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The Application of Topical, Injection, and
Oral Corticosteroids in Ocular Disease Management
- Mechanism of Action of Steroids
- Steroids Commonly Used in Clinical Practice
- Ocular Indications for Steroid Use
- Take Steroids with Food
- Tapering Steroid Dosages
- Treatment of Ocular Conditions
- Ocular and Systemic Side-Effects of Steroids
- Contraindications of Using Steroids
- Systemic Steroid Perscribing
Dry Eye Syndrome
The last few years have shown greater evidence that steroids may play a beneficial role in the initial short-term management of dry eye. The 2007 Report of the International Dry Eye Workshop (DEWS) described several clinical trials that demonstrated an improvement in the inflammatory nature of dry eye with topical ophthalmic methylprednisone 1% or lotoprednol 0.5% (Lotemax) on a four times a day drop dosage. The US Food and Drug Administration (FDA) labels topical ophthalmic steroids for the treatment “…of steroid responsive inflammatory conditions of the palpebral and bulbar conjunctiva, cornea and anterior segment of the globe such as allergic conjunctivitis, acne rosacea, superficial punctate keratitis, herpes zoster keratitis, iritis, cyclitis, selected infective conjunctivitides….” Based on this labeling, topical ophthalmic steroids may be indicated for treatment of keratoconjunctivitis sicca (KCS) due to dry eye. Further support for the inflammatory aspect of dry eye is seen in the increased benefit of topical ophthalmic cyclosporine 0.005% (Restasis), an antimetabolite drug that reduces the production of inflammatory cytokines that potentiate the dry eye cycle. Clinical use of steroids for KCS has been primarily with initiating ‘soft’ steroids (i.e. those that have less ocular side-effects) such as Lotemax or Alrex (lotoprednol 0.2% ophthalmic suspension) on a QID dosage for 1 to 4 weeks, reducing to BID dosage for another 4 to 8 weeks. This can be done in conjunction with preservative-free ocular lubricants. If improvement or resolution of signs or symptoms of dry eye results, then conversion to long-term ophthalmic cyclosporine 0.005% on BID dosage can be prescribed. At this time, long-term use of steroids for the management of dry eye syndrome is not recommended.
Uveitis is probably the most common ocular indication for steroid treatment seen in optometric practices. A general rule of thumb is to “hit hard” (i.e., initially use a topical steroid at least every 2 hours then taper), and use a steroid with good anti-inflammatory potency (such as ophthalmic prednisone acetate 1%) in combination with cycloplegia of the affected eye. Posterior uveitis, in which the patient may show haze and cells in the vitreous and/or chorioretinal inflammation, usually requires oral steroid treatment in addition to topical treatment. Determining the underlying etiology of uveitis is also essential. It is possible that the underlying etiology also requires an oral steroid for treatment – particularly if the cause is of an autoimmune nature.
Subconjunctival steroid injections are sometimes used in uveitis cases, but there is greater risk of ocular side effects such as globe perforation, posterior subcapsular cataract formation and ocular hypertension due to the bolus of steroid present. Regardless of route of administration, steroid dosages should be tapered appropriately once resolution begins.
Contact dermatitis is a type IV (cell-mediated) allergic reaction involving the eyelids and conjunctiva. It is typically caused by cosmetics as well as numerous antibiotics, preservatives, and other medications or chemicals. Removing the offensive substance is first priority, combined with cool compresses and possibly oral tetracycline or doxycycline.
Topical steroid ointments or creams such as 0.5% to 1% hydrocortisone or 0.1% dexamethasone three times a day for a few days may be very useful in reducing edema and inflammation. However, the practitioner should be aware that combination antibiotic/steroid drugs may worsen the condition if the patient is sensitive to the associated antibiotic (ie: neomycin). Also, fluorinated steroids can cause persistent dermatitis.
Occasionally, patients may present with scaly, itchy eyelids or periocular skin that indicates eczematous inflammation. These patients also benefit from topical steroid ointments or creams, as noted above. Once resolution begins, tapering of the steroid can occur.
Scleritis, typically involving inflammation of the scleral, episcleral, and conjunctival vessels, is another ocular condition in which steroids may be necessary. Their use may be indicated if NSAIDs are ineffective in treating the associated eye pain.
The presentation of scleritis is almost always raises the suspicion for underlying autoimmune disease such as rheumatoid arthritis or other connective tissue disorders, so, like certain uveitides, oral steroid treatment may benefit both the ocular and systemic conditions concurrently.
Typical dosage is 60 to 100 mg of oral prednisone per day for one week, followed by no more than a 10 mg per day taper for two to three weeks. It should be noted that topical steroids have limited effectiveness with scleritis, and that subconjunctival steroid injections are contraindicated with scleritis due to the higher risk of tissue necrosis.
