Steroid-Induced Glaucoma

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Disease Entity

Steroid-induced ocular hypertension and steroid-induced glaucoma are elevated intraocular pressure (IOP), and glaucomatous optic neuropathy, respectively, which develop in the setting of corticosteroid use. This association was first appreciated in the 1950s, when Drs. Gordon and McLean described an increase in IOP caused by the systemic administration of adrenocorticotrophic hormone[1], and again several years later when Dr. Francois reported a case of elevated IOP after locally administered cortisone[2].

Since it was first reported, the definition of steroid-induced ocular hypertension has varied, but today is considered to be an IOP increase greater than 10 mm Hg from baseline. Patients who experience an IOP rise in the setting of glucocorticoid use are considered, “steroid responders”.

The timeline over which the IOP will rise depends on the potency of the glucocorticoid, the dose, as well as the route of administration. With topical steroid use, the IOP rise most commonly occurs between three to six weeks from initial use, and typically normalizes within two weeks of the cessation of therapy.[3] However, though three to six weeks is the most common time to see an IOP increase, patients can “respond” to steroids well after six weeks[4], and before three weeks, from initial use.[3] In one series, 2.8% of eyes that experienced an IOP elevation in the setting of steroid use converted to glaucoma. Interestingly, all of these patients had a family history of glaucoma.[5] The duration of steroid treatment may play a role in the IOP elevation as well, as indicated by one study in which the IOP was found to remain elevated in patients being treated with steroid for more than four years.[6]

Etiology

Steroid-induced glaucoma is a form of secondary open angle glaucoma in which aqueous outflow resistance is increased, leading to an elevation in IOP. This likely occurs through a number of mechanisms, including: induction of physical and mechanical changes in the microstructure of the trabecular meshwork (TM), inhibition of proteases and TM endothelial phagocytosis, and deposition of substance in the TM.[2]

One of the most marked changes to the microstructure of the TM induced by glucocorticoids involves the formation of cross-linked actin networks[7], and increased expression of myocilin[8], both of which have a significant effect on the cytoskeleton structure. Glucocorticoids have also been shown to increase expression of fibronectin,[9][10] and extracellular matrix deposition in the trabecular meshwork[11], which similarly increases aqueous outflow resistance.

Glucocorticoids bind to multiple receptors throughout the body, including glucocorticoid receptor alpha (GRalpha) and glucocorticoid receptor beta (GRbeta), which are ligand-activated transcription factors. GRbeta is thought to play a role in steroid resistance, and has been shown to block glucocorticoid responsiveness in TM cells, thereby suppressing phagocyctic activity.[12] This may lead to increased deposition of material such as debris and pigment in the juxtacanalicular meshwork of eyes with steroid induced glaucoma.[13][14]

It has also been postulated that actual physical obstruction by glucocorticoids themselves contributes to a reduction in aqueous outflow. This is based on the observation of white crystals in the angle in a patient who developed elevated IOP after intravitreal triamcinolone injection.[15]

Risk Factors

Anyone can be at risk for steroid-induced glaucoma, and the risk of glaucoma increases as the duration of therapy increases.

A higher than average risk for steroid glaucoma is found in patients with:

  1. Primary open-angle glaucoma (POAG)[16] [17]
  2. A first degree relative with POAG[18] [19]
  3. A history of previous steroid-induced IOP elevation
  4. Type 1 diabetes mellitus[20]
  5. Very young age (age less than six years old) or an older age[21]
  6. Connective tissue disease[22]
  7. Penetrating keratoplasty, especially in eyes with Fuchs endothelial dystrophy or keratoconus
  8. High myopia[23]

(Table 23.1 in Shields Textbook of Glaucoma, Sixth Ed. p. 346)

In this subset of patients, IOPs should be monitored regularly. Care should be taken to avoid corticosteroids If possible. If corticosteroids are indicated, the judicious use of an adequate potency and duration should be considered.

Types of Steroids

Topical Ocular Preparations

Intraocular pressure rise may occur with corticosteroid drops or ointment applied to the eye or with steroid preparations applied to the skin of the eyelids. In general, the potency of the steroid as well as the frequency and duration of use, appears to correlate with the risk of elevating the IOP.[24] For example, dexamethasone and prednisolone are more potent steroids and similarly increase the IOP more frequently than less potent steroids such as fluoromethalone, hydrocortisone, and rimexolone.[25]

Difluprednate (Durezol) is one of the most potent topical steroids, and one of the most likely to cause an increase in IOP. An estimated 3% of patients treated with difluprednate experience a significant increase in IOP. This estimate is based on a study of patients who had recently undergone ocular surgery and were treated with difluprednate two or four times daily in the post-operative period. Amongst the difluprednate group, 3% exhibited an increase in IOP 10 mm Hg or greater above their baseline to an IOP of 21 mm Hg or greater, compared to 1% in the placebo (vehicle only) group.[26] These findings were supported by another study of patients who underwent cataract surgery, which showed that 3.7% of those treated with difluprednate twice daily exhibited an IOP increase greater than 10 mm Hg or more from baseline to greater than 21 mm Hg, compared to 0% in the placebo group.[27]

