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Steroid-induced glaucoma: causes, symptoms, diagnosis, treatment

 
, medical expert
Last reviewed: 08.07.2025
 
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Secondary open-angle glaucoma can develop with almost any route of administration of glucocorticoid drugs.

The increase in intraocular pressure can be pronounced and long-lasting.

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Epidemiology of steroid-induced glaucoma

The incidence of steroid-induced glaucoma in the general population is unknown. Significant increases in intraocular pressure with topical glucocorticoids have been reported in 50% to 90% of patients with glaucoma and in 5% to 10% of patients with normal intraocular pressure. The incidence of such reactions to glucocorticoids varies with the type, dose, and route of administration. Increases in intraocular pressure have been reported with topical, nitro-ocular, periocular, inhalation, oral, intravenous, and transdermal administration, as well as with endogenous increases in glucocorticoid levels in Cushing's syndrome.

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Pathophysiology of steroid-induced glaucoma

In response to glucocorticoid administration, the amount of glycosaminoglycans in the trabecular meshwork increases, which prevents normal outflow of intraocular fluid and leads to an increase in intraocular pressure. Glucocorticoids also reduce the permeability of the trabecular meshwork membranes, phagocytic activity of cells, and cause the breakdown of extracellular and intercellular structural proteins, which leads to a further decrease in the permeability of the trabecular meshwork. It has been shown that in response to glucocorticoid administration, the myocillin/TIGR gene (trabecular meshwork steroid-induced response) is activated in the endothelial cells of the trabecular meshwork. The connection between the gene and glaucoma and steroid-induced increase in intraocular pressure has not yet been identified.

Symptoms of steroid-induced glaucoma

The main fact in the anamnesis is the use of glucocorticoids in any form. The use of glucocorticoids in the distant past with subsequent normalization of intraocular pressure can lead to the development of typical normal-tension glaucoma. The presence of asthma, skin diseases, allergies, autoimmune diseases and similar conditions in the anamnesis indicates the possible use of glucocorticoids. Sometimes patients note a change in the quality of vision associated with a pronounced narrowing of the visual fields.

Diagnosis of steroid-induced glaucoma

Biomicroscopy

Usually nothing is detected. Even in the case of very high intraocular pressure due to a chronic process, corneal edema does not occur.

Gonioscopy

Usually nothing is found.

Posterior pole

In the case of a significant and prolonged increase in intraocular pressure, changes in the optic nerve characteristic of glaucoma are detected.

Special studies

Withdrawal of glucocorticoids, if possible, results in a sustained reduction in intraocular pressure. The time required to reduce intraocular pressure varies and may be very long in cases of prolonged glucocorticoid use. If local glucocorticoid use cannot be withdrawn (e.g., if there is a risk of corneal transplant rejection), steroid damage to the second eye may manifest as an increase in intraocular pressure, confirming the diagnosis.

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Treatment of steroid-induced glaucoma

Withdrawal of glucocorticoids may result in complete recovery. When using topical drugs, switching to weaker glucocorticoids that increase intraocular pressure to a lesser extent (e.g., loteprednol, rimexolone, fluorometholone) may be useful. Patients with severe uveitis require special attention, as treatment may require glucocorticoids. In addition, uveitis may lead to the development of various forms of glaucoma or mask glaucoma with decreased secretion of intraocular fluid.

Treatment of steroid-induced glaucoma

The day after the operation

Intraocular pressure (mmHg)

Treatment regimen

Operation #1. Vitrectomy/membranectomy, subconjunctival administration of glucocorticoid depot

1

25

Prednisolone, scopolamine, erythromycin

6

45

Timolol, iopidin, acetazolamide added

16

20

Acetazolamide has been discontinued.

30

29

Dorzolamide added, prednisolone tapering started

48

19

Prednisolone withdrawal

72

27

Continue to prescribe timolol, apraclonidine, dorzolamide

118

44

Latanoprost added; glaucoma consultation scheduled

154

31

Purpose of removal of glucocorticoid depots

Operation #2. Removal of glucocorticoid depot

1

32

Timolol, dorzolamide added

4

28

The same thing continues

23

24

The same thing continues

38

14

Discontinuation of dorzolamide

Note: The patient subsequently discontinued timolol; since discontinuation of the drug, intraocular pressure has remained at 10-14 mmHg.

In general, topical antiglaucoma drugs of all types are effective in patients with steroid-induced intraocular pressure elevation. In general, laser trabeculoplasty is less effective in these patients than in patients with other types of glaucoma. The results of operations aimed at increasing filtration are the same as in primary open-angle glaucoma.

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