Steroid Induced Glaucoma: Dr Shibal Bhartiya, fellowship trained glaucoma specialist, explains. Steroids are powerful medicines. Doctors use them to treat inflammation, autoimmune disease, allergies, and dozens of other conditions. But steroids carry a risk that many patients, and even some prescribing doctors, overlook. They can silently raise the pressure inside your eye. And raised eye pressure, left unchecked, damages the optic nerve and causes glaucoma.
This condition is called steroid-induced glaucoma. It is one of the most preventable causes of serious vision loss in India.
What Are Steroids and Why Do Doctors Use Them?
Steroids, specifically corticosteroids, reduce inflammation in the body. Doctors prescribe them in many forms: eye drops, oral tablets, inhalers, nasal sprays, skin creams, and injections directly into or around the eye.
Common brand names include prednisolone, dexamethasone, betamethasone, triamcinolone, and budesonide. Many are available over the counter in India without a prescription. This is a serious problem.
People often self-medicate with steroid eye drops for redness or allergy, sometimes for months, without any eye pressure monitoring.
How Do Steroids Raise Eye Pressure?
Your eye constantly produces a fluid called aqueous humour. This fluid drains out through a mesh-like structure called the trabecular meshwork. Steroids interfere with this drainage. The fluid builds up. Pressure inside the eye rises.
This process is called a steroid response. It does not happen to everyone. But certain people are far more susceptible. Glaucoma patients, first-degree relatives of glaucoma patients, people with high myopia, and diabetics have a higher risk of becoming steroid responders.
In a steroid responder, eye pressure can rise significantly, sometimes within days of starting treatment. More often, the rise is gradual and goes unnoticed for weeks or months.
The danger is that raised eye pressure causes no pain. No redness. No blurring. You feel nothing until the optic nerve is already damaged.
Which Steroids Carry the Highest Risk?
Eye drops carry the greatest risk. They deliver steroids directly into the eye in concentrated form. Potent drops like prednisolone and dexamethasone raise eye pressure more than weaker formulations like fluorometholone or loteprednol. Duration matters too: the longer the use, the greater the risk.
Periocular injections, injections around the eye used in uveitis and retinal disease, release steroids slowly over weeks to months. Triamcinolone acetonide injections are a particularly common cause of prolonged eye pressure elevation. Once the depot is in place, it cannot be removed easily.
Oral steroids carry a lower but real risk, especially with prolonged use at high doses.
Inhaled steroids for asthma and COPD, and nasal sprays for allergic rhinitis, carry a small but measurable risk, particularly with long-term use.
Skin creams applied around the eyes can absorb through the eyelid skin and raise eye pressure. This is underappreciated and often missed.
Symptoms of Steroid-Induced Glaucoma
In most cases, there are no symptoms. This is what makes steroid-induced glaucoma dangerous.
By the time vision changes become noticeable, significant optic nerve damage has often already occurred. Peripheral vision goes first — and most people do not notice peripheral vision loss until it is severe.
In rare cases, when eye pressure rises very rapidly, patients may experience headache, eye ache, blurring, or haloes around lights. But this is the exception, not the rule.
The only way to detect steroid-induced glaucoma early is to check eye pressure regularly while on any steroid therapy, especially eye drops.
How Is Steroid-Induced Glaucoma Diagnosed?
Diagnosis requires a full glaucoma evaluation. This includes:
Tonometry measures eye pressure. Normal pressure is usually between 10 and 21 mmHg. Steroid responders may reach 30, 40, or even higher.
Gonioscopy examines the drainage angle to confirm the trabecular meshwork is open, as it is in steroid glaucoma, distinguishing it from angle-closure glaucoma.
OCT (Optical Coherence Tomography) scans the optic nerve and the nerve fibre layer to detect structural damage before vision loss is symptomatic.
Visual field testing maps the field of vision to detect functional loss.
Optic disc examination allows direct visualisation of the nerve head for signs of damage and cupping.
Steroid-induced glaucoma looks identical to primary open-angle glaucoma on examination. The distinguishing clue is the history — elevated pressure that developed after starting a steroid, and that improves when the steroid is stopped or changed.
Is Steroid-Induced Glaucoma Reversible?
The short answer: sometimes, if caught early enough.
In many patients, stopping or switching the steroid allows eye pressure to normalise within weeks. If the optic nerve has not been damaged, the condition is fully reversible.
But optic nerve damage is permanent. Glaucoma does not recover. If pressure has been high long enough to injure the nerve, even partially, that damage remains even after the steroid is stopped.
This is why early detection is critical. A short course of steroid eye drops that goes unmonitored can cause permanent vision loss that no treatment can reverse.
Treatment Options
Step one is always to reconsider the steroid.
Can the dose be reduced? Can the steroid be stopped? Is there a possibility of using a less potent formulation? For eye drops, switching from prednisolone to fluorometholone or loteprednol often reduces the pressure response significantly.
Sometimes the underlying condition, uveitis, for example, requires continued steroid treatment. In these cases, eye pressure must be managed medically.
