Topical Steroids 101Often revered and reviled, corticosteroidsperhaps more than any other class of ophthalmic corticosterodis the conundrum of balancing tremendous therapeutic benefits with unwanted side effects. Developed in the s, these drugs remain the most potent agents against the ravages of inflammation. While many truths and myths abound about the dangers of steroids, far more harm has come from withholding steroids than has occurred from their potential sustanon aspen effects. Inflammation Inflammation is the bodys protective response to a stimulus it perceives as offensive. While it is protective for the body as a whole, the inflammatory processes can cause scarring and damage to surrounding relative potency of ophthalmic corticosteroids tissue. The signs and symptoms of inflammation are well known.
Difluprednate for the prevention of ocular inflammation postsurgery: an update
As the debate persists over when and how to use ocular steroids, four experts share insight on this topic and offer tips to achieve success with these powerful agents.
No one is allowed to die or go blind without a trial of steroids! Friedman and her colleagues rely on corticosteroids as first-line therapy for every inflammatory condition they treat. In many cases, the steroids are vision saving. The importance of ocular steroids to all of ophthalmology cannot be overstated. For more than 60 years, nothing has matched their effectiveness as fast-acting anti-inflammatory agents. Despite the fact that sequelae of uncontrolled inflammation are irreversible, many clinicians overlook corticosteroid therapy because of their fear of side effects.
Unlike in the past, physicians now have numerous steroid options; more types, various strengths and combinations, and multiple delivery routes are available. Clinicians need to be familiar with the profiles of each steroid they use so that they can choose the best one for each patient. Understanding exactly how corticosteroids work is an active field of research.
Sheppard explained that, specifically, steroids disrupt the inflammatory cascade by immobilizing arachidonic acid, downregulating multiple cytokine pathways including the vascular endothelial growth factor VEGF pathway, stabilizing cell membranes and mast cell granules, inhibiting leukocyte interaction, and slowing diapedesis.
All of these can lead to cataracts, glaucoma, secondary infection, or delayed healing. Prophylaxis for secondary infections and surface support for delayed healing can reduce those side effects, and intraocular pressure IOP can be closely monitored and controlled with IOP-lowering medication. No one wants to create a more serious problem than the initial condition. Systemic use of steroids may lead to diabetes, osteoporosis, hypertension, gastritis, depression, insomnia, weight gain, facial distortion, aseptic necrosis of the hip, or skin thinning.
When steroids are not essential, use another approach! The most common use of steroids in ophthalmology is to control postoperative inflammation. Steroids also are integral to treating conditions of immune hyperreactivity e. Contrary to what was taught years ago, long-term moderate dosing of a steroid is more likely to result in a cataract than is initial treatment with high doses of a strong steroid that is tapered and switched to a lower-strength steroid.
Sheppard, the best approach is to use the most potent steroid as quickly as possible, then taper to a lower-strength steroid for ongoing management. Wait until the inflammation is completely controlled before tapering, Dr.
Tapering when the eye is just starting to improve or stabilize may prolong the inflammation and the therapy. He learned it from Todd P. Proctor Foundation in San Francisco. Every patient is different. Systemic steroids are not a long-term option; they are appropriate only for induction therapy, said Dr. For chronic inflammatory conditions that require long-term maintenance therapy, corticosteroid tapering usually can be accomplished by adding an immunomodulatory agent, either a traditional drug such as methotrexate or a newer biologic agent such as infliximab.
Long-term intravitreal implants are now a safer steroid option than systemic therapy for some chronic conditions. The implants eliminate systemic absorption and related toxicity. Sheppard usually sees patients at intervals of two to five weeks, but he sees those with significant optic nerve disease weekly in the early stages of treatment. Despite the advances in surgical techniques, most patients will have some degree of inflammation after ophthalmic surgery.
There are several hyperinflammatory reactions to surgery that require aggressive steroid therapy, said Dr. Another is toxic anterior segment syndrome, a serious phenomenon that can occur after cataract surgery.
In addition to strict adherence to the basic tenets of steroid therapy described above , Dr. Sheppard incorporates the following clinical pearls into his practice. For elective surgery, Dr. Sheppard strongly advises that the eye be totally quiet for three months beforehand six months for children whenever possible. This means that ocular surface disease e. Examples of macular disease include cystoid macular edema, diabetic maculopathy, epiretinal membrane, and lamellar macular hole.
A steroid-induced cataract is preferable to irreversible ulcer cicatricial damage such as leukoma, endothelial depletion, synechiae, trabecular insufficiency, ciliary body fibrosis, and maculopathy, said Dr. If a patient takes so much steroid that he develops a cataract, then so be it. A cataract can be removed. Oral prophylaxis for toxoplasmosis and herpes simplex virus is imperative for preventing relapses after surgery.
Steroid penetration through the cornea is quite effective, so cornea specialists often achieve success with topical steroids for ocular surface disease and anterior segment inflammation. When choosing a steroidal agent, Dr.
