Corticosteroids and glaucoma risk

Biosafety and Efficacy Studies of Colchicine-Encapsulated Liposomes for Ocular Inflammatory Diseases

Inflammation is a critical component in the progression of various ocular diseases, such as age-related macular degeneration, diabetic retinopathy, and uveitis, leading to significant vision loss. Colchicine has been used for treating gout with its anti-inflammatory effect. However, free colchicine demonstrated cytotoxicity to ocular cells and cannot directly be used for eye disease. Thus, this study introduces, for the first time, the development and use of colchicine-encapsulated liposomes as a novel therapeutic approach for managing inflammation-driven ocular conditions. The encapsulation of colchicine within liposomes represents a significant innovation, aimed at enhancing biocompatibility and therapeutic efficacy while minimizing cytotoxic effects associated with free colchicine. Our research synthesized colchicine-loaded liposomes and assessed their therapeutic impact on human monocytes, macrophages, and retinal pigment epithelium (RPE) cells in an inflammatory environment. The findings reveal a groundbreaking improvement in treatment strategies, with a substantial reduction in TNF-alpha-induced reactive oxygen species (ROS) and nitric oxide (NO) production in RPE cells. Moreover, the colchicine-loaded liposomes significantly inhibited the proliferation and ROS production in activated monocytes and macrophages and effectively decreased interleukin (IL)-1β and IL-6 secretion, highlighting their strong anti-inflammatory properties and showed slightly better suppression of these two cytokines than dexamethasone-liposomes.

Risk for Ocular Hypertension With Intravitreal Dexamethasone Implants in Black and White Patients With Diabetic Macular Edema

Purpose: To compare the effects of intravitreal (IVT) 0.7 mg dexamethasone implants on the intraocular pressure (IOP) in Black patients and White patients with diabetic macular edema (DME). Methods: A retrospective cohort study was performed of Black patients and White patients with DME who received dexamethasone implants with 12 or more months of follow-up. Results: The study included 145 eyes (69 Black; 76 White) with a mean (±SD) of 3.6 ± 3.9 dexamethasone implants and 58 ± 31 months of follow-up. Black patients had higher baseline rates of glaucoma (23% vs 8%; P = .010) but similar rates of ocular hypertension after receiving IVT dexamethasone (20% vs 16%; P = .52). By the last follow-up visit, the mean central subfield thickness had decreased from 387 ± 129 µm to 314 ± 104 µm (P < .001). Conclusions: IVT dexamethasone implants decreased macular thicknesses in patients with DME; however, there was no difference in the rate of ocular hypertension after IVT dexamethasone between Black patients and White patients.

Evaluation of adjuvant role of topical cyclosporine 1% in acute Stevens-Johnson syndrome: a randomised control trial

PURPOSE

To evaluate the role of topical cyclosporine A 1% (CsA) as an adjuvant therapy in patients with acute Stevens-Johnson syndrome (SJS).

METHODS

This is a randomised controlled trial in which 44 patients (88 eyes) with acute SJS, presenting within 3 months from the onset of the disease, were enrolled and randomised. Group A (n=44 eyes) patients received treatment with topical CsA 1% along with standard therapy consisting of topical corticosteroids, antibiotics and lubricants. Group B (n=44 eyes) patients received topical saline drops in combination with standard therapy. Various ocular surface parameters were assessed at baseline and the 6-month follow-up.

RESULTS

The mean age of patients (years) was 23.9±15.1 in the CsA group and 26.0±18.7 in the control group (p=0.6840). The mean time from disease onset to presentation (days) was 17.0±14.0 and 12.9±11.3 in CsA and control groups, respectively (p=0.1568). At presentation, the mean grades of severity scores of various parameters were comparable. At 6 months, both groups showed a significant improvement in the mean severity grades of conjunctival hyperaemia (A, p=0.001; B, p=0.0001), mucocutaneous junction involvement (A, p=0.001; B, p=0.0001) and meibomian gland involvement (A, p=0.0471; B, p=0.006). Compared with baseline, the grades of corneal keratinisation (baseline, 0.48±0.7; 6 months, 1.02±0.8; p=0.0015) and neovascularisation (baseline, 1.07±1.2; 6 months, 1.57±1.0; p=0.0412) worsened after 6 months of CsA therapy. Intergroup comparison of grades of various parameters however did not reveal any significant difference at 6 months.

CONCLUSIONS

Adjuvant treatment with topical CsA is not superior to standard therapy, in cases of acute SJS.

The role of YAP/TAZ mechanosignaling in trabecular meshwork and Schlemm's canal cell dysfunction

This focused review highlights the importance of yes-associated protein (YAP)/transcriptional coactivator with PDZ binding motif (TAZ) mechanosignaling in human trabecular meshwork and Schlemm's canal cells in response to glaucoma-associated extracellular matrix stiffening and cyclic mechanical stretch, as well as biochemical pathway modulators (with signaling crosstalk) including transforming growth factor beta 2, glucocorticoids, Wnt, lysophosphatidic acid, vascular endothelial growth factor, and oxidative stress. We provide a comprehensive overview of relevant literature from the last decade, highlight intriguing research avenues with translational potential, and close with an outlook on future directions.

Advances in the ocular complications after hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) has benefited an increasing number of patients with hematological disease in the clinic. It is a curative therapy for malignant and nonmalignant hematological diseases. With the advancement and further clinical application of HSCT in recent years, the life expectancy of patients has increased, but complications have become more common. The occurrence of ocular complications is receiving increasing attention because they can seriously affect the quality of life of patients. Ocular complications require increased attention from clinicians because of their negative impact on patients and increasing incidence. Most of recent reports on posttransplant ocular complications involve ocular manifestations of graft-versus-host disease (GVHD), and a few ocular complications that do not originate from GVHD have also been reported. This review summarizes the diagnosis, scoring criteria, pathophysiology, and clinical manifestations of and common therapies for ocular graft-versus-host disease(oGVHD) after HSCT, and includes a description of some rare cases and novel therapies.

Inflammo-immune perspective on the association of eight migraine risk factors with migraine: a multi-omics Mendelian randomization study

Background

Migraine risk factors are associated with migraine susceptibility, yet their mechanisms are unclear. Evidence suggests a role for inflammatory proteins and immune cells in migraine pathogenesis. This study aimed to examine the inflammo-immune association between eight migraine risk factors and the disorder.

Methods

This study utilized inverse variance weighted (IVW) method and colocalization analysis to explore potential causal relationships between eight migraine risk factors, migraine, 731 immune cells, and 91 circulating inflammatory proteins. Mediation Mendelian randomization (MR) was further used to confirm the mediating role of circulating inflammatory proteins and immune cells between the eight migraine risk factors and migraine.

Results

Migraine risk factors are linked to 276 immune cells and inflammatory proteins, with cigarettes smoked per day strongly co-localized with CD33-HLA DR+ cells. Despite no co-localization, 23 immune cells/inflammatory proteins relate to migraine. Depression, all anxiety disorders, and sleep apnea are correlated with migraine, and all anxiety disorders are supported by strong co-localization evidence. However, the mediating effect of inflammatory proteins and immune cells between eight migraine risk factors and migraine has not been confirmed.

Conclusion

We elucidate the potential causal relationships between eight migraine risk factors, migraine, immune cells, and inflammatory proteins, enhancing our understanding of the molecular etiology of migraine pathogenesis from an inflammatory-immune perspective.

