Steroids and Glaucoma
Chat Highlights
August 27, 2003

Norma Devine, Editor

On Wednesday, August 27,2003, Dr. Elliot Werner, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Steroids and Glaucoma."

Moderator:  Dr. Werner, we have a lot of questions about the use of steroids.  First, what are they?  

Dr. Elliot Werner:  Steroids belong to a group of chemicals that have a common basic structure.  They are naturally occurring hormones that have a number of important functions in the body. Estrogen, for example, is a steroid.  Steroids are used in ophthalmology mainly for their powerful anti-inflammatory effects. 

P:  What is a steroid responder?  

Dr. Elliot Werner:  Steroid responders are people whose intraocular pressure (IOP) goes up very high when they use steroids.  That is a side effect of steroids. The basis of steroid responsiveness appears to be genetic. 

P:  Why keep a steroid responder on a steroid and use another medication to lower the IOP?

Dr. Elliot Werner:  Sometimes the steroids are necessary to control some worse disease, such as uveitis or asthma, and cannot be safely stopped.  Then you have to try to treat the IOP as best you can

P:  If I am a steroid responder, how long might I be on steroids again before problems would arise?

Dr. Elliot Werner:  The first time you are treated with steroids, it generally takes between four and six weeks to get the full response.  If you have been exposed to steroids in the past, the response can occur in a matter of days, the second or third time around.

P:  Is Gentak (gentamicin sulphate ophthalmology solution) a steroid?

Dr. Elliot Werner:  No.  Gentamicin is an antibiotic, not a steroid.

P:  I have been diagnosed with Chandlers syndrome in my left eye and had a tube shunt placement in March.  My doctor has me on prednisolone, one drop daily.  He says I will always have to use the steroid eye drop  because of Chandlers and the edema.  Do I have to be concerned about the long-term side effect of elevated eye pressure?

Dr. Elliot Werner:  Generally, a filtering procedure or a tube shunt will eliminate the steroid response by getting rid of the aqueous from the eye and keeping the IOP low.  If the operation fails at some time in the future, the steroid response might return.  But so long as the tube shunt is working, you probably don't have to worry.

P:  Do steroids always increase intraocular pressure?

Dr. Elliot Werner:  No.  Only about 8% of the general population seem to be steroid responders. The problem is that most patients with glaucoma, especially open-angle glaucoma, tend to be steroid responders.

P:  I was on Premarin for several years and am now on Estradiol.  Are they both steroids?

Dr. Elliot Werner:  They are steroids, but the sex hormones, such as estrogen and androgen, do not have any effect on IOP.

P:  What about using Vexol (rimexolone) or Lotemax (loteprednole) as a second choice?  Do they work effectively?  Pred forte gives me severe headaches.  

Dr. Elliot Werner:  Vexol and Lotemax are steroids and can increase the IOP, but they do not penetrate the eye as well as prednisolone (Pred Forte) and have much less tendency to raise IOP.  They can be quite useful in glaucoma patients who do not need a real strong steroid to control inflammation.

P:  What effect do steroids have on old blebs? 

Dr. Elliot Werner:  Probably none on an old, well-established bleb. Steroids can reduce the eye's immune response and increase the risk of infection.

P:  Is FML (fluorometholone) a weak steroid?  

Dr. Elliot Werner:  FML is a weak steroid that does not penetrate the eye at all, so it has little effect on IOP, but also has little effect on intraocular inflammation.

P:  Can steroids be used to treat someone with hypotony (low eye pressure)?

Dr. Elliot Werner:  Some cases of hypotony are due to inflammation of the ciliary body.  In that circumstance, steroids can be useful to reduce inflammation.  If the hypotony is only due to excessive filtration through the bleb, steroids probably won't help much.

P:  Are Maxidex and Pred Forte about the same? 

Dr. Elliot Werner:  Maxidex (dexamethasone) is actually a stronger steroid than Pred Forte, so it is usually given in lower concentrations.  One advantage is that Maxidex is a solution.  Pred Forte is a suspension and has to be shaken well before putting the drop in the eye.

P:  Besides increased IOP, what other long-term side effects can steroids have on the eye?

Dr. Elliot Werner:  Steroids can cause cataracts, thinning of the cornea, and increase the risk of infection by blocking the normal immune response of the eye.

P:  Is there the same risk of increased (and damaging) intraocular pressure from steroid use for patients with normal-tension glaucoma (NTG), whose pressures may not get very high in the first place, as for those with open-angle glaucoma?  

Dr. Elliot Werner:  Many NTG patients also seem to be steroid responders and will develop high IOP when using steroids. It is important to realize that it is not just steroid eye drops that can cause problems.  Steroids given by mouth, inhalers for asthma, and even skin creams can deliver enough steroid to the bloodstream and the eye to raise the IOP in susceptible patients.

P:  Are certain forms of steroids -- topical, nasal, oral, and their variants -- riskier to the eye than others?

Dr. Elliot Werner:  It depends more on the chemistry of the compound than on the route of delivery.  Certain forms of steroid molecules are more likely to raise IOP than others.

P:  If steroid use increases IOP to damaging levels, will stopping the use of the steroid allow the IOP to return to normal levels and thus halt glaucomatous damage?  

Dr. Elliot Werner:  Most of the time, if the steroids are stopped, the IOP will return to normal, unless the patient also has an underlying glaucoma.  The glaucoma will continue with or without steroids.

P:  Is there a risk of raising IOP by using intranasal steroids (e.g., Flonase for allergic rhinitis)?

Dr. Elliot Werner:  The risk from Flonase (fluticasone) is relatively low, but there is some risk.  Glaucoma patients using nasal steroids need to be monitored.

