Risk for Ocular Complications From Topical Corticosteroids
Risk for Ocular Complications From Topical Corticosteroids
Haeck IM, Rouwen TJ, Timmer-de Mik L, de Bruin-Weller MS, Bruijnzeel-Koomen CA
J Am Acad Dermatol. 2011;64:275-281
Topical, inhaled, and systemic corticosteroids can induce ocular complications such as glaucoma and cataracts, especially when used chronically or at high potencies. Unfortunately, inflammatory skin conditions such as atopic dermatitis (AD) and allergic contact dermatitis are chronic and recurrent in nature, necessitating long-term therapy. Although patients with these disorders are advised to avoid chronic topical corticosteroid application to the face, and especially around the eyes, these warnings sometimes go unheeded. But how likely are these "steroid-abusing" patients to develop ocular complications?
To address this important question, Haeck and colleagues recruited a cohort of 88 Dutch patients (41 men, 47 women, mean age: 37.2 years) with moderate to severe AD. These volunteers completed questionnaires to characterize variables including AD involvement of the eyelids and periorbital skin, comorbidities and habits associated with ocular disease (eg, diabetes mellitus, hypertension, alcohol use, smoking), and the presence of other atopic diseases (eg, asthma, allergic rhinitis). Next, investigators used patient pharmacy prescription data to estimate the cumulative amounts of topical, systemic, inhaled, and nasal corticosteroids used by these patients during the past 2 years (data available for all 88 patients) and 5 years (data available for 73 patients). Finally, all patients underwent ophthalmologic examinations to check for early signs of glaucoma and cataracts.
Eczema on the eyelids and periorbital skin was reported by 58 patients, and 37 of these patients reported applying topical corticosteroids (class III-IV) to these areas on a regular basis. In addition:
Intriguingly, only 1 patient developed transient ocular hypertension, which resolved without treatment. Seven patients had cataracts; however, only 2 of these were felt to be corticosteroid induced (posterior subcapsular). Four cases were attributed to age (nuclear or cortical), and 1 case was related to AD (anterior subcapsular).
These results suggest that topical application of class III and IV steroids to the eyelids and periorbital skin may not be associated with a significant risk for glaucoma or cataracts, even in cases of chronic, habitual use. Although 2 study patients did develop the type of bilateral cataracts commonly associated with corticosteroid use, these individuals both had significant systemic corticosteroid exposure.
As Haeck and colleagues state in their report, these data apply only to the use of relatively low potency topical corticosteroids. Furthermore, they acknowledge the relatively small sample size of their atopic cohort, raising the possibility that a larger and/or more diverse study population might yield different results. In addition, this study did not take into account the use of topical calcineurin inhibitors (tacrolimus, pimecrolimus) or other therapeutic agents (eg, antihistamines), and included only patients with AD. In this context, it seems prudent to continue advising patients against chronic periocular topical corticosteroid use, especially when other glaucoma or cataract risk factors are present.
Abstract
Topical Corticosteroids in Atopic Dermatitis and the Risk of Glaucoma and Cataracts
Haeck IM, Rouwen TJ, Timmer-de Mik L, de Bruin-Weller MS, Bruijnzeel-Koomen CA
J Am Acad Dermatol. 2011;64:275-281
Study Summary
Topical, inhaled, and systemic corticosteroids can induce ocular complications such as glaucoma and cataracts, especially when used chronically or at high potencies. Unfortunately, inflammatory skin conditions such as atopic dermatitis (AD) and allergic contact dermatitis are chronic and recurrent in nature, necessitating long-term therapy. Although patients with these disorders are advised to avoid chronic topical corticosteroid application to the face, and especially around the eyes, these warnings sometimes go unheeded. But how likely are these "steroid-abusing" patients to develop ocular complications?
To address this important question, Haeck and colleagues recruited a cohort of 88 Dutch patients (41 men, 47 women, mean age: 37.2 years) with moderate to severe AD. These volunteers completed questionnaires to characterize variables including AD involvement of the eyelids and periorbital skin, comorbidities and habits associated with ocular disease (eg, diabetes mellitus, hypertension, alcohol use, smoking), and the presence of other atopic diseases (eg, asthma, allergic rhinitis). Next, investigators used patient pharmacy prescription data to estimate the cumulative amounts of topical, systemic, inhaled, and nasal corticosteroids used by these patients during the past 2 years (data available for all 88 patients) and 5 years (data available for 73 patients). Finally, all patients underwent ophthalmologic examinations to check for early signs of glaucoma and cataracts.
Eczema on the eyelids and periorbital skin was reported by 58 patients, and 37 of these patients reported applying topical corticosteroids (class III-IV) to these areas on a regular basis. In addition:
The average frequency of application of topical corticosteroids was 3.9 days per week, 6.4 months per year, for 4.8 years;
In the 2 years and 5 years before investigation, patients used a median of 735 gm and 1630 gm of topical corticosteroids respectively; and
In the 5 years before investigation, patients used a median of 310 mg of systemic corticosteroids.
Intriguingly, only 1 patient developed transient ocular hypertension, which resolved without treatment. Seven patients had cataracts; however, only 2 of these were felt to be corticosteroid induced (posterior subcapsular). Four cases were attributed to age (nuclear or cortical), and 1 case was related to AD (anterior subcapsular).
Viewpoint
These results suggest that topical application of class III and IV steroids to the eyelids and periorbital skin may not be associated with a significant risk for glaucoma or cataracts, even in cases of chronic, habitual use. Although 2 study patients did develop the type of bilateral cataracts commonly associated with corticosteroid use, these individuals both had significant systemic corticosteroid exposure.
As Haeck and colleagues state in their report, these data apply only to the use of relatively low potency topical corticosteroids. Furthermore, they acknowledge the relatively small sample size of their atopic cohort, raising the possibility that a larger and/or more diverse study population might yield different results. In addition, this study did not take into account the use of topical calcineurin inhibitors (tacrolimus, pimecrolimus) or other therapeutic agents (eg, antihistamines), and included only patients with AD. In this context, it seems prudent to continue advising patients against chronic periocular topical corticosteroid use, especially when other glaucoma or cataract risk factors are present.
Abstract