Steroid-Dependency in Posner-Schlossman Syndrome: A Suggested Topical 2% Ganciclovir and Gradual Decrement of Topical Steroid Combination Therapy from Shanghai PSS Study

PURPOSE

This study focused on the prevalence, unique features, and required treatment of steroid-dependent Posner-Schlossman syndrome (SD-PSS), and analyzed the outcome of 2% Ganciclovir and gradual decrement steroid combination therapy in SD-PSS patients.

METHODS

Retrospective comparative and interventional study. SD-PSS was defined as PSS patients with continuous steroid use for over 3 months and relapsed within 2 weeks after steroid withdrawal or tapered dosage. Totally 74 SD-PSS eyes were compared with 78 randomly chosen non-steroid dependent PSS eyes. SD-PSS patients who underwent 2% GCV and gradual decrement steroid therapy with at least two follow-ups (n = 50) were analyzed for the treatment outcome.

RESULTS

The prevalence of SD-PSS is 26.87% (97/361) in our PSS patients. SD-PSS patients demonstrated significantly younger onset age, longer disease course, higher intraocular pressure (IOP), and higher degree of iris depigmentation at the first visit. They required significantly more IOP-lowering medication and stronger steroid after the first visit. Our 2% GCV and gradual decrement steroid therapy helped 66% (33/50) SD-PSS patients with steroid withdrawal (median stable time: 13 weeks) and another 32% (16/50) SD-PSS managed to lower the dose or strength of topical steroid. Steroid-induced ocular hypertension happened in 5.26% (19/361) of the PSS patients.

CONCLUSION

Young onset age, high IOP, and high iris depigmentation level during acute stage are indicators of steroid dependency in PSS patients. SD-PSS patients require more medical surveillance. Two percent ganciclovir and gradual decrement steroid combination therapy help with steroid withdrawal and minimize steroid use.

Glucocorticoids-based prodrug design: Current strategies and research progress

Attributing to their broad pharmacological effects encompassing anti-inflammation, antitoxin, and immunosuppression, glucocorticoids (GCs) are extensively utilized in the clinic for the treatment of diverse diseases such as lupus erythematosus, nephritis, arthritis, ulcerative colitis, asthma, keratitis, macular edema, and leukemia. However, long-term use often causes undesirable side effects, including metabolic disorders-induced Cushing's syndrome (buffalo back, full moon face, hyperglycemia, etc.), osteoporosis, aggravated infection, psychosis, glaucoma, and cataract. These notorious side effects seriously compromise patients' quality of life, especially in patients with chronic diseases. Therefore, glucocorticoid-based advanced drug delivery systems for reducing adverse effects have received extensive attention. Among them, prodrugs have the advantages of low investment, low risk, and high success rate, making them a promising strategy. In this review, we propose the strategies for the design and summarize current research progress of glucocorticoid-based prodrugs in recent decades, including polymer-based prodrugs, dendrimer-based prodrugs, antibody-drug conjugates, peptide-drug conjugates, carbohydrate-based prodrugs, aliphatic acid-based prodrugs and so on. Besides, we also raise issues that need to be focused on during the development of glucocorticoid-based prodrugs. This review is expected to be helpful for the research and development of novel GCs and prodrugs.

Wound Modulations in Glaucoma Surgery: A Systematic Review

Excessive fibrosis and resultant poor control of intraocular pressure (IOP) reduce the efficacy of glaucoma surgeries. Historically, corticosteroids and anti-fibrotic agents, such as mitomycin C (MMC) and 5-fluorouracil (5-FU), have been used to mitigate post-surgical fibrosis, but these have unpredictable outcomes. Therefore, there is a need to develop novel treatments which provide increased effectiveness and specificity. This review aims to provide insight into the pathophysiology behind wound healing in glaucoma surgery, as well as the current and promising future wound healing agents that are less toxic and may provide better IOP control.

Glucocorticoid-Induced Ocular Hypertension and Glaucoma

Glucocorticoid (GC) therapy is indicated in many diseases, including ocular diseases. An important side-effect of GC therapy is GC-induced ocular hypertension (GIOHT), which may cause irreversible blindness known as GC-induced glaucoma (GIG). Here, we reviewed the pathological changes that contribute to GIOHT including in the trabecular meshwork and Schlemm's canal at cellular and molecular levels. We also discussed the clinical aspects of GIOHT/GIG including disease prevalence, risk factors, the type of GCs, the route of GC administration, and management strategies.

Glucocorticoid-Induced Osteoporosis (GIOP)

Use of glucocorticoid in various diseases including rheumatology and respiratory diseases is on the rise because of its prompt beneficial effects. This culminates in osteoporosis and fragility fractures. Judicious use of glucocorticoid hence calls for attention with regard to the dose schedule, route of administration and accompanying enhancing factors. Institution of proper therapeutic management as per WHO risk stratification with anabolic and/or resorptive drugs like bisphosphonates, teriparatide or denosumab is necessary to prevent the eventuality of fragility fractures. Even otherwise, knowledge of glucocorticoid, its metabolism, various dose schedules, adverse effects are areas worth discussing.

The Effects of ROCK Inhibitor on Prevention of Dexamethasone-Induced Glaucoma Phenotype in Human Trabecular Meshwork Cells

Purpose

This study investigated the effects of dexamethasone (Dex) on human trabecular meshwork (TM) cells, a model of glucocorticoid-induced glaucoma, and evaluated the impact of ripasudil (Rip) as a co-delivery or sequential dosing strategy.

Methods

In vitro experiments were conducted to assess the effects of Dex and Rip on TM cells. Confocal microscopy was used to evaluate the impact of Dex and Rip on F-actin staining signals. Contractility of the TM cells upon Dex and Rip treatment mimicking co-delivery and sequential delivery was quantified using collagen gel contraction assay. Transepithelial electrical resistance (TEER) values and fluorescein isothiocyanate (FITC)-dextran permeability were also measured to assess the impact of Dex and Rip on TM cells.

Results

Dex and Rip did not exhibit cytotoxicity at the maximum tested concentration (20 µM). Dex-treated TM cells exhibited higher F-actin staining signals compared to controls, which were reduced when co-treated with Rip. Rip inhibited Dex-induced collagen gel contraction activity in both co-delivery and sequential treatments. Dex resulted in increased TEER values as the dose increased, whereas TEER values were maintained when co-treated with Rip.

Conclusions

Co-delivery of Rip has the potential to prevent glaucoma symptoms when patients are treated with Dex. This study highlights the importance of identifying strategies to reduce the side effects of prolonged use of glucocorticoids, such as Dex, in the treatment of various diseases.

Translational Relevance

This study demonstrates the potential of co-delivering ripasudil with dexamethasone to mitigate glucocorticoid-induced ocular hypertension and a secondary glaucoma that resembles primary open-angle glaucoma, providing insights for the development of novel preventive strategies in clinical care.

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

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

Refractive surgery for the glaucoma suspect

PURPOSE OF REVIEW

The aim of this study was to provide an update on perioperative considerations in the evaluation and management of patients undergoing primary corneal and intraocular refractive procedures who are at risk for progressive glaucomatous optic neuropathy.

RECENT FINDINGS

The necessity of a comprehensive baseline assessment prior to refractive procedures with structural and functional testing, along with documentation of preoperative intraocular pressure (IOP) measurements, is highlighted in recent literature. Substantiation of the increased risk of postoperative IOP elevation in keratorefractive procedures in patients with higher baseline IOP and lower baseline CCT, but not necessarily the degree of myopia, has been variably evidenced. Tonometry methods which are less influenced by postoperative corneal structural change should be considered in patients undergoing keratorefractive procedures. Vigilence in postoperative monitoring for progressive optic neuropathy is suggested given evidence of an increased risk of steroid-response glaucoma in these patients. Additional evidence for the IOP-lowering impact of cataract surgery in patients with an increased risk of glaucoma is provided, irrespective of intraocular lens choice.

