Posterior subcapsular cataracts and glaucoma associated with long-term oral corticosteroid therapy. In patients with rheumatoid arthritis and related conditions

Ocular and Systemic Factors Associated with Glaucoma

Glaucoma is one of the leading causes of irreversible blindness in the world. Although numerous factors have been implicated in the pathogenesis of glaucoma, the main focus of management still remains lowering the intraocular pressure (IOP) by medical or surgical therapy. However, a major challenge is that many glaucoma patients continue to progress despite good control of IOP. In this regard, the importance of other coexisting factors that may contribute to disease progression needs to be explored. Ophthalmologists need to be aware of ocular risk factors and the impact of systemic diseases and their medications, along with lifestyle modifications on the course of glaucomatous optic neuropathy and adopt a holistic approach in treating the eye as well as the patient to alleviate the suffering from glaucoma in a comprehensive manner.

How to cite this article

Dada T, Verma S, Gagrani M, et al. Ocular and Systemic Factors associated with Glaucoma. J Curr Glaucoma Pract 2022;16(3):179-191.

Evaluation and management of systemic corticosteroids-induced ocular hypertension in children with non-Hodgkin lymphoma

PURPOSE

To investigate the effect of systemic corticosteroids (CSs) on ocular hypertension (OHT) and to evaluate the management of OHT in children with non-Hodgkin lymphoma (NHL).

METHODS

Medical records of children with NHL treated in our institution between October 2016 and October 2019 were reviewed. The enrolled patients were divided into the mature B-cell lymphoma (MBL) group and lymphoblastic lymphoma (LBL) group based on pathology. Data on routine ophthalmic examinations and management of OHT were recorded.

RESULTS

Of the 54 recruited patients, 38 patients (70.4%) had LBL, and 16 (29.6%) had MBL. Thirty-one patients (57.4%) developed OHT, 24 patients (77.4%) in the LBL group, and 7 (22.6%) in the MBL group. Twelve patients (38.7%) were identified as high responders (10 with LBL and 2 with MBL). Symptomatic patients had a higher mean peak IOP than asymptomatic patients (p=0.006). A total of 74.2% of OHT was controlled with antiglaucoma medications (100% in the MBL group vs. 66.7% in the LBL group, significant variation, p < 0.001). In total, 8 patients (25.8%) underwent tapering of the CSs dose. The duration of OHT was shorter in the MBL group than in the LBL group (p = 0.003). No patients were found to have glaucomatous damage or cataracts.

CONCLUSIONS

Patients receiving systemic CSs had a higher risk of developing OHT, but the pattern of CSs administration might be a critical factor in the risk and severity of OHT. Tapering of CSs dose should be considered the first line for the management of OHT during high-dose CSs therapy.

An objective evaluation of crystalline lens density using Scheimpflug lens densitometry in different uveitis entities

AIM

To measure lens densities with a Pentacam HR device in patients with active uveitis. Measurements were taken at the onset of the attack and after the treatment of inflammation.

METHODS

The study included 51 eyes with different anterior uveitis aetiologies and a control group of 48 eyes of age- and gender-matched healthy subjects. Lens densitometry measurements were taken with a Scheimpflug camera on a Pentacam HR device. All the examinations and measurements were performed on the first presentation with the onset of the attack and were repeated at 1st and 3rd months after treatment. Lens densitometry measurements were compared with those of the healthy control group and the healthy fellow eyes of the uveitic patients.

RESULTS

No statistically significant difference was determined between the groups in respect of age and gender (p > 0.05). At 3 months, Pentacam densitometry of zones 3 value was determined to be significantly high in the uveitic eyes compared to the healthy eyes (p = 0.018). The average lens density value (ALD) at 1 month was statistically significantly higher than the baseline value in the uveitic eyes (p = 0.034). There was no significant change in the ALD value at 3 months compared to the baseline and 1-month values (p = 0.386, p = 0.736, respectively).

CONCLUSION

Even if there is no cataract development that can be clinically observed in eyes with anterior uveitis, lens density in zone 3 showed a significant increase at the end of 3 months compared to the baseline value. This change can be evaluated objectively with Scheimpflug imaging.

Intranasal Corticosteroids Do Not Lead to Ocular Changes: A Systematic Review and Meta-analysis

OBJECTIVES

The safety and efficacy of intranasal corticosteroids (INCS) are well established, but there remains apprehension that INCS could lead to systemic side effects, as with oral steroids. The objective of this systematic review was to assess whether the use of INCS lead to increased intraocular pressure (IOP) above 20 mm Hg, glaucoma, or formation of posterior subcapsular cataracts in adult patients with rhinitis.

METHODS

Two medical librarians searched the published literature for records discussing the use of "nasal steroids" in "rhinitis" and their effect on "intraocular pressure," "cataracts," or "glaucoma."

RESULTS

A total of 484 studies were identified, and 10 randomized controlled trials met our inclusion criteria. Meta-analysis of 2,226 patients revealed that the relative risk of elevated IOP in those who received INCS was 2.24 (95% confidence interval [CI]: 0.68 to 7.34) compared to placebo. The absolute increased incidence of elevated IOP in patients using INCS compared to placebo was 0.8% (95% CI: 0% to 1.6%). There were zero cases of glaucoma in both placebo and INCS groups at 12 months. The absolute increased incidence of developing a posterior subcapsular cataract was 0.02% (95% CI: -0.3% to 0.4%).

