Eyeworld

102 | EYEWORLD | SPRING 2025 G UCOMA by Ellen Stodola Editorial Co-Director About the physicians Rebecca Chen, MD Assistant Professor Department of Ophthalmology & Vision Science University of California, Davis Sacramento, California Malik Y. Kahook, MD Professor and Vice Chair Department of Ophthalmology Slater Family Endowed Chair in Ophthalmology University of Colorado Anschutz Medical Campus Aurora, Colorado Robert Noecker, MD, MBA Ophthalmic Consultants of Connecticut Fairfield, Connecticut Identifying and handling steroid-induced glaucoma S teroid-induced glaucoma can present a number of issues, most notably in- creased IOP. Several physicians dis- cussed identifying when and why this occurs and how to react to improve the pressure. Malik Y. Kahook, MD, noted that the exact incidence of steroid-induced glaucoma depends on the patient population and the type of ste- roid used. "Reports suggest that up to one-third of the general population are at least moderate 'steroid responders,' showing a significant rise in IOP with steroid use, though only a small subset develops clinically significant glaucoma. The incidence increases in high-risk groups, such as individuals with preexisting glaucoma or a strong family history of the condition," he said. Rebecca Chen, MD, said that it is estimated that 5% of the population is considered suscep- tible to developing increased eye pressure with steroid exposure. "Elevated eye pressure does not always lead to steroid-induced glaucoma (defined as optic nerve damage) if it is diag- nosed and treated in time," she said. Robert Noecker, MD, added that steroid-in- duced glaucoma is a problem that he sees quite frequently. "It's something I see probably every other week," he said. "I think the most common setting is when patients are put on steroids for surgery, like for cataract surgery." Because cat- aract surgery is a common surgery, that's when it's most likely to pop up, and he also noted that since all of his patients have glaucoma, they're a higher-risk population. Signs and symptoms "It's one of those things you often have to look for," Dr. Noecker said. Some patients may be symptomatic, but others may not. They might have a headache, or vision might be getting blurry a week or so after cataract surgery. "That's why we have to check the pressure," he said; the patient might seem fine, but the pres- sure could be 40. One of the things that helps diagnose steroid glaucoma is the magnitude. "It's not like their pressure went from 15 to 20; it's like it went from 15 to 45. The common setting is a couple weeks of being on steroids," he said. Dr. Kahook said that steroid-induced glau- coma typically "presents with an insidious rise in IOP." He also noted that patients are often as- ymptomatic until the IOP is significantly elevat- ed or optic nerve damage occurs. In cases where symptoms arise, patients may report blurred vision, halos around lights, or eye discomfort. Ophthalmologists should monitor for progressive optic nerve cupping, visual field defects, and elevated IOP during follow-up, he said. Steroid-induced pressure elevation can manifest within days to weeks of initiating ste- roids, depending on the route of administration. Topical steroids usually have a quicker onset of IOP elevation (within 2–6 weeks) compared to systemic or inhaled forms, which may take longer. Intravitreal steroid injections, such as triamcinolone or dexamethasone implants, can cause a delayed but substantial rise in IOP. Dr. Chen also pointed out that elevated eye pressure is usually asymptomatic, especially if the increase occurred gradually. "Most patients do not experience any symptoms. In cases of rapid and extreme elevation in eye pressure, patients may experience a severe headache and eye pain in the affected eye, which can be accompanied by tearing, redness, and vision changes such as blurred vision or halos around lights," she said. Dr. Chen agreed that this issue usually occurs several weeks after steroid use. "Most studies suggest that a steroid response occurs after 3–6 weeks of steroid exposure," she said. "In some susceptible patients, especially in those with a known history of steroid response, the elevation can be seen much sooner, within days." Most likely offenders and risk factors Dr. Kahook noted that certain steroids are more strongly associated with elevated IOP. Potent topical agents, like prednisolone acetate 1% and dexamethasone, are higher risk compared to fluorometholone or loteprednol, which are less likely to elevate IOP due to their structural modifications. Intravitreal steroids, especially triamcinolone and dexamethasone implants, also carry a significant risk. Systemic steroids

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