SUMMARY

Performing refractive procedures on patients at risk for glaucoma remains controversial. Definitive steps to optimize patient selection along with vigilance in disease state monitoring with longitudinal structural and functional testing can help mitigate potential adverse events.

Association of trabecular meshwork height with steroid-induced ocular hypertension

It is important to identify at-risk patients prior to administering steroid injections to prevent avoidable irreversible blindness inducted by steroid-induced ocular hypertension (SIOH). We aimed to investigate the association of SIOH following intravitreal dexamethasone implantation (OZURDEX) using anterior segment optical coherence tomography (AS-OCT). We conducted a retrospective case control study to assess the association between trabecular meshwork and SIOH. A total of 102 eyes that underwent both AS-OCT and intravitreal dexamethasone implant injection were divided into the post-steroid ocular hypertension and normal intraocular pressure groups. Ocular parameters that can contribute to intraocular pressure were measured using AS-OCT. Univariable logistic regression analysis was used to calculate the odds ratio of the SIOH and significant variables were further analyzed using a multivariable model. Trabecular meshwork (TM) height was significantly shorter in the ocular hypertension group (716.13 ± 80.55 μm) than that in the normal intraocular pressure group (784.27 ± 82.33 μm) (p < 0.001). The receiver operating characteristic curve technique analysis showed that the optimal cut-off of ≥ 802.13 μm for TM height specificity was 96.2%, and TM height with < 646.75 μm had a sensitivity of 94.70%. The odds ratio of the association was 0.990 (p = 0.001). TM height was identified as a newly observed association with SIOH. TM height can be assessed using AS-OCT, with acceptable sensitivity and specificity. Caution must be exercised while injecting steroids in patients with short TM height (especially < 646.75 μm) as it may cause SIOH and irreversible blindness.

Inflammatory signalling in atrial cardiomyocytes: a novel unifying principle in atrial fibrillation pathophysiology

Inflammation has been implicated in atrial fibrillation (AF), a very common and clinically significant cardiac rhythm disturbance, but its precise role remains poorly understood. Work performed over the past 5 years suggests that atrial cardiomyocytes have inflammatory signalling machinery - in particular, components of the NLRP3 (NACHT-, LRR- and pyrin domain-containing 3) inflammasome - that is activated in animal models and patients with AF. Furthermore, work in animal models suggests that NLRP3 inflammasome activation in atrial cardiomyocytes might be a sufficient and necessary condition for AF occurrence. In this Review, we evaluate the evidence for the role and pathophysiological significance of cardiomyocyte NLRP3 signalling in AF. We first summarize the evidence for a role of inflammation in AF and review the biochemical properties of the NLRP3 inflammasome, as defined primarily in studies of classic inflammation. We then briefly consider the broader evidence for a role of inflammatory signalling in heart disease, particularly conditions that predispose individuals to develop AF. We provide a detailed discussion of the available information about atrial cardiomyocyte NLRP3 inflammasome signalling in AF and related conditions and evaluate the possibility that similar signalling might be important in non-myocyte cardiac cells. We then review the evidence on the role of active resolution of inflammation and its potential importance in suppressing AF-related inflammatory signalling. Finally, we consider the therapeutic potential and broader implications of this new knowledge and highlight crucial questions to be addressed in future research.

Glypican-4 regulated actin cytoskeletal reorganization in glucocorticoid treated trabecular meshwork cells and involvement of Wnt/PCP signaling

A common adverse response to the clinical use of glucocorticoids (GCs) is elevated intraocular pressure (IOP) which is a major risk factor for glaucoma. Elevated IOP arises due to impaired outflow of aqueous humor (AH) through the trabecular meshwork (TM). Although GC-induced changes in actin cytoskeletal dynamics, contractile characteristics, and cell adhesive interactions of TM cells are believed to influence AH outflow and IOP, the molecular mechanisms mediating changes in these cellular characteristics are poorly understood. Our studies focused on evaluating changes in the cytoskeletal and cytoskeletal-associated protein (cytoskeletome) profile of human TM cells treated with dexamethasone (Dex) using label-free mass spectrometric quantification, identified elevated levels of specific proteins known to regulate actin stress fiber formation, contraction, actin networks crosslinking, cell adhesion, and Wnt signaling, including LIMCH1, ArgBP2, CNN3, ITGBL1, CTGF, palladin, FAT1, DIAPH2, EPHA4, SIPA1L1, and GPC4. Several of these proteins colocalized with the actin cytoskeleton and underwent alterations in distribution profile in TM cells treated with Dex, and an inhibitor of Abl/Src kinases. Wnt/Planar Cell Polarity (PCP) signaling agonists-Wnt5a and 5b were detected prominently in the cytoskeletome fraction of TM cells, and studies using siRNA to suppress expression of glypican-4 (GPC4), a known modulator of the Wnt/PCP pathway revealed that GPC4 deficiency impairs Dex induced actin stress fiber formation, and activation of c-Jun N-terminal Kinase (JNK) and Rho kinase. Additionally, while Dex augmented, GPC4 deficiency suppressed the formation of actin stress fibers in TM cells in the presence of Dex and Wnt5a. Taken together, these results identify the GPC4-dependent Wnt/PCP signaling pathway as one of the crucial upstream regulators of Dex induced actin cytoskeletal reorganization and cell adhesion in TM cells, opening an opportunity to target the GPC4/Wnt/PCP pathway for treatment of ocular hypertension in glaucoma.

A multidisciplinary consensus statement on the optimal pharmacological treatment for metastatic hormone-sensitive prostate cancer

Androgen deprivation therapy (ADT) is the mainstay treatment for metastatic hormone-sensitive prostate cancer (mHSPC). The addition of docetaxel or new hormone therapies (abiraterone, apalutamide, or enzalutamide) improves overall survival and is currently the standard of care. However, the decision on the specific regimen to accompany ADT should be discussed with the patient, considering factors such as possible associated toxicities, duration of treatment, comorbidities, patient preferences, as there is no sufficient evidence to recommend one regimen over the other in most cases. This paper summarizes the evidence on the management of mHSPC and provides consensus recommendations on the optimal treatment in combination with ADT in mHSPC patients, with special attention to the patient's clinical profile.

Topical treatment of diabetic macular edema using dexamethasone ophthalmic suspension: A randomized, double-masked, vehicle-controlled study

PURPOSE

To evaluate topical dexamethasone ophthalmic suspension OCS-01 (Oculis SA, Lausanne, Switzerland) in diabetic macular edema (DME).

METHODS

This was a multicenter, double-masked, parallel-group, randomized, Phase 2 study. Patients aged 18-85 years with DME of <3 years duration, ETDRS central subfield thickness ≥ 310 μm by SD-OCT, and ETDRS letter score ≤ 73 and ≥ 24 in the study eye were randomized 2:1 to OCS-01 or matching vehicle, 1 drop 3 times/day for 12 weeks. Efficacy was evaluated as change from baseline to Week 12 of ETDRS letter score and central macular thickness (CMT). The primary analysis used a linear model with baseline ETDRS letters as a covariate, and missing data imputed using multiple imputation pattern mixture model techniques. Active treatment was considered superior to vehicle if the one-sided p-value was <0.15 and the difference in mean change from baseline in ETDRS letters was >0.

