Steroid-induced glaucoma and childhood blindness

Steroid-Induced Ocular Hypertension in Children: A Review on Risk Factors

PURPOSE

Steroid-induced ocular hypertension is poorly understood in children, despite its frequent occurrence. Significant knowledge voids exist in steroid responsiveness, especially in the pediatric population. Therefore, highlighting the most critical risk factors in pediatric patients can help ophthalmologists identify who is at increased risk of developing a high steroid response.

METHODS

A manual search was conducted in PubMed and Google Scholar in search of relevant articles on the steroid-induced glaucoma subtopic.

RESULTS

Key risk factors for high steroid response include glaucoma family history, previous glaucoma diagnosis, young age, steroid type, administration route, and diseases such as vernal keratoconjunctivitis (VKC) and uveitis. Clinically, it presents similarly to primary glaucoma, except for steroid usage history. Steroid cessation or reduction can normalize intraocular pressure (IOP) levels; however, in some cases, pressure-lowering drugs are necessary for treatment.

CONCLUSION

Topical ocular steroids are frequently used by pediatricians and ophthalmologists alike. Understanding the importance of risk factors allows for a timely diagnosis of steroid response and adequate treatment before glaucomatous vision loss can occur.

Risk factors of pediatric steroid-induced ocular hypertension

PURPOSE

Steroid-induced ocular hypertension (SIOH) is a significant ocular complication of pediatric steroid administration. In this study, we analyzed the risk factors associated with pediatric SIOH.

METHODS

We retrospectively collected data from 78 children under 20 years of age who received systemic steroids during hospitalization. The data included age, gender, primary disease, intraocular pressure (IOP) before and one month after administration, total monthly steroid dose adjusted for body weight (BW), and one-month changes in red blood cell, white blood cell, and platelet counts. A multivariate analysis was used to identify risk factors related to steroid responsiveness.

RESULTS

Thirty patients (38.5%) were classified as steroid responders, and 48 as non-responders. The median IOP during the first month of steroid treatment was 24.0 mmHg (IQR; 23.0-28.3) for responders and 15.0 mmHg (IQR; 12.3-18.0) for non-responders. The Generalized Estimating Equations analysis revealed that younger age, male sex, primary disease, increase the amount of white blood cell (WBC) and total steroid dose per BW in one month were independently associated variables. The receiver operating characteristic analysis also revealed that the cutoff values for age, total monthly steroid dose, the increase amount of WBC were 11.0 years, 40.7 mg/kg and 3.40 × 10²/µl respectively.

CONCLUSION

High-dose steroid administration, especially in male, younger patients, necessitates careful monitoring for IOP changes during treatment. WBC count also needs to be monitored during IOP follow-ups.

KEY MESSAGES

What is known Steroid-induced ocular hypertension (SIOH) is one of the essential complications during steroid administration, but only limited analyses have been performed in children. What is new A comprehensive analysis of multiple factors was performed that are predicted to be associated with pediatric SIOH from previous literature. Younger age, male sex, primary disease, increase the amount of WBC, and higher total monthly steroid dose were extracted as risk factors of SIOH. This study can contribute to the prediction of cases in which ophthalmologic examinations are particularly important during systemic steroid administration in children.

Managing Bilateral Vernal Keratoconjunctivitis, Keratoconus, and Steroid-Induced Glaucoma: A Threefold Struggle

The coexistence of bilateral vernal keratoconjunctivitis (VKC), keratoconus, and steroid-induced glaucoma presents a complex ocular challenge, threatening visual acuity and long-term eye health. This combination poses significant risks, with VKC and keratoconus progressively affecting both eyes while glaucoma, induced by necessary steroid treatments, further complicates the clinical picture. We report a case of a young Malay girl who complained of bilateral eye itchiness with progressive blurring of vision, a history of frequent changes in prescribed glasses, and vigorous eye rubbing. Diagnosed with VKC at age 14, she defaulted on follow-up and began unsupervised use of topical steroids during flare-ups. This resulted in steroid-induced glaucoma, complicating the management of both VKC and coexisting keratoconus. This case underscores the importance of careful, supervised treatment, as improper management can significantly affect long-term outcomes.

Vernal keratoconjunctivitis in adults: a narrative review of prevalence, pathogenesis, and management

Vernal keratoconjunctivitis (VKC) is a chronic, progressive, allergic ocular surface disorder that can lead to sight-threatening complications. VKC occurs primarily in children and generally resolves about the time of puberty; however, case series and retrospective analyses indicate that approximately 10% of patients with VKC are adults, and that a subset of adult cases develop after puberty. Consequently, two age-related variants of VKC have recently been described: early-onset VKC-which manifests during childhood and persists into adult life-and late-onset disease, which emerges de novo after puberty. Although the signs and symptoms of adult and childhood VKC are similar, adult VKC is a long-lasting disease characterized by severe inflammation and increased risk of conjunctival fibrosis, which may place adult patients at higher risk for sight-threatening complications and adverse impacts on daily life. This review discusses the epidemiology, signs, symptoms, immunopathogenesis of adult VKC variants, and highlights current gaps in research and management of patients with this condition.

