Ubiquitous steroid use posing unwitting cause for glaucoma

All corticosteroids matter when it comes to the risk of an intraocular pressure (IOP) response, and that is an important point for ophthalmologists to remember because opportunities for corticosteroid exposure are growing.

“From the patient’s perspective and for many of our non-ophthalmology physician colleagues, there is a perception that only steroids used to treat the eye can affect the eye,” said Terri Pickering, MD, at the at the Glaucoma Symposium during the 2017 Glaucoma 360 meeting.

“Use of steroids by any route, however, can lead to permanently increased IOP and tip patients with pre-existing glaucoma into a state of significant visual loss,” said Dr. Pickering, clinical instructor, California Pacific Medical Center, San Francisco. “Therefore, ophthalmologists need to do a better job educating patients and our colleagues in the medical community that any corticosteroid must be used with caution and careful monitoring of IOP.”

Concern about adverse ocular effects of steroid treatment is magnified by the fact that there are many indications for their use across different specialties. Furthermore, prolonged use is common because most conditions treated with steroids are chronic diseases.

In addition, consumer access to products containing steroids is growing. Depending on the source, the steroid content may not be identified on the label. There is still concern with legitimate products because patients do not appreciate the risks.

“Patients are using these products without physician advice or monitoring,” Dr. Pickering pointed out. “Warnings about ocular adverse events in direct-to-consumer advertising for over-the-counter steroid products are inadequate. It is unlikely that patients are reading the package inserts to find this information.”

At-risk population

At-risk population

Nearly all patients with open-angle glaucoma may develop a steroid-induced IOP response if exposed long enough to a strong steroid. Other patients at risk include those who are glaucoma suspects, patients with a history of a steroid response, or family history of glaucoma, especially in a first-degree relative.

“It has been reported that the risk of a steroid response occurs with use of an ophthalmic corticosteroid drop for more than 8 weeks or a systemic corticosteroid for more than 4 years,” Dr. Pickering said. “However, the effect may occur sooner in patients who are more exquisitely sensitive and in anyone with the use of more potent steroids that are now available,”

Other risk factors for a steroid-induced IOP response include increased age, type I diabetes, high myopia, connective tissue disease, African-American ethnicity, and uveitic glaucoma.

Serious consequences

Dr. Pickering noted that in a study including 34 eyes of 34 patients with steroid-induced glaucoma, 9 patients (26.5%) required glaucoma surgery because their disease was medically uncontrolled. While a steroid-induced IOP response resolves with discontinuation of the steroid, irreversible steroid-induced glaucoma can occur.

“Irreversible steroid-induced glaucoma has been described in about 3% of patients who have repeated steroid exposure,” Dr. Pickering added. “Prolonged and repeated steroid exposure is becoming a more common situation because steroid use is so ubiquitous.”

She illustrated her point by presenting several case histories of patients with glaucoma using more than one steroid-containing product, including topical formulations for dermatologic indications, nasal inhalers, intra-articular injections, and oral tablets, who developed extensive visual field loss and required multiple surgeries.