When is ocular hypertension called glaucoma?

[BUTTERCUP109]

I'm having some trouble understanding the definition of or medical criteria defining "glaucoma". Specifically, if one has elevated IOP during treatment with steroids (Pred Forte x 1 year) that is presumed to have induced ocular hypertension, is it proper to say that a diagnosis of "glaucoma" can only be made if the IOP elevation remains after a period of time after discontinuation of the steroids? If so, how long after steroids are stopped before the IOP elevation is presumed permanent? If the IOP elevation resolves at a point after the steroids are stopped, and there is no optic nerve damage, then am I correct to say that there was and is no "glaucoma"? If some disc signs exist or vision loss on the visual field test after the steroids are stopped but the IOP returns to normal...is this considered "glaucoma"? Please help me understand. I'm having to make some very hard decisions in my treatment.

[BUTTERCUP109]

My treatment decisions are regarding the treatment of my cystoid macular edema, not regarding glaucoma treatment. I'm sorry if I did not explain that.I'm sorry if you think I'm second-guessing the professionals, but I have been given two very different treatment options and have found that professional opinions vary greatly. So, unfortunately, I am in the situation of deciding what to do. I am a steriod-responder. Pred Forte drops brought my pressure into the upper 30s even while I was on Cosopt and Alphagan. One camp of retina doctors tell me to avoid at at costs intravitreal steroids. I've failed to respond to anit-VEGF injections. I've tried every NSAID drop on the market. This only leaves the option of an internal limiting membrane peel which is kind of experimental for treating CME and only has limited studies. The other camp says to have intravitreal steroid, and if necessary surgically place a glaucoma shunt for the pressure. I know that even with a shunt, control of the pressure won't be perfect. I've had CME for over a year and I've got to find a way to resolve it before I have permanent vision loss. So, as you can see, I'm trying to get a handle on how dangerous even transient elevated IOP can be. No matter what I do, I will likely be having a pressure problem at the same time as I'm trying to treat the CME, but with the Kenalog it is sure to be more of a problem. Understanding the glaucoma question, helps me to know which of the two approachs to go with.  So far, I show no optic nerve damage, but have had pressure between the upper 20s and upper 30s for at least 2 months. Do you have an opinion which way I should go? I get a little confused when I get answers to my questions that basically say "ask my doctor". What is the purpose of this forum? Couldn't that be the answer to everyone who puts a question on this site?

[Michael J Kutryb, MD]

I don't understand what the hard decisions are?  If you are having damage to the optic nerve with loss of visual field due to glaucoma, then treatment is mandatory.  If it is a borderline case with no specific proof on diagnostic studies that damage has occured or is imminent, then careful observation is in order.  If the pressure has returned to normal and the visual field and optic nerve are normal then no treatment needed probably but it becomes trickier if there is supected damage.  In the end, its not so important to get caught up in definitions of when you have ocular hypertension or steroid induced ocular hypertension or true open angle glaucoma because sometimes the true diagnosis can be a little blurred.  It depends on so many factors and it comes down to the art of glaucoma managment.  If you are not comfortable with the current treatment, by all means get a second opinion with a glaucoma specialist.  It doesn't sound like you have some terrible, aggressive case of glaucoma but rather a borderline case.  In some of these cases we are making predictions on what your chances of future damage are and doing our best to treat or not treat based on these predictions (again based on such things as visual field raw numbers, nerve fiber layer readings, c/d ratio, pachymetry, age, intraocular pressure, diabetes, etc.)  Leave the decisions to a glaucoma expert and you should have very little to worry about.  Its not as cut and dry as you want it to be.

Michael Kutryb, MD
Kutryb Eye Institute
www.kutrybeye.com