Steroid-Induced Intraocular Pressure Rise in a Child with Severe Vernal Keratoconjunctivitis

Interpretation

The unilateral IOP rise from 14 to 28 mmHg after six weeks of dexamethasone 0.1% four times daily is consistent with a steroid response, not necessarily early primary glaucoma. Dexamethasone is a potent corticosteroid andchildren can be high responders. The absence of cupping is reassuring but does not exclude future damage. The right eye may be more exposed or more responsive; asymmetry is common.

Management

• Do not stop abruptly. Abrupt cessation can cause rebound inflammation and worsening of the shield ulcer. Taper dexamethasone to three times daily for one week, then twice daily, then stop, while monitoring IOP weekly.
• Switch to a lower-IOP-liability steroid such as fluorometholone 0.1% or loteprednol etabonate 0.5% if anti-inflammatory cover is still needed. These are less potent but also less likely to raise IOP.
• If IOP remains above 30 mmHg or rises further, add a topical IOP-lowering agent such as brimonidine 0.1–0.2% or dorzolamide 2%, with attention to fatigue and local allergy. Avoid prostaglandins as a first choice in a child because of periocular and iris pigmentation and limited pediatric data.
• Check IOP at every visit, and perform optic disc and visual field assessment when the child is cooperative.

Key point

The goal is to control inflammation with the lowest effective steroid potency and duration, not to eliminate steroids altogether.

Steroid-sparing options

• Topical cyclosporine 0.05–0.1% two to four times daily reduces T-cell-mediated inflammation and is the mainstay for severe vernal keratoconjunctivitis. It does not raise IOP.
• Topical tacrolimus 0.03% ointment once or twice daily is an effective alternative, especially for severe papillae and shield ulcers.
• Mast cell stabilizers such as sodium cromoglycate and antihistamines such as olopatadine reduce itching but are insufficient alone for a shield ulcer.
• A short course of a supratarsal corticosteroid injection can be considered for severe disease, but it carries a risk of pressure rise and globe perforation and is not a substitute for adherence.

Preservative and cost issues

Frequent BAK-preserved drops on a shield ulcer worsen epithelial toxicity. If unit-dose preservative-free products are unaffordable, choose a preserved product dosed less frequently rather than abandoning treatment, and use punctal occlusion. Generic cyclosporine may be cheaper; check whether the formulation is preserved and counsel accordingly. Do not use preserved drops more than four times daily if avoidable.

Rationale

The shield ulcer is an immune-mediated plaque; controlling eosinophils and T cells with a steroid-sparing agent addresses the cause, while reducing cumulative steroid exposure.

Counseling

• Explain that the pressure rise is detected early and reversible in most children; stopping everything suddenly could harm the cornea more than the pressure.
• Demonstrate how to apply drops, use punctal occlusion for 1 minute, and keep the bottle tip clean.
• Warn about redness, pain, or blurred vision after drops, and about missing follow-up.
• Clarify that cyclosporine/tacrolimus are not steroids and do not cause the same pressure rise, but they may sting initially.

Follow-up structure

• Week 1: IOP, slit lamp, shield ulcer size, adherence check.
• Weeks 2–4: taper steroid and monitor IOP; if stable, extend to 4-weekly visits.
• Every 3 months: optic disc assessment and refraction; annual visual field when age-appropriate.
• School plan: allow eye drops at school if needed, and provide a written schedule.

Safety net

Give a clear return plan for severe pain, worsening vision, or eye swelling. Document the steroid response in the chart so future prescribers avoid potent steroids without pressure monitoring. The cornerstone is frequent, low-potency steroid use plus a steroid-sparing agent and reliable follow-up.