Corticosteroid Use in Patients with Glaucoma

Introduction to Guideline Recommendations

The European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) recommend using the lower end of the therapeutic range (12.5 mg daily rather than 25 mg) as the initial dose of prednisone for conditions like polymyalgia rheumatica in patients with glaucoma 1
The EULAR/ACR guidelines specifically state that in patients with relevant comorbidities including glaucoma, a lower initial dose is preferred 1
Initial doses greater than 30 mg/day are strongly discouraged even in patients without glaucoma 1

The American Academy of Ophthalmology recommends documenting baseline intraocular pressure (IOP) and optic nerve status before initiating therapy, and establishing a target IOP approximately 20% lower than baseline 2, 3, 4
Regular ophthalmology follow-up with IOP monitoring throughout treatment is necessary, with follow-up visits every 4-8 weeks during the first year of treatment 1, 2, 3

If IOP elevation occurs during prednisone therapy, the American College of Rheumatology recommends initiating or intensifying topical IOP-lowering medications, considering accelerating the prednisone taper if clinically feasible, and maintaining close ophthalmology collaboration to adjust glaucoma therapy 1, 3
The Arthritis Foundation notes that topical ophthalmic corticosteroids carry a high risk for IOP elevation, with difluprednate showing increased risk compared to prednisolone acetate 1%, and that topical corticosteroid use at ≥2 drops/day is a strong risk factor for IOP elevation 5, 6

The American Academy of Ophthalmology recommends explaining the need for regular ophthalmology monitoring, discussing symptoms of acute angle closure, and emphasizing medication adherence for both the systemic corticosteroid and any glaucoma medications 3