Cataract corticosteroid side-effects

There are hundreds of topical steroid preparations that are available for the treatment of skin diseases. In addition to their aforementioned antiinflammatory effects, topical steroids also exert their effects by vasoconstriction of the capillaries in the superficial dermis and by reduction of cellular mitosis and cell proliferation especially in the basal cell layer of the skin. In addition to the aforementioned systemic side effects, topical steroids can have adverse local effects. Chronic treatment with topical corticosteroids may increase the risk of bacterial and fungal infections. A combination steroid and antibacterial agent can be used to combat this problem. Additional local side effects that can be caused by extended use of topical steroids are epidermal atrophy, acne, glaucoma and cataracts (thus the weakest concentrations should be used in and around the eyes), pigmentation problems, hypertrichosis, allergic contact dermatitis, perioral dermatitis, and granuloma gluteale infantum (251). 

Side effects of inhaled corticosteroids are relatively mild and include hoarseness, sore throat, oral candidiasis, and skin bruising. Severe side effects such as adrenal suppression, osteoporosis, and cataract formation are reported less frequently than with systemic corticosteroids, but clinicians should monitor patients receiving high-dose chronic inhaled therapy. 

Long-term use of oral corticosteroids may result in side-effects, such as peptic ulceration, adrenal suppression and subcapsular cataracts. 

The most commonly observed side effects associated with vidarabine are lacrimation, burning, irritation, pain, and photophobia. Vidarabine has oncogenic and mutagenic potential however, the risk of systemic effects is low because of its limited absorption. It should not be used in conjunction with ophthalmic corticosteroids, since these drugs increase the spread of HSV infection and may produce side effects such as increased intraocular pressure, glaucoma, and cataracts. 

The use of periocular steroids circumvents many of the side effects associated with systemic steroids however, complications may still arise. lOP response is a particular concern, because depot medications cannot be removed easily, as compared with tapering or discontinuing an oral preparation. Cataractogenesis may occur with any steroid preparation with intravitreal corticosteroid implants, the incidence of cataract formation requiring surgery over 2 years is nearly 90%. 

The ocular side effects of corticosteroids are many and are related to the route of administration. The most common concerns are increased intraocular pressure (lOP) and cataracts, but delayed epithelial woimd healing and increased risk of infection due to immime modulation and decreased tear lysozyme levels are issues for the cornea. Changes to other ocular tissues have been noted (subconjunctival hemorrhages, blue sclera, eyelid hyperemia and edema, retinal emboUc events, central serous choroidopathy) and neurologic compUcations reported (diplopia, nerve palsies, intracranial hypertension) (see Appendix 35-1). 

Horses appear to be more sensitive to the adrenosuppressive effects of aerosolized corticosteroids than human patients. Documentation of systemic absorption (adrenal suppression) of inhaled beclometasone and fluticasone raises concerns that other systemic glucocorticoid effects may occur following aerosol administration of corticosteroids. The administration of adrenosuppressive doses (>1600 p,g/day) of beclometasone dipropionate to asthmatic human patients does not produce the other systemic side-effects of glucocorticoid administration, including a roimd face (Cushingoid facies), polyuria, polydipsia, hyperglycemia, obesity, altered carbohydrate metabolism, osteoporosis, abortion, posterior subcapsular cataract and aseptic necrosis of the... 

In view of successful animal experiments (20 see also Chapter 14), a sustained-release dexamethasone device was implanted in one eye of a patient with bilateral severe uveitis associated with multiple sclerosis (20,21). The patient had previously undergone pars plana lensectomy and vitrectomy in the right eye for decreased vision associated with cataract. Despite chronic topical corticosteroids, the patient had persistent bilateral low-grade inflammation and recurrent severe bilateral iridocyclitis. Best corrected visual acuity was 20/400 in both eyes. Systemic corticosteroids and methotrexate controlled the intraocular inflammation but the patient was intolerant of these medications because of systemic side effects. The nondegradable dexamethasone device was inserted into the patient s left eye. 

Intravitreal injections to deliver corticosteroids minimize systemic side effects however, they may be associated with complications such as retinal detachment, retinal tears, vitreous hemorrhage, endophthalmitis, increased intraocular pressure (IOP), cataract formation, and, with repeated use (required for successful treatment), fibrosis and ptosis. The most common side effect is increased IOP, which has been found on rare occasion to increase drastically (up to 50mmHg in one case report by Detry-Morel et al.) (16,34,35). Close IOP monitoring is crucial following intravitreal injection. 

Despite the good that they do, many of these medications, particularly corticosteroids, DMARDs, and biologies do have a number of serious side effects. They can cause insomnia, stomach upset, moon fece, cataracts, osteoporosis, mood changes, increased risk of infections, diarrhea, hair loss, stomach pain, nausea, vomiting, dizziness, ulcers in the mouth, fevers or chills, tiredness, blood in the urine, skin rash, blurred vision, liver problems, and lightheadedness. They can cause a reaction at the site of injection of the drug or an infusion reaction, characterized by chest pain, change in blood pressure, shortness of breath, and hives. 

If corticosteroid therapy is not deemed necessary to treat disease, followup examination and objective testing should be performed on a yearly basis to monitor disease progression. Because of the need for lifelong treatment, patients should be informed of the long-term side effects of corticosteroids and be monitored and treated for consequences such as hypertension, hyperglycemia, osteoporosis, and cataracts. 

Inflammatory bowel disease (Crohn s disease and ulcerative colitis) occurs among all age groups but has peaks of incidence in the second and fourth decade of life. Currently, corticosteroid therapy is the most effective treatment for moderate to severe cases of IBD. Ocular pathology in the setting of IBD may be related to inflammation of the gastrointestinal tract or secondary to corticosteroid treatment. The two major ocular side effects of systemic corticosteroid therapy are posterior subcapsular cataract (PSC) and raised intraocular pressure (lOP). Recently, we reported that PSC was detected in 12 of 58 (20.7%) corticosteroid-treated pediatric IBD patients and that 21 patients of the same population (36.2%) had raised lOP. Because pediatric IBD patients continue corticosteroid therapy into adulthood, we analyzed the prevalence of PSC and raised lOP in a series of adult IBD patients. 

The incidence of PSC in the general adult population ranges from 0.2% to 6.0% and that of raised lOP in subjects of 40 years old is approximately 1.5%. The high incidence of PSC and raised lOP (50% and 8%, respectively) in our population of adult patients with IBD at a mean age of 38.5 years, implicates corticosteroids as the causative factor for the development of these ocular abnormalities. Association of IBD with certain inflammatory eye lesions such as uveitis, episcleritis, and keratoconjunctivitis has been reported. However, cataracts (PSC) and raised lOP, have not been ascribed as direct ocular side effects of IBD. Likewise, the supplementary medications which the IBD patients received have not been incriminated in inducing PSC or raised lOP. ... 

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