CONCLUSIONS

Use of INCS is not associated with a significant risk of elevating IOP or developing a posterior subcapsular cataract in patients with allergic rhinitis. Presence of glaucoma, however, is the real clinical adverse event of concern. There were zero reported cases of glaucoma at 12 months. Future studies should formally evaluate for glaucoma rather than use IOP measures as a surrogate. Laryngoscope, 129:6-12, 2019.

The suprachoroidal space as a route of administration to the posterior segment of the eye

The suprachoroidal space (SCS) is a potential space between the sclera and choroid that traverses the circumference of the posterior segment of the eye. The SCS is an attractive site for drug delivery because it targets the choroid, retinal pigment epithelium, and retina with high bioavailability, while maintaining low levels elsewhere in the eye. Indeed, phase III clinical trials are investigating the safety and efficacy of SCS drug delivery. Here, we review the anatomy and physiology of the SCS; methods to access the SCS; kinetics of SCS drug delivery; strategies to target within the SCS; current and potential clinical indications; and the safety and efficacy of this approach in preclinical animal studies and clinical trials.

Age-Related Cataract Is Associated with Elevated Serum Immunoglobulin E Levels in the South Korean Population: A Cross-Sectional Study

Background

Previous research has suggested that immunoglobulin E (IgE)-mediated events lead to several chronic diseases. We investigated the association between allergic conditions and age-related cataracts in the South Korean adult population.

Methods

A cross-sectional study was performed using data obtained from 1,170 participants aged 40 years or older who were enrolled in the Korean National Health and Nutrition Examination Survey 2010. Multivariable logistic regression was used to examine the relationship between age-related cataracts and allergic conditions, including total serum IgE and allergen-specific serum IgE levels, after adjustment for potential confounders (age, sex, alcohol consumption, smoking, sun exposure, blood pressure, plasma glucose and cholesterol levels, as well as histories of asthma, atopic dermatitis, and rheumatoid arthritis).

Results

After adjusting for potential confounders, the odds ratio (OR) for age-related cataract was greater in participants with higher total serum IgE levels (OR = 1.37; P = 0.044). In particular, increased IgE levels were significantly associated with nuclear cataract (OR = 1.42; P = 0.032). However, allergen-specific serum IgE levels did not differ significantly between groups. In the trend analysis, no significant relationship was observed between serum IgE and any type of age-related cataract.

Conclusion

Increased total serum IgE level is independently associated with age-related cataracts after adjustment for confounding factors.

The Association between Systemic Glucocorticoid Use and the Risk of Cataract and Glaucoma in Patients with Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

Objective

Glucocorticoids (GCs) are often used to treat Rheumatoid Arthritis (RA) despite their many side effects and the availability of other effective therapies. Cataract and glaucoma are known side effects of GCs but the risk of them developing in the setting of GC use for RA is unknown. The aim was to perform a systematic review and meta-analysis to determine the association between GCs and the risk of developing cataract and/or glaucoma in RA.

Methods

A systematic search was carried out using MEDLINE, EMBASE, and Web of Science. All RCTs comparing GC use to non-use in RA populations were sought. Observational studies reporting cataract and/or glaucoma amongst GC users and non-users were also included. Data extracted included incidence/prevalence of cataract and/or glaucoma in each arm, dose and duration of therapy. Two independent reviewers performed quality assessment.

Results

28 RCTs met eligibility criteria, however only 3 reported cataracts and glaucoma, suggesting significant under-reporting. An association between GC use and the development of cataracts in RA patients was seen in observational studies but not RCTs. There was no statistically significant association between GC use and the development of glaucoma, although data were sparse. There were insufficient data to determine the impact of dose and duration of therapy.

Conclusion

The current literature suggests a possible association between GC use and the development of cataract. However, this risk cannot be accurately quantified in RA from the available evidence. RCTs have not adequately captured these outcomes and well-designed observational research is required.

Posterior subtenon triamcinolone acetonide injection as a primary treatment in eyes with acute Vogt-Koyanagi-Harada disease

BACKGROUND/AIMS

To investigate the effectiveness of isolated subtenon triamcinolone acetonide injection (STI) as a primary treatment in eyes with acute Vogt-Koyanagi-Harada (VKH) disease.

DESIGN

Retrospective, observational, cross-sectional study.

METHODS

The data from 27 eyes in 14 patients with acute VKH treated with STI therapy were analysed retrospectively. The time course change in ocular inflammation, best corrected visual acuity (BCVA) and numbers of recurrences were examined.

RESULTS

STI led to prompt improvement of BCVA within a week after the primary treatment. After completing therapy, patients with VKH had improved BCVA compared with baseline. In six eyes of three patients (22.2%) treated with STI, ocular inflammation was refractory, or VKH was recurrent despite the treatment. There was significant difference between groups with and without recurrences of inflammation in the frequency of headaches before treatment. In the present study, 21 eyes of 11 patients (77.8%) achieved complete resolution of VKH without recurrence after STI therapy alone.

CONCLUSIONS

This study demonstrated that isolated STI therapy is a useful, minimally invasive, primary treatment option for patients with acute VKH without systemic disorders.

