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Steroids and Glaucoma: What's the Connection?

Many patients wonder about the relationship between steroids and glaucoma, and whether it is safe for people with glaucoma to use steroid medications.

Glaucoma may be divided into two groups: primary or secondary. Most types of glaucoma are primary and have no obvious cause.

However, there is an important sub-group of glaucoma types called the secondary glaucomas, where there is an identifiable cause for high eye pressure. Secondary types of glaucoma include traumatic, exfoliation, pigmentary, inflammatory, neovascular, and steroid-induced glaucoma.

Steroids were first used in the US in 1912. Steroid-induced glaucoma has been recognized for over 60 years after a report in 1950 of a rise in eye pressure after systemic adrenocorticotrophic hormone (ACTH).

Steroids are commonly used to treat a wide variety of medical conditions, including inflammatory, allergic, and immunologic diseases. This includes everything from nasal allergies to eczema, asthma, and rheumatoid arthritis. Preparations now include over-the-counter nasal sprays and skin creams. Prescription steroids include pills, inhalers, shampoo, joint injections, and ear drops. Outside the United States, steroid eye drops and pills may even be obtained over-the-counter.

Steroids cause changes in the aqueous fluid outflow system (trabecular meshwork, Schlemm’s canal, and the aqueous veins) resulting in increased eye pressure. This steroid response can occur in a few weeks, or in as little as a few days in highly sensitive people. If unrecognized, the steroid response can develop into steroid-induced glaucoma and cause permanent optic nerve damage.

There are many risk factors for developing steroid-induced glaucoma. It occurs in up to 8% of the general population but is much more common in patients with glaucoma and their blood relatives. In fact, 90% of patients with open-angle glaucoma develop a steroid response. Other risk factors include advanced glaucoma, family history of glaucoma (especially in a first-degree relative), African-Americans, previous steroid response, use of stronger steroids, diabetes, high myopia, connective tissue disease (e.g. rheumatoid arthritis), and inflammatory glaucoma (10 - 21% of patients).

If the steroids are discontinued in time, the eye pressure usually returns to previous levels. Unfortunately, patients who have repeated steroid exposure are at risk for irreversible steroid glaucoma. In fact, every week of steroid use averaged over a lifetime leads to a 4% increased risk of chronic steroid glaucoma.

If possible, people in high-risk groups should limit their exposure to steroids unless absolutely necessary. Fortunately, there are non-steroidal options for many conditions. High-risk patients considering steroid use should consult with their prescribing physician and ophthalmologist.

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Article by Terri Pickering, MD. Dr. Pickering completed her ophthalmology residency at the University of California San Francisco and a glaucoma fellowship at the USC-Doheny Eye Institute in Los Angeles after earning her degree from Harvard University Medical School. She is a clinical instructor at California Pacific Medical Center and a researcher with the Glaucoma Research and Education Group in San Francisco.

Last reviewed on June 13, 2019

This article appeared in the May 2019 issue of Gleams.

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