Management of Steroid-Induced Ocular Hypertension Post-Eye Surgery
This patient has severe steroid-induced ocular hypertension (IOP 37 mmHg) requiring immediate discontinuation or aggressive tapering of topical steroids combined with urgent initiation of multiple IOP-lowering medications and close monitoring to prevent irreversible optic nerve damage. 1, 2
Immediate Actions (Within Hours)
Discontinue or rapidly taper the steroid eye drops if the underlying surgical indication permits, as this is the most direct intervention for steroid-induced IOP elevation. 1 An IOP of 37 mmHg represents severe elevation requiring urgent intervention. 2
Initiate aggressive aqueous suppression immediately with multiple topical agents: 2, 3
- Timolol 0.5% twice daily (first-line beta-blocker achieving 7-9 mmHg reduction) 3
- Topical carbonic anhydrase inhibitor (dorzolamide or brinzolamide for additional 15-20% IOP reduction) 2
- Brimonidine 0.2% (alpha-2 agonist providing 4-6 mmHg reduction) 3
- Consider oral acetazolamide for rapid IOP reduction in this emergency situation 2
Administer medications at least 5 minutes apart to prevent washout. 3, 4
Monitoring Protocol
Check IOP within 2-4 hours after initiating treatment, then every 2-4 hours until below 30 mmHg. 2 The target IOP is less than 21 mmHg to prevent optic nerve damage. 2
Perform comprehensive examination including: 5, 2
- Slit-lamp examination to assess for corneal edema (which can occur with elevated IOP) 5
- Gonioscopy once corneal clarity permits to rule out angle closure 2
- Optic nerve examination for acute ischemic damage or glaucomatous changes 2
Schedule follow-up at 1 day, 1 week, 2 weeks, then monthly for the first 3 months. 2
Steroid Management Strategy
If steroids cannot be discontinued immediately due to surgical indication: 5, 1
Switch to lower-potency steroid such as fluorometholone or loteprednol, which have poorer ocular penetration and lower IOP risk. 1
Reduce frequency to absolute minimum (ideally <2 drops/day), as ≥2 drops/day is a strong risk factor for IOP elevation. 5, 1
Avoid prednisolone acetate ≥4 drops daily, which significantly increases complication risk. 5
Risk Factors to Consider
This patient's steroid response may be influenced by: 6, 7
- Duration of steroid use (1 month is significant) 5, 1
- Underlying diabetes mellitus if present (odds ratio 32.78 for steroid response) 7
- Family history of glaucoma 8
- Pre-existing glaucoma or ocular hypertension 9
Surgical Intervention Threshold
Urgent glaucoma specialist referral is indicated if: 2
- IOP remains >40 mmHg despite maximum medical therapy for 2-4 hours
- Evidence of acute optic nerve ischemia develops
- Angle closure is confirmed on gonioscopy
Surgical options include laser trabeculoplasty, trabeculectomy, or tube shunt depending on angle status and disease severity. 5, 2
Common Pitfalls to Avoid
Do not continue topical steroids at current frequency beyond what is absolutely necessary for the surgical indication, as this will perpetuate the IOP elevation. 1
Do not use difluprednate as an alternative, as it has higher risk of steroid-induced IOP elevation and cataract formation compared to prednisolone acetate 1%. 5
Do not delay treatment waiting for "observation," as IOP of 37 mmHg can cause irreversible optic nerve damage. 2
Do not use prostaglandin analogs (latanoprost) more than once daily, as more frequent dosing may paradoxically elevate IOP. 4
Avoid nighttime dosing of beta-blockers, which has limited efficacy and may contribute to visual field progression via nocturnal blood pressure reduction. 5