Identification of genes and transcription factors associated with glucocorticoid response in lens epithelial cells

Prolonged glucocorticoids (GCs) treatment may lead to the formation of posterior subcapsular cataracts. The present study aimed to investigate differential gene expression in lens epithelial cells (LECs) in response to GCs using DNA microarray profiling. The gene expression profile of GSE13040 was downloaded from the Gene Expression Omnibus database, which includes 12 human LECs treated with vehicle or dexamethasone (Dex) for 4 or 16 h with six samples at each time period, of which three samples were treated with vehicle (control group) and three samples were treated with Dex (Dex group) at each time point. The differentially expressed genes (DEGs) were identified between the control group and the Dex group at each time period with the thresholds of P<0.05 and |logFC|>1. The DEGs were further analyzed using bioinformatics methods. Firstly, DEGs were subject to a hierarchical cluster analysis. Subsequently, the functional enrichment analysis was performed for the common DEGs between the two time periods. Finally, the transcription factors and binding sites of DEGs associated with response to GC stimulus were analyzed. A total of 696 and 949 DEGs were identified at 4 h and 16 h, respectively. Hierarchical cluster analysis revealed that DEG expression was higher in the Dex group than in the control group (P<0.05). A total of 13 significant functions were enriched for the 72 common DEGs at the two time periods. Chemokine (C-C motif) ligand 2 (CCL2), dual-specificity phosphatase-1 (DUSP1) and FAS were associated with the response to GC stimulus and the transcription factor c-Jun bound to promoter regulation regions of CCL2, DUSP1 and FAS. In conclusion, the transcription factors and binding sites of DEGs associated with the response of LECs to GCs may provide potential gene targets for designing and developing drugs to protect against GC-induced cataract formation.

Inhibition of glucocorticoid-induced alteration of vimentin by a glucocorticoid receptor antagonist RU486 in the organ-cultured rat lens

PURPOSE

Long-term application of glucocorticoids as a treatment for conditions such as allergy, autoimmune diseases, and transplantation presents a high risk of development of steroid-induced cataract. The presence of a functional glucocorticoid receptor (GR) in human and rat lens epithelial cells suggests a direct and specific targeting of these lens cells by glucocorticoids. One important cytoskeletal protein in lens epithelial cells is vimentin, which plays an important role in maintaining the normal lens morphology and function. Previous studies have shown that vimentin is involved in signal transduction, changes in cell structure and differentiation, and apoptosis. Based on a model of steroid-induced cataract from our previous study, the present study focuses on whether changes in vimentin can be induced in vitro through specific GR activation in glucocorticoid-induced cataracts of the rat lens.

METHODS

Clear rat lenses, cultured in vitro, were treated with or without dexamethasone (Dex) or RU486 (a glucocorticoid receptor antagonist). Lenses were cultured for 7 days at 37 °C under 5% CO₂, and were observed daily with an inverted microscope. Changes in morphology were followed by Hematoxylin-eosin (HE) staining, transmission electron microscopy, and immunohistochemistry. The expression of vimentin mRNA and protein was examined by reverse transcription polymerase chain reaction (RT-PCR) and western blot analysis, respectively, in the capsule-epithelium and fiber tissue of the lenses.

RESULTS

Opacity was obviously present at day 7 in the Dex group. The lenses of the untreated group and the RU486+Dex group remained transparent throughout the incubation. Electron microscopy showed an orderly arrangement of fiber cells and normal cell junctions in the control group and the RU486+Dex group. However, in the Dex group, fiber cells were disarranged and the cell-cell junctions exhibited lacunae. The expression of vimentin protein in the lens capsule-epithelium and fiber tissue decreased in the Dex-treated group, but normal expression of vimentin mRNA was maintained.

CONCLUSIONS

These results suggest that the GR-mediated reduction in vimentin may be involved in the formation of steroid-induced cataract.

Inhibition of glucocorticoid-induced changes of Na(+), K(+)-ATPase in rat lens by a glucocorticoid receptor antagonist RU486

Cataract formation can be induced by prolonged use of glucocorticoids. The underlying mechanism is not fully understood yet. The presence of the functional glucocorticoid receptor (GR) in human and rat lens epithelial cells suggests that glucocorticoids target lens epithelial cells directly and specifically. Na(+), K(+)-ATPase has long been recognized for its role in regulating electrolyte concentration in the lens, contributing to lens transparency. We previously reported that the inactivation of Na(+), K(+)-ATPase induced by a glucocorticoid in rat lens. Therefore, the question is whether the changes of Na(+), K(+)-ATPase can be induced through the specific GR activation in glucocorticoid-induced cataract formation. Clear rat lenses were cultured in vitro and were treated with or without dexamethasone (Dex) or RU486 (a GR antagonist). The lenses were cultured for 7 days and photographed daily to record the development of opacity. The activity of Na(+), K(+)-ATPase was determined by using spectrophotometric analysis. The mRNA and protein level expressions of Na(+), K(+)-ATPase α1 were examined by reverse transcription polymerase chain reaction (RT-PCR), Western blot and immunohistochemistry analysis, respectively. Our findings are presented in this study and show that mist-like opacity of the lens was observed as early as 5 days after incubation with dexamethasone. The opacity was more obvious at day 7 in the Dex group. The lenses of the untreated group and the RU486+Dex group remained transparent throughout the incubation. The activity of Na(+), K(+)-ATPase in the Dex-treated group decreased in a time-dependent manner. There was no significant loss of enzyme activity in either the control or the RU486+Dex group throughout the incubation period. Both the protein and mRNA expression levels of Na(+), K(+)-ATPase α1 in the capsule-epithelium of lenses decreased in the Dex-treated group. The GR antagonist RU486 inhibited the decrease of the expression of Na(+), K(+)-ATPase α1 induced by Dex. All of the above results suggested that the GR-mediated reduction of Na(+), K(+)-ATPase may contribute to the formation of steroid-induced cataract. Intervention in this pathway maybe helpful to avoid glucocorticoids-cataract formation.