Pressure-lowering eye drops are the first line of treatment. The same drops used in primary glaucoma: prostaglandin analogues, beta-blockers, carbonic anhydrase inhibitors, and alpha agonists, are effective in steroid glaucoma.
Laser treatment (SLT) can improve drainage through the trabecular meshwork and reduce dependence on drops.
Surgery: trabeculectomy or a glaucoma drainage device , is reserved for cases where drops and laser do not control pressure adequately. Surgery in steroid glaucoma is generally highly effective.
For patients who have received a periocular steroid injection and cannot have it removed, sustained medical treatment is the mainstay until the depot is absorbed.
The Indian Context: A Hidden Epidemic
India has a particular problem with steroid-induced glaucoma. Steroid eye drops are widely available without prescription. Patients self-treat for red eyes, allergy, and post-operative care, often on the advice of pharmacists or non-specialist practitioners.
Many patients arrive in my clinic having used potent steroid drops every day for six, twelve, or even twenty-four months. Their pressure is grossly elevated. The optic nerves are damaged. Their peripheral vision is affected and will not return.
This is preventable. Every patient using steroid eye drops needs their eye pressure monitored. Every patient on long-term systemic steroids deserves at least an annual eye check. This is not optional.
When Should You See a Glaucoma Specialist?
See a fellowship-trained glaucoma specialist if:
- You are using steroid eye drops for more than two weeks
- You have been prescribed a periocular steroid injection
- You are on long-term oral steroids and have never had your eye pressure checked
- You have a family history of glaucoma and are on any steroid therapy
- You are a known glaucoma patient who requires steroids for any reason
- Your eye pressure has been noted to be high on a routine eye check
Do not wait for symptoms. There are none, until it is too late.
Frequently Asked Questions
Can steroid eye drops cause glaucoma even when used for a short time?
A brief course, less than two weeks, rarely causes a clinically significant pressure rise. But risk increases with duration and potency. Any steroid eye drop use lasting more than two weeks warrants a pressure check.
How long does it take for steroids to raise eye pressure?
In highly susceptible individuals, pressure can rise within days. In most steroid responders, the rise occurs over two to six weeks of use. With depot injections, pressure may continue to rise for months.
Does stopping the steroid cure steroid glaucoma?
It normalises the pressure in most patients, yes. But if the optic nerve has already been damaged, that damage is permanent. Stopping the steroid does not restore lost vision.
Can inhaled steroids for asthma cause glaucoma?
Yes, though the risk is lower than with eye drops. Long-term use of high-dose inhaled corticosteroids has been associated with a modest increase in glaucoma risk, particularly in patients who already have elevated eye pressure.
Can steroid skin creams cause glaucoma?
Yes. Creams applied to the face and eyelid skin can absorb into the eye in meaningful amounts. This is an underrecognised cause of steroid-induced ocular hypertension.
What is a steroid responder?
A steroid responder is someone whose eye pressure rises significantly on steroid therapy. Roughly 5% of the general population are high responders. Glaucoma patients, first-degree relatives of glaucoma patients, high myopes, and diabetics have a much higher rate of response.
Is steroid glaucoma the same as regular glaucoma?
The optic nerve damage is identical. The mechanism of pressure elevation differs: steroids impair drainage through the trabecular meshwork. The treatment approach is similar, but the critical first step is always to reassess and if possible stop or reduce the causative steroid.
Can I still use steroids if I have glaucoma?
Yes, but only under close specialist supervision with frequent pressure monitoring. Never use steroid eye drops without the oversight of an ophthalmologist if you have a diagnosis of glaucoma or a family history of the condition.
I had a steroid injection around my eye six months ago and my pressure is still high. What should I do?
This is a recognised complication of periocular depot steroids. The injection releases slowly over months. Pressure management with drops or laser is usually required until the depot is absorbed. See a glaucoma specialist, this situation requires careful, ongoing monitoring.
What should I do if my pharmacist gives me steroid eye drops for a red eye? Do not use steroid eye drops without a diagnosis from an ophthalmologist. Red eyes have many causes, viral conjunctivitis, allergic conjunctivitis, dry eye, most of which do not always require steroids and some of which can be worsened by them. Always get a proper diagnosis before using any steroid eye drop.
Book a consultation with Dr Shibal Bhartiya:
Marengo Asia Hospitals, Gurugram
Phone: +91 88826 38735
Website: drshibalbhartiya.com
Google Business Profile: maps.app.goo.gl/mcfegmHTuhqV5hSp6
Read the research articles
This article has been written by Dr Shibal Bhartiya, a glaucoma specialist in Gurgaon known for ethical, patient-centred glaucoma care and independent glaucoma second opinions. She is also a research collaborator with Mayo Clinic, Jacksonville, Florida, USA.
She has published peer-reviewed research on glaucoma laser and surgeries, examining how treatment decisions should balance medical evidence, patient preferences, and long-term vision outcomes.
These peer-reviewed articles discussing glaucoma treatment are benchmarks for glaucoma surgeons globally, and can be accessed on PubMed and Google Scholar
If you would like a structured glaucoma risk assessment or second opinion:
+91 88826 38735
drshibalbhartiya.com
