Glaucoma 360: Steroid induced glaucoma management

L. Jay Katz, MD, provides an overview of his presentation on steroid-induced glaucoma treatment and how the use of steroids and consistent monitoring can help patients suffering from Glaucoma at Glaucoma Research Foundation's annual Glaucoma Symposium with David Hutton of Ophthalmology Times®.

Editor's note - This transcript has been edited for clarity:

David Hutton:

Hi, I'm David Hutton of Ophthalmology Times. I'm joined today by Dr. L. Jay Katz, who presented "Steroid Induced Glaucoma Treatment" at this year's Glaucoma 360 event in San Francisco. Thank you so much for joining us today. Tell us a little bit about this presentation.

L. Jay Katz:

Thank you. Well, steroids have been a welcome addition to treating inflammatory diseases of the eye, both in the front and the back. So steroids have been an essential tool for years now. And in fact, it's expanded. Initially [it] was used as an oral form—topical injections around the eye. But now we're also injecting steroids within the eye itself, and using devices to give sustained release of steroid within the eye for the relief of inflammation, which affects vision and comfort for the eye.

But what's really important to keep in mind is that although it's extremely beneficial to have steroids used to combat inflammation in the eye, there's also the possibility of inducing pressure elevation, and the pressure elevation leading to glaucoma's damage of the eye. And just like chronic open angle glaucoma, the steroid-induced glaucoma is a process that is usually asymptomatic for patients, so they're not aware of anything happening early on.

There's a deposition material within the trabecular meshwork area, increasing the resistance to outflow fluid, building up the intraocular pressure gradually to a level that will damage the retinal ganglion cells comprising the optic nerve. So, what's critical is that the patient be aware and be brought in on regular checkups in order to monitor them during the course of steroids to make sure that there's not a pressure elevation, and that's critical. Unfortunately, patients don't get seen on a regular interval after a steroid is started. Many times it's because of the patient not being aware of the consequences that they can have a pressure elevation.

There are certain topical and intraocular steroids that have higher risks of pressure elevation, but nevertheless, even if it's a lower risk, they should be evaluated [at] regular intervals after the initiation of the steroid therapy.
The treatment of the pressure elevation would involve the use—as with primary open angle glaucoma—of topical medications. We have quite a few topical medications that are effective in lowering intraocular pressure. But if that doesn't work, laser trabeculoplasty, interestingly enough, works very well as it does with primary open angle glaucoma and lowering intraocular pressure. So that's a great tool to utilize in terms of lowering intraocular pressure in these individuals.

There's also been some interesting work now done in using glaucoma surgery. For a while we only had trabeculectomy and tube shunts primarily used to lower intraocular pressure, and those are quite effective in lowering pressure but there's also the risk element for patients. So fortunately, with the expansion of the different types of glaucoma surgeries, they're also the minimally invasive type of glaucoma surgeries, which include doing goniotomies, trabecular bypass, limbal stents that also have been used effectively in lowering intraocular pressures for these individuals. So we have a great range of tools to lower intraocular pressure for these folks.

And if you catch them early enough—which is critical—then we can prevent any visual loss. Some people have even taken upon themselves, the physicians, to recommend prophylactic treatment for really high risk individuals. In other words, these are folks that are about to undergo steroid therapy. Many times it's intraocular steroid therapy, where you really can't stop steroids, if you already place it inside the eye. With topical medications, we know that if we stop the medications, eventually the pressures in the majority of patients goes back down to a more acceptable level.

With the use of intraocular steroids, we really can't remove the steroid in an easy fashion. So you have to kind of, and many times you don't want to, because then you're going to have the problem with inflammation. So, in those situations, some folks have advocated, "Well, you know, hey, you have a high risk of your pressure going up, why don't we do prophylactic medication even though your pressure is okay, right now, or even laser trabeculoplasty, before we even start the steroids in anticipation of a pressure elevation." And some people have reported actually good results with that, as well. So that's kind of the discussion that we've gone through that I presented in discussing steroid induced glaucoma and the importance of constant monitoring. And really noting the pressure elevation at an early stage before there's any visual damage and the various types of treatment that we have including medical, laser and incisional surgery for these patients.