Chalazia are longstanding sterile granulomatous infiltrations of the meibomian glands resulting from a quiescent hordeola. They can also appear spontaneously. The patient reports a hard, immobile lump that is not painful to the touch. Most chalazia are simply an irritant or cosmetic inconvenience, and one in four resolve without treatment.
Persistent chalasia that do not respond to warm compresses, digital massage, and oral antibiotics may require curettage and excision or an intralesional injection of steroid such as triamcinolone (Kenalog). After local anesthesia, a dose of 0.05 to 0.3 ml of a 5 to 40mg/mL suspension can be injected into the lesion using a 27-30 gauge needle. Resolution typically occurs in 1-2 weeks, but may require a second injection a few weeks later if the chalazion is large. The steroid serves to suppress the inflammatory cells that reside within the chalazion.
Depigmentation of the skin at the injection site may occur, but may be avoided by conjunctival versus transepithelial injection. The depigmentation usually reverses.
Arteritic Anterior Ischemic Optic Neuropathy
Arteritic Anterior Ischemic Optic Neuropathy (also known as temporal arteritis) is an indication for the immediate prescription of oral prednisone. Classic findings include jaw claudication, tenderness of the temporal scalp area and the head and neck areas, notably reduced vision in one eye, and an elevated Erythrocyte Sedimentation Rate (ESR).
This idiopathic vasculitis typically affects 1:1000 individuals over the age of 50, most often women. Up to 75% of patients who have reduced vision in one eye (the typical initial presentation) will develop reduced vision in the contralateral eye within 24 hours to weeks, resulting in bilateral blindness in up to half of untreated patients. Although prognosis for the initially involved eye is poor, prompt steroid treatment (either oral or intravenous) may prevent the incidence of contralateral eye involvement to less than 1% over a five-year duration.
Usually treatment with 80-120 mg/day of prednisone may be initiated, but if significant visual reduction is present, up to 250 mg of intravenous hydrocortisone or 250 mg of methylprednisone every 6 hours for four days is preferred over oral treatment. The patient should be referred promptly for hospitalization and adjustment of steroid dosage according to symptoms and ESR levels. Oral prednisone 80-100 mg/day for 2-3 weeks typically follows the intravenous treatment with dosages tapered over several months to years.
Optic neuritis is another condition in which steroids can play an important treatment role. Typically in younger patients (e.g., ages 18-45 years), optic neuritis may be associated with a relatively sudden onset of pain on eye movement, poor to no pupil response in the affected eye or eyes, variable visual field defects, desaturation of color vision, and/or loss of visual acuity. Causes range from idiopathic to infective to systemic conditions such as multiple sclerosis, so the practitioner must first try to determine the cause if possible before initiating treatment.
The Optic Neuritis Treatment Trial (ONTT) demonstrated that using oral steroids alone may actually exacerbate the condition. The preferred treatment is intravenous methylprednisolone for the first few days followed by oral prednisone tapered over a few weeks.
Determining and treating the underlying cause is the most important management approach. One must remember that steroids are considered palliative therapy – that is, they suppress the inflammatory response (and often the pain associated with the inflammation) but the underlying cause of the disease remains.
Steroid treatment for herpetic keratitis has been a controversial subject. Steroids typically slow epithelial healing and suppress the host immune response, which may set the stage for worsening of the herpetic infection or lead to stromal keratitis.
Therefore, it is not recommended by this author to use steroids with epithelial dendritic keratitis. However, should the inflammation move to the stroma (e.g., disciform keratitis), topical steroids should be used alternating with antiviral medications several times per day to reduce the potential of stromal scarring and visual loss. Steroids also reduce stromal inflammation that impedes proper cornea epithelial migration.
Topical antibiotic/steroid ointment applied two to four times daily to vesicular skin lesions along the dermatome may be useful in cases of severe zoster-related post-herpetic neuralgia. Topical steroids can be also used to treat the many forms of herpes zoster keratitis that involve the corneal stroma, in conjunction with antiviral medications.
Although currently not part of the optometrist’s scope of practice, the benefits of intravitreal and sub-Tenon’s injections of steroid in the resolution of macular edema and inflammation has been increasingly noted both clinically, and in several studies. Ocular coherence tomography and fluorescein angiography have shown a faster resolution of macular swelling with intravitreal triamcinolone (Kenalog) injection. Typically a 4mg amount is injected into the vitreal space. Use of triamcinolone for the treatment of clinically-significant macular edema (CSME) and certain forms of macular degeneration have also been investigated, with positive results. Further protocols are being developed in the use of triamcinolone injections for these retinal conditions. For further information on this treatment, refer to the author’s other web C.E. article: Acquired Macular Diseases: Pathophysiology, Diagnosis and Management.
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