Extreme intraocular pressure and steroid-dependent iritis

Area of Science:

• Ophthalmology
• Glaucoma Research
• Uveitis Management

Background:

• A 50-year-old female with a history of chronic polyarticular juvenile rheumatoid arthritis and uveitis presented with markedly elevated intraocular pressure (IOP) in the left eye.
• The patient required ongoing topical steroid therapy, which complicated IOP management, and had previously received a sub-Tenon injection of triamcinolone.
• Despite aggressive medical therapy, including acetazolamide and topical anti-inflammatories, the IOP remained elevated.

Purpose of the Study:

• To describe the management of a complex case of elevated intraocular pressure (IOP) in a patient with co-existing chronic uveitis and juvenile rheumatoid arthritis.
• To evaluate the effectiveness of intensified medical therapy in controlling steroid-induced glaucoma in a challenging clinical scenario.
• To discuss the interplay between chronic inflammation, topical steroid use, and intraocular pressure management.

Main Methods:

• A 50-year-old female patient with a history of chronic inflammatory conditions and topical steroid use was evaluated for refractory elevated intraocular pressure (IOP).
• The patient's medical regimen was optimized, including substitutions in topical steroids and the addition of multiple IOP-lowering agents.
• Ophthalmic examinations, including gonioscopy, intraocular pressure measurements, and optical coherence tomography (OCT) of the retinal nerve fiber layer, were performed.

Main Results:

• The patient presented with an intraocular pressure (IOP) of 44 mm Hg in the left eye, which showed only slight improvement with initial medical adjustments.
• Following substitution of loteprednol for prednisolone acetate and addition of brimonidine, nepafenac, and a latanoprost/netarsudil combination, the IOP in the left eye decreased to 31 mm Hg.
• Despite the reduction, the IOP remained elevated, necessitating continued aggressive medical management. Visual fields and optic nerve appearance were stable.

Conclusions:

• Managing elevated intraocular pressure (IOP) in patients with chronic uveitis and concurrent steroid use presents significant challenges.
• Intensified medical therapy, including a combination of anti-inflammatory and IOP-lowering agents, is crucial for controlling refractory glaucoma in such cases.
• Close monitoring of IOP and optic nerve health is essential in patients with complex inflammatory eye conditions requiring long-term steroid treatment.