Intraocular pressure change in orbital disease

Intraocular pressure change has been found concurrent with many orbital pathologies, particularly those involving proptosis. The objective of this review is to offer an inclusive classification of orbital disease-related intraocular pressure change, not only for oculoplastics and glaucoma specialists, but also for general ophthalmologists. Various orbital conditions associated with increased intraocular pressure and glaucoma are comprehensively summarized, and pathophysiology, clinical manifestations, and treatment options of these diseases are discussed. Graves disease, arterio-venous shunts, trauma, and orbital neoplasia, and other common conditions are discussed in detail; less frequent syndromes such as orbitocraniofacial deformities, phakomatoses, and mucopolysaccharidoses are included for the sake of comprehensiveness, but discussed less extensively.

Search for a functional glucocorticoid receptor in the mammalian lens

Prolonged glucocorticoid treatment of medical conditions such as rheumatoid arthritis or asthma can lead to the formation of a posterior subcapsular cataract as a negative side effect. Currently, the only treatment for this cataract is surgery because very little is known about the mechanism of glucocorticoid action in the mammalian lens. Understanding of a lens glucocorticoid response is essential for the treatment and prevention of a steroid induced cataract. It has been suggested that glucocorticoids exert their effects on the lens indirectly, non-specifically, or through non-classical mechanisms. While these modes of action may contribute to the formation of glucocorticoid induced posterior subcapsular cataract, the finding of a classical, specific, functional lens glucocorticoid receptor suggests that glucocorticoids target lens epithelial cells directly, specifically, and similar to what has been observed in other cells types. This review explores the discovery of the glucocorticoid receptor in humans lens epithelial cells and the lens specific glucocorticoid response. The distinct changes in lens epithelial cell signaling pathways (MAPK and PI3K-AKT) suggest that glucocorticoids modulate several cellular functions and may explain why a lens glucocorticoid response has been difficult to elucidate.

Safety and efficacy of intravitreal triamcinolone acetonide for uveitic macular edema

BACKGROUND

To evaluate the safety and efficacy of intravitreal triamcinolone acetonide (TA) for treating macular edema secondary to non-infectious uveitis.

METHODS

Retrospective review of sixteen patients (20 eyes) with chronic cystoid macular edema (CME) as a consequence of controlled intermediate uveitis, posterior uveitis, or panuveitis who received at least one intravitreal injection of TA. Main outcome measures were visual acuity (VA), intraocular pressure (IOP), formation or progression of an existing cataract, and CME resolution during the follow-up period.

RESULTS

At last follow-up, VA showed improvement (compared to baseline) in 11 eyes (55%), deterioration in three eyes (15%), remained completely unchanged in one eye (5%), and showed improvement initially but returned to baseline levels in five eyes (25%). At last follow-up, CME had relapsed or was still present in 10 of the eyes (50%). The remaining eyes showed complete resolution of the CME, without evidence of recurrence during the follow-up time. Mean VA at last follow-up showed statistically significant improvement (p = 0.02) in nonvitrectomized eyes (mean baseline VA: 1.14 +/- 0.58; mean final VA: 0.96 +/- 0.66) compared to the almost unaltered mean visual acuity for vitrectomized eyes (mean baseline VA: 0.76 +/- 0.41; mean final VA: 0.71 +/- 0.48)(p = 0.40, paired samples t-test). Elevation of IOP was transient in all cases and responded well to topical medications, except for one patient who required placement of an Ahmed valve. Preexisting cataract progressed in three of the 15 phakic eyes (20%). One patient developed a retinal detachment and required additional surgery to reattach it. Patients were followed for a mean of 34 weeks (median: 32 weeks; range: 19-56 weeks).

CONCLUSIONS

Intravitreal TA may play a role in the treatment of uveitis-related CME. Further controlled studies are necessary to test this hypothesis.

The cost of glucocorticoid-associated adverse events in rheumatoid arthritis

OBJECTIVE

To estimate the costs of glucocorticoid associated adverse events (GAEs) in patients with rheumatoid arthritis (RA).

METHODS

We conducted a literature review of studies reporting GAEs in RA patients, and developed a Markov model with the following GAEs: fractures (vertebral, hip, pelvic), hypertension, diabetes, gastrointestinal complications, pneumonia, urinary tract infection, cataract and, in an extended model, myocardial infarction (MI) and stroke. Two-year total costs were calculated using direct medical costs (2001 US dollars [USD]) and by running 10,000 Monte Carlo simulations with probability values randomly selected from the GAE literature.

RESULTS

On average, glucocorticoid users spent USD 445 more than non-users, or USD 0.46 for each dollar spent on purchasing the drug. When adding MI and stroke, users spent on average USD 430 more than non-users, or USD 0.44 for each dollar spent on purchasing the drug; this incremental cost ranged from USD 193 to USD 682 if MI and stroke were excluded, respectively. In 70% of the simulations there were more deaths among users than among non-users, in both the model with and without MI and stroke.

CONCLUSIONS

Although results varied depending on attributed GAEs, in general glucocorticoid users spent more than non-users on GAE treatment, and had higher mortality. Patients, providers and policy makers should consider these potential costs of GAEs when making treatment decisions.

Cataract surgery in sympathetic ophthalmia

PURPOSE

To analyze the results of cataract surgery in patients with sympathetic ophthalmia.

SETTING

Sankara Nethralaya, Medical Research Foundation, Chennai, India.