Dexamethasone, prednisolone, and fluoromethalone are all early generation topical ocular corticosteroids. Because of their introduction prior to strict regulatory research requirements, placebo-controlled clinical trials are lacking.[28] The broadest comparative data comes from a small study which investigated the effect of multiple early generation topical corticosteroids on the IOP in ten known steroid responders. These patients underwent sequential testing with a number of topical steroids, including dexamethasone 0.005%, hydrocortisone 0.5%, fluoromethalone 0.1%, prednisolone acetate 1%, and dexamethasone 0.1%. Hydrocortisone 0.5% elicited the smallest IOP rise (average 3.2 mm Hg), followed by fluoromethalone 0.1% (average 6.1 mm Hg), dexamethasone 0.005% (average 8.2 mm Hg), and prednisolone 1.0% (average 10 mm Hg). Patients treated with dexamethasone 0.1% exhibited the greatest rise in IOP (average 22 mm Hg).[24]

As newer topical steroids have been released, comparative studies against earlier generation preparations have provided greater insight into their efficacy and effect on IOP. In a study comparing the postoperative management of uneventful cataract surgery, the proportion of patients who displayed a significant increase in IOP (defined as a 6 mm Hg greater than preoperative IOP) was twice that in the difluprednate group compared to the prednisolone group (8% compared to 4.14%, respectively).[29] A study comparing the efficacy and safety of loteprednol with prednisolone acetate (each administered four times daily) found that the mean IOP and mean change in IOP was higher in patients treated with prednisolone, though this finding did not reach statistical significance.[30]

As displayed in the aforementioned studies, the potency of topical ophthalmic steroids tends to correlate with the severity of IOP rise. Ultimately, difluprednate is the most likely to elevate IOP, followed by dexamethasone, prednisolone, loteprednol, and fluoromethalone. However, the proportion of patients who will experience an IOP rise is not as well defined. As mentioned, it is likely strongly correlated with patient risk factors for developing glaucoma regardless of steroid use; however, comparisons and incidence estimates in studies are confounded by non-modifiable glaucoma risk factors within the patient population as well as varying definitions of categorical IOP elevation.

Periocular

This route of steroid delivery includes subconjunctival, sub-Tenon, and retrobulbar injections. The elevation in IOP noted cannot always be predicted by the patient’s response to topical steroid treatment;[31] however, the proportion of patients who experience an IOP response from periocular steroid is considerably greater than that of topical ophthalmic steroids. The IOP elevation after periocular steroids typically occurs after a few months, though can be seen within a week in early cases, and may return to baseline at the sixth to ninth month after injection.[32] In cases of IOP spikes after periocular steroid administration, it may be necessary to excise the depot of steroids in order to control the IOP. As a result, it can be useful to inject inferiorly as well as anteriorly when performing a subconjunctival or sub-Tenon’s injection.

Given the differing ocular pathology they are best used for, there are not many studies which offer direct comparison between periocular mechanisms of steroid delivery. Of the studies which compare routes of periocular steroid delivery, it appears that while all periocular steroids may increase IOP, the delivery route likely plays an important role in the timing to the peak effect, as well as how long this effect lasts. In one study on subconjunctival injection of repository corticosteroid, the mean peak in IOP occurred at 7.1 weeks, and lasted for a mean duration of 3 months.[33]

In a retrospective review primarily on the efficacy of retrobulbar versus sub-Tenons corticosteroid in treating pseudophakic cystoid macular edema (CME), the mean IOP peak was similar between the two groups (mean pretreatment IOP 14.1 mm Hg to peak IOP 17.7 mm Hg with sub-Tenon, mean pretreatment IOP 15.1 mm Hg to peak IOP 17.6 mm Hg with retrobulbar). However, while the peak IOP occurred at a median of 1 month after treatment in the sub-Tenon steroid group, it occurred at a median of 10 months after treatment in the retrobulbar group, though the authors presumed this was likely due to the sub-tenon steroid administration as three injections at biweekly intervals.

