Correspondence
Inhaled Steroid Use and Glaucoma
N Engl J Med 1993; 329:1822December 9, 1993
- Article
To the Editor:
Inhaled steroids are commonly used in the treatment of chronic asthma, partly because of their diminished systemic side effects as compared with systemic steroids1. Irrespective of the route of administration, however, steroid use has been associated with both glaucoma and cataract formation2. A substantial number of people have elevated intraocular pressure when treated with long-term topical or systemic glucocorticoids3. Although glaucoma is more common in certain populations (e.g., African Americans, Northern Europeans, and first-degree relatives of patients with glaucoma), it can also develop in people without risk factors3.
We have evaluated three patients in whom glaucoma developed apparently as a consequence of using inhaled steroids. The following case is representative.
A 57-year-old white woman reported diminished visual acuity. She had no history of ophthalmic conditions or risk factors for the development of glaucoma. A full ophthalmic examination 18 months earlier had shown no evidence of disease. Although she had a long history of asthma, she had taken no steroid preparations until six months before she reported diminished visual acuity, when she was started on beclomethasone dipropionate, three puffs three times a day.
The woman's best corrected acuity was 20/20 in the right eye and 20/50 in the left. Her applanation tensions were 28 mm Hg in the right eye and 42 mm Hg in the left (normal range, 12 to 21 mm Hg). Both optic nerves had a cup-to-disc ratio of 0.9. There was a full visual field on the right and substantial loss of visual field on the left, sufficient to compromise central acuity. Open-angle glaucoma was diagnosed. The patient underwent a trabeculectomy of the left eye and, in consultation with her pulmonologist, gradually stopped using inhaled steroids. Three months after surgery, without glaucoma therapy, her applanation tensions were 12 mm Hg in the right eye and 7 mm Hg in the left. A return to normal pressure in the unoperated right eye coincident with the tapering of inhaled steroids supports the view that the glaucoma was most likely secondary to the use of beclomethasone. This patient was fortunate -- not all steroid-induced glaucomas stabilize with cessation of the drug.
The risk of steroid-induced glaucoma with inhaled preparations is unknown. However, our experience with three patients suggests the need to be alert to the possibility, as well as the need for a prospective study to evaluate patients before and after they receive these medications.
3 ReferencesEvan Benjamin Dreyer, M.D., Ph.D.
Massachusetts Eye and Ear Infirmary, Boston, MA 021141
Barnes PJ . A new approach to the treatment of asthma. N Engl J Med 1989;321:1517-1527
Full Text | Web of Science | Medline2
Urban RC Jr ,Dreyer EB . Corticosteroid-induced glaucoma. Int Ophthalmol Clin 1993;33:135-139
CrossRef | Medline3
Schwartz B . Physiological effects of corticosteroids on the eye. Int Ophthalmol Clin 1966;6:753-797
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Bryan Ballantyne. 2009. Ophthalmic Toxicology. .
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Robert L Stamper, Marc F Lieberman, Michael V Drake. 2009. Secondary open angle glaucoma. , 266-293.
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Leonard Bielory. (2006) Ocular toxicity of systemic asthma and allergy treatments. Current Allergy and Asthma Reports 6:4, 299-305
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Michael A. Kaliner. (2006) Pharmacologic characteristics and adrenal suppression with newer inhaled corticosteroids: A comparison of ciclesonide and fluticasone propionate. Clinical Therapeutics 28:3, 319-331
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Christina M. Bui, Heidi Chen, Yu Shyr, Karen M. Joos. (2005) Discontinuing nasal steroids might lower intraocular pressure in glaucoma. Journal of Allergy and Clinical Immunology 116:5, 1042-1047
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Ian P. Herring, Erin S. Herring, Daniel L. Ward. (2004) Effect of orally administered hydrocortisone on intraocular pressure in nonglaucomatous dogs. Veterinary Ophthalmology 7:6, 381-384
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J. S. W. Li Voon Chong, J. Sen, Z. Johnson, G. Kyle, I. A. MacFarlane. (2001) Hydrocortisone replacement dosage influences intraocular pressure in patients with primary and secondary hypocortisolism. Clinical Endocrinology 54:2, 267-271
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Mei-Sheng Duh, Alexander M Walker, Bertil Lindmark, Alan M Laties. (2000) Association between intraocular pressure and budesonide inhalation therapy in asthmatic patients. Annals of Allergy, Asthma & Immunology 85:5, 356-361
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Joram S Seggev. (2000) Effect of inhaled corticosteroids on intraocular pressure. Annals of Allergy, Asthma & Immunology 85:5, 327-329
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Paul Mitchell, Robert G Cumming, David A Mackey. (1999) Inhaled corticosteroids, family history, and risk of glaucoma. Ophthalmology 106:12, 2301-2306
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K H Baratz, M G Hattenhauer. (1999) Indiscriminate use of corticosteroid-containing eyedrops.. Mayo Clinic Proceedings 74:4, 362-366
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William C. Stewart. (1997) Chronic open-angle glaucoma and lifestyle. Progress in Retinal and Eye Research 16:4, 567-590
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&NA;. (1993) Beclomethasone. Reactions Weekly &NA;:482, 6
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