METHODS

This study comprised 66 patients (132 eyes) with sympathetic ophthalmia seen at the uveitis referral clinic between January 1990 and July 2001; 42 eyes (31.8%) had cataract. Cataract surgery was performed in 17 sympathizing eyes and 1 exciting eye (17 patients). The records of these 18 eyes were retrospectively analyzed. Three eyes had extracapsular cataract extraction (ECCE) with intraocular lens (IOL) implantation, 6 eyes had ECCE without IOL implantation, and 9 eyes had phacoemulsification with IOL implantation. The mean follow-up was 28.7 months (range 3 to 60 months).

RESULTS

The causes of sympathetic ophthalmia were penetrating trauma (n = 8 eyes), ocular surgery (n = 6), perforated corneal ulcer (n = 2), and cyclocryotherapy (n = 1). The most common cataract type, present in 7 eyes (38.8%), was mixed (posterior subcapsular and posterior polar). Visual acuity improved after surgery in 13 eyes (72.2%). The main factors impairing visual recovery were submacular scar and optic atrophy, which were sequelae of the sympathetic ophthalmia. Posterior capsule opacification was noted in 14 eyes (77.7%); it was visually significant in 6 eyes. There was no significant difference in postoperative inflammation or disease reactivation between the 3 types of surgery.

CONCLUSIONS

Cataract extraction in cases of sympathetic ophthalmia can be safely and successfully performed with vigilant preoperative and postoperative control of inflammation, careful surgical planning, and meticulous surgical technique. The final visual outcome, however, depends on the posterior segment complications of the disease.

The safety of intranasal steroids

The increasing use of intranasal steroids in the management of allergic rhinitis reflects their efficacy, tolerability, and safety. However, issues related to the safety of intranasal steroids continue to generate debate and confusion among clinicians. Consequently, there is often reluctance and uncertainty in prescribing these effective agents for the treatment of perennial and seasonal allergic rhinitis. Issues of particular concern are whether intranasal steroids adversely affect various homeostatic systems, influence growth and bone metabolism, and compromise ocular function. Furthermore, the expanding role of intranasal steroids in the pediatric, geriatric, and postmenopausal populations has raised concerns that these agents may result in a steroid burden that more readily causes adverse effects. An extensive review of the literature overwhelmingly supports the assertion that intranasal steroids are safe in prescribed doses and should allay the misconceptions regarding their appropriate use in the management of allergic rhinitis.

Cataract surgery in patients with Vogt-Koyanagi-Harada syndrome

PURPOSE

To evaluate the outcomes of cataract surgery in patients with Vogt-Koyanagi-Harada's (VKH) syndrome.

SETTING

Medical Research Foundation, Sankara Nethralaya, Chennai, India.

METHODS

Fifty-nine eyes of 39 patients with VKH syndrome who had cataract surgery between May 1985 and June 2001 were retrospectively analyzed.

RESULTS

Extracapsular cataract extraction (ECCE) with intraocular lens (IOL) implantation was performed in 15 eyes and without IOL implantation in 31 eyes. Phacoemulsification with IOL implantation was performed in 13 eyes. Twenty-three eyes (38.9%) had mixed cataract (posterior subcapsular and posterior polar). Small pupils were managed by synechiolysis with an iris spatula (43 eyes) or iris hooks (8 eyes). Nine eyes were lost to follow-up and not included in the postoperative analysis. The mean postoperative follow-up was 39.4 months (range 9 to 120 months). Visual acuity improved by 1 or more lines in 40 eyes (80.0%). Subretinal gliosis and optic atrophy, sequelae of the syndrome, restricted improvement in vision in the remaining eyes. Posterior capsule opacification developed in 38 eyes (76.0%), of which 21 (42.0%) required a neodymium:YAG laser posterior capsulotomy. There were no significant differences in postoperative inflammation or syndrome reactivation between the types of surgery.

CONCLUSIONS

The results show that cataract extraction in patients with VKH syndrome can be safely and successfully performed if there are good preoperative and postoperative control of inflammation, careful surgical planning, and meticulous surgical technique. The final visual outcome depends on the posterior segment complications of the syndrome.

Posttransplant cataract: lessons from kidney-pancreas transplantation

INTRODUCTION

Cataract is a major cause of visual disturbance after transplantation. Although corticosteroid therapy has been linked with posterior subcapsular cataract, its natural history in the cyclosporine era is not well understood.

METHODS

Baseline and regular postoperative slit-lamp biomicroscopy and ophthalmic examinations (n=432) were performed in 108 eyes of simultaneous kidney/pancreas (SPK) recipients (n=54) for up to 10 years after transplantation. Triple therapy immunosuppression of cyclosporine, azathioprine, and prednisolone was used.

RESULTS

Cataract was present in 40% of eyes at simultaneous kidney/pancreas associated with duration of diabetes, lower insulin dose, and the use of pretransplant hemodialysis (P<0.05-0.01). Cataract became increasing more common 2 years after simultaneous kidney/pancreas, and lens abnormalities were virtually universal at 6-10 years by slit lamp biomicrosopy. The instantaneous hazard rate for new cataract formation was highest within the first 2 years and remained abnormal for the study duration. Nuclear and posterior subcapsular cataract increased significantly after transplantation (P<0.05) and were the predominant types of cataract presenting late. Risk factors for posttransplant cataract formation included older age and high-dose pulse methylprednisolone dose. Visual acuity was reduced by severity of cataract grade, presence of combined nuclear and subcapsular cataract, retinal hemorrhage and underlying diabetic retinopathy (P<0.05-0.001). Cataract formation imposed significant additional impairment of visual acuity above that of diabetic retinopathy. Cataract surgery was undertaken in 14% of eyes, improving visual acuity from mean decimalized score of 0.28 to 0.43, P<0.01 but did not normalize it to the noncataract level of 0.72.

