The response of ocular pressure to corticosteroids

Association Between the Use of Systemic Steroids and Ocular Hypertension as a Side Effect in Pediatric Population: A Systematic Review

Steroids are commonly used in children for the treatment of various medical conditions. However, systemic steroids can lead to the development of ocular hypertension (OHT), an increase in intraocular pressure. Limited literature is available on the systemic route of steroid administration in children and the development of this side effect. For literature writing and review, a thorough research was conducted across various platforms, such as PubMed, PubMed Central (PMC), Medline, and Cochrane Database of Systematic Reviews (CDSR). After all the screening processes and quality checks, 12 articles were finalized for review writing. The aim was to explore if OHT development is a common side effect developed in children on systemic steroid use for various medical conditions and if any particular risk factors were present among children that lead to its development. The results indicate that OHT is a common side effect of systemic steroid use in children. Children may or may not present with the symptoms of raised intraocular pressure. The development of OHT occurs within one month of the beginning of the steroid treatment in most of the reviewed studies. Several risk factors associated with developing this side effect were also found. In conclusion, systemic steroid use in children leads to the development of OHT. Awareness among healthcare professionals regarding this potential association is necessary. This information can be used to develop guidelines for serial ocular examinations in children on prolonged systemic steroid use.

Risk of ocular hypertension in children treated with systemic glucocorticoid

PURPOSE

To investigate the risk of steroid-induced ocular hypertension in children treated with systemic glucocorticoid.

METHODS

Prospective cohort study of children treated with high-dose systemic glucocorticoid (prednisolone-equivalent >0.5 mg/kg/day) for more than 2 weeks. Intraocular pressure (IOP) was measured by an Icare tonometer. An intraocular hypertensive response was defined as a net increase in IOP ≥6 mmHg from baseline or a peak IOP ≥21 mmHg in either eye. Patients with a peak IOP ≥31 mmHg or a net increase in IOP ≥15 mmHg were considered as high responders.

RESULTS

Sixteen children with median age 12 years (range 5-17) were included in the study. Nine children (56%) developed a steroid-induced ocular hypertensive response. Two children (12%) were high responders with peak IOP between 32 and 44 mmHg and a net increase in IOP between 15 and 23 mmHg. All children were asymptomatic and IOP was normalized in all after withdrawal of steroid. Steroid responders were significantly younger than nonresponders (p = 0.03). No associations were found between net IOP increase and time to peak pressure, steroid dose at peak pressure or accumulated prednisolone dose at peak IOP.

CONCLUSION

Systemic treatment of children with glucocorticoid can cause a significant increase in IOP which indicates the need for IOP screening of these children. The risk of steroid-induced ocular hypertension may depend on age and ethnicity. In this perspective, further studies on Caucasian children are needed.

Formulation and ex vivo evaluation of polymeric nanoparticles for controlled delivery of corticosteroids to the skin and the corneal epithelium

Controlled delivery of corticosteroids using nanoparticles to the skin and corneal epithelium may reduce their side effects and maximize treatment effectiveness. Dexamethasone-loaded ethyl cellulose, Eudragit® RS and ethyl cellulose/Eudragit® RS nanoparticles were prepared by the solvent evaporation method. Dexamethasone release from the polymeric nanoparticles was investigated in vitro using Franz diffusion cells. Drug penetration was also assessed ex vivo using excised human skin. Nanoparticle toxicity was determined by MTT and H2DCFDA assays. Eudragit® RS nanoparticles were smaller and positively charged but had a lower dexamethasone loading capacity (0.3-0.7%) than ethyl cellulose nanoparticles (1.4-2.2%). By blending the two polymers (1:1), small (105nm), positively charged (+37mV) nanoparticles with sufficient dexamethasone loading (1.3%) were obtained. Dexamethasone release and penetration significantly decreased with decreasing drug to polymer ratio and increased when Eudragit® RS was blended with ethyl cellulose. Ex vivo, drug release and penetration from the nanoparticles was slower than a conventional cream. The nanoparticles bear no toxicity potentials except ethyl cellulose nanoparticles had ROS generation potential at high concentration. In conclusion, the nanoparticles showed great potential to control the release and penetration of corticosteroids on the skin and mucus membrane and maximize treatment effectiveness.

