Is it safe to give prednisone (corticosteroid) to a patient with a history of open angle glaucoma?

Prednisone Use in Open-Angle Glaucoma Patients

Prednisone can be given to patients with open-angle glaucoma when medically necessary, but requires aggressive IOP monitoring, baseline documentation, and often preemptive intensification of glaucoma therapy—systemic corticosteroids like prednisone pose lower risk than topical ophthalmic or intravitreal routes, but still carry significant risk of IOP elevation and glaucoma progression. 1, 2, 3

Risk Stratification and Decision Framework

Understanding the Risk Hierarchy

The risk of corticosteroid-induced IOP elevation varies dramatically by route of administration:

• Highest risk: Topical ophthalmic corticosteroids and intravitreal preparations (16-18% IOP elevation at one year for intravitreal formulations) 2
• Moderate risk: Systemic corticosteroids like oral prednisone 1, 4
• Key consideration: Patients with open-angle glaucoma have 46-92% steroid responsiveness compared to 18-36% in the general population 5

Patient-Specific Risk Factors

Before prescribing prednisone, assess these critical risk factors for steroid responsiveness:

• Personal or family history of primary open-angle glaucoma (the single most significant risk factor) 3, 4
• Age over 40 years 5
• Diabetes mellitus 5
• High myopia 5

Pre-Treatment Requirements

Mandatory Baseline Documentation

Before initiating prednisone, you must document baseline IOP, optic nerve status, and visual field testing. 2, 3 This establishes a reference point for detecting steroid-induced changes and is specifically recommended by the American Academy of Ophthalmology. 2

Patient Education

Educate patients about symptoms requiring immediate evaluation:

• Eye pain 3
• Blurred vision 3
• Halos around lights 3

The FDA label specifically warns that "intraocular pressure may become elevated in some individuals" and recommends IOP monitoring if steroid therapy continues beyond 6 weeks. 6

Monitoring Protocol During Treatment

IOP Surveillance Strategy

• Frequency: Monitor IOP closely during steroid use, with frequency based on route and duration 3
• Duration threshold: If steroid therapy continues beyond 6 weeks, IOP monitoring becomes mandatory 6
• Mechanism: Corticosteroids cause morphological and functional changes in the trabecular meshwork, similar to primary open-angle glaucoma pathogenesis 5

Common Pitfall to Avoid

The most dangerous scenario is undetected IOP elevation during aggressive corticosteroid treatment, which can cause gradual, insidious, and irreversible vision loss. 7 This is particularly problematic because patients may be asymptomatic until significant damage occurs.

Management Strategy When Prednisone Is Necessary

Concurrent Glaucoma Treatment Optimization

When prednisone cannot be avoided:

• Minimize steroid exposure: Use the smallest effective dose and shortest duration 2
• Preemptive intensification: Consider initiating or intensifying IOP-lowering medications concurrently with prednisone 2, 3
• Alternative considerations: If medically feasible, consider less potent corticosteroid preparations 2

When to Discontinue or Modify

Immediate discontinuation or minimization of steroids is required whenever medically feasible, particularly if IOP elevation is detected. 3 The American Academy of Ophthalmology notes that corticosteroid use represents secondary glaucoma rather than primary open-angle glaucoma, emphasizing the importance of addressing the underlying cause. 2

Contrasting Evidence on Surgical Context

One older study from 1991 showed that postoperative topical prednisolone after trabeculectomy actually improved surgical outcomes with lower IOP at 5 years (14.5 vs 19.3 mm Hg). 8 However, this represents a unique surgical context where controlled inflammation is critical for bleb function and should not be extrapolated to general systemic corticosteroid use in glaucoma patients.

Route-Specific Considerations

The FDA label warns that "use of corticosteroids may produce posterior subcapsular cataracts, glaucoma with possible damage to the optic nerves" through ophthalmic effects. 6 While this warning applies broadly to all corticosteroid routes, systemic prednisone carries substantially lower risk than topical ophthalmic preparations, which pose the highest risk for IOP elevation. 2

Clinical Bottom Line

Prednisone is not absolutely contraindicated in open-angle glaucoma, but requires a structured approach: baseline documentation, close IOP monitoring, patient education, and often preemptive glaucoma treatment intensification. The decision hinges on whether the systemic indication for prednisone outweighs the risk of glaucoma progression, with continuous reassessment of whether steroid therapy remains medically necessary. 1, 2, 3