CONCLUSION

Transplantation substantially increases all types of cataract, and is highly prevalent by slit lamp examination. High-risk patients are older and diabetic, and received hemodialysis and pulse corticosteroid therapy. In contrast to older studies using high-dose corticosteroid and azathioprine, the pattern of cataract in the cyclosporine era is different with broader cataract types, a weaker association with corticosteroids and a progressive course. Regular screening of visual acuity and appropriate surgery for posterior subcapsular or severe cataract are recommended.

Inhaled corticosteroids, family history, and risk of glaucoma

OBJECTIVE

Until recently, inhaled corticosteroids were not considered to cause elevated intraocular pressure (IOP), although topical and oral corticosteroids have been shown to do so in susceptible individuals. The authors aimed to (1) identify whether an association existed between inhaled corticosteroid use and elevated IOP or open-angle glaucoma and (2) determine whether this effect may have a genetic basis.

DESIGN

Cross-sectional, population-based study of 3654 persons 49 to 97 years of age attending the Blue Mountains Eye Study, near Sydney, Australia.

METHODS

A series of questions assessed use of inhaled and other corticosteroids as well as family history of glaucoma. Elevated IOP was assessed using applanation tonometry. Diagnosis of glaucoma was based on automated perimetry defects and optic disc signs but without reference to IOP.

MAIN OUTCOME MEASURE

Statistical analysis of associations between inhaled corticosteroid use and elevated IOP or glaucoma, by family history, adjusting for other risk factors.

RESULTS

Open-angle glaucoma was diagnosed in 108 subjects, and elevated IOP was found in 160 subjects. In persons with a glaucoma family history, there was a strong association between inhaled corticosteroid use and presence of either glaucoma or elevated IOP (odds ratio [OR], 2.6; 95% confidence interval, 1.2-5.8). The risk increased with higher doses (OR, 6.3; 95% CI, 1.0-38.6) for persons who used more than four puffs per day. These findings were not explained by concurrent use of oral or ocular corticosteroids. In persons without a family history of glaucoma, no association was found between use of inhaled corticosteroids and glaucoma or elevated IOP.

CONCLUSIONS

These findings suggest an association between ever use of inhaled corticosteroids and a finding of elevated IOP or glaucoma in subjects with a glaucoma family history. Patients being treated with inhaled corticosteroids need review by an ophthalmologist if they report a glaucoma family history.

Risk of ocular hypertension or open-angle glaucoma in elderly patients on oral glucocorticoids

BACKGROUND

Ocular hypertension and open-angle glaucoma are well-known side-effects of treatment with topical ophthalmic glucocorticoids. There is uncertainty about the risk of these disorders with oral glucocorticoid therapy.

METHODS

Data from the Quebec universal health insurance programme for the elderly were used to identify 9793 patients with a new diagnosis of ocular hypertension or open-angle glaucoma, or on newly prescribed treatment for these disorders (cases). 38,325 controls were randomly selected from ophthalmology patients seen in the same month and year as the case (index date). Current use of oral glucocorticoids was defined as that within 14 days of the index date. All glucocorticoid doses were converted to the equivalent amount of hydrocortisone. The case-control analysis was done by conditional logistic regression and adjusted for age, sex, systemic hypertension, diabetes mellitus, ophthalmic glucocorticoids, glucocorticoid injections, and variables related to general health.

FINDINGS

The mean ages of cases and controls were similar (74.9 [SD 6.3] vs 74.7 [6.4]). The adjusted odds ratio of ocular hypertension or open-angle glaucoma for current users of oral glucocorticoids compared with non-users was 1.41 (95% CI 1.22-1.63). There was a dose-related increase in the adjusted odds ratios for current users: 1.26 (1.01-1.56) for less than 40 mg per day of hydrocortisone, 1.37 (1.06-1.76) for patients on 40-79 mg per day, and 1.88 (1.40-2.53) for patients on 80 mg or more per day. The odds ratios also increased with the duration of treatment over the first 11 months of exposure.

INTERPRETATION

The use of oral glucocorticoids increases the risk of ocular hypertension or open-angle glaucoma in elderly patients. In patients in this age-group who need long-term treatment with high doses of oral glucocorticoids, monitoring of intraocular pressure may be justified.

Steroid-induced cataract: new perspective from in vitro and lens culture studies

The prevailing view regarding the mechanism of steroid cataract formation holds that glucocorticoids are covalently bound to lens proteins resulting in destabilization of the protein structure allowing further modification (i.e. oxidation) leading to cataract. Alternative hypotheses (e.g. that cataracts result from glucocorticoid receptor mediated effects) have been difficult to test since protein binding does in fact occur for many cataractogenic steroids. A glucocorticoid lacking the typical glucocorticoid hydroxy group at C21 (fluorometholone, FML), other steroids which can bind to proteins but lack glucocorticoid activity, and a glucocorticoid antagonist (RU486) have been utilized to discriminate between these two hypotheses. Purified bovine beta-crystallin incubated with three different 3H-steroids, dexamethasone (Dex), aldosterone or progesterone demonstrated that the C-21 hydroxyl group is not essential for steroid binding. Progesterone (with no C-21 OH) bound to the greatest extent. Pretreatment of the protein with aspirin to acetylate the free protein amino groups blocked this binding, demonstrating the probability of a Schiff base mechanism. Lens culture studies with the same three radiolabeled steroids demonstrated much the same result. Rat lenses cultured for 48 hr-11 days, demonstrated that loss of GSH is an early and significant effect of several glucocorticoids (Dex, prednisolone and FML) but is not seen with other non-glucocorticoid steroids. However, none of the steroids tested consistently produced lenticular opacification (i.e. cataracts) in this in vitro system, nor did they alter rubidium transport. We suggest that a mechanism other than covalent binding of steroids to lens proteins is responsible for glucocorticoid induced cataracts because: (1) non-glucocorticoids were demonstrated to bind lens proteins as well or better than the glucocorticoid Dex and (2) only glucocorticoids, and not other steroids, lowered lens reduced glutathione content which has been demonstrated to be associated with other forms of cataract.