Outcome of primary trabeculotomy ab interno (Trabectome) surgery in patients with steroid-induced glaucoma

To determine the efficacy and safety of Trabectome surgery on patients with steroid response, ranging from ocular hypertension refractory to maximal medical therapy to the development of steroid-induced glaucoma.A nonrandomized, nonblinded, retrospective study of 20 subjects with steroid response was conducted. All 20 eyes underwent Trabectome surgery alone. Nine subjects had steroid response with unremarkable visual field, 3 had mild steroid-induced glaucoma, and 8 had advanced steroid-induced glaucoma. Outcome measures included intraocular pressure (IOP), number of glaucoma medications, need for secondary glaucoma surgery, and steroid regimen. Mann-Whitney U test was used to compare postoperative IOP and number of medications to preoperative IOP and number of medications. Kaplan-Meier was used for survival analysis, and success was defined as: IOP reduced by 20% or more on any 2 consecutive visits after 3 months; IOP ≤21 mm Hg on any 2 consecutive visits after 3 months; and no secondary glaucoma surgery.The average preoperative IOP was 33.8 ± 6.9 mm Hg and average preoperative glaucoma medication usage was 3.85 ± 0.75 medications. At 12 months, the IOP was reduced to 15.00 ± 3.46 mm Hg (P = 0.03) and glaucoma medication was reduced to 2.3 ± 1.4 (P < 0.01). The survival rate at 12 months was 93%. At 12 months, 10 patients were continued on their preoperative steroid treatments, 5 were on tapered steroid treatments, and 5 had ceased steroid treatments entirely. One patient required secondary glaucoma surgery (glaucoma drainage device). No other complications were noted.The Trabectome procedure is safe and highly effective for steroid-response glaucoma, even in the context of continued steroid treatment.

Pathological findings of pemphigus vulgaris showing giant cobblestone-like conjunctival papillae

Purpose

To describe the pathophysiological findings of a patient with pemphigus vulgaris (PV) showing giant conjunctival papillae.

Methods

A 64-year-old man who had mucosal-dominant PV with giant conjunctival papillae, resembling those of vernal keratoconjunctivitis (VKC), underwent an ophthalmological workup. The clinical and pathological findings were investigated.

Results

Ophthalmic interventions were unable to provide the desired beneficial effects, and multiple excisions were necessary to remove the proliferative conjunctival lesions. Histopathological investigations of the excised tissues demonstrated acantholysis and a subconjunctival infiltration with numerous inflammatory cells such as lymphocytes, plasma cells, and neutrophils. However, in contrast to typical VKC, mast cells and eosinophils were rarely found in the subconjunctival tissues. Direct immunofluorescent staining showed a significant deposition of immunoglobulin G and complement component 3 in the epithelial intercellular substance, consistent with mucosal-dominant PV. Then, the patient was hospitalized because of oral erosion exacerbation and malnutrition. Because of the patient's declining general condition, we administered an increasing dose of a systemic steroid with an intravenous immunoglobulin, after which his ocular lesions and symptoms improved.

Conclusions

The histological conjunctival papilla findings were quite different from those of VKC papillae. If PV causes a lesion in a patient, systemic immunosuppression might be more effective than topical ophthalmic treatment because of overall immunological involvement.

Release of Ciprofloxacin-HCl and Dexamethasone Phosphate by Hyaluronic Acid Containing Silicone Polymers

The purpose of this study was to determine the effect of the covalent incorporation of hyaluronic acid (HA) into conventional hydrogel and hydrogels containing silicone as models for contact lens materials on the uptake and release of the fluoroquinolone antibiotic ciprofloxacin and the anti-inflammatory steroid dexamethasone phosphate. A 3 mg/mL ciprofloxacin solution (0.3% w/v) and a 1 mg/mL dexamethasone phosphate solution (0.1%) was prepared in borate buffered saline. Three hydrogel material samples (pHEMA; pHEMA TRIS; DMAA TRIS) were prepared with and without the covalent incorporation of HA of molecular weight (MW) 35 or 132 kDa. Hydrogel discs were punched from a sheet of material with a uniform diameter of 5 mm. Uptake kinetics were evaluated at room temperature by soaking the discs for 24 h. Release kinetics were evaluated by placing the drug-loaded discs in saline at 34 °C in a shaking water bath. At various time points over 6–7 days, aliquots of the release medium were assayed for drug amounts. The majority of the materials tested released sufficient drug to be clinically relevant in an ophthalmic application, reaching desired concentrations for antibiotic or anti-inflammatory activity in solution. Overall, the silicone-based hydrogels (pHEMA TRIS and DMAA TRIS), released lower amounts of drug than the conventional pHEMA material (p < 0.001). Materials with HA MW132 released more ciprofloxacin compared to materials with HA MW35 and lenses without HA (p < 0.02). Some HA-based materials were still releasing the drug after 6 days.

