Steroid Use and IOP
November 13, 2002
Norma Devine, Editor
On Wednesday, November 13, 2002, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed “Steroid Use and IOP.”
Moderator: Welcome, Dr. Rick. We have lots of newcomers tonight. The topic is “Steroid Use and Intraocular Pressure.”
P: When was it determined that steroids can cause elevated intraocular pressure (IOP) and glaucoma?
Dr. Rick Wilson: I think it was back in the Sixties (Bernie Becker at Washington University in St. Louis, Missouri.)
Moderator: Are we talking about all steroids or topical steroids?
Dr. Rick Wilson: Mostly topical. Systemic steroids act by a different mechanism, as far as we can tell, and the effect is much quicker than topical steroids.
P: What are the usual effects of steroid use on IOP?
Dr. Rick Wilson: A small percent of patients will get a large rise in IOP, about a third will get a modest rise in IOP, and the rest will not get much of a rise unless the steroids are taken for a prolonged period, for example, six months or more.
P: I have been on steroids since July, due to various procedures that I have had. Can that be affecting my IOP now? I recently had shunt surgery.
Dr. Rick Wilson: Yes. But the shunt surgery usually will overcome the effects of the steroid.
P: What is the connection between steroids and the increase in IOP? I was using prednisone for asthma and my IOP shot sky high.
Dr. Rick Wilson: While only 5% five percent of the general population is steroid responders, 95% of primary open-angle glaucoma patients are classified as steroid responders. If steroid use is prolonged, 50% or more of the population is steroid responders. Children may be especially susceptible. There’s an increased incidence of steroid responders in relatives with glaucoma, and persons with diabetes and high myopia.
P: How are steroids used in the treatment of glaucoma and for how long?
Dr. Rick Wilson: If steroids are taken orally, that seems to increase the amount of fluid the eye makes. Steroids are only used to decrease inflammation. Steroids have a basic role in fighting inflammation in inflammatory glaucoma. In most glaucoma cases, the only time steroids are used is after laser and other kinds of surgery.
P: Why do steroids cause elevated IOP?
Dr. Rick Wilson: No one knows for sure, but it is thought that steroids decrease the ability of the cells lining the drain in the eye to get rid of debris that is deposited in the drain. That leads to more blockage over time.
P: How long does it take for the use of steroids (drops) to increase IOP?
Dr. Rick Wilson: The rise in IOP takes, on average, three weeks to months. The decrease in IOP is also slow, taking weeks to resolve.
P: If IOP is elevated by steroid use, will it return to normal when steroid use is stopped? If so, will progression of any glaucomatous damaged caused by that increase in IOP also stop?
Dr. Rick Wilson: Usually. Response to steroids is considered a genetic marker for predisposition to open-angle glaucoma, so there are people on the on the verge of developing glaucoma for whom using steroids would push them into frank glaucoma.
P: Some eye infections are best treated with steroids. Doesn’t that lead to other problems?
Dr. Rick Wilson: It can. Chronic steroid use can cause cataracts, in addition to an increase in IOP in susceptible people.
P: How long would the use of steroids take to cause glaucoma?
Dr. Rick Wilson: That varies. In really susceptible people, it can be just two weeks. In others, it might take six months.
P: How long can a person use topical steroids to help with uveitis/inflammation? I am 37 years old and have a failed trabeculectomy.
Dr. Rick Wilson: Usually steroids would be used as long as there is inflammation.
P: Does a steroid injected to relieve pain in a heel or shoulder cause less of a problem with IOP?
Dr. Rick Wilson: Yes, less of a problem. And remember that 65% of the population doesn’t need to be very concerned about steroid use. A single shot, unless it was a large amount and a time-release type, would not pose much of a problem, as a general rule.
P: Does the body produce natural steroids, and could an increase in these trigger a rise in IOP?
Dr. Rick Wilson: Yes, the body does produce natural steroids, but these do not cause a rise in IOP at normal levels.