Ocular complications in renal transplant patients

One hundred and seventy-six patients who received a renal transplant between 1982 and 1988 were examined for ocular complications of steroid therapy. Posterior subcapsular cataracts (PSC) were present in 60 patients (34.1%). Patients were classified into three groups (HS, LS, NoS) depending on their maintenance immunosuppression therapy. The HS group received high doses of steroids after renal transplantation. LS had low steroid doses, and NoS had no steroids. The incidence of PSC was 21 of 38 in HS (55.3%), 33 of 117 in LS (28.2%), and 1 of 16 in NoS (6.2%). The difference between HS and LS was statistically significant (chi 2 = 8.1, P < 0.01). Grading the severity of PSC (PSC 0, PSC +, PSC > ++) showed a significant correlation between the degree of PSC and the steroid therapy. In the HS group, five patients had PSC +, and 16 had PSC > ++ (76%), compared to 19 patients with PSC +, 14 patients with PSC > ++ (42%) in the LS group (chi 2 = 4.6; P < 0.05). There was no correlation between the incidence of PSC and use of steroids for more than three months before dialysis. Comparison with the results of our earlier series (1973-1981) using high doses of steroids showed a similar incidence of PSC with HS (40.7% Series 1; 55.3% Series 2) but a lower incidence with LS and NoS.

Ocular implications of long-term prednisone therapy in children

We compared 23 patients (ages 4 to 18 years) who were receiving long-term oral prednisone therapy with 31 normal controls (ages 7 to 16 years). Indications for corticosteroid treatment included renal transplant in 11 patients, nephrotic syndrome in 7, glomerulonephritis in 4, and vasculitis without renal disease in 1. The mean duration of prednisone therapy was 5.0 +/- 3.5 years, and the mean dose at the time of examination was 0.29 +/- 0.18 mg/kg/day. Mean intraocular pressure was 16.0 +/- 3.0 mm Hg (range, 12 to 25 mm Hg) in the prednisone group and 15.4 +/- 2.1 mm Hg (range, 12 to 20 mm Hg) in the control group. The difference between the means was 0.6 mm Hg (P = 0.35). Posterior subcapsular cataracts were present in seven (30%) of the prednisone patients, but in none of the controls (P = .001). None of the cataracts were visually significant. We found no evidence that pediatric patients on long-term, low-dose prednisone have higher intraocular pressures (IOPs) than normal children, although they are more likely to develop posterior subcapsular cataracts.

Cataract extraction in uveitis patients

Cataracts are known to develop at an accelerated rate in many forms of uveitis. Until recently, cataract surgery in such eyes was regarded as a hazardous procedure that yielded unpredictable and often discouraging results. Recent evidence from a number of reports suggests that newer surgical techniques and careful medical management allow a significant number of patients with uveitis to undergo cataract extraction successfully. Intraocular lens implantation using in-the-bag posterior chamber lens technique has been successful in selected cases. Careful patient selection, coupled with the use of an appropriate surgical technique, appear to be of major importance. Herein we review the current literature on cataract extraction in uveitis and provide guidelines for patient and technique selection based on the type of inflammation present. The management of common surgical problems and complications is discussed, as is the role of the intraocular lens. Specific surgical techniques useful in the management of eyes with cataract and uveitis are discussed.

Cataracts and hypertension in salt-sensitive rats. A possible ion transport defect

In previous unrelated studies, we observed a 35 to 50% incidence of cataract formation in several groups of Dahl salt-sensitive hypertensive rats (DS) over a 4-year period. In the present study we evaluated longitudinal changes in blood pressure in DS in which cataracts eventually developed and those in which cataracts did not develop when all animals were maintained on a high sodium diet. Lenses were evaluated by slit-lamp microscopy to determine if cataractous lesions were similar among rats, to classify lesion types, and to define the age at which cataracts were detectable in DS. The possible participation of several cataractogenic risk factors as major influences on cataract formation also was evaluated. Finally, aqueous humor concentrations and lenticular content of sodium and potassium were determined to evaluate the possibility that a defect in ion transport at the lens epithelium and ciliary body might play a role in cataractogenesis in DS, since ion transport defects have been shown to lead to lens opacification in other models of genetic and experimental cataracts. Parallel studies were performed in Dahl salt-resistant control rats (DR). A high incidence of cataract formation was found in DS. Although systolic blood pressure was not consistently greater in adult DS with cataracts compared with values in age-matched DS without cataracts, the initial pressor response to a high salt diet was greatest in weanling DS in which cataractous lesions later developed. Slit-lamp analysis revealed that cataracts in this genetic model were cortical, with one mixed cortical, nuclear lesion. Posterior subcapsular lesions were not observed, suggesting that lesions were not steroid-induced.(ABSTRACT TRUNCATED AT 250 WORDS)

Corticosteroid-induced cataracts

The association linking corticosteroid therapy with the development of posterior subcapsular cataracts has been well documented. These drugs are widely used therapeutically, principally to capitalize on their ability to inhibit inflammatory responses. The literature on corticosteroid-induced posterior subcapsular cataracts is reviewed here. Data from the previously published series and individual lens susceptibility to corticoids do not allow the establishment of a direct factor relating cataract formation to corticosteroid dose and the duration of therapy; however, significant progress has been made in elucidating the mechanism by which corticoids bring about the development of these opacities. Exploration into the development of these lesions has shed light on the similarities these opacities share with other cataracts, especially with regard to location and pathogenesis.

