Subsequent visits showed much improvement with IOP reaching a baseline low of 15mmHg in both eyes. Prednisone dose was tapered slowly to 5mg (this dose was maintained for the duration of the pregnancy), and one month into this regimen, the patient was back to seeing 20/30 in both eyes. Brimonidine was stopped two months before delivery; the rest of the pregnancy and the delivery were uneventful. 

In a follow-up visit one month post-delivery, IOP was 13mmHg in the right eye and 14mmHg in the left eye, corrected visual acuity was 20/30 in both eyes, and angles were wide open (grade 4 Schaffer) for 360 degrees. At this time, the prednisone regimen was discontinued.

In this case, the use of oral steroids, in addition to an alpha-2 agonist ophthalmic agent, effectively managed the patient’s condition. Because of the serious consequences of fluid overload in her previous pregnancies, clinicians were hesitant to withdraw furosemide, and elected to try oral steroids alone. While neither furosemide or pregnancy, or the combination of both, have been reported to cause acute anterior chamber shallowing with angle-closure glaucoma, previous literature regarding sulfa-containing drugs and clinical course suggest that both may be etiologic factors.

The authors conclude “that in clinical settings in which conventional medical options are contraindicated or limited, discontinuation of the offending agent and treatment with oral prednisone starting at a dose of 1mg/kg with clinically guided taper may be a relatively safe and effective therapeutic measure.”

References

1. Boundaoui, O.N., Woodruff, T.E. Presumed Furosemide-associated Bilateral Angle-Closure Glaucoma. Journal of Glaucoma. 2016, DOI: 10.1097.