41 EyeWorld Asia-Pacific | June 2025 these patients after the discontinuation of the offending agent. Since steroids have different potencies, you could try using a lower potency, but some people will still respond to these options, so the best thing is to get them off the steroid. “I’ll usually do SLT to hasten the process to get the pressure down,” he said. What the steroids are doing is working at the level of the trabecular meshwork, and they’re stopping the cells from doing normal activities. While steroid-induced glaucoma often appears within a couple of weeks post-op, timing may vary depending on preexisting risk factors. Often, the steroid is the straw that breaks the camel’s back, he said. Sometimes, you test people who are labeled as ocular hypotensive or glaucoma suspect and you put them on steroids for cataract surgery, and they spike. That response may solidify their glaucoma diagnosis moving forward. Dr. Kahook said that management of steroid-induced glaucoma begins with addressing the source of steroid exposure. “If clinically feasible, tapering or discontinuing the steroid is the first step,” he said. “If the steroid is necessary for controlling an underlying condition, switching to a less potent steroid, such as loteprednol, may help.” Concurrently, he said that lowering IOP through glaucoma medications is essential. “First-line therapies include prostaglandin analogs, beta blockers, or carbonic anhydrase inhibitors. Laser trabeculoplasty may also be considered if medications are insufficient. In more severe or unresponsive cases, surgery such as trabeculectomy or tube shunt placement may be required.” When treating these patients, Dr. Chen said the best approach varies depending on the individual situation. “I usually work with the patient and the provider who prescribed the steroids to determine if there are any alternatives to steroid therapy. It is ideal if the steroid can be discontinued or switched to steroid-sparing therapy. We also assess whether reduced drug dose, frequency, or potency is an option,” she said. “For many patients, steroids are a medically necessary treatment. In those cases, we focus on controlling IOP while the patient is on steroid therapy.” Dr. Chen said that a typical first-line approach is to start ocular hypotensive medications (usually eye drops) to lower the eye pressure. If inadequate, surgical options are considered. Reversibility In most cases, IOP returns to normal within a few weeks after cessation of the steroid, Dr. Chen said. “However, in some cases, IOP remains elevated even after the medication is discontinued. Steroid exposure induces changes to the tissue that makes up the eye’s internal drainage system. This results in a ‘bottleneck’ effect that obstructs outflow and raises pressure.” Steroid-induced IOP elevation is often reversible if detected early and treated promptly, Dr. Kahook said. Upon discontinuation or reduction of the steroid, IOP generally normalizes over several weeks, and further glaucomatous damage can be prevented. “However, if optic nerve damage or significant visual field loss has already occurred, those effects are irreversible. This underscores the importance of early intervention and ongoing surveillance.” Additional Thoughts Dr. Noecker again stressed the importance of checking the eye pressure. “We get lazy when everything looks good after routine procedures, but there is value in checking the eye pressure,” he said. Dr. Kahook also stressed that close monitoring of IOP is critical for any patient on steroids, particularly those in high-risk groups. “Baseline IOP measurement, followed by periodic monitoring, is essential for detecting early changes.” He added that educating patients about the potential risks of steroid use and the importance of adherence to follow-up appointments can significantly mitigate the risk of steroid-induced glaucoma. GLAUCOMA
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