Profile of Newly Diagnosed Childhood Glaucoma in India: Indian Childhood Glaucoma Study (ICGS) Group 1

OBJECTIVE

To report the profile of newly diagnosed childhood glaucoma using the Childhood Glaucoma Research Network (CGRN) classification, presenting over 1 year from across centers in India.

DESIGN

Prospective observational multicentric study.

SUBJECTS

Newly diagnosed children aged < 18 years diagnosed with childhood glaucoma according to CGRN criteria presenting between January and December 2019 to 13 centers across India.

METHODS

All children underwent a comprehensive ocular examination, including examination under anesthesia for younger children, and were diagnosed with childhood glaucoma as per CGRN. Data were entered in a standard Excel chart. Refraction and visual acuity assessments were done when feasible.

MAIN OUTCOME MEASURES

The profile of newly diagnosed childhood glaucoma in different parts of India and the severity of glaucoma at presentation.

RESULTS

A total of 1743 eyes of 1155 children fulfilled the definition of glaucoma and were analyzed. Primary congenital glaucoma (PCG) comprised the single largest group (34.4%), most of which were infantile onset (19%). Neonatal-onset PCG comprised 6.2% of all glaucoma. Secondary glaucoma constituted 53.4% of all glaucoma, one-half of which were acquired conditions (28%), followed by isolated ocular anomalies (14.7%), glaucoma after cataract surgery (6.7%), and glaucoma with nonacquired systemic diseases (4.5%). Of the 1743 eyes with glaucoma, all 3 parameters for severity grading were available in 842 eyes, of which 501 (59.5%) eyes presented with mild, 320 (38%) with moderate, and 21 (2.5%) with severe glaucoma. Nearly one-third of the children (28.5%) were not brought back for follow-up after the initial treatment given.

CONCLUSIONS

Our study has one of the largest numbers of consecutive children with glaucoma classified according to the CGRN classification. Despite a widely diverse population, the profile of childhood glaucoma was relatively uniform across India. Childhood glaucoma is a significant problem in India, primarily treated in tertiary care hospitals. The data presented may be the tip of the iceberg because we have only reported the children who reached the hospitals offering treatment for this challenging disease.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Role of Glucocorticoids and Glucocorticoid Receptors in Glaucoma Pathogenesis

The glucocorticoid receptor (GR), including both alternative spliced isoforms (GRα and GRβ), has been implicated in the development of primary open-angle glaucoma (POAG) and iatrogenic glucocorticoid-induced glaucoma (GIG). POAG is the most common form of glaucoma, which is the leading cause of irreversible vision loss and blindness in the world. Glucocorticoids (GCs) are commonly used therapeutically for ocular and numerous other diseases/conditions. One serious side effect of prolonged GC therapy is the development of iatrogenic secondary ocular hypertension (OHT) and OAG (i.e., GC-induced glaucoma (GIG)) that clinically and pathologically mimics POAG. GC-induced OHT is caused by pathogenic damage to the trabecular meshwork (TM), a tissue involved in regulating aqueous humor outflow and intraocular pressure. TM cells derived from POAG eyes (GTM cells) have a lower expression of GRβ, a dominant negative regulator of GC activity, compared to TM cells from age-matched control eyes. Therefore, GTM cells have a greater pathogenic response to GCs. Almost all POAG patients develop GC-OHT when treated with GCs, in contrast to a GC responder rate of 40% in the normal population. An increased expression of GRβ can block GC-induced pathogenic changes in TM cells and reverse GC-OHT in mice. The endogenous expression of GRβ in the TM may relate to differences in the development of GC-OHT in the normal population. A number of studies have suggested increased levels of endogenous cortisol in POAG patients as well as differences in cortisol metabolism, suggesting that GCs may be involved in the development of POAG. Additional studies are warranted to better understand the molecular mechanisms involved in POAG and GIG in order to develop new disease-modifying therapies to better treat these two sight threatening forms of glaucoma. The purpose of this timely review is to highlight the pathological and clinical features of GC-OHT and GIG, mechanisms responsible for GC responsiveness, potential therapeutic options, as well as to compare the similar features of GIG with POAG.

Vernal Keratoconjunctivitis: A Systematic Review

Vernal keratoconjunctivitis (VKC) is a chronic, bilateral corneal and conjunctival problem which typically presents in young individuals. VKC is characterized by itching, photophobia, white mucous discharge, lacrimation, foreign body sensation, and pain due to corneal involvement of shield ulcers. Vernal keratoconjunctivitis is categorized within ocular diseases. The diagnosis is clinical, as no sure biomarkers pathognomonic of the disease have yet been identified. The VKC therapy relies on different types of drugs, from antihistamines and topical steroids to cyclosporine or tacrolimus eye drops. In extremely rare cases, there is also the need for surgical treatment for the debridement of ulcers, as well as for advanced glaucoma and cataracts, caused by excessive prolonged use of steroid eye drops. We performed a systematic review of the literature, according to PRISMA guideline recommendations. We searched the PubMed database from January 2016 to June 2023. Search terms were Vernal, Vernal keratoconjunctivitis, and VKC. We initially identified 211 articles. After the screening process, 168 studies were eligible according to our criteria and were included in the review. In this study, we performed a systematic literature review to provide a comprehensive overview of currently available diagnostic methods, management of VKC, and its treatments.

