Drug-Induced Glaucoma Clinical Presentation

  • Author: Douglas J Rhee, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 15, 2012
 

History

Elicit the patient's current medications.

  • Symptoms
    • With steroid-induced glaucoma, the pressure elevation is gradual. Therefore, like primary open-angle glaucoma, very few symptoms exist.
    • Visual symptoms of drug-induced acute angle-closure glaucoma are the same as primary acute angle-closure glaucoma.
  • Past ocular history/past medical history
    • Elicit history of systemic medical disease, which could require chronic corticosteroid use (eg, uveitis, collagen vascular disease, asthma, dermatitis).
    • Patients with preexisting primary open-angle glaucoma, a family history of primary open-angle glaucoma, diabetes mellitus, high myopia, or connective tissue diseases are at greater risk to be steroid responders.
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Physical

Perform a complete ophthalmic examination.

  • Vision and refraction - Patients with hyperopia are at an increased risk for narrow angles.
  • Pupils - Test for the presence of an afferent pupillary defect if topical use has been unilateral or if the attack has only occurred in one eye.
  • External examination - Use a flashlight test to identify an anatomically narrow angle.
  • Slit lamp examination - Exclude stigmata of other causes of secondary glaucoma.
    • Cornea - Krukenberg spindle (eg, pigmentary glaucoma), keratic precipitates (eg, uveitic glaucoma, Fuchs heterochromic iridocyclitis)
    • Anterior chamber - Anterior chamber depth to indicate narrow angle
    • Iris - Heterochromia (ie, Fuchs heterochromic iridocyclitis), iris transillumination defects (eg, pseudoexfoliation, pigment dispersion, previous episodes of intermittent angle closure)
    • Lens - Pseudoexfoliation material (pseudoexfoliation glaucoma)
  • Gonioscopic evaluation - Examine angle anatomy to determine if the angle is at risk for occlusion with dilation.
  • Dilated examination - Inspect the optic nerve for glaucomatous optic nerve damage. See Glaucoma, Primary Open Angle for a description of glaucomatous patterns. Dilate after potentially occludable narrow angles or plateau iris has been excluded by gonioscopy.
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Causes

Drug-induced glaucoma can occur via two mechanisms, as follows: open-angle glaucoma is generally steroid induced, and closed-angle glaucoma is generally from pupillary dilation.

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Contributor Information and Disclosures
Author

Douglas J Rhee, MD  Assistant Professor, Department of Ophthalmology, Harvard Medical School; Consulting Staff, Massachusetts Eye and Ear Infirmary

Douglas J Rhee, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Glaucoma Society, American Medical Association, Association for Research in Vision and Ophthalmology, and Phi Beta Kappa

Disclosure: Alcon Grant/research funds Independent contractor; Allergan Grant/research funds Independent contractor; Santen Consulting fee Consulting; Alcon Consulting fee Consulting; Allergan Consulting fee Consulting

Coauthor(s)

Steven Gedde, MD  Program Director, Assistant Professor, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine

Steven Gedde, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew I Rabinowitz, MD  Consulting Staff, Department of Ophthalmology, Barnet Dulaney Perkins Eye Center

Andrew I Rabinowitz, MD is a member of the following medical societies: Aerospace Medical Association, American Academy of Ophthalmology, and American Medical Association

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Martin B Wax, MD  Clinical Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Ophthalmology Research and Development, Head, Ophthalmology Discovery Research, Alcon Labs, Inc

Martin B Wax, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Society for Neuroscience

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Rudkin AK, Gray TL, Awadalla M, Craig JE. Bilateral simultaneous acute angle closure glaucoma precipitated by non-prescription cold and flu medication. Emerg Med Australas. Oct 2010;22(5):477-9. [Medline].

  2. Razeghinejad MR, Pro MJ, Katz LJ. Non-steroidal drug-induced glaucoma. Eye (Lond). Aug 2011;25(8):971-80. [Medline]. [Full Text].

  3. Armaly MF. Effect of corticosteroids on intraocular pressure and fluid dynamics. I. The effect of dexamethasone in the normal eye. Arch Ophthalmol. 1963;70:482.

  4. Armaly MF. Effect of corticosteroids on intraocular pressure and fluid dynamics. II. The effect of dexamethasone in the glaucomatous eye. Arch Ophthalmol. 1963;70:492.

  5. Nguyen N, Mora JS, Gaffney MM, et al. A high prevalence of occludable angles in a Vietnamese population. Ophthalmology. Sep 1996;103(9):1426-31. [Medline].

  6. Ohji M, Kinoshita S, Ohmi E, et al. Marked intraocular pressure response to instillation of corticosteroids in children. Am J Ophthalmol. Oct 15 1991;112(4):450-4. [Medline].

  7. Panday VA, Rhee DJ. Review of sulfonamide-induced acute myopia and acute bilateral angle-closure glaucoma. Compr Ophthalmol Update. Sep-Oct 2007;8(5):271-6. [Medline].

  8. Polansky JR. Side effects of ophthalmic therapy with anti-inflammatory steroids. Curr Opin Ophthalmol. 1992;3:259-272.

  9. Rhee DJ, Peck RE, Belmont J, et al. Intraocular pressure alterations following intravitreal triamcinolone acetonide. Br J Ophthalmol. Aug 2006;90(8):999-1003. [Medline].

  10. Rhee DJ, Ramos-Esteban JC, Nipper KS. Rapid resolution of topiramate-induced angle-closure glaucoma with methylprednisolone and mannitol. Am J Ophthalmol. Jun 2006;141(6):1133-4. [Medline].

  11. Wolfs RC, Grobbee DE, Hofman A, et al. Risk of acute angle-closure glaucoma after diagnostic mydriasis in nonselected subjects: the Rotterdam Study. Invest Ophthalmol Vis Sci. Nov 1997;38(12):2683-7. [Medline].

 
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