Several studies offer comparisons between intravitreal and periocular delivery of corticosteroids. A study examining the efficacy of intravitreal and retrobulbar triamcinolone in patients with macular edema associated with branch retinal vein occlusion found an IOP increase in both therapy groups. However, the incidence of an IOP rise 20 mm Hg or greater was significantly higher in the intravitreal group (33.3%), compared to the retrobulbar group (7.4%). Although no significant difference in mean IOP throughout the follow-up period was appreciated, patients were only followed to three months before being re-treated.[34] Another study investigating the IOP elevation after intravitreal or sub-Tenons injection of triamcinolone found a statistically significant mean IOP elevation above baseline at all follow-up periods, though likely became clinically insignificant beyond 6 months. However, the mean IOP of eyes receiving sub-Tenon injection increased significantly at all follow-ups (1, 2, 3, 6 months), whereas the mean IOP of eyes receiving intravitreal injection was only significantly increased at the 1 month time point.[32]

All periocular steroids carry a risk of increasing IOP, though to different degrees. There aren’t many head-to-head comparisons between subconjunctival, sub-Tenon's, and retrobulbar corticosteroid delivery to fully understand the risk comparison between the three. However, the proportion of those who receive periocular corticosteroids and experience an IOP elevation is likely greater than that with topical ophthalmic steroids, but less than that with intravitreal corticosteroids. In addition, the IOP elevation with periocular steroids is more likely to reach a peak months from the time of injection compared to intravitreal and topical steroids.

Intravitreal

The most common corticosteroids administered intravitreally include triamcinolone, fluocinolone, and dexamethasone. Dexamethasone, often used at 0.4-mg or 0.8-mg dosing, is the more potent steroid, with a shorter duration of action. Triamcinolone is often dosed at 4 mg and has a duration of action extending to three months.[35] Most ocular pathology requiring treatment with intravitreal corticosteroids requires multiple treatments to maintain therapeutic effect, raising the risk of adverse events, such as endophthalmitis, as well as patient discomfort with multiple injections. For this reason, sustained release corticosteroid implants have an important role in the treatment of many ocular microvascular and inflammatory pathologies. Ozurdex is the shortest acting and only biodegradable, sustained-release implant, which is inserted into the vitreous where it releases dexamethasone at a controlled rate for up to 6 months. Retisert and Iluvien are non-biodegradable implants that release fluocinolone at a controlled rate for 30 and 36 months, respectively. Retisert is inserted via the pars plana and sutured to the sclera, whereas Iluvien is inserted via the pars plana into the vitreous.[35]

The timing and incidence rate of IOP elevation that develops after intravitreal administration of corticosteroids varies depending on the molecule and the dose. In about half of patients that received intravitreal triamcinolone, IOP elevation developed between two to four weeks after the injection. In eyes that are pseudophakic or have undergone vitrectomy, the rise can happen more rapidly.[36] [37] [38] In a systemic review of patients who had been treated with triamcinolone 4 mg, the onset of IOP elevation (defined as IOP of or greater than 21 mm Hg, or IOP of or greater than 10 mm Hg from baseline) was 2-4 weeks in randomized controlled trials and 1-8 weeks in non-randomized controlled trials.[39]

As mentioned, the incidence rate of IOP elevation varies according to the implant formulation. In the MEAD study, a randomized clinical trial of varying doses of dexamethasone implants, one third of patients in each implant group had a clinically significant increase in IOP necessitating treatment. None of these patients required implant removal, though one patient in each implant group (0.3%) did require incisional glaucoma surgery. Notably, this study found that the patients requiring IOP-lowering medications remained the same from year to year due to a lack of additional IOP increase after the first year, suggesting that there was no cumulative effect on IOP from the dexamethasone implant.[40] In a randomized clinical trial investigating the Retisert implant, elevated IOP was observed in 67% of patients, 5.8% of whom required filtering glaucoma surgery to manage IOP.[41] These rates are higher than those found in a randomized clinical trial investigating the Iluvien implant. The patients in this trial were divided into treatment groups according to dosage and amongst patients who received the lower dose (correlates with 0.19 mg Iluvien implant), 37.1% exhibited an IOP-related adverse event, and 4.8% required incisional glaucoma surgery.[42]

As indicated above, the incidence of IOP elevation associated with intravitreal corticosteroids appears to be directly correlated with the molecule and dose administered. Between the two fluocinolone implants, Retisert, which is inserted pars plana and sutured to sclera may carry a greater risk of IOP elevation.

Dermatologic

Steroid-induced glaucoma may develop after application of steroid preparations applied to the skin of the eyelids. This elevation occurs most frequently with chronic use, such as in patients with atopic dermatitis, and in patients with a family history of glaucoma.[43]

Close IOP monitoring of these patients is essential and consideration of a non-steroidal topical medication, such as tacrolimus and pimecrolimus, should be considered as an alternative in patients with glaucoma. Elevation in IOP has also been noted with application of steroids on skin that was not periocular, either from ocular contamination or systemic absorption. [44] Patients should be advised to wash their hands after applying dermatologic steroids or to use gloves.

