[Retina and glaucoma: therapeutic considerations]

This review describes the possible interactions between several retinal diseases, their treatment, and intraocular pressure (IOP). The use of the intravitreal route in the delivery of drugs to the retina has recently gained widespread acceptance with the development of the VEGF inhibitors and glucocorticoids such as triamcinolone. Although the intravitreal route offers high local concentrations in the vitreous, in the retina these advantages are offset by side effects, particularly short-term and chronic elevation of IOP. This review describes the clinical features of steroid glaucoma induced by triamcinolone or sustained-release systems of glucocorticoid drugs. Another aspect of the relationships between glaucoma and retina is also described: published reports of the occurrence of cystoid macular edema (CME) in eyes being treated with the prostaglandin analogs (PGAs) have led to concern regarding a possible causal relationship between the two. A review of the literature suggests that most PGA-treated eyes with CME had independent risk for development of CME, with a disruption of the blood-aqueous barrier: open or absent posterior capsule, history of dipivefrin-associated CME, epiretinal membrane, complicated cataract surgery, history of macular edema associated with branch retinal vein occlusion, ocular inflammation, and diabetes mellitus. In eyes at risk for CME, the use of PGAs is acceptable but must be prudent.

Oculohypotensive effects of foeniculum vulgare in experimental models of glaucoma

PURPOSE

Evaluation of oculohypotensive activity of single drop application of aqueous extract of Foeniculum vulgare in experimental models of glaucoma.

METHODS

The evaluation of oculohypotensive activity of Foeniculum vulgare was done in rabbits with normal intraocular pressure (IOP) and with experimentally elevated IOP. The experimental increase in IOP was achieved using water loading and steroid induced glaucoma models.

RESULTS

The aqueous seed extract of Foeniculum vulgare exhibited 17.49, 21.16 and 22.03% reduction of intraocular pressure (IOP) in normotensive rabbits at 0.3%, 0.6% and 1.2% (w/v) concentrations respectively. The 0.6% concentration was further evaluated in acute and chronic models of glaucoma. A maximum mean difference of 31.20% was observed between vehicle treated and extract treated eyes in water loading model while a maximum mean IOP lowering of 31.29% was observed in steroid induced model of glaucoma.

CONCLUSIONS

The aqueous extract of Foeniculum vulgare possesses significant oculohypotensive activity, which was found to be comparable to that of timolol. Further investigations into the mechanism of action, possible toxicity and human clinical trials are warranted before the Foeniculum vulgare finds place in the arsenal of antiglaucoma drugs prescribed by physicians.

Steroid-induced glaucoma in an infant

A 3-week-old infant developed buphthalmos and glaucoma after a 1-week course of topical steroid drops. The glaucoma resolved after cessation of the medication. This report underscores the sensitivity of infants and very young children to steroid-related intraocular pressure rises.

Thyroid remnant radioiodine ablation in a case of concurrent thyroid carcinoma, Graves' disease, and thyroid ophthalmopathy

High-dose I-131 thyroid remnant ablation postthyroidectomy for differentiated thyroid carcinoma is beneficial but the risk of visual complications including loss of vision in patients with coexisting Graves' ophthalmopathy is not well documented. We report the case of a 42-year-old man who presented for radioiodine ablation post total thyroidectomy for metastatic papillary carcinoma, who also had Graves' ophthalmopathy and juvenile onset glaucoma. Concurrent presence of all these conditions in the same patient is rarely encountered and this case demonstrates the challenge faced by the clinicians in balancing the benefits and risks of currently recommended management strategies for these conditions. There is a potential risk of visual complications with I-131 therapy in patients with Graves' disease as it can lead to development of or exacerbation of preexisting ophthalmopathy. The acute exacerbation is usually transient and preventable with prophylactic corticosteroids. However, the use of corticosteroids is associated with various complications including exacerbation of glaucoma as demonstrated in this patient.