RESULTS

Mean CMT showed a greater decrease from baseline with OCS-01 (N = 99) than vehicle (N = 45) at Week 12 (-53.6 vs -16.8 μm, p = 0.0115), with significant differences favouring OCS-01 from Weeks 2 to 12. OCS-01 was well-tolerated, and increased intraocular pressure was the most common adverse event. Mean change in ETDRS letter score from baseline to Week 12 met the p was +2.6 letters with topical OCS-01 and 1 letter with vehicle (p = 0.125). In a post-hoc analysis, there was a greater difference in patients with baseline BCVA ≤65 letters, the OCS-01 group improved 3.8 letters compared with 0.9 letters with vehicle.

CONCLUSION

Topical OCS-01 was significantly more effective than vehicle in improving central macular thickness in patients with DME. Visual improvement was better in eyes with lower baseline vision.

Use of Glucocorticoids in Patients With Cancer: Potential Benefits, Harms, and Practical Considerations for Clinical Practice

PURPOSE

Glucocorticoids are commonly used in patients with cancer for symptom relief or as part of their anticancer treatment. Despite their frequent use, indications and dosing regimens are not exclusively evidence-based and can come with a multitude of adverse effects, some of which can be life-threatening. The objective of this review is to update our current state of knowledge on the use of glucocorticoids in adult patients with cancer.

METHODS AND MATERIALS

A comprehensive literature review (1949-2022) was conducted using search terms "glucocorticoids," "corticosteroids," and "cancer." Information was organized by main concepts including indications, potential benefits, and prevention and management of common side effects of glucocorticoid therapy, in addition to appropriate dosing and taper regimens.

RESULTS

Glucocorticoids can be highly effective in improving outcomes and quality of life in patients with cancer. Their uses include management of disease manifestations, symptoms, and complications of cancer treatment. The lowest effective dose should be used and treatment duration should be minimized as clinically feasible. Side effects can be minimized by careful monitoring, continued assessment of benefits versus harms, and preventative measures for expected side effects.

CONCLUSIONS

This review provides general principles and practical recommendations on the use of glucocorticoids in patients with cancer. Further prospective studies on the outcomes of patients on glucocorticoids may help guide practice.

Size-switchable polymer-based nanomedicines in the advanced therapy of rheumatoid arthritis

Chronic inflammatory diseases such as rheumatoid arthritis represent a substantial socio-economic impact and have a high prevalence in the modern world. Nano-sized polymer therapeutics have shown suitable characteristics for becoming the next generation of anti-inflammatory nanomedicines. Here, we present biocompatible and stimuli-sensitive N-(2-hydroxypropyl)methacrylamide based polymer conjugates with the anti-inflammatory drug dexamethasone (DEX), which has been tailored for prolonged blood circulation, enhanced inflammatory site accumulation, site-specific drug release and subsequent elimination of the carrier via urine excretion. The hydrodynamic size of novel polymer-DEX nanomedicine was adjusted to prolong its blood circulation whilst maintaining the renal excretability of the polymer carrier after drug release in inflamed tissue. The therapeutic efficacy of the studied polymer nanomedicines was evaluated in a model of dissipated chronic arthritis, i.e. collagen II-induced arthritis, in mice. The pH-sensitive drug attachment enabled enhanced blood circulation with minimal systemic drug release, as well as rapid drug activation in affected joints. Importantly, unlike free DEX, the polymer nanomedicines were able to diminish joint inflammation and arthritis-induced bone damage - even at a reduced dosing regimen - as evaluated by micro computed tomography (micro-CT).

Increased Risk of Ocular Hypertension in Patients With Cushing's Disease

PRCIS

An increased risk of ocular hypertension was seen in Cushing's disease.

INTRODUCTION

Systemic steroid use is a significant risk factor for increased intraocular pressure (IOP). The incidence of ocular hypertension may rise to 30%-40% of the general population due to topical or systemic glucocorticoid usage. However, the incidence of ocular hypertension in endogenous hypercortisolemia, as well as the ophthalmological outcomes after endocrine remission due to surgical resection, remain unknown.

MATERIALS AND METHODS

The IOP, visual field, and peripapillary retinal nerve fiber layer thickness were documented in all patients with Cushing's disease (CD) admitted to a tertiary pituitary center for surgery from January to July 2019. Patients with acromegaly and patients with nonfunctioning pituitary adenoma (NFPA) during the same study period served as controls. We calculated the odds ratio (OR), identified the risk factors of developing ocular hypertension, and presented postoperative trends of the IOP.

RESULTS

A total of 52 patients (38.4±12.4 y old) with CD were included. The IOP was higher in patients with CD (left 19.4±5.4 mm Hg and right 20.0±7.1 mm Hg) than in patients with acromegaly (left 17.5±2.3 mm Hg and right 18.6±7.0 mm Hg, P =0.033) and patients with NFPA (left 17.8±2.6 mm Hg and right 17.4±2.4 mm Hg, P =0.005). A total of 21 eyes (20.2%) in patients with CD were diagnosed with ocular hypertension compared with 4 eyes (4.7%) in the acromegaly group and 4 eyes (4.5%) in the NFPA group. The OR of developing ocular hypertension in patients with CD was 5.1 [95% confidence interval (CI), 1.3-25.1, P =0.029] and 6.6 (95% CI, 1.8-30.3, P =0.007) when compared with the 2 control groups. Among patients with CD, those with a higher urine-free cortisol were more likely to develop ocular hypertension (OR=19.4, 95% CI, 1.7-72.6). The IOP decreased at 1 month after surgery in patients with CD, and the change was sustained for 3 months after surgery.

CONCLUSIONS

An increased risk of ocular hypertension was seen in CD and suggests that endogenous hypercortisolemia should be considered as part of the glaucoma assessment. This result warrants the discretion of both ophthalmologists and neuroendocrinologists.

Efficacy of Topical Administration of Corticosteroids for the Management of Dry Eye Disease: Systematic Review and Meta-Analysis

The efficacy of corticosteroids (CS) for dry eye disease (DED) has been investigated in the clinical setting. The present study investigated whether topical CS application improves the clinical outcome at last follow-up compared to the baseline. The present study was conducted according to the PRISMA 2020. All the randomized clinical trials (RCTs), which investigated the efficacy of corticosteroids in the management of DED, were accessed. In September 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar, and Embase. The following data were extracted at baseline and at last follow-up: Ocular Surface Disease Index (OSDI), tear breakup time test (TBUT), Schirmer I test (SIT), and corneal staining. Data from 425 patients were retrieved. A total of 69.4% (295 of 425 patients) were women. CS were effective to improve SIT (p = 0.02) and corneal staining (p = 0.003) at the last follow-up of 10.0 ± 15.3 weeks. TBUT was greater in the CS than in the control group at the last follow-up (p = 0.002). Concluding, topical CS administration led to an increase of SIT and a reduction of corneal staining at a mean of 10 weeks follow-up in patients with DED. Compared to a control group, topical CS administration evidenced greater values of TBUT. Altogether, a good safety profile was witnessed in DED patients receiving CS. However, different safety profiles of different CS formulations were not investigated due to a lack of quantitative data. The exact dosing frequency, duration of therapy, and favorable potency of the CS are still under investigation. Future randomized, controlled trials with larger sample sizes are warranted to provide higher-quality evidence to establish the role of CS in DED.

Topical Ocular Anti-TNFα Agent Licaminlimab in the Treatment of Acute Anterior Uveitis: A Randomized Phase II Pilot Study

Purpose

Licaminlimab is a new anti-TNFα antibody fragment for topical ocular application. This phase II study assessed the tolerability, treatment effect, and pharmacokinetics of licaminlimab in acute anterior uveitis (AAU).

