Cataracts with corticosteroids

Our study reveals that adult patients with IBD who are treated with corticosteroids have a high incidence (56%) of PSC, raised lOP, or both. These patients, therefore, are at risk for continued opacification of their lenses and the development of steroid-induced glaucoma. Upon lowering the dose of steroids, raised lOP is reversible in the majority of patients and PSC, in its early stages, is reversible in some. To avoid ocular and other systemic complications of therapy, acute and chronic doses of steroids should be minimized. Because of individual susceptibility for glaucoma and cataract and their time-and dose-dependent nature, each patient receiving corticosteroids for IBD or any other condition must be carefully followed by an experienced ophthalmologist. 

R.B. Oglesby, R.L. Black, L. von Sallmann L, and J.J. Bunim, Cataracts in rheumatoid arthritis patients treated with corticosteroids, Arch Ophthalmol. 66 519(1961). 

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). 

Adverse reactions associated with administration of the corticosteroid ophthalmic preparations include elevated IOP with optic nerve damage, loss of visual acuity, cataract formation, delayed wound healing, secondary ocular infection, exacerbation of comeal infections, dry eyes, ptosis, blurred vision, discharge, ocular pain, foreign body sensation, and pruritus. 

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. 

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. 

Forman AR, Loreto JA, Tina LU. Reversibility of corticosteroid-associated cataracts in children with the nephrotic syndrome. Am J Ophthalmol 1977 84(l) 75-8. 

Chen YC, Gajraj NM, Clavo A, Joshi GP. Posterior sub-capsular cataract formation associated with multiple lumbar epidural corticosteroid injections. Anesth Analg 1998 86(5) 1054-5. 

Garbe E, Suissa S, LeLorier J. Association of inhaled corticosteroid use with cataract extraction in elderly patients. JAMA 1998 280(6) 539-43Erratum in JAMA 1998 280(21) 1830. 

Posterior snb-Tenon s injection of corticosteroids is most often nsed in the treatment of chronic eqnatorial and mid-zone posterior uveitis, including inflammation of the macnlar region. Cystoid macular edema after cataract extraction and diabetic macular edema are treated occasionally with snb-Tenon s repository steroids. 

Posterior subcapsular cataracts (PSCs) can occur with all routes of administration (Figure 12-2), including systemic, topical, cutaneous, nasal aerosols, and inhalation corticosteroids. In a study of 44 rheumatoid arthritis patients treated with various steroids, including prednisone and dexamethasone, 17 (39%) developed bilateral PSCs. Dosage and duration of therapy appeared to be correlated with the incidence of cataract development. Patients who received prednisone therapy for 1 to 4 years showed an 11% incidence if the dose range was less than 10 mg/day a 30% incidence if the dose was... 

Several extended-release devices able to deliver a consistent level of corticosteroid to the retina have been devised. Two will be presented in this chapter, although other devices are under evaluation or in the development pipeline at the time of writing. The primary indications for these devices are persistent macular edema associated with several conditions, including diabetic retinopathy, retinal vascular occlusive disease, cataract surgery, and posterior uveitis. 

Lens Pigment and cellular debris, similar to KPs, are often detected on the anterior lens surfece. Faint fibrin membranes at the pupillary margin may precede areas of posterior synechiae. Cataracts are an important consideration in chronic recalcitrant uveitis and for those on long-term corticosteroid therapy, because the latter is also linked with the development of posterior subcapsular cataracts. 

Potential complications associated with topical corticosteroids include infectious keratitis, cataract formation, and lOP elevation. The latter two conditions are dose and duration dependent. 

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%. 

Increases in intraocular pressure and development of posterior subcapsular cataracts are femiliar sequelae to corticosteroid therapy. Increased intraocular pressure after IVTA is considerably more common than endophthalmitis and has been established in different studies. Results are not readily comparable, because different amounts of triamcinolone were administered. However, it should be noted that approximately 30% or more of patients had an increase in intraocular pressure, regardless of the dose given, which is consistent with the finding that a significant number of patients are steroid... 

---