Clinical Side Effects during Aerosol Therapy: Cutaneous and Ocular Effects

Aerosolized medications maximize clinical benefit by targeting the airways and minimize side effects by reducing (though not eliminating) systemic exposure. Aerosolized drugs delivered with a facemask may inadvertently deposit on the face and in the eyes, raising concerns about cutaneous and ocular side effects with these drugs. Cases of anisocoria have been reported from exposure of the eyes to aerosol bronchodilators. Whether inhaled corticosteroids (ICS) can cause skin and eye problems like those seen with systemic or topical steroids is more difficult to answer. Patients who take ICS may have other corticosteroid exposures, or have other conditions that predispose them to side effects, making the analysis of the ICS risk challenging. Also, many studies were not designed to search for cutaneous or ocular effects, or may have been too short to detect these effects. Nevertheless, ICS have been associated with an increased risk of skin thinning, bruising, cataracts and possibly glaucoma in adults, but not in children. The risks increase with advanced age, higher doses, and longer duration of use. In children, the risks of cataracts and glaucoma were negligible with ICS, whether a mouthpiece or a mask interface was used. Side effects like skin rash and conjunctivitis occurred at low frequencies similar to placebo or comparator drugs. We do not know whether exposed children will have increased risks from ICS later in life. Therefore, it is wise to avoid face and eye deposition when possible, and to use the minimally effective dose.

Linsenveränderungen nach Langzeittamponade mit schwerem Öl (Densiron®)

BACKGROUND

This study aims to analyse the long-term effect of Densiron on the crystalline lens.

MATERIALS AND METHODS

Eleven patients (53-77 years old) underwent macular surgery with pars plana vitrectomy and intraocular tamponade with Densiron. After 2-4 months the Densiron was removed. The lens was extracted by phacoemulsification and an intraocular lens was implanted. Visual acuity, slit-lamp examination and fundus ophthalmoscopy were performed pre- and postoperatively. During surgery the anterior chamber, the lens und the posterior capsule of the lens were photographed and analysed.

RESULTS

All patients (mean age: 68 +/- 7 years) developed a nuclear cataract combined with a posterior capsule opacification. Four patients demonstrated vacuoles within the lens cortex and in five patients a pseudohypopyon consisting of emulsified Densiron was found. Mean visual acuity was 0.1 before removal of Densiron and 0.1 postoperatively.

CONCLUSIONS

Long-term tamponade with Densiron was complicated by early cataract formation in patients aged 68 years on average. The additional posterior capsule opacification showed a distinct pattern and localisation when compared to the use of 5000 mPas-silicone oil as tamponade.

[Treatment of diabetic macular edema with intravitreal triamcinolone acetonide injection: functional and anatomical outcomes]

PURPOSE

This prospective study aimed to investigate the effectiveness and safety of intravitreal triamcinolone acetonide (TA) injection in diabetic macular edema unresponsive to an initial argon laser photocoagulation procedure.

MATERIAL

and methods: Fifty-six eyes of fifty patients were included in this study. All the eyes had refractory and clinically significant diabetic macular edema with a central macular thickness (CMT) greater than 300 microm. All the eyes were injected 4 mg/0.1 ml TA intravitreally. The main outcome parameters were best corrected visual acuity (BCVA) and CMT. Elevation of intraocular pressure (IOP) and other potential complications were monitored carefully. All the patients were followed at least 9 months.

RESULTS

Preinjection mean BCVA was 0.128+/-0.11 and statistically significant improvement in BCVA started in the 1st week and was observed during the first 6 months of the follow-up period. BCVA reached 0.289+/-0.19 at the 2nd month and decreased gradually to 0.169+/-0.1 at the 9th month. However, clinically significant improvement after TA injection in BCVA (> or =0.2) was observed in 50%, 67.8%, 67.8%, 28.5%, and 12.5% of the eyes in the 1st, 2nd, 3rd, 6th, and 9th months, respectively. The central macular thickness measured by OCT, which was reduced by 45% at the 3rd month, returned nearly to its initial level at the 9th month. High IOP was observed in 35.7% of eyes and appeared between the 1st week and the 2nd month. Other complications were cataract development and progression (7.1%), pseudoendophthalmitis (3.56%), and bacterial endophthalmitis (1.78%).

