Is prednisolone (a corticosteroid) a suitable first-line treatment for a patient with glaucoma?

Prednisolone Drops Are Contraindicated as First-Line Treatment for Glaucoma

Prednisolone drops should never be used to treat glaucoma—they cause glaucoma and worsen existing disease. This is a fundamental contraindication clearly stated in the FDA drug label and supported by all major ophthalmology guidelines 1, 2.

Why Corticosteroids Cause Glaucoma

Corticosteroids, including prednisolone acetate ophthalmic drops, increase intraocular pressure (IOP) through trabecular meshwork dysfunction, the exact pathophysiology underlying primary open-angle glaucoma 2. The FDA label explicitly warns that "prolonged use of corticosteroids may increase intraocular pressure in susceptible individuals, resulting in glaucoma with damage to the optic nerve, defects in visual acuity and fields of vision" 1.

Risk Magnitude in Glaucoma Patients

• 46-92% of patients with primary open-angle glaucoma are corticosteroid responders, compared to only 18-36% of the general population 2
• Patients with glaucoma have 2.5-5 times higher risk of steroid-induced IOP elevation 2
• The FDA mandates that "steroids should be used with caution in the presence of glaucoma" and "intraocular pressure should be checked frequently" 1

Correct First-Line Treatment for Glaucoma

Prostaglandin analogs (latanoprost, travoprost, bimatoprost, tafluprost) are the recommended first-line therapy for glaucoma according to the American Academy of Ophthalmology 3, 4. These agents:

• Provide the greatest IOP reduction: bimatoprost reduces IOP by 5.61 mmHg, latanoprost by 4.85 mmHg, and travoprost by 4.83 mmHg at 3 months 4
• Require only once-daily dosing, improving adherence 3
• Are well-tolerated with minimal systemic side effects 5, 4

Alternative First-Line Options

If prostaglandin analogs are contraindicated:

• Beta-blockers (timolol, levobunolol) reduce IOP by 3.70-4.51 mmHg 4
• Alpha-2 agonists (brimonidine) reduce IOP by 3.59 mmHg 4
• Carbonic anhydrase inhibitors (dorzolamide, brinzolamide) reduce IOP by 2.42-2.49 mmHg 4

When Prednisolone Is Used in Glaucoma Patients (Limited Scenarios)

The only appropriate use of prednisolone drops in glaucoma patients is for treating inflammatory eye conditions (uveitis, post-surgical inflammation), not for treating the glaucoma itself 6. Even in these scenarios:

Strict Limitations Required

• Topical glucocorticoids should be used as short-term therapy ≤3 months 6
• Goal is to discontinue topical glucocorticoids due to risk of glaucoma and cataracts 6
• Doses of prednisolone acetate 1% greater than 1-2 drops/eye/day increase risk for ocular complications 6
• The Arthritis Foundation notes that topical corticosteroid use at ≥2 drops/day is a strong risk factor for IOP elevation 7

Mandatory Monitoring Protocol

When prednisolone must be used in a glaucoma patient for inflammatory disease:

• Document baseline IOP and optic nerve status before initiating therapy 7
• If used for 10 days or longer, IOP should be routinely monitored 1
• Follow-up visits every 4-8 weeks during treatment 7
• If IOP elevation occurs, initiate or intensify topical IOP-lowering medications and consider accelerating the prednisolone taper 7

Critical Clinical Pitfall

The most dangerous error is confusing anti-inflammatory treatment with glaucoma treatment. Prednisolone treats inflammation; it does not treat glaucoma and will actively worsen it. If a patient has both glaucoma and ocular inflammation requiring steroids, they need:

1. IOP-lowering medication (prostaglandin analog) for the glaucoma 3, 4
2. Prednisolone for the inflammation (time-limited, closely monitored) 6
3. Close ophthalmology follow-up to balance inflammatory control against IOP elevation 7