Uveitis in Children: The Role of Biological Agents in Its Management

We aimed to determine medium and long-term effects of TNF-α inhibitors in patients with pediatric uveitis. This was a retrospective review of medical charts. Included were 50 patients (84 eyes). Mean age at diagnosis was 7.22 ± 4.04 years. At baseline (time of initiation of biologic therapy), all patients had active uveitis. Complete control of uveitis was achieved in 84.52% (n = 71) of eyes, after a median of 3 months (IQR 2 months). Mean LogMAR BCVA at baseline was 0.23 ± 0.44; it remained stable at 12 and 24 months. At baseline, 64% of patients were treated with oral corticosteroids, this decreased to 29.5% at 12 months (p = 0.001) and to 21.9% at 24 months (p < 0.001). Mean time to prednisone dose of ≤0.2 mg/kg/day was 8.1 ± 2.02 months after baseline. A total of 40.5% of eyes were treated with topical steroids at baseline and this significantly decreased to 5.8% at 12 months. Multiple linear regression model was calculated to predict moderate and severe visual loss; only presenting visual acuity accounted for a unique variance in the model. In conclusion, TNF-α inhibitors achieved rapid disease control while enabling a remarkable steroid-sparing effect in children suffering from chronic uveitis. Presenting visual acuity was the sole predictor of moderate to severe visual loss.

Management of Vernal Keratoconjunctivitis in Children in the United Kingdom: A Review of the Literature and Current Best Practice Across Six Large United Kingdom Centers

Vernal keratoconjunctivitis (VKC) is a form of ocular allergy primarily affecting children. Considered a rare disease in Europe, its prevalence varies by geographic region and is poorly studied in the United Kingdom. There is considerable national variation in the management of VKC within the United Kingdom, risking misdiagnosis and delays to treatment for some children. This can significantly impact their quality of life, with the potential for lasting negative consequences. Based on discussions between experienced clinicians from six large centers across the United Kingdom, this article describes best practice recommendations for United Kingdom settings, including principles for diagnosis, referral, initial and long-term management, and supportive care. Recommendations include guidance on referral timing, which should depend on VKC severity, and a stepwise approach to treatment. Joint management by primary care and secondary care is recommended and the importance of supportive care, including emotional support and outreach to schools, is highlighted. Because frequent flareups are common in VKC, it is essential that families have access to the information they need to manage the disease and routes to access rapid care if needed. A thorough understanding of the nature of VKC, its triggers, and how best to manage it, by both patients and their families, is critical to ensuring appropriate management and to improving patient outcomes. [J Pediatr Ophthalmol Strabismus. 2023;60(1):6-17.].

A comparative analysis of surgical outcome in uveitic and non-uveitic steroid-induced glaucoma in children

Purpose

To compare outcomes of surgical management of uveitic glaucoma (UG) and steroid-induced glaucoma (SIG) in children in terms of intraocular pressure (IOP) control, visual acuity, and associations for failure.

Methods

This was a retrospective case-control study of consecutive UG (cases) and non-uveitic SIG (controls) in children <18 years of age who underwent surgery between January 2005 and December 2017.

Results

Primary trabeculectomy with mitomycin C (MMC) was performed in 12 cases (mean age: 9.2 ± 4.3 years) and 40 controls (mean age: 10.4 ± 3.7 years) (P = 0.33). Primary phaco-trabeculectomy with MMC was performed in 11 cases (mean age: 11.4 ± 4.7 years) and 16 controls (mean age: 10.4 ± 3.4 years) (P = 0.57). IOP control (P = 0.26), visual acuity (P = 0.97), number of glaucoma medications (P = 0.06), and survival rates (49% cases vs. 68% controls at 5 years; P = 0.22) were similar between the two groups following trabeculectomy. Survival rates in the phaco-trabeculectomy group at 5 years were 68% cases vs. 69% controls (P = 0.71). IOP was higher (P = 0.008) and visual acuity was worse (P = 0.02) in cases at the last visit. Associations for failure (univariate analysis) were younger age (OR: 6.29, 95% CL: 1.43, 27.67; P = 0.03) and male gender (OR: 4.79, 95% CL: 1.09, 20.97; P = 0.04). On multivariate analysis, younger age (OR: 11.985, 95% CL: 1.071, 134.153; P = 0.04) remained significant. Preoperative number of uveitic attacks was protective on univariate (OR: 0.75, 95% CL: 0.48, 1.15; P = 0.1) and multivariate analyses (OR: 0.49, 95% CL: 0.24, 0.09; P = 0.04).

Conclusion

Outcomes of trabeculectomy between cases and controls were similar in our series. However, phaco-trabeculectomy in pediatric uveitic eye group fared worse than eyes with SIG.

Topical 0.1% Nepafenac versus 0.09% Bromfenac Eye Drops for Inflammation after Laser Peripheral Iridotomy: A Randomized Controlled Trial

PURPOSE

To assess the safety and efficacy of 0.1% nepafenac versus 0.09% bromfenac eye drops in controlling inflammation after neodymium yttrium-aluminum-garnet (YAG) laser peripheral iridotomy (LPI).