CONCLUSION

Intravitreal TA injection is a relatively safe and beneficial therapeutic method for intractable diabetic macular edema. The recurrence of edema warrants reinjections, even though the risk of complication is higher, especially infectious endophthalmitis, which might be devastating. Further studies should be conducted with newer, slow corticosteroid release methods such as intravitreal devices in the treatment of diabetic macular edema.

Safety considerations of intranasal corticosteroids for the treatment of allergic rhinitis

Allergic rhinitis (AR) is a major chronic inflammatory disease of the upper airways. AR is increasing in prevalence and causes negative effects on quality of life, impairs performance and productivity, and imposes a serious economic burden. More than 20% of the American population suffers from AR. Intranasal corticosteroids (INS) are an effective and safe first-line treatment for AR, with potent anti-inflammatory properties and a high therapeutic ratio. The systemic bioavailability of the majority of INS is relatively low; however, the pharmacokinetics of absorption, first-pass metabolism, volume of distribution, half-life, and clearance of INS varies considerably, depending on lipophilicity, receptor affinity, and lipid conjugation in the nasal tissue. The short-term (e.g., effect on linear lower-leg growth rate) and long-term (e.g., effect on height) systemic side effects of INS in patients with AR are determined by these important characteristics. AR is present in up to 75% of patients with asthma, and patients with AR are three times more likely to develop asthma compared with patients without AR. Therefore, the overall increased systemic steroid burden resulting from concomitant use of inhaled corticosteroids (ICS) and INS in adult and pediatric patients with comorbid AR and asthma warrants critical monitoring of systemic side effects. This review evaluates the overall safety of INS in AR and the importance of systemic safety considerations of INS, particularly when coadministered with ICS.

[Origin of corticosteroid glaucoma]

Cortisonic glaucoma is frequent, clinically similar to chronic open angle glaucoma but directly linked to a corticosteroid treatment. Four risk factors are involved in the hypertonic effect of steroids: genetic ground: primary open angle glaucoma, diabetes, myopia, young age; intraocular penetrance and anti-inflammatory efficacy; the mode and duration of administration.

Glaucome cortisonique : étude épidémiologique, clinique et thérapeutique

INTRODUCTION

Cortisone glaucoma is a secondary glaucoma induced by local or oral steroids used to treat chronic inflammatory diseases.

PATIENTS AND METHODS

Retrospective study including 43 eyes of 23 patients (three patients were monophthalmos). We present epidemiological and clinical features with evaluation of functional damage (visual acuity, visual field), and therapeutic results with a follow-up period ranging from 2 to 10 years.

RESULTS

Topical steroids were incriminated in 15 of 23 cases (self-medication), whereas general steroids (for chronic diseases) were used by eight patients. Visual function was seriously affected (visual acuity<1/10 in 23/43 eyes at the first visit with pronounced visual field abnormalities). Surgery was necessary in 16 of 43 eyes (deep sclerectomy with or without implant, trabeculectomy).

DISCUSSION

Cortisone glaucoma is rather frequent in Tunisia where conjunctival allergy and self-medication are common. Young adults are concerned, making it a high surgical risk usually requiring surgical devices such as a T Flux implant.

CONCLUSION

Cortisone glaucoma is a serious complication of steroid therapy that usually affects young adults. The disease is usually detected late, explaining the severe functional damage.

[Acute glaucoma originating from medication]

Secondary angle-closure glaucoma with pupillary block can be related with anticholinergic drugs or sympathicomimetics alpha1. Secondary angle-closure glaucoma with ciliary body oedema is predominantly related with Topiramate.

Methylphenidate (Ritalin)-associated cataract and glaucoma

Methylphenidate hydrochloride (Ritalin) is the drug of choice for attention deficit hyperactivity disorder (ADHD). However, an association of Ritalin with glaucoma has been reported. We report a case of Ritalin-associated cataract and glaucoma. A 10-year-old boy was diagnosed with ADHD and had received methylphenidate hydrochloride, 60 mg/day for 2 years. He presented with blurred vision. Best-corrected visual acuity was 6/60 in both eyes. Ocular examinations revealed intraocular pressure (IOP) of 30 mmHg under medication, dense posterior subcapsular opacity of lens, pale disc with advanced cupping, and marked constriction of visual field. Despite maximal anti-glaucomatous medication, IOP still could not be controlled. The patient then received combined cataract and glaucoma surgery. Visual acuity improved and IOP was within normal limits in both eyes postoperatively. Large dose of methylphenidate may cause cataract and glaucoma. The mechanism remains unclear. Doctors should be aware of the possible ocular side effects of methylphenidate.

