I have a patient in my chair who I diagnosed with anterior uveitis two weeks ago. At that time, I had prescribed a potent topical steroid. (He’s had uveitis before, but was never a steroid responder.) The inflammation is now much improved, but his IOP has risen from 18mm to 28mm Hg. How should I manage this patient?

“It depends,” says Anthony Litwak, OD, who specializes in glaucoma at the Baltimore VA Medical Center. “Because each steroid responder is unique, it’s best to focus on the individual patient’s history and presentation, and not expect an ‘average’ patient.”

For instance, “a typical steroid response happens within two to three weeks. But if you pass that point, it doesn’t mean your patient is in the clear,” he says. “Actually, I think that the longer that you keep the patient on steroids, the more likely that he’ll develop that steroid response.”

And if that happens, then what do you do? Here are some variables to consider.

Does the Patient Already Have Glaucoma Damage?
“If the patient does not have glaucoma damage and develops a steroid response, then a short period of elevated IOP can easily be tolerated, and IOP-lowering medication may not be necessary as you taper the patient off steroids,” Dr. Litwak says.

However, “if the patient already has glaucoma damage and develops a steroid response, then that elevated pressure is probably going to exacerbate the damage,” he says.

If so, you’ll probably need to put the patient on additional glaucoma treatment—depending on how high the pressure is and how long the course of the steroids is going to be.
   A patient with severe anterior uveitis was prescribed a potent topical steroid. Now, two weeks later, the inflammation has improved but the patient’s IOP has risen to 28mm Hg. It’s too soon to stop the steroid, so is it time to Rx a glaucoma drop? Photo: Michael Trottini, OD, and Candice Tolud, OD

How Bad is the Uveitis?
Grade the anterior chamber. “Patients who seek early evaluation and get treated immediately and aggressively tend to require a shorter course of steroids, whereas a patient who’s been symptomatic for a week or longer and presents with significant inflammation will probably need several weeks of steroid therapy,” Dr. Litwak says.

Also bear in mind that some patients simply respond sooner, while others are more refractory to treatment. See these uveitis patients often. “I tend to see patients with uveitis at least on a weekly basis, or more often if they’re showing significant complications,” he says.

If the inflammation is improving but the IOP is still going up, then taper the steroid. “But don’t taper too quickly, or you can get a rebound in the inflammation,” Dr. Litwak says.

On the other hand, if the pressure has gone up but the inflammation is not improving, “it could be that the inflammation itself—not the steroid—is causing the pressure to go up,” he says. “In that case, you actually increase the steroid to try to quell the inflammation, which should bring the pressure down.”

Pick a Potent Steroid
Soft steroids don’t penetrate the anterior chamber as well as more potent steroids. This means that they tend to cause a steroid response less often—but it also means that they are less effective for uveitis.

“For mild to moderate uveitis we typically use Pred Forte (prednisolone acetate 1%, Allergan),” Dr. Litwak says. Use the brand name if you can get it. “However, in the unlikely event that the patient has a history of a steroid response on Pred Forte, I sometimes use Vexol (rimexolone 1%, Alcon), which is a slightly weaker steroid but it does penetrate into the anterior chamber. And some clinical studies have shown it delays the onset of a steroid response.”1

For severe cases, consider the “big gun” steroid Durezol (difluprednate 0.05%, Alcon). But be aware that it carries an increased risk for a steroid response, so monitor these patients even more closely.

Add Hypotensive Drops
“Always check the pressure on your follow-up visits,” Dr. Litwak says. If the patient has glaucoma damage on top of uveitis, and also has a steroid response, he’ll require additional glaucoma medication along with steroid therapy.

But, avoid prostaglandins to lower IOP because they can mediate inflammation in the eye, he says. Instead, use aqueous suppressants—beta blockers, carbonic anhydrase inhibitors or alpha agonists.

Last but not least, Dr. Litwak says, “for those uveitic glaucoma patients who already have significant glaucomatous damage and aren’t responding well to glaucoma therapy, a steroid response on top of that can be disastrous. This triad of problems suggests that this patient needs to be referred out.”

1. Biswas J, Ganeshbabu TM, Raghavendran SR, et al. Efficacy and safety of 1% rimexolone versus 1% prednisolone acetate in the treatment of anterior uveitis? A randomized triple masked study. Int Ophthalmol. 2004 May;25(3):147-53.