DESIGN

Single-masked, single-center, randomized controlled trial.

PARTICIPANTS

One hundred and sixty eyes of patients with primary angle-closure suspect (PACS) and primary angle closure (PAC) undergoing bilateral LPI.

METHODS

Patients were randomized in a 1:1 ratio to receive 0.1% nepafenac thrice daily or 0.09% bromfenac eye drops twice daily for 2 weeks after neodymium YAG LPI. Assessment was performed by masked investigators at 2 weeks after LPI. A Glaucoma Symptom Scale (GSS) questionnaire was administered both at baseline and 2 weeks after LPI. Subjective comfort scores to the study medications were assessed on the basis of a Likert scale at 2 weeks after LPI. In patients with bilateral PACS or PAC, the right eye was analyzed, and in asymmetrical disease (i.e., when one eye had PACS and the other eye had PAC), the eye with PAC was analyzed.

MAIN OUTCOME MEASURES

The primary outcome (end point) was uncontrolled inflammation, defined as symptomatic inflammation within 1 week after LPI, the presence of anterior chamber cells at 2 weeks, or rebound inflammation after medication discontinuation. The secondary outcome was patient-reported comfort levels with study medications based on the GSS and Likert scale.

RESULTS

At 2 weeks after LPI, 7 patients (6 with PACS and 1 with PAC) in the nepafenac group and 2 patients with PACS in the bromfenac group achieved the primary end point, without a difference between the medication groups (P = 0.09). Post-LPI burning, smarting, and stinging was more common in the bromfenac group (P = 0.01), which also had a higher comfort score on the Likert scale (P = 0.004). The need for repeat LPI was comparable (10.0% in the nepafenac group vs. 15.4% in the bromfenac group; P = 0.22). A multivariate analysis revealed that a greater number of laser shots was associated with the need for repeat LPI (odds ratio, 1.05; 95% confidence interval, 1.00-1.10; P = 0.04).

CONCLUSIONS

Topical 0.09% bromfenac is noninferior to 0.1% nepafenac in controlling inflammation after LPI in eyes with PACS and PAC. Nepafenac may be associated with higher patient-reported comfort.

The short-term effects of intranasal steroids on intraocular pressure in pediatric population

PURPOSE

To evaluate the effect of intranasal mometasone furoate (INMF) on short-term intraocular pressure (IOP) alterations in children with allergic rhinitis (AR).

METHODS

Children diagnosed with AR and to whom INMF nasal spray had been firstly prescribed were enrolled. Cases with any ocular diseases except for refractive errors were excluded. Complete ophthalmologic examinations including IOP measurements using Tonopen XL were performed before the treatment as well as at the first and sixth weeks of follow-up. Demographics and ophthalmologic findings were noted and statistically analyzed.

RESULTS

Study population consisted of 62 right eyes of 62 children with a mean age of 8.55 ± 3.14 years. Of them, 29 were female (46.8%) and 33 were male (53.2%). Dilated fundoscopy revealed an enlarged Cup/Disc ratio in 12 eyes (19.4%). Family history of glaucoma was positive in 13 cases (21.0%). Mean best corrected visual acuity was found as 0.05 ± 0.08 logMAR. Initial IOP was 17.1 ± 2.3 mmHg; whereas it was measured as 18.2 ± 2.0 mmHg and 17.3 ± 2.1 mmHg at the first and sixth weeks of follow-up, respectively (p < 0.001). Both at the first and sixth weeks of follow-up, significant IOP rise was present in children with a positive family history of glaucoma (p < 0.001 and p = 0.003, respectively). Besides, increased IOP was found in participants with cupping revealed on fundoscopy at the first week of follow-up (p = 0.044).

CONCLUSION

Since children have greater risk for steroid-induced ocular hypertensive response than adults, ophthalmologic evaluation must be recommended in children receiving intranasal steroids.

Combination Therapy of 0.1% Fluorometholone and 0.05% Azelastine in Eyes with Severe Allergic Conjunctival Diseases: A Randomized Controlled Trial

This study sought to evaluate the efficacy of the isolated use of fluorometholone compared with the combined use of azelastine and fluorometholone for the treatment of severe allergic conjunctival disease (ACD). One hundred and eleven patients with severe ACD were randomized into two groups: one treated with topical 0.1% fluorometholone combined with 0.05% azelastine and the other with 0.1% fluorometholone alone. The Ocular Surface Disease Index (OSDI) and the signs of keratopathy, palpebral conjunctiva papillae and conjunctival congestion were scored before and at one, two and six weeks after treatment and compared between the groups. The intra-ocular pressure (IOP) was also monitored. There were no significant differences between the groups in the baseline mean scores of signs and OSDI scores, which gradually improved at all visits after therapy in both groups. Although the time effect was significant for all the parameters (all p < 0.001), the reduction in corneal involvement scores from week 2 to week 6 was insignificant in both groups (p = 0.460 for the steroids group and p = 0.074 for the combination group). All signs and symptoms were significantly more improved in the combination group than in the isolated group at each control visit. IOP remained stable at all visits (all p < 0.001), except one patient in each group had elevated IOP over 21 mmHg. While both the isolated use of fluorometholone and combined use of azelastine and fluorometholone are effective in alleviating the signs and symptoms of severe ACD, optimal response can be achieved with adjunctive treatment including azelastine.

