Steroid response after complete trabecular meshwork removal

Steroid-induced hypertensive response is a common, yet underdiagnosed complication of steroid therapy. Certain patients, referred to as high responders, can experience a rapid and severe rise in intraocular pressure (IOP) potentially reaching sight-threatening levels. This report presents two high-responder patients with multiple risk factors.

Medical records of two patients who underwent 360° angle surgery and experienced postoperative IOP spikes were reviewed, and clinical data was extracted.

Two male patients aged 8 and 22 years old with juvenile open angle glaucoma (JOAG) with elevated IOP despite maximum medical therapy underwent gonioscopy-assisted transluminal trabeculotomy with canaloplasty in both eyes and were started postoperatively on prednisolone. Patient 1 had an IOP of 61 mmHg on postoperative day (POD) 6, prednisolone was discontinued, and treatment was switched to ketorolac, antiglaucoma drops and oral agents. Patient 2 had an IOP of 48 mmHg on POD 9 and IOP was controlled upon discontinuing prednisolone and glaucoma drops. His second eye was treated with fluorometholone after surgery but presented with an IOP of 39 mmHg on POD 8 and also switched to ketorolac. Both patients had controlled IOPs after steroid cessation.

Steroid response can occur even in procedures targeting the trabecular meshwork. Identifying risk factors, including a glaucoma diagnosis, family history, young age, and use of potent steroids enables closer monitoring. Early detection and cessation of steroid therapy are crucial to preventing sustained IOP elevation, underscoring the importance of vigilance in high-risk patients.