Drug-Induced Glaucoma Treatment & Management

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

Medical Care

  • Open angle
    • If the patient's underlying medical condition can tolerate discontinuation of corticosteroids, then cessation of the medication will usually result in normalization of IOP.
    • In the case of topical corticosteroid drops, using a lower potency steroid medication, such as the phosphate forms of prednisolone and dexamethasone, rimexolone, loteprednol etabonate, fluorometholone, or medrysone, should be considered. These lower potency drugs have a lesser chance of raising IOP, but they are usually not as effective as an anti-inflammatory drug. Topical nonsteroidal anti-inflammatory medications (eg, diclofenac, ketorolac) are other alternatives that have no potential to elevate IOP, but they may not have enough anti-inflammatory activity to treat the patient's underlying condition.
    • In the occasional cases in which the patient's IOP does not normalize upon cessation of the steroid or in those patients who must continue on corticosteroid medications, use standard antiglaucoma medications, as described in Glaucoma, Primary Open Angle.
  • Closed angle
    • If the etiology is because of sulfa containing medications, the increase in IOP generally will resolve upon stopping the medication. However, severe cases of sulfonamide-induced angle closure (ie, IOP >45 mm Hg) may not respond to simply discontinuing the offending medication. These cases may respond to intravenous Solu-Medrol and mannitol.
    • For other etiologies, treat the same as primary acute angle-closure glaucoma.
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Surgical Care

  • Open angle
    • When medical therapy is ineffective at lowering the IOP to target pressure or the patient is intolerant of medical therapy, then surgical therapy is indicated.
    • In patients with an open angle and the absence of ocular inflammation, argon laser trabeculoplasty can be attempted to lower the IOP.
    • In patients whom both medical and laser therapy have failed to lower the IOP adequately, surgical therapy is warranted. Usually, trabeculectomy (guarded filtration procedure), with or without intraoperative antimetabolites, is the primary procedure. In cases of eyes with active neovascularization or inflammation, a glaucoma drainage implant may be used as the primary procedure.
  • Closed angle: Treat the same as primary acute angle-closure glaucoma.
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Consultations

If not able to control IOP, refer the patient to a glaucoma specialist.

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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

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  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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