits 5

Long-Term Considerations

Permanent damage correlates with duration and severity:

• Baseline vertical cup-to-disc ratio correlates with duration of steroid use (P=0.014) and baseline IOP (P<0.0001) 6
• Damage produced by prolonged steroid-induced IOP elevation is irreversible, though the IOP elevation itself is reversible 7
• All patients were off glaucoma treatment at 18 months follow-up after steroid cessation in prospective studies 6

Critical Pitfalls to Avoid

• Never assume all steroids carry equal risk—dexamethasone and betamethasone are significantly more dangerous than alternatives 7
• Do not delay monitoring—IOP elevation can occur within 24 hours of steroid exposure 5
• Avoid continuing steroids when IOP is elevated—this leads to irreversible optic nerve damage 7
• Do not underestimate systemic steroid risk—both topical and systemic routes cause glaucoma 7, 4