Methods

In this multicenter, randomized, parallel-group, double-masked study, 43 adult patients with non-infectious AAU and Standardization of Uveitis Nomenclature (SUN) anterior chamber (AC) cell score of 2+ or 3+ were randomized (3:1 ratio) to licaminlimab (60 mg/mL, 8 drops/day for 15 days, 4 drops/day for 7 days, then matching vehicle for 7 days) or dexamethasone eye drops (8 drops/day for 15 days, tapering to 1 drop/day over 14 days). The primary efficacy end point was clinical response (≥2-step decrease in AC cell grade at day 15). A treatment effect was considered as established if the lower limit of the 95% posterior interval of the responder rate was >30%. Serum levels of licaminlimab were determined.

Results

The day 15 response rate for licaminlimab was 56%; the lower bound of the 95% credible interval was 40% (i.e. >30%), demonstrating a treatment effect according to prespecified criteria. By day 4, 36% of licaminlimab-treated patients were responders; 76% had an AC cell grade of 0 on ≥1 post-treatment visit. The day 15 dexamethasone response rate was 90% (no inferential between-arm comparison was planned). Both treatments were well-tolerated. Intraocular pressure increased from baseline with dexamethasone but not licaminlimab. Licaminlimab was undetectable in serum in most patients.

Conclusions

Licaminlimab is the first biologic demonstrated to have a treatment effect on an intraocular condition with topical ocular application. The trial met its primary objective and the observed responder rate for licaminlimab was 56.0%. Ocular administration of licaminlimab was well-tolerated in adult subjects with AAU for up to 35 days.

The Effects of Intranasal, Inhaled and Systemic Glucocorticoids on Intraocular Pressure: A Literature Review

Topical glucocorticoids are a well-known risk factor of intraocular pressure (IOP) elevation in one third of the general population and in up to 90% of glaucomatous patients. Whether this steroid response is caused by intranasal, inhaled or systemic glucocorticoids, is less known. This study presents an overview of the current literature on the topic, thereby providing guidance on when ophthalmological follow-up is indicated. A literature study was performed in Medline, and 31 studies were included for analysis. Twelve out of fourteen studies discussing intranasal glucocorticoids show no significant association with an elevated IOP. Regarding inhaled glucocorticoids, only three out of twelve studies show a significant association. The observed increase was either small or was only observed in patients treated with high inhaled doses or in patients with a family history of glaucoma. An elevated IOP caused by systemic glucocorticoids is reported by four out of the five included studies, with one study reporting a clear dose–response relationship. This review concludes that a steroid response can be triggered in patients treated with systemic glucocorticoids. Inhaled glucocorticoids may cause a significant IOP elevation when administered in high doses or in patients with a family history of glaucoma. At present, there is no evidence for a clinically significant steroid response caused by intranasally administered glucocorticoids.

Steroid-Induced Ocular Hypertension in a Pediatric Patient with Acute Lymphoblastic Leukemia: A Case Report

Glucocorticoids play a pivotal role in therapeutic protocols in acute lymphoblastic leukemia (ALL) treatment. Systemic steroids are known to be less likely to elevate the intraocular pressure when compared to topical administration, and reports addressing hypertensive ocular response in the Asian pediatric ALL population are currently limited. We report a case of a nine-year-old girl with acute lymphoblastic leukemia (ALL) who was found to have highly elevated intraocular pressure (IOP) during maintenance treatment when taking oral dexamethasone (6 mg/m²/day). Her IOP increased on day 5 after taking dexamethasone, reached a peak on day 7 or 8, and returned back to baseline on day 13 before anti-glaucoma medications were used. Thus, we prescribed IOP-lowering agents for 10 consecutive days starting on the day oral dexamethasone was administered, and observed that not only did the peak levels lower remarkably, but the IOP levels returned to baseline more rapidly as well.

Efficacy and tolerability of combination treatment of topiramate and greater occipital nerve block versus topiramate monotherapy for the preventive treatment of chronic migraine: A randomized controlled trial

OBJECTIVE

To compare the efficacy and tolerability of combination treatment of topiramate and greater occipital nerve block to topiramate monotherapy in adult chronic migraine patients.

BACKGROUND

Options for the preventive treatment of chronic migraine are limited and costly. Combination treatments do not have an evidence base yet.

METHODS

This was a parallel group, 3 arms with 1:1:1 allocation ratio randomized controlled study in consecutive adult chronic migraine patients attending Headache Clinic in a tertiary care hospital. Patients received either topiramate monotherapy 100 mg/day (group A), or topiramate plus greater occipital nerve block with 40 mg lidocaine (2%) and 80mg (2 ml) methylprednisolone as the first injection followed by monthly injections of lidocaine for the next 2 months (group B) or topiramate plus greater occipital nerve block with 40 mg lidocaine (2%) injections monthly for 3 months (group C). The primary endpoint was the mean change in monthly migraine days at Month 3. Multiple secondary endpoints were assessed that included among others, achievement of ≥50% reduction in mean monthly headache days compared to baseline at Month 3 and assessment for any adverse events.

RESULTS

One hundred and twenty-five patients were randomized; 41 to group A, 44 to group B, and 40 to group C. Efficacy assessments were done for 121 patients. Patients receiving combination treatment of topiramate and greater occipital nerve block with steroids and lidocaine and greater occipital nerve block with only lidocaine compared to topiramate monotherapy showed greater reductions in monthly migraine days at Month 3 (-9.6 vs -7.3 days; p = 0.003) and (-10.1 vs -7.3 days; p < 0.001) respectively. Greater proportion of patients in both the combination treatment groups (added greater occipital nerve block with and without steroid) achieved ≥50% reduction in mean monthly headache days [71.4% vs 39%; OR (95% CI) 3.9(1.6-9.8); p = 0.004] and [62.4% vs 39%; OR (95% CI) 2.7(1.1-6.7); p = 0.034] respectively, compared to those receiving topiramate monotherapy. Adverse effects between the groups were comparable although patients receiving combination treatment with added greater occipital nerve block reported transient adverse effects like post-injection dizziness, local site swelling, and pain. No serious adverse event was reported.

CONCLUSION

Combination treatments of topiramate with monthly injections of greater occipital nerve block were more effective in reducing monthly migraine days in chronic migraine than topiramate monotherapy at Month 3. Combination treatments were well tolerated.

Consequences of seasonal allergic conjunctivitis on ocular parameters of anterior and posterior segments: An up-to-date imaging approach

Aims

To investigate consequences of seasonal allergic conjunctivitis (SAC) on the ocular anterior and posterior segment parameters.

Materials and Methods

Forty healthy participants (mean age: 25.90 ± 5.7 years, 20 females, 20 males) and 40 patients with SAC (mean age: 26.20 ± 5.7 years, 20 females, 20 males) were included in this prospective study. The anterior segment parameters including central corneal thickness (CCT) and anterior chamber depth (ACD) were measured by Scheimpflug imaging system. Axial length (AL) was measured by optical biometry. The posterior segment parameters, including retinal nerve fiber layer (RNFL), subfoveal choroidal thickness, and central macular thickness were measured by optical coherence tomography.

Results

Similar values of the ACD, AL, RNFL as well as central macular thickness between healthy participants and patients with SAC were revealed. Despite the CCT being thinner in SAC, there was no statistically significant difference between the two groups. On the other hand, SAC was found to be associated with an increase in subfoveal choroidal thickness, the condition of which may be attributed to the inflammatory nature of the disease.

Conclusion

The present study has managed to demonstrate non-significant alterations in the ocular anterior and posterior segment parameters of patients with SAC. Yet, the increase in subfoveal choroidal thickness may be linked to the accompanying inflammation of both the conjunctiva and other ocular tissues, particularly the choroidal layer.

