Drug-Induced Glaucoma Treatment & Management

Updated: Oct 23, 2018
  • Author: Michael D Greenwood, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

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.

In addition, in laser peripheral iridotomy is typically counterproductive in patients with drug-induced glaucoma. Pupil dilation benefits this cohort of patients, as it stimulates posterior rotation of the ciliary body, which can break the angle closure.

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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. Historically, trabeculectomy (guarded filtration procedure), with or without intraoperative antimetabolites, was the primary procedure of choice. Recently, the rise of microinvasive glaucoma surgery (MIGS) has allowed for safer, more effective surgical options. 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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Prevention

Drugs that have the potential of inducing glaucoma should only be used if truly indicated.

If drugs must be used, IOP should be monitored closely.

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Further Outpatient Care

Open angle

It is recommended that all patients who use chronic corticosteroid medications in any capacity should have a full ophthalmologic evaluation.

Patients on topical corticosteroid therapy should receive follow-up care at regular intervals by an ophthalmologist to monitor their ocular condition and IOP. Steroid-induced IOP elevation typically occurs within 2-6 weeks of beginning steroid therapy.

Upon stopping corticosteroids, the IOP usually normalizes in a few weeks to months. For patients on medical therapy alone, the interval of follow-up care is determined by the extent of the IOP elevation and the degree of optic nerve and visual field damage.

Patients who have had surgical intervention should have follow-up care consistent with routine postoperative care for the appropriate procedure.

Closed angle

It is recommended that people older than the 40 years should have routine eye examinations to screen for various conditions. One of these conditions should be the presence of narrow anterior chamber angles.

Treat the same as primary acute angle-closure glaucoma.

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