Reciprocal Regulation between lncRNA ANRIL and p15 in Steroid-Induced Glaucoma

Steroid-induced glaucoma (SIG) is the most common adverse steroid-related effect on the eyes. SIG patients can suffer from trabecular meshwork (TM) dysfunction, intraocular pressure (IOP) elevation, and irreversible vision loss. Previous studies have mainly focused on the role of extracellular matrix turnover in TM dysfunction; however, whether the cellular effects of TM cells are involved in the pathogenesis of SIG remains unclear. Here, we found that the induction of cellular senescence was associated with TM dysfunction, causing SIG in cultured cells and mouse models. Especially, we established the transcriptome landscape in the TM tissue of SIG mice via microarray screening and identified ANRIL as the most differentially expressed long non-coding RNA, with a 5.4-fold change. The expression level of ANRIL was closely related to ocular manifestations (IOP elevation, cup/disc ratio, and retinal nerve fiber layer thickness). Furthermore, p15, the molecular target of ANRIL, was significantly upregulated in SIG and was correlated with ocular manifestations in an opposite direction to ANRIL. The reciprocal regulation between ANRIL and p15 was validated using luciferase reporter assay. Through depletion in cultured cells and a mouse model, ANRIL/p15 signaling was confirmed in cellular senescence via cyclin-dependent kinase activity and, subsequently, by phosphorylation of the retinoblastoma protein. ANRIL depletion imitated the SIG phenotype, most importantly IOP elevation. ANRIL depletion-induced IOP elevation in mice can be effectively suppressed by p15 depletion. Analyses of the single-cell atlas and transcriptome dynamics of human TM tissue showed that ANRIL/p15 expression is spatially enriched in human TM cells and is correlated with TM dysfunction. Moreover, ANRIL is colocalized with a GWAS risk variant (rs944800) of glaucoma, suggesting its potential role underlying genetic susceptibility of glaucoma. Together, our findings suggested that steroid treatment promoted cellular senescence, which caused TM dysfunction, IOP elevation, and irreversible vision loss. Molecular therapy targeting the ANRIL/p15 signal exerted a protective effect against steroid treatment and shed new light on glaucoma management.

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.

Knowledge, Attitude, and Practice Among Caregivers of Children With Vernal Keratoconjunctivitis in a Tertiary Care Pediatric Hospital

PURPOSE

To determine the knowledge and attitude about vernal keratoconjunctivitis (VKC) and factors affecting the practice and compliance with treatment in caregivers of children with VKC.

METHODS

The study was conducted in a tertiary care pediatric hospital in northern India. It was a hospital-based cross-sectional study in which 65 caregivers (parents or guardians) were interviewed regarding their knowledge about the disease and attitude of caregivers.

RESULTS

Of 268 children with VKC visiting the ophthalmology department during the study period, 65 children met the inclusion criteria; 53 (81.54%) were boys and 12 (18.46%) were girls. A total of 69.2% of caregivers were not aware of the symptoms of the disease and 83% of caregivers were unaware of the side effects of eye drops used. A total of 24.61% of caregivers considered VKC affected school hours and other recreational activities of children (P < .001). Compliance with treatment decreases with more episodes of VKC and longer duration of symptoms.

CONCLUSIONS

The chronic course of the disease affects compliance with treatment and follow-up with an eye specialist. Proper education of caregivers of children with VKC can influence the compliance with treatment. [J Pediatr Ophthalmol Strabismus. 2021;58(6):390-395.].

Pediatric uveitis: A comprehensive review

Pediatric uveitis accounts for 5-10% of all uveitis. Uveitis in children differs from adult uveitis in that it is commonly asymptomatic and can become chronic and cause damage to ocular structures. The diagnosis might be delayed for multiple reasons, including the preverbal age and difficulties in examining young children. Pediatric uveitis may be infectious or noninfectious in etiology. The etiology of noninfectious uveitis is presumed to be autoimmune or autoinflammatory. The most common causes of uveitis in this age group are idiopathic and juvenile idiopathic arthritis-associated uveitis. The stepladder approach for the treatment of pediatric uveitis is based on expert opinion and algorithms proposed by multidisciplinary panels. Uveitis morbidities in pediatric patients include cataract, glaucoma, and amblyopia. Pediatric patients with uveitis should be frequently examined until remission is achieved. Once in remission, the interval between follow-up visits can be extended; however, it is recommended that even after remission the child should be seen every 8-12 weeks depending on the history of uveitis and the medications used. Close follow up is also necessary as uveitis can flare up during immunomodulatory therapy. It is crucial to measure the impact of uveitis, its treatment, and its complications on the child and the child's family. Visual acuity can be considered as an acceptable criterion for assessing visual function. Additionally, the number of cells in the anterior chamber can be a measure of disease activity. We review different aspects of pediatric uveitis. We discuss the mechanisms of noninfectious uveitis, including autoimmune and autoinflammatory etiologies, and the risks of developing uveitis in children with systemic rheumatologic diseases. We address the risk factors for developing morbidities, the Standardization of Uveitis Nomenclature (SUN) criteria for timing and anatomical classifications, and describe a stepladder approach in the treatment of pediatric uveitis based on expert opinion and algorithms proposed by multi-disciplinary panels. In this review article, We describe the most common entities for each type of anatomical classification and complications of uveitis for the pediatric population. Additionally, we address monitoring of children with uveitis and evaluation of Quality of Life.