Ocular manifestations of liver disease in children: Clinical aspects and implications

Liver and eyes are interlinked to each other in various medical conditions. There are certain ocular findings which directly indicate specific liver disorders. Thus, it becomes critical to identify disorders of liver and eyes early in the course of illness, so that prompt management may be initiated before the commencement of complications. It is highly advantageous in metabolic liver disorders as it offers prognostic value and spares the patient of unnecessary invasive and detailed work up. However, due to its silent and heterogeneous presentation, it is often unrecognized and ignored. Eye abnormalities could be due to, either direct toxic effects of abnormal metabolites, excess of normal metabolites, or by deficient energy metabolism. A number of inherited liver conditions have associated ocular lesions such as Kayser-Fleischer rings in Wilson's disease, posterior embryotoxon or optic drusen in Alagille's syndrome, and cherry-red spot in Niemann-Pick's type A. A thorough eye examination is important in distinguishing between several different forms of familial intrahepatic cholestasis which are associated with anomalies of the heart, bones, or kidneys. Early diagnosis is important, as in most cases, dietary restriction and early therapy prevents the onset of disability. The aim of this review is to sensitize and make pediatricians, hepatologists and ophthalmologists aware of specific ocular findings, suggestive of certain hepatobiliary disorders, thus helping in early referral. The pediatric and adult literature was thoroughly reviewed to organize the present review.

Sodium 4-Phenylbutyrate Reduces Ocular Hypertension by Degrading Extracellular Matrix Deposition via Activation of MMP9

Ocular hypertension (OHT) is a serious adverse effect of the widely prescribed glucocorticoid (GC) therapy and, if left undiagnosed, it can lead to glaucoma and complete blindness. Previously, we have shown that the small chemical chaperone, sodium-4-phenylbutyrate (PBA), rescues GC-induced OHT by reducing ocular endoplasmic reticulum (ER) stress. However, the exact mechanism of how PBA rescues GC-induced OHT is not completely understood. The trabecular meshwork (TM) is a filter-like specialized contractile tissue consisting of TM cells embedded within extracellular matrix (ECM) that controls intraocular pressure (IOP) by constantly regulating aqueous humor (AH) outflow. Induction of abnormal ECM deposition in TM is a hallmark of GC-induced OHT. Here, we investigated whether PBA reduces GC-induced OHT by degrading abnormal ECM deposition in TM using mouse model of GC-induced OHT, ex vivo cultured human TM tissues and primary human TM cells. We show that topical ocular eye drops of PBA (1%) significantly lowers elevated IOP in mouse model of GC-induced OHT. Importantly, PBA prevents synthesis and deposition of GC-induced ECM in TM. We report for the first time that PBA can degrade existing abnormal ECM in normal human TM cells/tissues by inducing matrix metalloproteinase (MMP)9 expression and activity. Furthermore, inhibition of MMPs activity by chemical-inhibitor (minocycline) abrogated PBA's effect on ECM reduction and its associated ER stress. Our study indicates a non-chaperone activity of PBA via activation of MMP9 that degrades abnormal ECM accumulation in TM.

Safety of intravitreal triamcinolone and its impact on optic nerve morphology in patients treated for diabetic macular edema

PURPOSE

To assess the impact of one intravitreal injection (IVT) of Triamcinolone Acetonide (TA) on intraocular pressure (IOP) and optic nerve structural parameters in patients treated for Diabetic Macular Edema (DME).

METHODS

This retrospective study included patients with DME that were naïve to intraocular steroids and underwent one IVT of TA of 4 mg/0.1 mL and age-matched controls with DME without criteria for IVT. Patients records were reviewed for IOP (at baseline and a month after IVT) and optic nerve parameters measured by optical coherence tomography (up to 6 months before and 6 months after IVT). Exclusion criteria included glaucoma and treatment with hypotensive agents.

RESULTS

Twenty-six eyes were included in the Control Group and 29 in the IVT Group, with a mean age of 65.10 ± 10.08 and 67.30 ± 4.71 years, respectively (p = 0.06). At baseline, IOP and optic nerve measurements were equivalent between groups (p > 0.05). One month after IVT, mean IOP measurements in IVT Group were higher than those of controls (17.84 ± 4.50 vs 11.59 ± 3.09 mmHg, p < 0.001). Ocular hypertension (OHT) developed in 17.24% of cases and reversed with topical medication. After one IVT, vertical cup/disc ratio was higher (0.57 ± 0.25 vs 0.60 ± 0.14, p = 0.04) and retinal nerve fiber layer thickness was globally lower (mean: 91.03 ± 4.25 vs 81.33 ± 19.10 µm, p = 0.001) in the IVT Group.

CONCLUSION

Our results confirmed that intravitreal TA results in IOP increase. This seems to negatively affect optic nerve morphology, even in patients without OHT or adequately treated with hypotensive agents.

Recent Developments in HLA B27 Anterior Uveitis

There has been steady progress in understanding the pathogenesis, clinical features, and effective treatment of acute anterior uveitis (AU) over the past 5 years. Large gene wide association studies have confirmed that AU is a polygenic disease, with overlaps with the seronegative arthropathies and inflammatory bowel diseases, associations that have been repeatedly confirmed in clinical studies. The role of the microbiome in AU has received increased research attention, with recent evidence indicating that human leukocyte antigen B27 (HLA B27) may influence the composition of the gut microbiome in experimental animals. Extensive clinical investigations have confirmed the typical features of acute AU (AAU) and its response to topical, regional and systemic immunosuppressive treatment. Increased understanding of the role of cytokines has resulted in studies confirming the value of anti-cytokine therapy [anti-tumor necrosis factor (anti-TNF) and interleukin 6 (IL-6) therapy] in severe and recurrent cases of AAU, particularly in subjects with an associated spondyloarthopathy (SpA) and in juvenile idiopathic arthritis (JIA)-associated AAU.

Thyroid and Eye: Where They Meet in Clinical Practice

OBJECTIVE

Thyroid Hormones (TH) are essential for normal growth, development and continued optimal function of most of the body organs including the eye. TH signaling plays a central role in the regulation of retinal development and maturation. Deficiency in TH during fetal and early postnatal development impairs growth of the eye and proliferation of all retinal cell types. The present article reviews the most important topics of the different derangements in thyroid function and structure and its relation with eye diseases.

METHODS

A literature search strategy was conducted for all English-language literature.

RESULTS

From a clinical practice viewpoint, it should be mentioned that both hypothyroidism and hyperthyroidism are accompanied by ocular diseases i.e. thyroid-associated ophthalmopathy, diabetic retinopathy and age-related macular degeneration. Although the orbit and globe are not common sites for metastatic thyroid cancers, orbital metastasis may be the primary clinical manifestation of thyroid carcinoma. Finally, some medications as amiodarone may be accompanied by both thyroid dysfunction and adverse ocular events.

CONCLUSION

Thyroid disorders and eye diseases are interrelated through several mechanisms thus, awareness of this relation has a great impact on early diagnosis and treatment.

Effect of 808-nm Laser Photobiomodulation Treatment in Blepharitis Rat Model

PURPOSE

Blepharitis, simply defined as eyelid inflammation, is one of the common ocular conditions associated with discomfort and irritation. Because blepharitis causes meibomian gland dysfunction and dry eye, this study aimed to confirm the effect of photobiomodulation (PBM) on blepharitis.

METHODS

A total of 20 rats were randomly assigned to 4 equal groups, including control, blepharitis, PBM, and eye drop. Blepharitis was induced in rats by injecting complete Freund's adjuvant in the eyelid margins. PBM intervention was given every 3 days after blepharitis induction. Clinical signs including tear volume, tear breakup time (TBUT), meibomian gland swelling, fluorescein, telangiectasia, and meibomian gland secretion scores were measured every week, and the rats were killed for histological analysis after 4 weeks. Immunohistochemistry was performed to compare the level of inflammatory cytokines, interleukin-1β and tumor necrosis factor-α, and terminal deoxynucleotidyl transferase dUTP nick end labeling staining on retina was performed to observe any retinal damage.

