Ophthalmologic Considerations

Intraocular Pressure and Steroid Use

Steroid use can cause underestimation of intraocular pressure (IOP) in patients who have had LASIK surgery, potentially leading to further optic nerve damage in patients with already compromised optic nerves, as noted by the American Academy of Ophthalmology 1, 2
Post-LASIK patients using steroids are at risk of developing pressure-induced intralamellar stromal keratitis, highlighting the need for careful IOP monitoring in this population 1, 2
Patients with glaucoma considering keratorefractive surgery should be informed about potential IOP measurement inaccuracies after these procedures, according to the American Academy of Ophthalmology 1, 2

The American Academy of Ophthalmology recommends confirming diagnosis of open-angle glaucoma with characteristic optic nerve damage and open angles on gonioscopy 2
Glaucoma suspects are considered if they have an IOP of 17.3 mmHg, optic nerve abnormalities, visual field defects, or strong risk factors for developing glaucoma, such as older age, family history of glaucoma, African-derived race or Latino/Hispanic ethnicity, thin central cornea, large cup-to-disc ratio, disc hemorrhage, low ocular perfusion pressure, diabetes mellitus, or myopia 3, 4
Baseline imaging of the optic nerve and retinal nerve fiber layer (RNFL) is recommended for future comparison 3, 4

Dark-room dynamic gonioscopy should be performed to diagnose primary angle-closure glaucoma and verify improvement in angle configuration following treatment, as recommended by the American Academy of Ophthalmology 5
The presentation of acute angle-closure glaucoma includes pressure-induced corneal edema, mid-dilated pupil, conjunctival and episcleral vascular congestion, severe eye pain and headache, nausea and vomiting, and rock-hard ocular globe on palpation 5
Laser peripheral iridotomy (LPI) or surgical iridectomy should be performed as soon as possible to create a bypass channel between posterior and anterior chambers and relieve pupillary block, as recommended by the American Academy of Ophthalmology 5

Prostaglandin analogs, such as latanoprost, are consistently ranked as the most effective drug class for IOP reduction in network meta-analyses, according to the American College of Physicians 6
The American Academy of Ophthalmology suggests starting latanoprost 0.005% one drop in each eye at bedtime, with a target IOP reduction of 20-30% below baseline 2
A 20-25% reduction from baseline intraocular pressure (IOP) is a reasonable initial target for glaucoma treatment, with more aggressive targets (>25% reduction) for patients with severe optic nerve damage, rapidly progressing disease, or additional risk factors, as recommended by the American Academy of Ophthalmology 4, 1
Monotherapy with prostaglandin analogs may achieve the target IOP reduction in some cases, but combination therapy is frequently needed, especially in normal pressure glaucoma, with fixed-combination products considered to improve adherence when adding a second medication, as reported by 7, 3
Acetazolamide is an oral carbonic anhydrase inhibitor that serves primarily as a second-line or adjunctive therapy in glaucoma management, providing significant IOP reduction (20-30%) but with notable systemic side effects that limit its long-term use, as recommended by the American Academy of Ophthalmology 3

Selective laser trabeculoplasty (SLT) can be considered as an alternative first-line treatment, with similar efficacy to medication therapy, as stated by the American Academy of Ophthalmology 1
Laser trabeculoplasty, including selective laser trabeculoplasty (SLT) and argon laser trabeculoplasty (ALT), is as effective as medical treatment as a first-line therapy for controlling IOP in open-angle glaucoma, with similar IOP-lowering efficacy, as reported by 7
Trabeculectomy, glaucoma drainage devices, and minimally invasive glaucoma surgery (MIGS) are options for patients who fail to achieve adequate IOP control with medical and laser therapies, with surgical complications including hypotony, hyphema, shallow anterior chambers, cataract, and choroidal detachment, as reported by the American College of Physicians 4, 3, 8

Regular follow-up examinations (typically every 6-12 months) should be scheduled to monitor changes in IOP, optic disc appearance, and RNFL, and development of visual field defects 3, 4
Regular measurement of IOP and periodic electrolyte monitoring are recommended to assess efficacy and monitor for systemic effects during treatment 3
The American Academy of Ophthalmology recommends regular monitoring without treatment for patients with an IOP of 17.3 mmHg, scheduling follow-up examinations to monitor IOP measurements, optic disc and retinal nerve fiber layer (RNFL) evaluation, and visual field testing 3