Steroid-induced iatrogenic glaucoma

Steroids in susceptible individuals can cause a clinical condition similar to primary open-angle glaucoma. Five percent of the population are high steroid responders and develop an intraocular pressure (IOP) elevation of more than 15 mm Hg above baseline. IOP elevation may occur as early as 1 day to as late as 12 weeks after intravitreal triamcinolone in 20-65% of patients. On average, 75% of eyes with steroid implants require IOP-lowering therapy at some point within 3 years of follow-up. The exact mechanism of steroid-induced glaucoma is not totally understood, but decreased trabecular meshwork outflow is regarded as the main cause of IOP elevation. High-risk patients who receive steroids should be monitored closely and if they develop elevated IOP, steroids with lower potency or steroid-sparing agents should be used. The IOP usually returns to normal within 2-4 weeks after stopping the steroid. About 1-5% of patients do not respond to medical therapy and need surgery. Trabeculectomy, trabeculotomy, shunt surgery, and cyclodestructive procedures are among the methods employed. Removal of residual sub-Tenon or intravitreal steroids may help hasten the resolution of the steroid response. Early results with anecortave acetate, an analog of cortisol acetate with antiangiogenic activity, in controlling IOP have been promising.

Bernard Schwartz, MD, PhD, Founding Chair of Ophthalmology, Tufts University School of Medicine, and Founding Editor of Survey of Ophthalmology

Bernard Schwartz, MD, PhD (1927-2007) was first and foremost a scholar. He was a teacher, serving as Professor of ophthalmology for many years at Tufts University; an administrator, chairing the department of ophthalmology for over 20 years; a clinician, practicing primarily in the field of glaucoma; a scientist with a broad interest in ophthalmic research; an historian, especially of medical history; and an editor, primarily of Survey of Ophthalmology. Throughout all of his activities, the central theme was always scholarship.

A Sick Eye in a Sick Body? Systemic Findings in Patients with Primary Open-angle Glaucoma

Despite intense research, the pathogenesis of primary open-angle glaucoma (POAG) is still not completely understood. There is ample evidence for a pathophysiological role of elevated intraocular pressure; however, several systemic factors may influence onset and progression of the disease. Systemic peculiarities found in POAG include alterations of the cardiovascular system, autonomic nervous system, immune system, as well as endocrinological, psychological, and sleep disturbances. An association between POAG and other neurodegenerative diseases, such as Alzheimer disease and Parkinson disease, has also been described. Furthermore, the diagnosis of glaucoma can affect the patient's quality of life. By highlighting the systemic alterations found in POAG, this review attempts to bring glaucoma into a broader medical context.

Decreased response of plasma cortisol to intravenous metyrapone in ocular hypertension and primary open-angle glaucoma

PURPOSE

To determine if there is a difference in response to metyrapone, which blocks the conversion of 11-deoxycortisol to cortisol in the adrenal gland between normals and ocular hypertensives (OH) plus primary open-angle glaucomas (POAG) without pigmented angles.

METHODS

Intravenous metyrapone was given to 20 normals and 15 ocular hypertensives plus primary open-angle glaucomas without pigmented angles. Blood samples were obtained at 4, 6, and 8 hours after administration of intravenous metyrapone for analyses of 11-deoxycortisol and cortisol.

