Eye Pressure Problem Induced By A Steroid Medication

Ophthalmologist Carolina Valdivia discusses how an eye pressure problem can be caused by the use of a steroid medication.

Dear Doctor Valdivia,

I have been suffering from symptoms of dry eyes for six years now. It was triggered by working on the computer for a magazine using my contact lenses. All these years, I have been using artificial tears that contain carboxymethylcellulose. I have noticed that other artificial tears do not work for me. A few months ago, my eyes became inflamed. I think some dust or dirt triggered redness and puffiness. I was treated successfully by a doctor in India. After a while, it recurred. I met another doctor who also treated it successfully. Unfortunately, my eyes became inflamed again when I came down to Kenya. Hence, I saw a doctor and she prescribed Maxitrol, which worked very well on my eyes and I was content. However, I developed ocular hypertension; my intraocular pressure shot up to 25 in my left eye and 22 in my right eye. I am clearly a steroid responder and I have been using steroid eye drops for the past two months. My doctor then prescribed DuoTrav and Acular for my eye pressure problem and inflammation. Unfortunately, when the first drop of DuoTrav was administered, my eyes became bright red, terribly inflamed and dry like never before. The doctor has not helped much since I informed her about this side effect. It has been a week and this side effect of DuoTrav is just not subsiding. What should I do?



Thank you for your question and for your interest in glaucoma-eye-info.com.

Let us first review your information. You have been suffering from symptoms of dry eyes for about six years that you attribute to working on a computer while wearing contact lenses. You have used artificial tears containing carboxymethylcellulose successfully during this time. You suffered three recent bouts of eye inflammation problems. All three incidences were treated successfully. However, the third time, your doctor prescribed a drug called Maxitrol, which caused ocular hypertension in both eyes. This drug was exchanged for DuoTrav to control your eye pressure problem and Acular to help with the inflammation. However, the DuoTrav also has caused an adverse reaction and your eyes are severely dry and inflamed.

The term ocular hypertension refers to a specific situation in which the pressure inside the eye, called intraocular pressure, is higher than normal without any apparent optic nerve damage or visual field loss. However, the general public tends to use ocular hypertension and elevated intraocular pressure interchangeably. Intraocular pressure is measured in millimeters of mercury (mmHg). I define normal eye pressure as ranging from 10-20 mm Hg. Ocular hypertension is an eye pressure consistently at or greater than 21 mm Hg.

You did not specify in your description if you still are using contact lenses. If yes, you will need to stop using them and switch to regular eye glasses. Contact lens wear is contraindicated in people with ocular surface problems and you appear to fall into this category. Conditions such as dry eye syndrome, blepharitis, and eye allergies can be aggravated by the use of contact lenses and can predispose your eyes to infection.

A person with blepharitis may have red eyes and eyelids, burning, and a sensation that there is a foreign body in the eye. Symptoms of dry eyes occur because our tears are composed of secretions from glands in the eyelid margin. Abnormalities in these secretions cause tears to evaporate more rapidly than usual.

An additional sign of blepharitis is the presence of debris in the tears at the eyelid margin.

Another common cause of symptoms of dry eyes is the presence of allergic conjunctivitis. It occurs in both eyes and has symptoms of redness, itching, foreign body sensation in the eye, and burning. Allergic conjunctivitis is caused by allergens, such as dust, pollen, and smoke.

If blepharitis and allergic conjunctivitis already have been ruled out as possibilities for your symptoms of dry eyes, then it would be appropriate to explore whether the cause is systemic. Autoimmune diseases can cause symptoms of dry eyes. Among these are rheumatoid arthritis, systemic lupus erythematosus, and sarcoidosis.

If you have not already done so, it is important that you discontinue use of the steroid medication. Although they represent a class of drugs that can significantly help relieve symptoms of dry eyes in the short term, they are not recommended for long-term use, specifically because they can cause ocular hypertension.

In many cases, a person suffering from ocular hypertension due to use of a steroid medication can have their eye pressure problem return to normal upon suspending its use. However, reductions do not occur in all patients. In some cases, prolonged use of a steroid medication and/or increased sensitivity in the patient to steroid-induced eye-pressure elevations can cause injuries to the trabecular meshwork (the structure that filters aqueous humor before it leaves the eye). When this happens, the patient is said to have drug-induced glaucoma.

Maxitrol contains dexamethasone. You mention that you used it for two months and then it apparently was discontinued. However, you did not mention in your question if you currently are using or have used another steroid medication (for any reason) in the past. If you used Maxitrol only for a period of two months and you have no other history of steroid medication use, there is a high probability that the eye pressure problem will be transitory. However, this must be monitored over time and confirmed by your ophthalmologist.

DuoTrav is a combination medication. This means that it contains two medicines that are designed to treat ocular hypertension: Travoprost and Timolol maleate. A reported side effect of DuoTrav is eye redness that at times can be severe. However, the redness usually subsides after 7-10 days of use. Another potential side effect is symptoms of dry eyes. This commonly is produced by the Timolol maleate component of DuoTrav.

When a patient visits my office and I determine that she or he has an eye pressure problem due to steroid use, I usually advise the patient to stop using the steroid medication immediately. If their eye pressure problem is not severe (between 20-25 mmHg), I monitor the patient carefully over the next few days. In most cases, the eye pressure problem resolves and drops back to a normal range within a period of one week or less. If the ocular hypertension remains, but stays within a range that is at or below 25 mmHg, I may opt to prescribe an antiglaucoma medication. On the other hand, if the eye pressure problem is serious, greater than 25 mmHg, then using an antiglaucoma medication is the first line defense. All of this also depends on the state of the patient's optic nerve, that is, whether or not your eye pressure problem has caused damage to the patient's optic nerve.

I recommend that you talk to your ophthalmologist and ask if you have drug-induced glaucoma. You also should inquire about the status of your optic nerve. If you have developed glaucoma, then this justifies the use of an antiglaucoma medication, such as DuoTrav. If the side effects that you are experiencing with DuoTrav do not clear up within 7-10 days, you should ask your ophthalmologist to explore other treatment alternatives. There are a number of glaucoma medications available from which to choose.

Carolina Valdivia, MD

REFERENCES:

Asbell P and Lemp M. Dry Eye Disease: The Clinician's Guide to Diagnosis and Treatment. New York: Thieme, 2006.

Johnson DH and Lutjen-Drecoll E. Glaucomatous Changes in the Trabecular Meshwork. In: Tombran-Tink J, Barnstable CJ, and Shields MB. Mechanisms of the Glaucomas: Disease Processes and Therapeutic Modalities. Totowa, New Jersey: Humana Press, 2008:99-116.

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