Glaucoma

IOP Effects of Intravitreal Injections

Prophylactic measures and appropriate monitoring decrease risk of significant consequences.

IOP Effects of Intravitreal Injections
Cheryl Guttman Krader
Cheryl Guttman Krader
Published: Wednesday, October 1, 2025

Intravitreal injections are known to cause both acute and chronic elevations in intraocular pressure (IOP). Lilian Nguyen MD discussed these risks and strategies for mitigating potential harm at a recent conference.

In most patients, any intravitreal injection will cause an immediate and very transient increase in IOP. This acute increase occurs as a volume effect and tends to be lower in those with longer eyes and those with a deeper anterior chamber. However, IOP can spike above 40 mmHg, re-equilibration may take longer in glaucomatous eyes, and the increase in IOP is sometimes sustained.

Reviewing some literature on this topic, Dr Nguyen cited a case-control study suggesting a dose-related association between chronic IOP elevation and anti-VEGF injection. In this study, eyes receiving seven injections or more per year had a higher incidence of glaucoma surgery compared to eyes receiving three injections or fewer per year.1

She also discussed a retrospective cohort study that found eyes receiving anti-VEGF injections for exudative age-related macular degeneration (AMD) were not at increased risk of developing glaucoma compared with controls that had dry AMD or no AMD.2 However, in a subgroup analysis of eyes with a pre-existing glaucoma diagnosis, eyes receiving intravitreal injections showed greater glaucoma progression and required more intensive management.

Relative to anti-VEGF agents, intravitreal corticosteroid agents are associated with a greater risk of sustained IOP elevations and glaucoma. Patients with glaucoma, a family history of glaucoma, type 1 diabetes, connective tissue disease, high myopia, and those who are older or very young (six years old or younger) are at particular risk for steroid-induced glaucoma.

“For appropriate management, it is important to know IOP elevations after intravitreal steroid injections typically occur two to four weeks after the procedure, although earlier onset can occur in pseudophakic or post-vitrectomised eyes,” Dr Nguyen said. “In addition, although IOP tends to peak at two months post-injection, chronic ocular hypertension can occur in up to one-third of eyes.”

Management strategies

Prophylactic measures for mitigating the acute IOP response to intravitreal injections include treatment with a topical IOP-lowering medication before the injection or anterior chamber paracentesis in high-risk eyes. For managing sustained IOP elevations, there is evidence of efficacy using topical IOP-lowering medications, selective laser trabeculoplasty, and various surgical procedures.

Vigilance for early detection of IOP elevations, however, is paramount for effective management, Dr Nguyen said.

“That means IOP should be checked immediately before and immediately after injection and then at every subsequent follow-up visit,” she explained. “In patients receiving intravitreal steroids, it is especially important to monitor IOP at around four to six weeks post-injection, as this is when subacute increases in IOP tend to occur.”

Dr Nguyen noted the need for more research on the long-term effects of repeated intravitreal injections and of the more recently available intravitreal agents. She also advocated for standardised protocols for IOP monitoring after intravitreal injections.

“Protocols are especially needed in patients with known risk factors and could include implementing IOP measurement into the routine workflow of injection clinics,” she said.

Dr Nguyen presented at the 2025 ASCRS annual meeting in Los Angeles.

 

Lilian Nguyen MD is Clinical Assistant Professor of Ophthalmology, The University of Texas Health Science Center at San Antonio, Texas, US. lilian.nguyen@gmail.com

 

 

 

1. Levin AM, et al. J Glacuoma, 2021; 30(12): 1019–1026.

2. Shah SM, et al. Am J Ophthalmol, 2022; 243: 98–108.

Tags: glaucoma, IOP, intraocular pressure, anti-VEGF treatment, age-related macular degeneration, AMD, chronic IOP elevation, IOP management, IOP control, intravitreal injection, patient monitoring, Lilian Nguyen
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