Effect of dexamethasone on the expression of MMPs, adenosine A1 receptors and NFKB by human trabecular meshwork cells

Objectives Steroid-induced ocular hypertension and glaucoma are associated with extracellular matrix remodeling at the trabecular meshwork (TM) of the eye due to reduced secretion of matrix metalloproteinases (MMPs), a family of enzymes regulating extracellular matrix proteolysis. Several biological functions of steroids are known to involve regulation of adenosine A1 receptors (A1AR) and nuclear factor kappa B (NFKB). Since MMPs expression in TM has been shown to be regulated by A1AR as well as transcription factors, it is likely that dexamethasone-induced changes in aqueous humor dynamics involve reduced MMP and A1AR expression and reduced NFKB activation. Hence, the current study investigated the association of dexamethasone-induced reduction in MMP secretion with reduced NFKB activation and A1AR expression. Methods Human trabecular meshwork cells (HTMCs) were characterized by estimating myocilin and alpha smooth muscle actin expression and then were treated with dexamethasone 100 nM for 2, 5 and 7 days. The MMP secretion was estimated in culture media using Western blot. Immunocytochemistry (ICC) and ELISA were done to investigate the effect of dexamethasone on NFKB phosphorylation. A1AR expression in HTMCs was determined using Western blot and ELISA. Results Dexamethasone caused a significant reduction in both MMP-2 and -9 expression compared to untreated group after five and seven days but not after two days of culture. Significantly reduced phosphorylated NFKB and A1AR protein levels were detected in dexamethasone treated compared to vehicle treated HTMCs after five days of culture. Conclusions Dexamethasone reduces MMP-2 and -9 secretion by HTMCs and this effect of dexamethasone is associated with reduced NFKB phosphorylation and A1AR expression.

Safety and Efficacy of 0.1% Nepafenac versus 1% Prednisolone Acetate Eye Drops after Laser Peripheral Iridotomy: A Prospective, Randomized Trial

PURPOSE

To compare 0.1% nepafenac, a topical nonsteroidal anti-inflammatory drop, with 1% prednisolone acetate in controlling inflammation after neodymium:yttrium-aluminum-garnet laser peripheral iridotomy (LPI) in primary angle-closure suspects (PACS).

DESIGN

Randomized controlled trial.

PARTICIPANTS

One hundred fifty-two PACS undergoing bilateral LPI.

METHODS

Patients were randomized to 0.1% nepafenac or 1% prednisolone acetate eye drops in both eyes. Medications were given 4 times daily for 7 days, then twice daily for additional 7 days. Investigators were masked to the type of medication. Right eyes in patients with bilateral PACS and the PACS eye in asymmetrical disease (primary angle closure in fellow eye) were analyzed.

MAIN OUTCOME MEASURES

Noninferior control of inflammation, defined as absence of cell in the anterior chamber at 2 weeks and absence of rebound iritis with medication discontinuation, was the primary outcome, whereas difference in the rise in intraocular pressure (IOP) was a secondary outcome.

RESULTS

Both groups were comparable in baseline characteristics, including IOP and total laser energy. Nepafenac was noninferior to prednisolone with regard to inflammation control, with 1 nepafenac-treated eye (1.3%) not meeting the primary end point because of 1+ anterior chamber cell at 2 weeks and 4 prednisolone-treated eyes (5.4%) failing to meet the primary end point because of rebound iritis (P < 0.001). A greater increase in IOP from baseline to 2 weeks was observed in the prednisolone group compared with the nepafenac group (+2.6 mmHg vs. +0.6 mmHg; P = 0.004), although at 4 weeks, IOP was not significantly different than baseline in either group (P > 0.05 for both). Two weeks after LPI, 3 nepafenac-treated eyes and 10 prednisolone-treated eyes demonstrated a 6- to 15-mmHg IOP elevation from baseline (P = 0.10), whereas 2 prednisolone-treated eyes and no nepafenac-treated eyes showed IOP elevation of more than 15 mmHg (P = 0.20). Four weeks after LPI, more prednisolone-treated eyes showed IOP elevation of 6 to 15 mmHg as compared with nepafenac-treated eyes (6 eyes vs. 1 eye; P = 0.04); no eyes showed IOP elevation of more than 15 mmHg.

CONCLUSIONS

Nepafenac was noninferior to prednisolone in controlling inflammation after LPI in PACS.

Age as a risk factor for steroid-induced ocular hypertension in the non-paediatric population

BACKGROUND/AIMS

To evaluate the age-related risk of steroid-induced ocular hypertension by analysing intraocular pressure (IOP) changes after intravitreal dexamethasone (DEX, Ozurdex) implant injection.