Systemic and Non-Ocular Targeted

Steroids by mouth (PO) or intravenously (IV) have been shown to elevate IOP, as have non-ocular targeted localized steroids such as intranasal, inhaled,  and intraarticular.[45] The elevation appears to be correlated to the patient’s IOP response to topical steroids.[46][47]

An increase in IOP and glaucomatous change is a well-known risk of systemic corticosteroids for immunosuppression in the renal transplant patient population.[48][49] In a more recent study on pediatric inflammatory bowel patients treated with oral prednisone, 17 of the 54 patients (31.5%) were characterized as “steroid responders” (defined as IOP of 20 mm Hg or greater or a change in IOP of 6 mm Hg or greater, or a difference of 6 mm Hg or greater between the two eyes). Notably in this group, when prednisone was reduced to 0-10 mg/day for 30 days or more, 7 patients showed a decrease in IOP of 6 mm Hg or greater.[50] Similar findings were uncovered in a large case-control study on elderly patients with new diagnoses of ocular hypertension or open angle glaucoma. This study found an adjusted odds ratio of having one of the aforementioned diagnosis, of 1.41 when comparing patients who used oral glucocorticoids with those who didn’t. Further, there was a dose-related increase in the adjusted odds ratio when categorized by 5-40 mg/day of hydrocortisone, 40-79 mg/day of hydrocortisone, and 80 mg/day or more of hydrocortisone.[51]

There is a relative paucity of large studies on the IOP effects of non-ocular targeted localized corticosteroids. In one cohort study based out of an orthopedic clinic, the IOP of patients receiving intraarticular knee injections of triamcinolone were compared to those receiving hyaluronic acid. This study showed a difference in the mean increase in IOP between the groups as well as a significant difference in the number of patients who developed an IOP increase > 7 mm Hg (29% in the triamcinolone group, 0% in the hyaluronic acid group)[52].

Several studies have explored the effect of intranasal steroids on IOP elevation.  One of the initial studies that raised a concern regarding IOP effects of intranasal corticosteroids was a case series of three patients with elevated IOP, thought to have developed after 3-5 months of beclomethasone intranasal spray.[45] More recent research has not produced similar findings, with multiple studies showing no significant change in IOP in all-comers, taking various preparations of intranasal corticosteroids.[53][54] However, in one study of patients already established with a glaucoma service, intranasal steroids were found to be associated with an increase in IOP, and a reduction in IOP upon removal.[55]

Multiple studies have shown that inhaled corticosteroids can increase the risk of IOP elevation, though as above, the evidence is strongest in patients with a personal or family history of glaucoma. One large cross-sectional study found that inhaled corticosteroids were associated with a rise in IOP and magnification of glaucoma in patients who had a first-degree family history of glaucoma.[56]

Systemic corticosteroids carry a widely appreciated risk of ocular hypertension. However, as noted in the studies mentioned, there is a strong association between the risk of steroid response and the numerous non-modifiable risk factors associated with the development of glaucoma, namely a positive family history of glaucoma or pre-existing ocular hypertension or glaucoma in the patient themselves.

Diagnosis

All patients receiving topical ocular steroids, periocular or intravitreal steroids need to be monitored regularly. Chronic ocular steroids should not be administered by non-ophthalmic physicians, unless patients are also being followed by an ophthalmologist. All patients using dermatologic steroids on the face should also have perioidic IOP measurements. Patients in the high risk groups mentioned above should use steroids judiciously and be monitored closely if the steroids are used long term.

Management

  • Discontinue steroids: In the acute form of IOP elevation from steroids, discontinuing steroids can cause the IOP to normalize in days. In the chronic form, elevation of IOP can last one to four weeks[3], though if steroid therapy has been maintained for more than 18 months, the IOP can stay elevated far longer after withdrawal of therapy.[57] In a small subset of patients, the IOP may remain chronically elevated despite discontinuation of steroids.
  • Removal of depot steroids: One can cause a decrease in IOP by excising depot steroids.[36][38][58] For intravitreal steroids, vitrectomy can also be used to reduce IOP, however, due to the need for ongoing steroid therapy to control underlying inflammation, many of these patients may require glaucoma medications or surgery to control IOP.[37]
  • Glaucoma treatment: Treatment of steroid-induced glaucoma is very similar to that for POAG, and includes the use of topical glaucoma medications, laser trabeculoplasty, filtering surgery, and glaucoma drainage implant surgery. Selective laser trabeculoplasty (SLT) has been proven to be effective in lowering IOP in patients with steroid-induced glaucoma by over 35% at one year[59], as well as preventing IOP spike in patients undergoing sub-tenon’s triamcinolone.[60]
  • Goniotomy is considered by some to be a particularly effective treatment in patients with steroid-induced glaucoma, with one small case series showing the achievement of surgical success in all patients who underwent goniotomy.[61] Similarly, canaloplasty has been proven to be a promising treatment for steroid-induced glaucoma, as indicated by a small cohort of patients who underwent this procedure, all of whom achieved complete success without serious complication.[62]

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