USE OF MEDICATIONS WITH GLAUCOMA WARNINGS

There are many medications that carry warnings or contraindications regarding use in patients
with glaucoma. These warnings and contraindications are relevant regardless of whether or not
the patient is taking glaucoma medications; they are not drug-drug interactions.

These warnings can pose difficulties for clinicians, as potential adverse outcomes vary according
to the type of glaucoma (open- versus narrow-angle) and the type of laser treatment (iridotomy
versus trabeculoplasty). Iridotomy may protect against certain medication effects, but its
protective effect varies among patients, as well as over time, and requires ophthalmological
confirmation.

The most clinically relevant specific glaucoma interactions are discussed below by drug type.
Ophthalmologic consultation is suggested when prescription of these agents is being considered
in patients with glaucoma.

Glucocorticoids — Glucocorticoid preparations (ie, ocular, oral, inhaled, and periocular

dermatologic preparations) can raise intraocular pressure (IOP) in open-angle glaucoma patients.
For example, 90 percent of primary open-angle glaucoma patients have been reported to develop
an elevation in pressure after one month of topical ocular use [52]. Intranasal steroids (despite
carrying a warning about use in glaucoma) typically do not cause an increase in IOP [53].

In general, a two-week (or longer) course of glucocorticoids is required before an increase in IOP
is seen. The mechanism is not well established but is thought to be related to reduced outflow at
the trabecular meshwork. A glucocorticoid-induced increase in IOP is sometimes referred to as a
“steroid response.”

Typically, the pressure goes up when a threshold of dose and duration is reached, although this
threshold varies from patient to patient. Additionally, for an individual patient, the threshold
tends to get lower with additional courses of glucocorticoid treatment. Therefore, once a steroid
response is triggered, providers must be vigilant against further steroid responses at even lower
doses or duration of therapy. Patients known to have an increase in IOP with topical ocular
glucocorticoids are at increased risk of pressure rise with other preparations.

Dermatologic preparations can raise IOP if they are used on the lids, particularly with chronic
use such as in atopic dermatitis. These patients require close monitoring by an ophthalmologist,
and use of alternative calcineurin inhibitors should be considered. (See "Treatment of atopic
dermatitis (eczema)", section on 'Topical calcineurin inhibitors'.)

Elevation in IOP has also been reported with application of glucocorticoids on skin that was not
periocular, either from ocular contamination or systemic absorption, although this is rare [54].
Glaucoma patients should be advised to wash their hands after applying dermatologic steroids or
to use gloves.

Guidance — Guidance for consideration of ophthalmologic evaluation during glucocorticoid

treatment in patients with open-angle glaucoma is as follows:
●All patients with primary open-angle glaucoma can be safely treated with a short course (less
than two-weeks’ duration) of any glucocorticoid preparation without ophthalmologic evaluation.

●Patients prescribed a course of oral, inhaled, ocular, or topical periocular glucocorticoids of

longer than two weeks should be seen by their treating eye doctors within three to four weeks of
initiating such treatment. The same applies to any increase in glucocorticoid therapy for patients
being treated or monitored for glaucoma.

●It is not sufficient to have “a pressure check” by someone not familiar with the extent of
glaucoma, as the target pressure for that particular patient may be lower than what is the high end
of the normal range for IOP in patients with normal optic nerves and fields.

In addition, patients without a history of glaucoma but who are at increased risk because of
treatment with chronic oral glucocorticoids at any dose, pulmonary inhaler, or potent topical
glucocorticoid to the face (especially the eyelids) should have comprehensive eye evaluations to
detect steroid response at least annually.