Intravitreal triamcinolone acetonide treatment of macular edema associated with central retinal vein occlusion

PURPOSE

To evaluate treatment of macular edema associated with central retinal vein occlusion (CRVO) using intravitreal triamcinolone acetonide.

METHODS

Retrospective review of data for 29 eyes of 29 patients with CRVO and macular edema treated with intravitreal triamcinolone acetonide. Initial visual acuity, intraocular pressure, and history of glaucoma were recorded. Final visual acuity, intraocular pressure, and adverse events were recorded during the treatment period.

RESULTS

Twenty-nine eyes were treated with intravitreal injection. The mean follow-up was 348 days. The median initial Early Treatment Diabetic Retinopathy Study visual acuity was 20/250 (median logMAR, 1.1). The median visual acuity 3 months after injection was 20/125 (median logMAR, 0.8). This difference was statistically significant. The median final visual acuity was 20/250 (median logMAR, 1.1). This difference in visual acuity was not statistically significant. Elevated intraocular pressure, excluding that related to neovascularization, occurred in 5 of 22 patients. Subgroup analysis revealed that patients who received multiple injections had better outcomes.

CONCLUSION

Intravitreal triamcinolone acetonide may improve vision transiently but does not appear to result in a sustained visual acuity benefit for patients with macular edema associated with CRVO. Repeated injections may be necessary. The risk of glaucoma is significant, and additional study is required to further characterize this and other risks.

Corticosteroid-induced glaucoma: a review of the literature

The intraocular pressure rise that can complicate the use of topical or systemic corticosteroid has been recognised for 50 years. More recently, following isolation of the myocilin gene (previously known as the trabecular meshwork inducible glucocorticoid response or TIGR gene), there has been renewed interest in this steroid-responsive phenomenon. Furthermore, the currently fashionable use of injectable intraocular steroids in the management of clinically significant subretinal fluid and macular oedema has resulted in an increased incidence. Animal studies, cell biology, molecular biology, and an improved knowledge of genetics have provided a better understanding of the mechanisms behind the response. The purpose of this review is to describe the risk factors for developing corticosteroid-induced glaucoma, to discuss the underlying mechanisms and genetics of the condition and to present management options.

Prospective, long-term evaluation of steroid-induced glaucoma

PURPOSE

To evaluate the intraocular pressure (IOP) after cessation of steroid use in steroid-induced glaucoma and its control with medication or surgery.

METHODS

Thirty-four eyes of 34 patients having steroid-induced glaucoma were prospectively evaluated after cessation of steroid for IOP, visual acuity, and optic disc status at 3 months, and every 3 months for 18 months.

RESULTS

Topical steroid use (73.5%) was the most frequent cause for glaucoma. The baseline IOP was 35.47+/-12.59 mmHg. The baseline vertical cup-disc ratio correlated with duration of steroid use (P=0.014) and the baseline IOP (P<0.0001). In 25 patients (73.5%), IOP could be controlled by topical medications alone, whereas nine patients (26.5%) required surgery. The mean baseline IOP in eyes requiring surgery was 49.67+/-13.28 mmHg and in eyes managed medically, 30.36+/-7.51 mmHg (P=0.002). The vertical cup-disc ratio in surgically treated patient was 0.87+/-0.13:1 as compared to 0.71+/-0.15:1 (P=0.012) in the medically treated group. At 6, 12, and 18 months follow-up, 22 (64.7%), 33 (97.1%), and all 34 (100%) patients were off treatment, respectively.

