Elevated Intraocular Pressure After Intravitreal Steroid Injection in Diabetic Macular Edema: Monitoring and Management

Francisco J Goñi, Ingeborg Stalmans, Philippe Denis, Jean-Philippe Nordmann, Simon Taylor, Michael Diestelhorst, Antonio R Figueiredo, David F Garway-Heath, Francisco J Goñi, Ingeborg Stalmans, Philippe Denis, Jean-Philippe Nordmann, Simon Taylor, Michael Diestelhorst, Antonio R Figueiredo, David F Garway-Heath

Abstract

Introduction: With the increasing use of intravitreal administration of corticosteroids in macular edema, steroid-induced intraocular pressure (IOP) rise is becoming an emergent issue. However, for patients in whom intravitreal steroids are indicated, there are no specific recommendations for IOP monitoring and management after intravitreal administration of corticosteroids.

Method: An expert panel of European ophthalmologists reviewed evidence on corticosteroid-induced IOP elevation. The objective of the panel was to propose an algorithm based on available literature and their own experience for the monitoring and management of corticosteroid-induced IOP elevation, with a focus on diabetic patients.

Results: Data from trials including diabetic patients with a rise of IOP after intravitreal steroid administration indicate that IOP-lowering medical treatment is sufficient for a large majority of patients; only a small percentage underwent laser trabeculoplasty or filtering filtration surgery. A 2-step algorithm is proposed that is based on the basal value of IOP and evidence for glaucoma. The first step is a risk stratification before treatment. Patients normotensive at baseline (IOP ≤ 21 mmHg), do not require additional baseline diagnostic tests. However, patients with baseline ocular hypertension (OHT) (IOP > 21 mmHg) should undergo baseline imaging and visual field testing. The second step describes monitoring and treatment after steroid administration. During follow-up, patients developing OHT should have baseline and periodical imaging and visual field testing; IOP-lowering treatment is proposed only if IOP is >25 mmHg or if diagnostic tests suggest developing glaucoma.

Conclusion: The management and follow-up of OHT following intravitreal corticosteroid injection is similar to that of primary OHT. If OHT develops, IOP is controlled in a large proportion of patients with standard IOP treatments. The present algorithm was developed to assist ophthalmologists with guiding principles in the management of corticosteroid-induced IOP elevation.

Funding: Alimera Sciences Limited.

Keywords: Diabetic macular edema; Intravitreal implants; Intravitreal steroid injection; Ocular hypertension; Steroid-induced glaucoma; Steroid-induced ocular hypertension.

Figures

Fig. 1
Fig. 1
Algorithm for the management of IOP elevation by retinal specialists: pre-injection considerations. IOP intraocular pressure, OHT ocular hypertension, RNFL retinal nerve fibre layer
Fig. 2
Fig. 2
Algorithm for the management of IOP elevation by retinal specialists: Post-injection IOP management. IOP intraocular pressure

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