Glaucoma
Spring 2025
by Ellen Stodola
Editorial Co-Director
Steroid-induced glaucoma can present a number of issues, most notably increased IOP. Several physicians discussed identifying when and why this occurs and how to react to improve the pressure.
Malik Y. Kahook, MD, noted that the exact incidence of steroid-induced glaucoma depends on the patient population and the type of steroid used. “Reports suggest that up to one-third of the general population are at least moderate ‘steroid responders,’ showing a significant rise in IOP with steroid use, though only a small subset develops clinically significant glaucoma. The incidence increases in high-risk groups, such as individuals with preexisting glaucoma or a strong family history of the condition,” he said.
Rebecca Chen, MD, said that it is estimated that 5% of the population is considered susceptible to developing increased eye pressure with steroid exposure. “Elevated eye pressure does not always lead to steroid-induced glaucoma (defined as optic nerve damage) if it is diagnosed and treated in time,” she said.
Robert Noecker, MD, added that steroid-induced glaucoma is a problem that he sees quite frequently. “It’s something I see probably every other week,” he said. “I think the most common setting is when patients are put on steroids for surgery, like for cataract surgery.” Because cataract surgery is a common surgery, that’s when it’s most likely to pop up, and he also noted that since all of his patients have glaucoma, they’re a higher-risk population.
Signs and symptoms
“It’s one of those things you often have to look for,” Dr. Noecker said. Some patients may be symptomatic, but others may not. They might have a headache, or vision might be getting blurry a week or so after cataract surgery. “That’s why we have to check the pressure,” he said; the patient might seem fine, but the pressure could be 40. One of the things that helps diagnose steroid glaucoma is the magnitude. “It’s not like their pressure went from 15 to 20; it’s like it went from 15 to 45. The common setting is a couple weeks of being on steroids,” he said.
Dr. Kahook said that steroid-induced glaucoma typically “presents with an insidious rise in IOP.” He also noted that patients are often asymptomatic until the IOP is significantly elevated or optic nerve damage occurs. In cases where symptoms arise, patients may report blurred vision, halos around lights, or eye discomfort.
Ophthalmologists should monitor for progressive optic nerve cupping, visual field defects, and elevated IOP during follow-up, he said. Steroid-induced pressure elevation can manifest within days to weeks of initiating steroids, depending on the route of administration. Topical steroids usually have a quicker onset of IOP elevation (within 2–6 weeks) compared to systemic or inhaled forms, which may take longer. Intravitreal steroid injections, such as triamcinolone or dexamethasone implants, can cause a delayed but substantial rise in IOP.
Dr. Chen also pointed out that elevated eye pressure is usually asymptomatic, especially if the increase occurred gradually. “Most patients do not experience any symptoms. In cases of rapid and extreme elevation in eye pressure, patients may experience a severe headache and eye pain in the affected eye, which can be accompanied by tearing, redness, and vision changes such as blurred vision or halos around lights,” she said.
Dr. Chen agreed that this issue usually occurs several weeks after steroid use. “Most studies suggest that a steroid response occurs after 3–6 weeks of steroid exposure,” she said. “In some susceptible patients, especially in those with a known history of steroid response, the elevation can be seen much sooner, within days.”
Most likely offenders and risk factors
Dr. Kahook noted that certain steroids are more strongly associated with elevated IOP. Potent topical agents, like prednisolone acetate 1% and dexamethasone, are higher risk compared to fluorometholone or loteprednol, which are less likely to elevate IOP due to their structural modifications. Intravitreal steroids, especially triamcinolone and dexamethasone implants, also carry a significant risk. Systemic steroids may cause IOP elevation, but their impact is typically 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 individuals 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 elevated 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 corticosteroid nasal sprays, inhalers, or creams, which are used to treat allergy, nasal congestion, asthma, 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 medication-related risks. Oral and intravenous steroids are less likely to cause steroid response compared to topical steroids.
Those patients who require prolonged or repeated 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 applying 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. Fortunately, 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 continue to see these patients after the discontinuation 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-induced 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 steroid-induced glaucoma begins with addressing the source of steroid exposure. “If clinically feasible, tapering or discontinuing the steroid is the first step,” he said. “If the steroid is necessary for controlling an underlying condition, switching 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 implantation, may be required.”
When treating these patients, Dr. Chen said the best approach varies depending on the individual situation. “I usually work with the patient and the provider who prescribed the steroids to determine if there are any alternatives to steroid therapy. It is ideal if the steroid can be discontinued or switched to steroid-sparing therapy. We also assess whether reduced drug dose, frequency, or potency is an option,” she said. “For many patients, steroids are a medically necessary treatment. In those cases, we focus on controlling IOP while the patient is on steroid therapy.” Dr. Chen said that a typical first-line approach is to start ocular hypotensive medications (usually eye drops) to lower the eye pressure. If that is insufficient, surgical procedures may be considered.
Reversibility
In most cases, IOP returns to normal within a few weeks after cessation of the steroid, Dr. Chen said. “However, in some cases, IOP remains elevated even after the medication is discontinued. Steroid exposure induces changes to the tissue that makes up the eye’s internal drainage system. As a result, there is a ‘bottleneck’ effect in the drainage outflow that leads to increased intraocular pressure.”
Steroid-induced IOP elevation is often reversible if detected early and treated promptly, Dr. Kahook said. Upon discontinuation or reduction of the steroid, IOP generally normalizes over several weeks, and further glaucomatous damage can be prevented. “However, if optic nerve damage or significant visual field loss has already occurred, those effects are irreversible. This underscores the importance of early detection and intervention.”
Additional thoughts
Dr. Noecker again stressed the importance of checking the eye pressure. “We get lazy when everything looks good after routine procedures, but there is value in checking the eye pressure,” he said.
Dr. Kahook also stressed that close monitoring of IOP is critical for any patient on steroids, particularly those in high-risk groups. “Baseline IOP measurement, followed by periodic monitoring, is essential for detecting early changes.” He added that educating patients about the potential risks of steroid use and the importance of adherence to follow-up appointments can significantly mitigate the risk of steroid-induced glaucoma.
About the physicians
Rebecca Chen, MD
Assistant Professor
Department of Ophthalmology & Vision Science
University of California, Davis
Sacramento, California
Malik Y. Kahook, MD
Professor and Vice Chair
Department of Ophthalmology
Slater Family Endowed Chair in Ophthalmology
University of Colorado Anschutz Medical Campus
Aurora, Colorado
Robert Noecker, MD, MBA
Ophthalmic Consultants of Connecticut
Fairfield, Connecticut
Relevant disclosures
Kahook: Alcon, FCI, New World Medical, SpyGlass Pharma
Contact
Chen: rebeccaichen@gmail.com
Kahook: malik.kahook@gmail.com
Noecker: noeckerrj@gmail.com
