Can You Use Flonase with Elevated Intraocular Pressure?
Yes, you can safely use Flonase (intranasal fluticasone) if you have elevated intraocular pressure or ocular hypertension. The evidence demonstrates that intranasal corticosteroids, including fluticasone, do not cause clinically significant increases in intraocular pressure when used at recommended doses.
Evidence Supporting Safety in Ocular Hypertension
The FDA label for fluticasone nasal spray acknowledges that rare instances of increased intraocular pressure and glaucoma have been reported, but these are exceptional cases, not the expected outcome. 1 This warning reflects post-marketing surveillance requirements rather than a common or predictable effect.
High-Quality Clinical Trial Data
A 2-year randomized, double-blind, placebo-controlled trial of fluticasone furoate nasal spray in 548 patients found no statistically significant difference in time to first occurrence of an intraocular pressure event compared to placebo (P = 0.34). 2 This represents the longest and highest-quality study directly addressing your question.
A 6-month prospective study of 100 patients using mometasone furoate and fluticasone furoate found no statistically significant elevation in intraocular pressure during the entire treatment period in normal healthy individuals. 3
A randomized controlled trial specifically examining patients with well-controlled open-angle glaucoma and ocular hypertension found no clinically significant increase in mean IOP after 6 weeks of twice-daily inhaled fluticasone propionate compared to placebo. 4 Importantly, no participants exceeded their individualized target IOP. 4
Mechanism Explaining the Safety Profile
Intranasal corticosteroids have negligible systemic bioavailability (<0.5–1%), resulting in virtually no systemic corticosteroid exposure. 5 This pharmacokinetic profile explains why intranasal steroids do not produce the IOP elevation seen with oral or periocular corticosteroids.
Important Distinctions and Caveats
Differentiate from High-Risk Corticosteroid Routes
The IOP risk associated with corticosteroids is route-dependent: periocular injections and oral corticosteroids carry significant risk, while intranasal administration at recommended doses does not. 5
Sympathomimetic decongestants (phenylephrine, pseudoephedrine) are contraindicated in patients at risk of increased intraocular pressure because they cause pupil dilation and acute angle-closure attacks. 6, 7 Intranasal corticosteroids work through an entirely different anti-inflammatory mechanism and do not cause mydriasis. 5
Monitoring Recommendations
Major allergy and rhinology guidelines do not recommend routine IOP monitoring for patients using intranasal corticosteroids at standard doses, even in those with pre-existing ocular hypertension. 5 However:
The FDA label advises that patients using fluticasone nasal spray over several months should be examined periodically for adverse effects on the nasal mucosa. 1
A 2-year safety study concluded that current data "neither support nor negate current recommendations for regular ophthalmic monitoring in patients treated with intranasal corticosteroids." 2 This reflects the absence of evidence for harm rather than proven risk.
Rare Exceptions Documented in Literature
One comparative study of 360 patients found that fluticasone propionate, mometasone furoate, and beclomethasone dipropionate caused variations in IOP, but all variations remained within normal limits over 1 year of use. 8
In the glaucoma/ocular hypertension trial, one patient in the steroid group had a >20% IOP elevation (from 9 to 11 mmHg), but this remained well below treatment thresholds. 4
Practical Clinical Algorithm
Initiate intranasal fluticasone at standard dosing (2 sprays per nostril once daily for adults) without delay for ocular hypertension alone. 5
Avoid oral decongestants and sympathomimetic agents (phenylephrine, pseudoephedrine), which genuinely increase IOP risk through vasoconstriction and mydriasis. 6, 7
Continue routine ophthalmologic follow-up as already established for your ocular hypertension (typically every 6–12 months), but do not add extra visits solely because of intranasal steroid use. 5
Use proper nasal spray technique: direct the spray away from the nasal septum using the contralateral hand to minimize local side effects like epistaxis. 5
If you develop acute eye symptoms (sudden pain, redness, halos around lights, blurred vision), seek immediate ophthalmologic evaluation—but recognize these would suggest acute angle-closure (unrelated to intranasal steroids) rather than gradual IOP elevation. 9
Bottom Line
The evidence strongly supports that intranasal fluticasone does not pose a clinically meaningful risk to patients with elevated intraocular pressure when used at recommended doses. The rare FDA-reported cases of IOP elevation likely reflect either excessive dosing, individual susceptibility, or coincidental findings rather than a predictable drug effect. Your ocular hypertension should not prevent you from using this highly effective first-line treatment for allergic rhinitis.