Glaucoma with corticosteroids

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). 

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. 

Cystoid macular edema developed in two patients treated with topical latanoprost for glaucoma (23). Latanoprost was withdrawn, and the cystoid macular edema was treated with topical corticosteroids and ketorolac, with improvement in visual acuity. The macular edema resolved in both cases. 

Corticosteroids should be used cautiously in the presence of congestive heart failure, myocardial infarction, hypertension, diabetes mellitus, epilepsy, glaucoma, hepatic disorders, osteoporosis, peptic ulceration, and renal impairment. Children are more susceptible to these adverse effects. To avoid cardiovascular collapse, steroids must be given slowly by intravenous injection. Large doses produce Cushing s syndrome (with moon face and sometimes hirsutism). 

Studies have investigated the pharmacoeconomics of drug therapy. The drug price may reflect only part of the medication cost. Other costs, such as those associated with adverse drug effects, additional laboratory tests, and office visits, may more realistically reflect the pharmacoeconomics of therapy. For ophthalmic medications, the daily cost of medications also depends on the volmne of the medication, the drop size, dosing regimen, compU-ance, and other fectors. PubUcations have reviewed glaucoma and topical corticosteroid therapy and described more cost-effective treatment options not based solely on the actual medication cost. 

After the introduction of corticosteroids for treating ocular inflammatory disease, reports began to appear in the literature that implicated topical steroid therapy as a cause of elevated lOP. In 1962 after reported observations with topical steroid therapy it became generally accepted that these agents can produce the clinical picture of open-angle glaucoma. 

Because side effects can complicate the use of corticosteroids, a careful history and certain tests may be advisable, particularly if a patient may require prolonged ocular therapy. Steroids should be used with great caution in patients with diabetes mellitus, infectious disease, chronic renal feilure, congestive heart feilure, and systemic hypertension. Systemic administration is generally contraindicated in patients with peptic ulcer, osteoporosis, or psychoses. Topical steroids should be used with caution and only when necessary in patients with glaucoma. 

Leibowitz HM, Ryan WJ, Kupferman A. Comparative antiinflammatory efficacy of topical corticosteroids with low glaucoma-inducing potential. Arch Ophthalmol 1S>92 110 118-120. 

Corticosteroid administration by systemic (oral or intravenous), topical (ophthalmic and cutaneous), injected (periocular and subcutaneous), and inhalation and possibly nasal routes can elevate lOP In patients who are steroid responders, oral steroids produce approximately 60% the increase in lOP as compared with topical agents, most likely because of differences in achieved anterior chamber concentrations of the drug. Those with primary open-angle glaucoma respond to steroids at a rate of 46% to 92% compared with 18% to 36% of... 

A 70-year-old woman treated with topical timolol for glaucoma developed a papular eruption on the arms and back, consistent with prurigo. All tests were within the reference ranges. There was no improvement after 1 month of topical corticosteroids. The eruption cleared completely within 1 month of timolol withdrawal. Betaxolol eye-drops were introduced and the eruption recurred within 1 week. When beta-blocker therapy was replaced by synthetic cholinergic eye-drops (drug unspecified) the eruption cleared completely without any recurrence a year later. 

Gonzalez AV, Li G, Suissa S, Ernst P. Risk of glaucoma in elderly patients treated with inhaled corticosteroids for chronic airflow obstruction. Pulm Pharmacol Ther 2010 23 (2) 65-70. 

Uveitis is the most common ocular manifestation of sarcoidosis in most series (4,5). Anterior uveitis occurs in 20% to 70% of patients with ocular sarcoidosis (4—6) and typically presents as an iritis or iridocyclitis (1,7). Symptoms include blurred vision, red eyes, painful eyes, and photophobia. However in one-third of patients, the patient may present without ocular symptoms. Therefore, all sarcoidosis patients require a slit-lamp and fundoscopic examination regardless of the presence of ocular symptoms. The slit-lamp examination may reveal mutton-fat keratic precipitates (Fig. 1), which are aggregates of inflammatory cells in the comeal epithelium (1,7). Other lesions of anterior sarcoid uveitis that may be seen with a slit lamp include Busacca nodules on the iris (Fig. 2) and Koeppe nodules on the papillary margin (8). Both these nodules are almost exclusively found when anterior sarcoid uveitis is a chronic condition (8). Chronic anterior sarcoid uveitis may cause cataracts and glaucoma. Since corticosteroid use can also lead to cataract formation and... 

The mean lOP in the corticosteroid-treated population was 13.62 3.29 mm Hg. Four of the 50 patients (8%) had raised lOP (i.e., >21 mm Hg in either eye, or a difference in lOP of > 6 mm Hg between the two eyes). Seven patients with lOP in the normal range had an asymmetric cup/disc ratio > 0.2. Of those, only one patient had a family history of glaucoma. We found no positive correlation between the age, sex, or subtype of disease and lOP (P>0.05). No significant differences existed in the measured indices between the patients with or without raised lOP. 

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. 

J. Williamson, R.W.W. Paterson, D.D.M. McGavin, M.K. Jasani, J.A. Boyle, and W.M. Doig, Posterior subcapsular cataracts and glaucoma associated with long-term corticosteroid therapy, Br J Ophthalmol 53 361(1969). 

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