Prednisone Use in Patients with Glaucoma
Prednisone can be prescribed to patients with glaucoma when medically necessary, but requires lower initial doses (12.5 mg rather than 25 mg daily), close intraocular pressure monitoring, and ophthalmology collaboration to prevent vision-threatening complications.
Key Principle: Glaucoma is a Relative Contraindication, Not an Absolute One
Systemic corticosteroids like prednisone pose significant risk for worsening glaucoma through IOP elevation, but the medication can still be used when the underlying condition requires it 1, 2, 3.
Risk Stratification
High-risk patients include:
- Those with primary open-angle glaucoma (46-92% are steroid responders vs 18-36% in general population) 4
- Age >40 years 4
- Family history of glaucoma 5
- Diabetes mellitus or high myopia 4
- Patients already classified as glaucoma suspects 5
Dosing Strategy for Glaucoma Patients
When prescribing prednisone for conditions like polymyalgia rheumatica:
- Use the lower end of the therapeutic range (12.5 mg daily rather than 25 mg) as initial dose 1
- The 2015 EULAR/ACR guidelines specifically state that in patients with relevant comorbidities including glaucoma, a lower initial dose is preferred 1
- Avoid initial doses >30 mg/day, which are strongly discouraged even in patients without glaucoma 1
Mandatory Monitoring Protocol
Baseline assessment:
- Document baseline IOP and optic nerve status before initiating therapy 6, 7
- Establish target IOP approximately 20% lower than baseline 6, 8
Ongoing surveillance:
- Regular ophthalmology follow-up with IOP monitoring throughout treatment 6, 7
- If corticosteroid use extends ≥10 days, routine IOP monitoring becomes essential 2
- Follow-up visits every 4-8 weeks during the first year of treatment 1
Mechanism and Timeline of IOP Elevation
Corticosteroids increase IOP through accumulation of extracellular matrix material in the trabecular meshwork, similar to the pathogenesis of primary open-angle glaucoma 4, 5. The degree of IOP elevation depends on:
- Specific corticosteroid preparation 4, 9
- Dose and frequency 4, 9
- Duration of therapy 4, 9
- Individual patient responsiveness 4, 9
Treatment Adjustments if IOP Rises
If IOP elevation occurs during prednisone therapy:
- Initiate or intensify topical IOP-lowering medications 9
- Consider accelerating the prednisone taper if clinically feasible 1
- Maintain close ophthalmology collaboration to adjust glaucoma therapy 7
Critical Pitfall to Avoid
Do not assume all corticosteroid formulations carry equal risk. While this question addresses systemic prednisone, be aware that topical ophthalmic corticosteroids (prednisolone acetate, difluprednate) carry even higher risk for IOP elevation, with difluprednate showing increased risk compared to prednisolone acetate 1% 1. Topical corticosteroid use at ≥2 drops/day is a strong risk factor for IOP elevation 1.
Special Consideration: Post-Surgical Context
Interestingly, in the specific context of trabeculectomy surgery for glaucoma, postoperative systemic prednisone may actually improve surgical outcomes by reducing scarring, though this represents a unique exception to general principles 10.