P:  A doctor once told me that the best way to combat my CME (cystoid macular edema) was a steroid injected into the eye, rather than topical or systemic use.  Why would that be?  I had severe uveitis. 

Dr. Elliot Werner:  That is true.  Injection of steroids into the vitreous has now become a standard treatment for certain forms of CME and uveitis.  It is done quite commonly and is often quite effective.

P:  Is a particular steroid drug used for a particular condition? Do you consider the health of the eye when prescribing a steroid?

Dr. Elliot Werner:  As with any other drug, you always consider the effectiveness and safety of the drug for the particular condition and the individual patient.  You also weigh the potential risks and benefits of any treatment.

P:  What is the mechanism or chemistry by which steroids can increase IOP?  What actually happens in the eye with a steroid effect?  And, by understanding this effect, do you think it's possible to learn more about the causes (and cures) for glaucoma?

Dr. Elliot Werner:  The mechanism of the steroid response is not well understood.  Steroids appear to induce changes in the chemical makeup of the support structures in the trabecular meshwork (the extracellular matrix) and inhibit the outflow of the aqueous.  That's an active area of research, but the details of the mechanism still need to be worked out.

P:  Since cataracts are a possible side effect of prednisolone, would it be advisable to take lutein for prevention?  

Dr. Elliot Werner:  My understanding is that lutein has been shown to be effective in preventing macular degeneration, not cataracts.

P:  Can using hydrocortisone cream be dangerous for people with glaucoma?

Dr. Elliot Werner:  Yes.  If used in large enough dosages over a large enough area of skin, steroid skin creams can increase IOP.  Patients with glaucoma using steroid skin creams need to be monitored carefully.

P:  In general, how long are steroids used after a trabeculectomy or valve surgery?  

Dr. Elliot Werner:  Practices vary from doctor to doctor.  Assuming that all goes well, most of us use steroids for six to eight weeks after glaucoma surgery.  

P:  Can't these steriods in the eyes cause some strange systemic reactions as well?  

Dr. Elliot Werner:  Some patients do complain of a variety of symptoms while using steroid drops.  Steroid eye drops, however, do not deliver a large enough systemic dose to cause the usual kinds of side effects, such as weight gain, osteoporosis, loss of muscle mass, etc.  Unless a glaucoma patient has uveitis or recently had surgery, there is generally no need to use steroids.

P:  How long are steroids used after cataract surgery?

Dr. Elliot Werner:  About two to four weeks, depending on how the inflammation subsides.

P:  Can naturally occurring steroids in the body cause damage to the eyes?

Dr. Elliot Werner:  Only in certain disease states, such as Cushing's syndrome, where excessive natural steroids are produced.  The normally produced steroid hormones do not seem to harm the eyes.  But one theory of glaucoma is that it is an abnormal response to natural steroids produced in the body, due to an abnormal sensitivity of the eye to steroids.

P:  Are steroids a standard prescription after cataract surgery?

Dr. Elliot Werner:  Most surgeons use steroids for some time after cataract surgery.  There are some doctors, a minority, who use nonsteroidal anti-inflammatory drops, such as Acular or Voltaren, instead of steroids.

P:  If a glaucoma patient is on steroids after cataract surgery, how high is the risk and how often should the IOP be monitored?

Dr. Elliot Werner:  The risk is moderate, and I would see the patient at least weekly until the steroids are stopped.

P:  Why are allergy eye drops ("get-the-red-out" types) bad for glaucoma patients?

Dr. Elliot Werner:  Most older-type allergy drops contain vasoconstrictors.  They constrict the blood vessels and can cause decreased blood flow to the optic nerve and the other structures in the eye.  Glaucoma patients already have compromised blood flow; they don't need any additional problems.  The newer allergy drops, such as Patanol or Zaditor, are safer and do not constrict blood vessels.

P:  My mother will be having having cataract surgery and is a glaucoma suspect.  Should she be given steroids after her cataract surgery?

Dr. Elliot Werner:  Generally, steroids are necessary after cataract surgery to control inflammation and promote healing.  If the patient is carefully monitored and the steroids are stopped as soon as the inflammation subsides, usually the use of steroids does not entail much risk or danger.

P:  If cataract surgery is performed on a glaucoma patient by a cataract surgeon, should that surgeon or the patient's glaucoma specialist monitor the patient's IOP after the surgery?  

Dr. Elliot Werner:  The cataract surgeon should probably follow the patient in the immediate post-op period.

P:  After a combined cataract operation and a trabeculectomy on July 29, I needed the steroids for inflammation and still need six drops a day.  I am concerned about a small bloody spot near the bleb.  My next appointment with the surgeon isn't until September 18.  

Dr. Elliot Werner:  Some blood under the conjunctiva near the bleb is quite common after combined surgery.  If you're not having pain and if your vision is not getting worse day by day, you probably don't have to worry.

P:  I have an infected bleb in my left eye.  Is it standard procedure to use Cefazolin and Tobramycin, alternating every 30 minutes for 24 hours?

Dr. Elliot Werner:  Yes, that would be the standard treatment for an infected bleb.  It kind of ruins your night's sleep.

P:  Usually, how many days does that treatment last? 

Dr. Elliot Werner:  It varies, but usually not longer than three to five days.  

P:  I read an article this week about a man, blinded at the age of three, who has gained some sight through stem-cell surgery.  He’s happy with this gift of light, but he said something that I thought was really important.  He said that for him, life was very full even when he couldn't see at all.   

Dr. Elliot Werner:  What goes on inside our head is probably more important than what we are physically capable of. Look at Helen Keller's life. 

End of highlights for August 27, 2003.

On September 2, Dr. Wilson discussed "Lasers for Glaucoma" in the Chat room. Click here for highlights of that meeting.

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