Ocular complications of systemic steroid after renal transplantation and their association with HLA

The eyes of 62 patients who had received allogenic renal transplants were examined for eye disease. Thirty-six patients were found to have steroid induced cataract. Six patients had ocular hypertension. Twelve patients showed arteriosclerotic changes in their fundi relating to their previous hypertensin. There was no significant difference in HLA type in patients who developed cataract and those who did not. 83.3% of the 6 patients with ocular hypertension had HLA B12 in common. None of the patients had cytomegalic retinitis.

Corticosteroid-induced cataracts in idiopathic nephrotic syndrome

Th incidence and severity of posterior subcapsular cataracts were studied in 58 children with steroid-sensitive nephrotic syndrome. Eight (14%) children had cataracts. Visual acuity was normal in all but one child. There was no relationship between total dose or mean daily dose of prednisolone (corrected for body surface area) and cataract formation. Alternate-day treatment with prednisolone for an average of half the total treatment time did not prevent cataracts. These studies show there is little risk of causing permanent visual handicap in children with steroid sensitive nephrotic syndrome, provided prednisolone treatment is carefully controlled.

Hormonal regulation of intraocular pressure

A detailed review of the hormonal effects on intraocular pressure is presented. There is evidence that corticotropin, vasopressin, thyroxin, insulin, glucocorticoids and mineralocorticoids may play a role in the physiologic regulation of intraocular pressure. Growth hormone, melanocyte stimulating hormone, progesterone, estrogen, chorionic gonadotropin and relaxin may influence intraocular pressure when administered in pharmacologic doses. Whether the key to understanding primary open-angle glaucoma lies in recognizing abnormal endocrine mechanisms, especially involving glucocorticoids, remains unclear at the present time.

Reversibility of corticosteroid-associated cataracts in children with the nephrotic syndrome

We reexamined the eyes of 39 nephrotic children to investigate further the relationship between oral corticosteroid therapy and posterior subcapsular cataract formation. The corticosteroid dosage was proportional to each patient's weight. Six children had posterior subcapsular cataracts an average of 16 months after the first examination. Nine patients had complete regression of their posterior subcapsular cataracts. We found no correlation between the age at onset of the nephrotic syndrome, the dosage or duration of corticosteroid therapy, or the renal biopsy findings and posterior subcapsular cataract formation. Cushingoid manifestations were significantly more common in the patients with posterior subcapsular cataracts. These patients may be more sensitive to the effects of corticosteroids than those who never had cataracts and those whose cataracts regressed.

Cortisone cataract in children with nephrotic syndrome

In a group of 16 children with idiopathic nephrotic syndrome treated with corticosteroids for longer than 12 months, 9 developed a posterior subcapsular cataract (PSC). No correlation between the frequency of PSC and the duration of treatment and the total dose of treatment with steroids was demonstrable. However, the patients with PSC had received considerably higher average daily doses than those without PSC. Two patients with normal ophthalmologic findings at the end of treatment showed PSC 6 and 9 months later respectively. Only one patient acquired a significant impairment of visus.

Lymphocyte sensitivity to glucocorticoids

We evaluated the possibility of identifying patients with open-angle glaucoma based on the in vitro behavior of their lymphocytes in the presence of glucocorticoids. Our results do not support the hypothesis that lymphocytes from patients with open-angle glaucoma, as compared to those from normal subjects, are more sensitive to the presence of corticosteroids in vitro. In addition, the degree of inhibition induced by glucocorticoids was closely related to the amount of activation of the lymphocyte membrane induced by different concentrations of phytohemagglutinin. Our results indicated that this may be a general phenomenon rather than one that is specific to a particular ophthalmological condition.

Posterior subcapsular cataracts: posttransplantation in children

Posterior subcapsular cataracts (PSC) were noted in 41 of 69 (60%) recipients of renal allografts. The PSC were noted during the first posttransplant year (Group 1) in 21 (30%) recipients and after the first posttransplant (Group 2) year in 20 (30%) recipients. The dosage of prednisone during the first posttransplant year corrected for patient weight showed a significant correlation with the development of PSC during the first posttransplant year. The severity of the PSC were correlated with time of onset and prednisone dosage. Four recipients in Group 1 required cataract extraction to obtain sufficient vision to facilitate school work.

Incidence of ocular complications in patients undergoing renal transplantation

The eyes of 39 patients who had received allogenic renal transplants were examined for signs of disease. Nine (23%) had early posterior subcapsular cataracts, two (5%) developed acute cytomegalovirus retinitis, and one developed steroid-induced glaucoma. The lesions which were found were all attributable to the immunosuppressive drug therapy. Thirty-five (87%) had detectable complement-fixing antibodies to cytomegalovirus.