P: Since the steroid response seems to be genetic, and steroids seem to modulate gene transcription, how does that work?
Dr. Rick Wilson: The gene that controls the response to steroids with an increase in IOP must be intimately associated with the genes that cause glaucoma.
P: I am sure that after my surgery next Tuesday I will be using dexamethasone for a while. Would that increase IOP in an aniridic eye?
Dr. Rick Wilson: The surgery should result in enough outflow to overcome the effect of the steroid. An aniridic would not be expected to be especially steroid responsive, according to my understanding. Good luck to you.
P: Last fall, after a back injury, I was given prednisone. I had a horrible (general) reaction to the first tablet and had to be taken to the hospital. I was told never to take it again. Could the drug have harmed my eyes?
Dr. Rick Wilson: Not with one dose.
P: Couldn’t an eye drop like Ocuflox do just as a good job as a steroid drop for inflammation? Are there any other drugs that can be used instead of steroids to treat inflammation?
Dr. Rick Wilson: Ocuflox is an antibiotic and does nothing for inflammation. A steroid or a non-steroidal like Motrin or Voltaren is needed to decrease inflammation.
P: If steroids raise eye pressure, what about using steroids for people with low pressure?
Dr. Rick Wilson: We often try that. Usually, the effect of the steroids is overmatched by the reason for the low IOP, and the steroids don’t work.
P: I was told that steroids in nasal sprays do not enter the bloodstream or affect any part of the body except the nose and sinus areas.
Dr. Rick Wilson: Wrong. The mucosa of the nose is very vascular (contains lots of vessels) and absorbs most anything that comes in contact with it. Putting a medicine in contact with the nasal mucosa is almost the same as injecting it intravenously.
P: Does chronic steroid use, as by weight lifters, sometimes result in exophthalmia (bulging eyes)?
Dr. Rick Wilson: The steroids that the weight lifters and athletes use are anabolic steroids, totally different from the corticosteroids that suppress inflammation. The anabolic steroids have grave effects, especially for the liver and testicles or ovaries, when overused.
P: My IOP has been about 39 mm Hg for two months. I am currently using Lotemax, Alphagan, Lumigan, and Cosopt, and I have been using a steroid for about a year. The steroid has helped to control the uveitis, but my IOP is rising. My doctor said we need to decide, come December, about doing another trabeculectomy. The first trabeculectomy, with mitomycin C, that I had lasted only eight months. Yesterday, my doctor said he is considering a shunt. Does shunt surgery have more complications than a trabeculectomy?
Dr. Rick Wilson: I prefer shunt surgery to trabeculectomy for inflammatory glaucoma. The aqueous shunts seem to last much better in the face of inflammation. I would not leave your IOP at 39 mm Hg for very long. You are losing ground slowly at that IOP.
P: Would four steroid injections in the foot raise IOP?
Dr. Rick Wilson: Possibly, but the chances that they would are not that great.
Moderator: Does the angle in the eye make a difference in whether or not steroids would raise the pressure in the eye?
Dr. Rick Wilson: Not anything that is visible using the slit lamp or even light microscopy, to my knowledge.
P: Would steroids be used after a shunt? If so, which ones?
Dr. Rick Wilson: Usually prednisolone 1%.
P: I had hypotony after my trabeculectomy, and I was on prednisolone. Does the trabeculectomy slow down or prevent a rise in IOP when the patient is using the steroid?
Dr. Rick Wilson: The trab may let so much fluid out of the eye that a further blockage of the eye’s natural drain may have no effect on the IOP.
P: I had hypotony after my tube shunt surgery and I was on Pred Forte. What is the purpose of using steroids if they don’t help to reduce the risk of hypotony?
Dr. Rick Wilson: Steroids are usually used for 8 to 10 weeks after surgery. Steroids reduce inflammation to prevent too much scarring, which is usually a serious problem in young patients.