RESULTS

Tear volume and TBUT increased with PBM intervention, and with improved eyelid swelling, corneal staining, telangiectasia, and meibomian gland secretion scores increased. Hematoxylin and eosin staining showed no structural abnormalities of meibomian gland caused by blepharitis induction. Immunohistochemistry revealed that the levels of inflammatory cytokines interleukin-1β and tumor necrosis factor-α were lowered with PBM treatment in both eyelid and conjunctiva. Terminal deoxynucleotidyl transferase dUTP nick end labeling staining showed no retinal damage.

CONCLUSIONS

Laser PBM at 808 nm was effective in alleviating ocular signs and controlling inflammation in blepharitis rat model. The in vivo results suggest that PBM has the potential to be used in treating blepharitis patients.

Role of greater occipital nerve block for preventive treatment of chronic migraine: A critical review

Objective:

The aim of this study is to critically analyze the evidence of the efficacy and safety of greater occipital nerve (GON) block for the preventive treatment of chronic migraine (CM).

Background:

A rigorous scientific assessment of efficacy and safety of the GON block for preventive treatment in CM is not available. This critical review was undertaken for this purpose.

Methods:

References for this review were identified by searches of articles published in the English language in PubMed between 1969 and April 15, 2020 using “greater occipital nerve block,” “chronic migraine,” “migraine,” “headache,” and “treatment” as keywords.

Results:

Out of potential 532 articles, 9 open-label and 4 placebo-controlled trials that studied the role of GON block for prevention of CM were identified and reviewed. Open-label trials reported a reduction of headache severity and frequency in 35–68% of patients. The beneficial effect of a single block lasted up to 4 weeks. Randomized controlled trials (RCTs) used varied methodology and techniques of GON block and the outcomes were reported at different time points. A single RCT showed a beneficial effect of the GON block at 1 week. However, the GON block was found to be safe and well tolerated.

Conclusion:

Long-term efficacy of GON block in CM shall need further well-designed RCTs using standardized methodology. This study, in addition, reviewed the limitations and uncertainties regarding the technique and methods of use of GON block in CM.

Anterior Migration of Triamcinolone Acetonide after Posterior Subtenon Injection for Macular Edema Predisposes to Intraocular Pressure Elevation

PURPOSE

To evaluate the effect of anterior migration of triamcinolone acetonide on intraocular pressure (IOP) elevation after posterior subtenon injection of triamcinolone acetonide (PSTA) for macular edema.

METHODS

One hundred and ten eyes from 89 patients who received PSTA for macular edema were prospectively enrolled. The extent of anterior migration of triamcinolone acetonide was recorded immediately after the injection. If TA particles were visible in the subtenon space (or subconjunctival space), it was recorded as "anterior subtenon migration" (or "anterior subconjunctival migration"). The correlation between anterior migration of triamcinolone acetonide and severe IOP elevation, which was defined as an increase of 8 mm Hg or more in IOP, was evaluated.

RESULTS

A total of 159 PSTAs were given to 110 eyes. After PSTA, anterior subtenon migration occurred in 70.4% and anterior subconjunctival migration occurred in 12.0% of injection. Severe IOP elevation occurred in 7.1% of those without anterior migration, in 25.9% of those with anterior subtenon migration, and in 31.6% of those with anterior subconjunctival migration after PSTA (P = .052). Compared to those without anterior migration of triamcinolone acetonide, the hazard ratio for severe IOP elevation was 3.307 in those with anterior subtenon migration (P = .12) and 5.289 in those with anterior subconjunctival migration (P = .042).

CONCLUSIONS

Anterior migration of triamcinolone acetonide after PSTA predisposes eyes to severe IOP elevation. Careful injection to restrict the triamcinolone particle within the subtenon space and behind the equator may lower the rate of IOP elevation after PSTA.

Corticosteroids in ophthalmology: drug delivery innovations, pharmacology, clinical applications, and future perspectives

Corticosteroids remain the mainstay of the treatment for various ocular conditions affecting the ocular surface, anterior and posterior segments of the eye due to their anti-inflammatory, anti-oedematous, and anti-neovascularization properties. Prednisolone, prednisolone acetate, dexamethasone, triamcinolone acetonide, fluocinolone acetonide, and loteprednol etabonate are amongst the most widely used ophthalmic corticosteroids. Corticosteroids differ in their activity and potency in the eye due to their inherent pharmacological and pharmaceutical differences. Different routes and regimens are available for ocular administration of corticosteroids. Conventional topical application to the eye is the route of choice when targeting diseases affecting the ocular surface and anterior segment, while periocular, intravitreal, and suprachoroidal injections can be potentially effective for posterior segment diseases. Corticosteroid-induced intraocular pressure elevation and cataract formation remain the most significant local risks following topical as well as systemic corticosteroid administration. Invasive drug administration via intracameral, subconjunctival, and intravitreal injection can enhance ocular bioavailability and minimize dose and dosing frequency of administration, yet may exacerbate ocular side effects of corticosteroids. This review provides a critical appraisal of the ophthalmic uses of corticosteroid, routes of administration, drug delivery fundamentals and novel ocular implantable steroid delivery systems, factors influencing side effects, and future perspectives for ocular corticosteroid therapy.

The Molecular Processes in the Trabecular Meshwork After Exposure to Corticosteroids and in Corticosteroid-Induced Ocular Hypertension

Purpose

To identify processes that contribute to corticosteroid-induced ocular hypertension and candidate target genes for treatment.

Methods

A systematic search identified five human microarray datasets investigating the effect of dexamethasone versus a control medium on trabecular meshwork (TM) tissue. After thorough quality control, samples of low quality were removed, and the datasets were integrated. Additionally, a bovine RNA-sequencing dataset allowed to investigate differences in gene expression profiling between cows with and without corticosteroid-induced ocular hypertension (responders vs. nonresponders). The obtained datasets were used as input for parallel pathway analyses. Significantly changed pathways were clustered into functional categories and the results were further investigated. A network visualizing the differences between the responders and nonresponders was created.

Results

Seven functional pathway clusters were found to be significantly changed in TM cells exposed to dexamethasone versus a control medium and in TM cells of responders versus nonresponders: collagen, extracellular matrix, adhesion, WNT-signaling, inflammation, adipogenesis, and glucose metabolism. In addition, cell cycle and senescence were only significantly changed in responders versus nonresponders. The network of the differential gene expression between responders and nonresponders shows many connections between the identified processes via shared genes.

Conclusions

Nine functional pathway clusters synthesize the molecular response to dexamethasone exposure in TM cells and are likely to be involved in the pathogenesis of corticosteroid-induced ocular hypertension.

Comprehensive bioinformatics analysis of trabecular meshwork gene expression data to unravel the molecular pathogenesis of primary open-angle glaucoma

PURPOSE

Performing bioinformatics analyses using trabecular meshwork (TM) gene expression data in order to further elucidate the molecular pathogenesis of primary open-angle glaucoma (POAG), and to identify candidate target genes.

METHODS

A systematic search in Gene Expression Omnibus and ArrayExpress was conducted, and quality control and preprocessing of the data was performed with ArrayAnalysis.org. Molecular pathway overrepresentation analysis was performed with PathVisio using pathway content from three pathway databases: WikiPathways, KEGG and Reactome. In addition, Gene Ontology (GO) analysis was performed on the gene expression data. The significantly changed pathways were clustered into functional categories which were combined into a network of connected genes.

