History
Elicit the patient's current medications, including any recent changes in medications or dietary supplements.
Symptoms
With steroid-induced glaucoma, the pressure elevation is gradual. Therefore, like primary open-angle glaucoma, very few symptoms exist.
Visual symptoms of drug-induced acute angle-closure glaucoma are the same as primary acute angle-closure glaucoma.
If the angle closure is related to anterior rotation of the ciliary body, the patient is also likely to have a significant myopic shift in vision.
Past ocular history/past medical history
Elicit history of systemic medical disease, which could require chronic corticosteroid use (eg, uveitis, collagen vascular disease, asthma, dermatitis).
Inquire about any recent use of sulfa-based medications. In particular, ask about the use of topiramate for migraines or other reasons.
Patients with preexisting primary open-angle glaucoma, a family history of primary open-angle glaucoma, diabetes mellitus, high myopia, or connective tissue diseases are at greater risk to be steroid responders.
Physical
Perform a complete ophthalmic examination.
Vision and refraction
Patients with hyperopia are at an increased risk for narrow angles.
Pupils
Test for the presence of an afferent pupillary defect if topical use has been unilateral or if the attack has only occurred in one eye.
External examination
Use a flashlight test to identify an anatomically narrow angle.
Slit lamp examination
Exclude stigmata of other causes of secondary glaucoma, as follows:
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Cornea - Krukenberg spindle (eg, pigmentary glaucoma), keratic precipitates (eg, uveitic glaucoma, Fuchs heterochromic iridocyclitis)
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Anterior chamber - Anterior chamber depth to indicate narrow angle
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Iris - Heterochromia (ie, Fuchs heterochromic iridocyclitis), iris transillumination defects (eg, pseudoexfoliation, pigment dispersion, previous episodes of intermittent angle closure)
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Lens - Pseudoexfoliation material (pseudoexfoliation glaucoma)
Gonioscopic evaluation
Examine angle anatomy to determine if the angle is at risk for occlusion with dilation.
Dilated examination
Inspect the optic nerve for glaucomatous optic nerve damage. See Glaucoma, Primary Open Angle for a description of glaucomatous patterns. Dilate after potentially occludable narrow angles or plateau iris has been excluded by gonioscopy.
Causes
Drug-induced glaucoma can occur via two mechanisms, as follows: open-angle glaucoma is generally steroid induced, and closed-angle glaucoma is generally from pupillary dilation.
Complications
Untreated glaucoma can lead to permanent visual damage and blindness.