RESULTS

The ocular hypertensives plus primary open-angle glaucoma group showed significantly lower cortisol values compared with the normal group at 6 hours (P = 0.002) but not at 4 or 8 hours. There were no significant differences between the two groups for 11-deoxycortisol values at 4, 6, or 8 hours. The percent decrease of plasma cortisol from baseline was significantly greater for the ocular hypertensives plus open-angle glaucoma group compared with the normals at 4 hours (P = 0.010) and 6 hours (P = 0.0004). Significant negative correlations were observed for the total group of subjects between levels of plasma cortisol at 6 hours and intraocular pressure, worse eye (P = 0.029), percent area of cupping, worse eye (P = 0.045), pallor, worse eye (P = 0.001), and visual field loss, worse eye (P = 0.048), so that the less the plasma cortisol, the greater the abnormality of the glaucomatous parameters. Multivariate analyses with the 6-hour plasma cortisol level as the dependent variable showed that the only significant (P = 0.0004) independent variable was the percent area of pallor, worse eye, associated with a smaller level of plasma cortisol at 6 hours. Similarly, the multiple regression models using the percent change from baseline of the 6-hour plasma cortisol value showed a significant association of larger percent decreases of plasma cortisol in the ocular hypertensives plus open-angle glaucoma compared with the normals.

CONCLUSIONS

The ocular hypertensives plus primary open-angle glaucoma subjects show greater adrenal inhibition to metyrapone in the synthesis of cortisol from 11-deoxycortisol compared with normals. This observation suggests an adrenal abnormality in the ocular hypertensive plus primary open-angle glaucoma subjects.

Dose response of dexamethasone for the enhanced ocular hypotensive response to epinephrine in rabbits with prior dexamethasone treatment

We have previously shown that administration of epinephrine to the rabbit eye with dexamethasone pretreatment resulted in a significant decrease in intraocular pressure (IOP), compared to the use of epinephrine alone. Furthermore, this decrease in IOP is dose-dependent on epinephrine with the largest response of decrease of IOP occurring at the lower doses of epinephrine. We now extend this study to determine whether the decrease in IOP is dose-dependent on dexamethasone. Rabbit eyes were pretreated with five applications of topical dexamethasone or saline, administered at fifteen-minute intervals. Eyes were then treated with 0.005% epinephrine (0.01% epinephrine bitartrate). IOP was monitored for the next four hours. Different groups of rabbits received varying concentrations of dexamethasone base, from 0.0004% to 0.07% (dexamethasone phosphate), and a dose response curve was obtained. When compared to eyes treated with epinephrine alone, eyes pretreated with dexamethasone showed a significantly greater decrease in pressure at free base dexamethasone concentrations of 0.07%, 0.007% and 0.0007%, with the greatest difference at the 0.007% concentration (mean = 6.8 mm Hg). Similarly, the duration taken for the IOP to return to baseline levels was prolonged in the groups receiving dexamethasone pretreatment. The synergism between dexamethasone and epinephrine in lowering IOP may be a useful alternative in the treatment of ocular hypertension and glaucoma especially using a combination of a low dose of epinephrine with a low dose of dexamethasone.

Reduced plasma cortisol binding to albumin in ocular hypertension and primary open-angle glaucoma

PURPOSE

To compare plasma cortisol binding as well as total plasma cortisol, free cortisol and percent free cortisol in normals, ocular hypertensives and primary high pressure open-angle glaucomas.

METHODS

Blood samples were obtained on outpatient visits of 18 normals, 19 ocular hypertensives and 18 primary open-angle glaucomas. Plasma cortisol binding was determined after the endogenous steroids were removed by charcoal absorption. Scatchard analysis was used to determine both the affinity of binding and the cortisol binding capacity of corticosteroid binding globulin and albumin. Plasma total and free cortisol were measured by radioimmunoassay.

RESULTS

Both the ocular hypertensive and the open-angle glaucomas in comparison to normals were found to have a highly significant reduced cortisol binding capacity to albumin (p = 0.006) with a borderline significantly increased binding affinity to plasma corticosteroid binding globulin (p = 0.0495) and no significant difference in binding affinity to albumin or cortisol binding capacity to plasma globulin. Both the ocular hypertensives and the open-angle glaucomas in comparison to normals were found to have significantly elevated levels of free cortisol (p = 0.012) and percent free cortisol (p = 0.003). Multivariate analyses showed that the reduced cortisol binding capacity to albumin was significantly associated with an increased percent free cortisol, with ocular hypertension and open-angle glaucoma and with male gender.

CONCLUSION

Both ocular hypertension and primary open-angle glaucoma are associated with elevated levels of plasma free cortisol which are related to a reduced cortisol binding capacity to albumin.