McLeod considers a combination of potency and penetration. For high potency and penetration, he uses prednisolone acetate or prednisolone phosphate; if surface activity is especially important, he uses fluorometholone. Sheppard prefers difluprednate for potency and induction therapy, and loteprednol etabonate for surface activity and maintenance therapy. The negatives include heightened risk of infections, indolent ulcers, recurrent ulcers, perforations, endophthalmitis, and impaired re-epithelialization.
McLeod, who was one of the SCUT investigators, explained that the study was designed to determine whether adding topical steroids to the treatment of a bacterial corneal ulcer would improve post-treatment visual acuity.
The SCUT actually showed that steroids were not associated with higher complication rates. Nor were they associated with any benefit overall. However, a subset of more severe ulcers with central axial involvement did benefit from steroids—and these are the cases clinicians worry about most.
Because the study was not designed to compare the usefulness of steroids in more severe vs. McLeod advises caution when drawing conclusions. When inflammation in and of itself threatens eye structure and vision, using steroids is important, noted Dr. For example, they should be used for bacterial keratitis, in which corneal scarring is a concern. For bacterial conjunctivitis, a course of antibiotics typically is sufficient; the same is true for bacterial blepharitis, according to Dr.
Chalazion and vernal keratoconjunctivitis. Steroid therapy is used in nearly all cases of chalazion and vernal keratoconjunctivitis. Despite the potential side effect of depigmentation, this can effectively manage tenacious chalazia. Steroid therapy for dry eye is controversial.
Many clinicians treat this condition with cyclosporine, either alone or in combination with a steroid. On the other hand, Dr. Sheppard reports successful outcomes when using cyclosporine in patients with dry eye who have pure aqueous tear deficiency.
For patients with dry eye accompanied by redness, blepharitis, significant tarsal changes, or ocular allergy, he administers induction therapy with a topical steroid at one visit and then maintains them on cyclosporine for the long term. Once the patients are in a successful maintenance phase, Dr. Sheppard recommends that they use their steroid for acute flare-ups triggered by travel, allergies, respiratory infection, or exposure to environmental irritants.
His steroid of choice for this indication is loteprednol. The mainstay for graft preservation is topical steroids, even in the event of an acute immunologic attack. A bigger question is how long to keep the patient on steroids after a transplant. Many comprehensive ophthalmologists are not comfortable managing steroids indefinitely and may discontinue them. This is inadvisable because most cases of rejection occur in patients who stopped using steroids.
At the first sign of rejection—reduced vision, graft thickening, or photophobia—steroids should be started immediately, said Dr. Sins of omission and commission. For patients with Thygeson superficial punctate keratitis TSPK , some ophthalmologists steer clear of steroids because they worry that the lumps will return or become more persistent. McLeod has found that judicious use is very helpful in alleviating discomfort.
McLeod sometimes sees a patient with a corneal dendrite that was overlooked, and the patient is being treated with steroids for epithelial keratitis. This is definitely not recommended.
However, steroids do have a role in a specific type of epithelial herpetic keratitis: The answers can help you choose the appropriate treatment, said Dr. This algorithm also applies to scleritis, noted Dr. If the uveitis has an infectious component e. But you must treat concomitantly with aggressive antibiotic therapy. For uveitic conditions caused by an overactive immune system, such as ankylosing spondylitis, Vogt-Koyanagi-Harada syndrome, juvenile idiopathic arthritis, and birdshot chorioretinopathy, you need steroids for induction therapy and steroid-sparing immunosuppressive agents for maintenance therapy, said Dr.
When lecturing about uveitis treatment, Dr. Sheppard emphasizes zero tolerance for inflammation. Sustained-release corticosteroid implants are an exciting development for long-term therapy and are appropriate for advanced noninfectious posterior uveitis. Implants guarantee compliance, provide continuous dosing, avoid systemic toxicity, bypass gastrointestinal absorption, and eliminate the risks associated with topical toxicity, Dr.
A fluocinolone acetonide implant Retisert and a dexamethasone implant Ozurdex are currently approved in the United States. Retisert, which is implanted surgically, has a much longer duration of action up to three years than the dexamethasone implant about four to six months , which is administered by injection.
However, dexamethasone is more potent. It is currently used in Europe but not yet approved in the United States. Intravitreal steroids are major players in retinal practice, beyond posterior uveitis.
They are used to treat cystoid macular edema secondary to diabetes, retinal vein occlusions, exudative macular degeneration, and pseudophakia. Morse, mainly because of their side effects. The steroids used most frequently for intraocular administration are triamcinolone and dexamethasone, which may be given as injections Triesence and Kenalog, respectively.
Triamcinolone is believed to have high activity for two months; dexamethasone has a shorter clinical effect. Retisert fluocinolone and Ozurdex dexamethasone , the sustained-release implants discussed in the uveitis section, are used for vitreoretinal disorders, as well.