CONCLUSIONS

Patients with steroid-induced glaucoma, who were <or=20 years old, with a higher IOP, and greater glaucomatous optic neuropathy, were more likely to need surgery. After cessation of steroid therapy, all eyes were off treatment at 18 months.

Safety of inhaled corticosteroids in the treatment of persistent asthma

OBJECTIVE

Inhaled corticosteroids (ICSs) are the most effective medications available for patients with persistent asthma of all severities and currently are recommended as the preferred asthma controller therapy by the National Heart, Lung and Blood Institute. Nevertheless, lingering concerns about potential adverse systemic effects of ICSs contribute to their underuse. This review discusses the safety of ICSs with respect to potential systemic effects of most concern to physicians and patients.

METHODS

Articles reporting on the safety of ICSs in children and adults with persistent asthma were identified from the Medline database from January 1966 through December 2003, reference lists of review articles and international respiratory meetings.

RESULTS

Ocular effects of ICSs and ICS effects on bone mineral density and adrenal function are minimal in patients maintained on recommended ICS doses. One-year growth studies in children have shown decreased growth velocity with ICSs, but long-term studies with inhaled budesonide and beclomethasone show no effect on final adult height, suggesting that these effects are transient. In addition, extensive data from the Swedish Medical Birth Registry show no increased risk of adverse perinatal outcomes when inhaled budesonide is administered to pregnant women with asthma.

CONCLUSIONS

ICSs have minimal systemic effects in most patients when taken at recommended doses. The benefits of ICS therapy clearly outweigh the risks of uncontrolled asthma, and ICSs should be prescribed routinely as first-line therapy for children and adults with persistent disease.

Fluocinolone acetonide implant (Retisert) for noninfectious posterior uveitis: thirty-four-week results of a multicenter randomized clinical study

PURPOSE

To report the interim 34-week safety and efficacy results of a 3-year study to evaluate an investigational intravitreal fluocinolone acetonide (FA) implant in patients with noninfectious posterior uveitis.

DESIGN

Prospective, dose-masked, dose-randomized, historically controlled, multicenter trial in patients with unilateral or bilateral disease.

PARTICIPANTS

A total of 278 patients with recurrent noninfectious posterior uveitis were randomized to receive a 0.59-mg (n = 110) or 2.1-mg (n = 168) implant. In patients with bilateral disease, the more severely affected eye received the implant.

METHODS

The implant was inserted surgically into the vitreous cavity through a pars plana incision. Follow-up visits were scheduled on day 2, week 1, and then every 4 to 6 weeks through 34 weeks after implantation. Systemic, periocular, and topical therapies were reduced as allowed by the clinical response.

MAIN OUTCOME MEASURES

The primary efficacy outcome was a comparison of the recurrence rate in the implanted eye from the 34 weeks before implantation to the 34 weeks after implantation. Visual acuity (VA), need for adjunctive therapy, and safety also were assessed.

RESULTS

Combining both doses, the FA implant reduced the rate of recurrences from 51.4% in the 34 weeks preceding implantation to 6.1% postimplantation (P<0.0001) in the study eyes. Comparatively, there was a significant increase in the recurrence rate in the fellow nonimplanted eyes from 20.3% preimplantation to 42.0% postimplantation (P<0.0001). Visual acuity was stabilized or improved in 87% of implanted eyes and generally was associated with reductions in the area of macular hyperfluorescence. The percentage of eyes that required systemic medications, periocular injections, and topical corticosteroids decreased from 52.9%, 63.0%, and 35.7%, respectively, preimplantation to 12.1%, 2.2%, and 16.5% postimplantation (P< or =0.0001 in all cases). At week 34, 51.1% of implanted eyes required ocular antihypertensive drops, and 5.8% underwent glaucoma filtering surgery. Lens opacity scores increased by > or =2 grades in 19.8% of phakic implanted eyes, and 9.9% required cataract surgery. There were no statistically significant differences in any of the parameters studied for the 0.59-mg implant, compared with the 2.1-mg implant.

CONCLUSIONS

The FA implant significantly reduced uveitis recurrences, improved VA, and decreased the need for adjunctive therapy in the studied patient population. The most common side effects included increased intraocular pressure and cataract progression.