Ocular toxicity and cancer chemotherapy. A review

BACKGROUND

Systemic anticancer therapies can produce acute and chronic organ damage, but the eye is usually considered a protected site. Nonetheless, the oculo-visual system has a potentially high degree of sensitivity to toxic substances. Ocular toxicity induced by cancer chemotherapy includes a broad spectrum of disorders, reflecting the unique anatomic, physiologic, and biochemical features of this essential organ.

METHODS

A review of the literature regarding the ocular toxicity of chemotherapeutic agents, hormonal agents, biologic agents, and high dose chemotherapy with allogeneic and autologous bone marrow transplantation was conducted.

RESULTS

Ocular toxicity induced by anticancer chemotherapy is not uncommon. The development of more aggressive regimens as well as new agents and combination chemotherapies have resulted in a significant increase of reported cases of chemotherapy-induced ocular side effects. In most instances, the mechanisms of ocular toxicity continue to be poorly understood.

CONCLUSIONS

Ocular toxicities induced by chemotherapeutic agents are generally not preventable; therefore, clinicians must be aware of potential vision-threatening complications. Prompt consultation with an ophthalmologist can lead to early detection, proper diagnosis, and appropriate therapeutic measures. Dose reduction or discontinuation of incriminated drugs may help in reducing the severity and the duration of side effects.

Risk factors of ocular hypertension and glaucoma. The Casteldaccia Eye Study

A case-control study was planned as a part of the Casteldaccia Eye Study in order to investigate about risk factors of ocular hypertension and glaucoma. Cases were 44 subjects with glaucoma or intraocular pressure of 24 mm Hg or more. Controls were 220 subjects with intraocular pressure of 20 mm Hg or less and no signs of glaucoma. A number of environmental, behavioral, systemic and ocular variables were studied. Among the others we investigated the following: sunlight exposure, smoking, alcohol intake, pregnancies, systemic hypertension, diabetes, use of corticosteroids, refractive status, anterior chamber depth, lens nuclear sclerosis, iris color and texture. After univariate analysis the use of ocular corticosteroids and antibiotics, myopia, shallow anterior chamber and myopic macular degeneration were associated with ocular hypertension or glaucoma. However, the logistic regression showed that only the use of ocular corticosteroids (odds ratio = 7.79) and the myopia (odds ratio = 5.56) were independently associated.

Identification of high intraocular pressure responders to topical ophthalmic corticosteroids

To locate suitable candidates to study the intraocular pressure (IOP) effects of new ocular steroids, healthy volunteers must be challenged with topically applied steroids to verify that such individuals are indeed high "steroid responders"; that is, they respond with IOP elevations of at least 5 mmHg during a 4- to 6-week challenge with the topically applied steroid. We used first-degree offspring of individuals with primary open-angle glaucoma to develop a model to identify high steroid responders to topical ophthalmic prednisolone. We conducted a prospective, randomized, open-label, placebo-controlled study of prednisolone phosphate 1.0% in which 13 subjects received either topical prednisolone phosphate 4 times daily to the right eye and placebo to the left eye, or vice versa. Baseline evaluations occurred on study Day 0, and follow-up examinations were on Days 7, 14, 21, 28, 35, and 42. The medications were administered continuously for 6 weeks or until the IOP rose > or = 10 mmHg. After the effect of diurnal variation in IOP was taken into account, 4 of the 13 subjects (31%) had a maximum elevation in IOP of 4 mmHg or less, 7 subjects (54%) showed maximum elevations in IOP of 5 to 9 mmHg, and 2 subjects (15%) had a maximum IOP elevation of > or = 10 mmHg. Thus, a cumulative total of 9 subjects (69%) had IOP elevations of at least 5 mmHg and could be classified as moderate to high steroid responders. This model should become useful as a productive source of subjects for studies evaluating the effect on IOP of new ocular steroids.

Ocular complications of systemic cancer chemotherapy

Cancer chemotherapy has changed rapidly in recent years. New agents are constantly being developed. Established agents are being used with increased frequency, in new combinations, at higher dosages, and via new routes of administration. Enhanced survival, as well as increased drug toxicity, has resulted. Ocular toxicity is not uncommon and can greatly impact on quality of life. Practitioners in all fields are increasingly caring for patients who are receiving cancer chemotherapy. The recognition of eye disease resulting from chemotherapy is essential to appropriate patient management. We provide a review of the rapidly growing body of literature on the ocular toxicity of systemic cancer chemotherapy with particular attention to context, clinical course, mechanism, prevention and treatment.