METHODS

A retrospective observational study was conducted among patients (n=455; 570 eyes) who had received DEX injection. IOP was measured prior to injection and after 1 week and 1, 2, 3, 6 and 12 months. Results were divided into seven categories based on patient age: 16-30, 31-40, 41-50, 51-60, 61-70, 71-80 and 81-90 years. The IOP elevation rate was compared among the groups.

RESULTS

The IOP elevation rate was 42.9% in patients aged ≤30 years (35.3%, 28.3%, 14.9%, 12.2%, 8.4% and 9.1% in the 31-40, 41-50, 51-60, 61-70, 71-80 and 81-90 groups, respectively). Regardless of how IOP was measured, there was an increasing trend in the incidence of IOP elevation with decreasing age. Furthermore, there was a significant stepwise increase in the OR with decreasing age groups. After the 51-60 group was set as the reference point, the ORs (95% CIs) were 5.048 (1.436 to 17.747), 3.671 (1.101 to 12.238), 2.538 (1.043 to 6.178), 0.947 (0.431 to 2.078), 0.713 (0.312 to 1.626) and 0.646 (0.137 to 3.048) in the ≤30, 31-40, 41-50, 61-70, 71-80 and 81-90 groups, respectively.

CONCLUSION

The rate of adverse elevations in IOP after steroid use was significantly lower in older patients than in younger patients. Therefore, caution is required when prescribing steroids to younger patients (<51 years).

Steroid-induced glaucoma: Epidemiology, pathophysiology, and clinical management

Glucocorticoids are a class of anti-inflammatory drugs commonly used to treat various ocular and systemic conditions. Although the role of glucocorticoids in the treatment of numerous serious inflammatory diseases is pivotal, their prolonged use may increase intraocular pressure resulting in steroid-induced glaucoma. We provide a detailed update on steroid-induced glaucoma as a preventable cause of blindness in the adult and pediatric population and describe its epidemiology, social impact, and risk factors. Furthermore, we explore the propensity of different steroids to increase the intraocular pressure, the role of different routes of steroid administration, dosage and duration of treatment, as well as the clinical features, genetics, and management of steroid-induced glaucoma.

Pattern of steroid misuse in vernal keratoconjunctivitis resulting in steroid induced glaucoma and visual disability in Indian rural population: An important public health problem in pediatric age group

Purpose

To know the pattern of presentations and management outcome of steroid induced glaucoma in vernal keratoconjunctivitis (VKC).

Methods

Children of VKC using steroid with two of the following criteria were enrolled: Intraocular pressure (IOP) >21 mm Hg, glaucomatous optic disc and visual field defects. Misused topical steroids were classified in 4 groups; A- Highly potent drugs (dexamethasone, betamethasone), B- Moderate (prednisolone), C- Weak (loteprednol, fluorometholone), D- Unknown drugs. Active/conservative interventions were done to control IOP. Corrected distance visual acuity (CDVA), IOP, anterior segment and fundus examinations were noted. One-way ANOVA test and post hoc Tukey HSD test were used to compare the groups.

Results

Out of 1423 VKC patients, 240 were using topical steroid without prescriptions. 92 eyes of 47 patients had steroid induced glaucoma. Hence prevalence of this complication was 3.30% in this study population. Mean age was 14.1 ± 3.8 years. Mean IOP was 38 ± 12 mm of Hg and mean vertical cup disc ratio was 0.67 ± 0.25. IOP was controlled by withdrawal of steroids (9 eyes), with antiglaucoma medications (27), trabeculectomy (57) and glaucoma drainage device (1). Mean CDVA at presentation was better in group C (0.23 log MAR). Mean IOP was highest in group A (43.1 mm Hg) followed by group D (40.5 mm Hg). At presentation 17 were blind (CDVA <3/60). Post treatment marginal improvement in CDVA was found (P = 0.46). However, statistically significantly improvement was noticed in IOP (P < 0.00001).

Conclusion

Injudicious use of steroids leads to vision threatening complications like ocular hypertension and glaucoma in children of VKC. Weak steroids like loteprednol or fluorometholone should be used instead of higher potency drugs. Vision and IOP should be monitored fortnightly in children using topical steroids to detect steroid responders at the earliest.

Steroid-induced glaucoma and blindness in vernal keratoconjunctivitis

PURPOSE

To report the clinical features, treatment outcomes and blindness associated with steroid-induced glaucoma in vernal keratoconjunctivitis (VKC).

MATERIALS AND METHODS

Records of patients with VKC, who visited our tertiary centre from 1992 and 2009, were reviewed and those with steroid-induced glaucoma were included in the study. Glaucoma was diagnosed based on intraocular pressure (IOP) ≥22 mm Hg on two consecutive visits (ocular hypertension) and/or glaucomatous optic disc damage. Blindness was defined as best corrected visual acuity of ≤20/400 or visual field <10°.

RESULTS

Of the 4062 VKC subjects, 91 (157 eyes) had steroid-induced glaucoma (SIG), showing a prevalence of 2.24%. Of these 87% were men. The median (IQR) age at onset of VKC was 12 years (7-17). At presentation, the median duration of VKC was 48 months (24-72) and the median duration of steroid usage was 24 months (12-36). The median cup-to-disc ratio (CDR) was 0.9 (0.7-0.9) and median mean deviation was -21.9 dB (-30.0 to -10.2). IOP was medically controlled in 66% eyes (104/157) and 34% eyes (53/157) needed glaucoma surgery. High presenting IOP (OR: 1.04; p=0.05) and increased duration of steroid usage (OR: 1.07; p=0.02) were significantly associated with need for glaucoma surgery. At presentation, 29/91 subjects (31.8%) were bilaterally blind due to SIG. Higher CDR at presentation was significantly associated with blindness in this cohort (p=0.02).

