Eyeworld

SPRING 2025 | EYEWORLD | 103 G may cause IOP elevation, but their impact is typ- ically less than that of potent local treatments, he added. Patients with certain predisposing factors are at higher risk of developing steroid-induced glaucoma. Dr. Kahook said these include indi- viduals with primary open angle glaucoma, a family history of glaucoma, and high myopia, among other conditions. Pediatric patients are also susceptible, and care should be taken in this patient population to check IOP when using steroids chronically since they may not report the symptoms. Dr. Chen noted that steroids administered to the eye have the strongest association with steroid response. Among them, eye drops are the most common mode of administration associated with steroid response, largely related to how commonly they are used to treat diverse ophthalmic conditions. "The incidence of elevat- ed eye pressure is higher for intraocular steroid injections, which can have sustained release of corticosteroid up to several years. In general, steroid exposure near the eyes and head region are at higher risk of eliciting a steroid response; some easily overlooked causes include cortico- steroid nasal sprays, inhalers, or creams, which are used to treat allergy, nasal congestion, asth- ma, chronic obstructive pulmonary disease, or dermatologic conditions," she said, adding that many of these are available over the counter, so patients may not be aware of potential medica- tion-related risks. Oral and intravenous steroids are less likely to cause steroid response com- pared to topical steroids. Those patients who require prolonged or re- peated ocular steroid treatment are at increased risk of developing steroid-induced glaucoma. Some common ophthalmic scenarios include corneal transplantation, uveitis (inflammatory ocular disease), and macular edema (retinal swelling), according to Dr. Chen. She also noted that patients who use topical steroid creams on the head/face or over a large surface area of the body should be aware. "I recommend avoiding the eye area when apply- ing the medication and making sure to wash hands carefully to avoid unintentional ocular exposure." Treatment The way to treat, Dr. Noecker said, is to stop the steroid, then you can treat the patient with an NSAID or another short-term solution. Fortu- nately, most patients' pressures drift back down. But he said you never know how long it will take for it to come back down, and it depends on how vulnerable they are. Drops or SLT can be used to help these patients. You should con- tinue to see these patients after the discontinua- tion of the offending agent. Since steroids have different potencies, you could try using a lower potency, but some people will still respond to these options, so the best thing is to get them off the steroid. "I'll usually do SLT to hasten the process to get the pressure down," he said. What the steroids are doing is working at the level of the trabecular meshwork, and they're stopping the cells from doing normal activities. While Dr. Noecker noted that steroid-in- duced glaucoma issues usually pop up a couple weeks after surgery, the timeframe can vary. If you have a preexisting glaucoma patient, it might occur quicker. Often, the steroid is the straw that breaks the camel's back, he said. Sometimes, you test people who are labeled as ocular hypotensive or glaucoma suspect and you put them on steroids for cataract surgery, and they spike. It declares them as a glaucoma patient going forward. Dr. Kahook said that management of ste- roid-induced glaucoma begins with addressing the source of steroid exposure. "If clinically fea- sible, tapering or discontinuing the steroid is the first step," he said. "If the steroid is necessary for controlling an underlying condition, switch- ing to a less potent steroid, such as loteprednol, may help." Concurrently, he said that lowering IOP through glaucoma medications is essential. "First-line therapies include prostaglandin analogs, beta blockers, or carbonic anhydrase inhibitors. Laser trabeculoplasty may also be considered if medications are insufficient. In severe or refractory cases, surgical intervention, such as trabeculectomy or tube shunt implanta- tion, may be required." continued on page 104

• Cover