RESULTS

Ninety-two significantly changed pathways were clustered into five functional categories: extracellular matrix (ECM), inflammation, complement activation, senescence and Rho GTPase signalling. ECM included pathways involved in collagen, actin and cell-matrix interactions. Inflammation included pathways entailing NF-κB and arachidonic acid. The network analysis showed that several genes overlap between the inflammation cluster on the one hand, and the ECM, complement activation and senescence clusters on the other hand. GO analysis, identified additional clusters, related to development and corticosteroids.

CONCLUSION

This study provides an overview of the processes involved in the molecular pathogenesis of POAG in the TM. The results show good face validity and confirm findings from histological, biochemical, genome-wide association and transcriptomics studies. The identification of known points of action for drugs, such as Rho GTPase, arachidonic acid, NF-κB, prostaglandins and corticosteroid clusters, supports the value of this approach to identify potential drug targets.

Pediatric liver diseases and ocular changes: What hepatologists and ophthalmologists should know and share with each other

Several rare pediatric liver disorders are accompanied by ophthalmic signs whose awareness and early identification may be of value in confirming/accelerating their diagnosis. Many of these signs are asymptomatic and can only be detected with an ophthalmological examination. Corneal signs are described in patients with Wilson's disease, Alagille's syndrome and some liver storage diseases. Cataract plays an important role to diagnose galactosemia. Retinal involvement is seen in some peroxisomal disorders (e.g. Zellweger's syndrome), in mucopolysaccharidoses (pigmentary retinopathy), and in Niemann-Pick disease (macular cherry red spot). In mucopolysaccharidoses optic nerve can be involved as optic atrophy secondary to pigmentary retinopathy or to chronic papilledema. Children with neonatal cholestasis due to hypopituitarism may present septo-optic dysplasia. Several infectious agents have an ophthalmological/hepatic involvement in the fetal life and/or thereafter. Some mitochondrial liver diseases, such as Pearson's syndrome, present pigmentary retinopathy and a chronic progressive external ophthalmoplegia. Finally, some drugs while protecting the liver may damage the ocular system as seen with long-term glucocorticoids and Nitisinone administration. This review provides a synopsis of those conditions that hepatologists and ophthalmologists should share among themselves to better take care of patients. Synoptic tables are presented to facilitate the mutual understanding of the issues.

Comparison of prednisolone acetate 1.0% and difluprednate ophthalmic emulsion 0.05% after cataract surgery: Incidence of postoperative steroid-induced ocular hypertension

PURPOSE

To compare intraocular pressure (IOP) outcomes between 2 common, commercially available corticosteroid drops: difluprednate ophthalmic emulsion 0.05% and prednisolone acetate 1.0%.

SETTING

TLC Eyecare and Laser Centers, Jackson, Michigan, USA.

DESIGN

Retrospective chart review.

METHODS

The outcomes of consecutive patients who had uneventful cataract surgery from April 2013 to September 2013 and used prednisolone acetate postoperatively were compared with the outcomes of consecutive patients who had uneventful cataract surgery from June 2014 to October 2014 and used difluprednate postoperatively.

RESULTS

The study included 224 eyes treated with prednisolone acetate 4 times daily for 30 days and 225 eyes treated with difluprednate 2 times daily for 30 days. There was no significant difference between the 2 groups in age, sex, or race. In addition, the mean IOP did not differ significantly between the prednisolone acetate group and the difluprednate group at the preoperative measurement or 1 month after surgery, nor was there a difference in the 1-month change in IOP between groups. No association was found between the incidence of a 6 mm Hg or higher increase in IOP 1 month after surgery and steroid treatment. One month postoperatively, 4 eyes in the prednisolone acetate group and 5 eyes in the difluprednate group had an IOP higher than 21 mm Hg.

CONCLUSIONS

There was no significant difference in the mean IOP or percentages showing IOP elevation between eyes treated with difluprednate and eyes treated with prednisolone acetate after cataract surgery. This was likely the result of low-frequency dosing and short duration of steroid use.

Ocular Co-Morbidities of Atopic Dermatitis. Part II: Ocular Disease Secondary to Treatments

Treatments used for managing atopic dermatitis (AD) may have adverse ocular effects that permanently affect vision. The objective of this review is to raise awareness among dermatologists regarding the potential ocular adverse effects of various AD therapies, including corticosteroids, calcineurin inhibitors, an interleukin-4 receptor α (IL-4Rα) antagonist, and phototherapy. Pertinent potential short- and long-term risks of these therapies include elevations in intraocular pressure from use of topical corticosteroids and conjunctivitis from use of dupilumab. Since some of these adverse effects may not exhibit symptomatology until permanent vision impairment occurs, it is important for dermatologists to understand these risks and proactively ensure their patients are receiving appropriate measures to prevent them.

Evaluating the Impact of Uveitis on Visual Field Progression Using Large-Scale Real-World Data

PURPOSE

To compare rates of visual field (VF) loss in uveitis patients with glaucoma against patients with primary open-angle glaucoma (POAG) and explore the association between intraocular pressure (IOP) and rate of VF loss.

DESIGN

Retrospective cohort study.

METHODS

Anonymized VFs and IOP measurements extracted from the electronic medical records of 5 regionally different glaucoma clinics in England. A total of 205 eyes with diagnosis of uveitis plus glaucoma were compared with 4600 eyes with POAG only. Minimum inclusion criteria were ≥4 visits within a 4-year window. Relative risk (RR) of being a "rapid progressor" (mean deviation [MD] loss ≥1.5 dB/year) was calculated. A mixed-effects model (MEM) and a pointwise VF progression analysis of pattern deviation were used to confirm differences between the groups. Longitudinal IOP mean, range, and variability were compared with rate of VF progression.

RESULTS

Median (interquartile range) baseline MD in the uveitis and POAG groups was -3.8 (-8.7, -1.5) dB and -3.1 (-6.6, -1.2) dB, respectively. The uveitis and POAG groups had 23 of 205 (11%) and 331 of 4600 (7%) "rapidly progressing" eyes, respectively. Age-adjusted RR for "rapid progression" in uveitic vs POAG eyes was 1.9 (95% confidence interval: 1.8-2.0). The MEM confirmed that uveitic eyes (-0.49 dB/year) showed higher rates of VF progression than the POAG group (-0.37 dB/year; P < .01). IOP range and variability were higher in the "rapidly progressing" uveitic eyes.

CONCLUSIONS

Our analysis suggests that VF loss occurs faster in glaucoma patients with uveitis than those without uveitis. The risk of progressing rapidly in glaucoma with uveitis is almost double than in those without uveitis. Early identification of "rapid progressors" may enable targeted intervention to preserve visual function in this high-risk group.

A review of systemic medications that may modulate the risk of glaucoma

With increasing longevity, patients are developing more and more chronic diseases that require treatment with medications. Yet, it is not fully understood the extent by which these systemic medications affect ocular structures and whether they may increase or decrease the risk of sight-threatening ocular diseases. This review provides a summary of reported associations between different systemic medications and the risk of developing glaucoma or experiencing disease progression. Medication classes covered in this review that are known to or may modulate the risk of open-angle glaucoma include corticosteroids, beta blockers, calcium channel blockers, metformin, statins, selective serotonin reuptake inhibitors, bupropion, postmenopausal hormones, and cannabinoids. Medication classes addressed in this review that may increase the risk of angle closure glaucoma include anticholinergics, adrenergic agonists, certain classes of antidepressants, sulfonamides, and topiramate.