CONCLUSION

In this cohort of VKC with SIG, the disease predominantly affected adolescent males. Glaucoma was severe with one-third needing surgery and one-third blind due to SIG.

Steroid-induced protracted severe ocular hypertension in a 14-year-old girl

Steroid-induced ocular hypertension (SIOH) is a challenging entity in paediatric age, with many being refractory to medical therapy. Literature is scarce about surgical options in these cases. A 14-year-old girl with bilateral uveitis and macular oedema had received an intravitreal and subconjunctival triamcinolone injection in the right (OD) and left (OS) eye, respectively. While the steroid was effective in resolving the oedema, intraocular pressure (IOP) increased to about 40 mm Hg OD and 34 mm Hg OS, despite being under maximal IOP-lowering therapy. An initial conservative approach was preferred due to the young patient age and given that most cases of SIOH are transient. However, progressive structural changes were documented, and bilateral sequential minimally invasive glaucoma surgery (MIGS: XEN gel stent) was taken. With a follow-up of 6 months, the patient is drug-free with IOP around 14 mm Hg. This report discusses the role and efficacy of MIGS in a paediatric case of SIOH.

Steroid-induced Glaucoma: An Avoidable Irreversible Blindness

Steroids are a group of anti-inflammatory drugs, commonly used to treat ocular and systemic conditions. Unmonitored use of steroids especially in eye drop formulations is common in situations when it is easily available over-the-counter, resulting in undesirable side effects. Among the ocular side effects, cataract and glaucoma are common. Steroid-induced ocular hypertension was reported in 1950, when long-term use of systemic steroid was shown to increase the intraocular pressure (IOP). Chronic administration of steroids in any form with raised IOP can cause optic neuropathy resulting in steroid-induced glaucoma. This review describes the pathophysiology and epidemiology of steroid-induced glaucoma, recognition of side effects, and principles of management. The purpose is to familiarize all clinicians with the potential dangers of administering steroids without monitoring the eye and the dangers of irreversible blind -ness in some instances of habitual self-prescription by patients.

HOW TO CITE THIS ARTICLE

Phulke S, Kaushik S, Kaur S, Pandav SS. Steroid-induced Glaucoma: An Avoidable Irreversible Blindness. J Curr Glaucoma Pract 2017;11(2):67-72.

Steroid-induced glaucoma in the pediatric population

Steroid medications may cause elevation of intraocular pressure, sometimes with permanent damage to the optic nerve. These therapies, via various routes of administration, are commonly prescribed for children, but the potential sequelae of elevated intraocular pressure and glaucomatous optic nerve damage can be even more severe and devastating in children than in adults. This review discusses the pathophysiology and potential risk factors, including the impact of intraocular pressure elevation via the different common routes of administration of steroids, clinical evaluation, and management of steroid response and steroid-induced glaucoma in children.

Steroid-induced Glaucoma: An Avoidable Irreversible Blindness

Steroids are a group of anti-inflammatory drugs, commonly used to treat ocular and systemic conditions. Unmonitored use of steroids especially in eye drop formulations is common in situations when it is easily available over-the-counter, resulting in undesirable side effects.

Among the ocular side effects, cataract and glaucoma are common. Steroid-induced ocular hypertension was reported in 1950, when long-term use of systemic steroid was shown to increase the intraocular pressure (IOP). Chronic administration of steroids in any form with raised IOP can cause optic neuropathy resulting in steroid-induced glaucoma.

This review describes the pathophysiology and epidemio­logy of steroid-induced glaucoma, recognition of side effects, and principles of management. The purpose is to familiarize all clinicians with the potential dangers of administering steroids without monitoring the eye and the dangers of irreversible blindness in some instances of habitual self-prescription by patients.

How to cite this article

Phulke S, Kaushik S, Kaur S, Pandav SS. Steroid-induced Glaucoma: An Avoidable Irreversible Blindness. J Curr Glaucoma Pract 2017;11(2):67-72.

Severe Corticosteroid-Induced Ocular Hypertension Requiring Bilateral Trabeculectomies in a Patient with Takayasu's Arteritis

We present a rare case of severe corticosteroid-induced ocular hypertension (OHT) after prolonged systemic corticosteroid use in a young woman with Takayasu's arteritis. As she did not sufficiently respond to ocular antihypertensive therapies, bilateral enhanced trabeculectomies were required to normalize her intraocular pressures. The systemic side effects of corticosteroids are well known, yet steroid-induced OHT and glaucoma remain silent causes of ocular morbidity. This case highlights the importance of IOP-monitoring in visually asymptomatic patients on systemic corticosteroids. It further emphasizes the need to raise awareness of the potential ocular side effects of steroids amongst physicians, in particular those looking after patients with autoimmune and inflammatory diseases.