Is the Risk of Steroid-Associated IOP Elevation Overblown?
Many clinicians retain an disproportionate concern about secondary
increased IOP with steroid usage. A study of known steroid
responders nicely addresses this issue.
In this study, a group of steroid responders was treated with
four different steroids: rimexolone, fluorometholone, dexamethasone
and prednisolone.1 The results showed that IOP didn’t start
to rise until after three weeks of treatment with prednisolone
and dexamethasone, and five weeks with the relatively IOP-sparing
rimexolone and fluorometholone.
The beauty of these findings is that in the worst of scenarios,
there is about a three-week window of relative safety when
treating with a topical ophthalmic corticosteroid. The great
majority of inflammatory eye disorders are controlled well
within this time frame, which explains why IOP increases are
not a substantial concern in the medical management of eye
disorders.
Interestingly, topical steroids may in some cases actually
help lower IOP. When a patient presents with severe inflammation
and concurrent increased intraocular pressure—indicating that
inflammatory debris or trabecular inflammation itself has retarded
aqueous outflow—steroids suppress the trabeculitis and the
inflammation. This in turn helps reestablish normal outflow
facility and reduces IOP. Examples of this are glaucomatocyclitic
crisis and post-zoster uveitis.
Traditional thinking holds that increased IOP is a major pitfall
in steroid therapy. This, plus a fear of causing posterior
subcapsular cataracts, makes many clinicians gun-shy when it
comes to prescribing topical steroids.
The truth is that these side effects are extremely rare when
steroids are used short term—that is, three weeks or less.
If longer suppressive therapy is needed, then consider a relative
IOP-sparing steroid such as loteprednol 0.5%. Steroids are
extremely useful in managing most acute eye presentations,
and are by far the most common acute care drugs we prescribe.
1. Leibowitz HM, Bartlett JD, Rich R, McQuirter H, Stewart
R, Assil K. Intraocular pressure-raising potential of 1.0%
rimexolone in patients responding to corticosteroids. Arch
Ophthalmol 1996 Aug;114(8):933-7.
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