Based on the 2000 Census, 17.2% of the US population over 40 years old had at least one cataract.1 The percentage increases with age, as those 75 years or older had a 53% prevalence.2
Furthermore, prevalence is expected to increase as the size of the aging population grows. Older patients, women, and Caucasian ethnicities, compared to Hispanic and Black patients, have higher risks.1
Although cataracts are generally related to normal aging changes and are considered non-preventable vision impairments, factors such as the use of steroids can induce cataract-related changes.
Oral glucocorticoid use of Americans between 1999 and 2008 was 1.2% of the population, with more than half using them long-term for a variety of health conditions.3 Corticosteroid use exponentially increased from 2009 to 2018, with a prevalence of 6.8% in the United States.3
Corticosteroids in the management of systemic disease
Indications
When it comes to managing inflammation in the body, there are a variety of medications and relieving treatments we may consider for patients. Among the multitude of pharmaceutical options are local and systemic steroids.
They are typically prescribed for their anti-inflammatory and immunosuppressive properties, minimizing pro-inflammatory factors. Due to their efficacy, they are excellent modes of management for a myriad of diseases.
Three common chronic conditions of long-term oral corticosteroid (OCS) users:3
- Arthritis and non-traumatic joint disorders
- Chronic obstructive pulmonary disorder (COPD), asthma, and other respiratory conditions
- Systemic lupus and connective tissue disorders
Commonplace practices for short-term oral steroid use are Bell-palsy-related inflammation and occasionally acute gout.4
Contraindications for oral steroid use
Prescribers should be aware of absolute and relative contraindications, and when adverse events of steroid use need to be monitored closely. Ask about any allergies to avoid any formulation hypersensitivities.
Avoid use when getting live or live-attenuated vaccines with immunosuppressive dosages. Steroids should not be used with concurrent fungal infections, herpes simplex keratitis, and varicella infection.
Relative contraindications are highlighted with conditions of osteoporosis, diabetes mellitus, glaucoma, joint inflammation, and uncontrolled hypertension, where risk-benefit analysis should be done.5
Short-term systemic complications
Dosage and duration of treatment play roles in possible corticosteroid-related complications such as cataract formation. After the 2-week to 3-month mark, adverse reactions are more commonly noted.
They can manifest with a spike in blood sugar, weight gain, raised blood pressure, euphoria, altered mood, and sleep patterns.5-6 In addition, patients are more prone to sepsis, fractures, and venous thromboembolism.5
Long-term systemic complications
Although chronic conditions may require prolonged use of steroids, the risk of steroid-induced adverse effects is higher. In fact, corticosteroids are the leading cause of drug-induced diabetes mellitus.5 The likelihood of hypertension and cardiovascular events rises in long-term users as well.5-6
Muscle weakness may occur weeks or months into use, with the opportunity to resolve if discontinued. Patients may be subject to osteoporosis and fractures if the daily intake of 5mg of prednisone is used at the 3- to 6-month mark due to detrimental effects on bone mineral density.5
Cushing syndrome and moonface are well-known as a steroid-related disorder, where signs may be identified around 2 months into use. Furthermore, be cautious of possible psychosis and depression may be notable with long-term treatments.5,7
Table 1: Summary of short- and long-term complications associated with corticosteroid use for systemic diseases.
| Short-Term Complications | Long-Term Complications |
|---|---|
| Glucose spike | Cushing syndrome |
| Weight gain | Moonface |
| Elevated blood pressure | Drug-indued diabetes |
| Euphoria | Higher risk of hypertension and cardiovascular events |
| Altered mood | Muscle weakness |
| Poor sleeping patterns | Osteoporosis risks |
| Higher risk of sepsis | Psychosis |
| Fracture risks | Depression |
| Venous thromboembolism risk |
Table 1: Courtesy of Sasha Patel, OD.
Suppression of the immune system
There is undeniable importance in being careful in those who are predisposed to immunocompromised conditions—where a comparison of risk versus benefits should be taken. Due to the immunosuppressive nature of steroids, pediatric and elderly patients are susceptible populations.
Steroid use in pediatric patient populations is subject to increased risk of infections. They can also lead to growth suppression and affect the reproductive system.6,8,9 It is also recommended to be cautious in monitoring patients with peptic ulcer disease and congestive heart failure.5
Be attentive to long-term steroid use in women, who can be more prone to osteoporosis compared to men. Likewise, pregnant or nursing patients should be cautious of oral steroid use to avoid possible fetal complications and preterm birth.9
Corticosteroids in the management of ocular disease
Ophthalmic steroid indications
Chronic or acute inflammation may need close management in ophthalmologic conditions. Prescribing steroids for ocular conditions actively controls inflammation in uveitis, dry eye, certain non-central presentations of corneal ulcers, as well as specific types of conjunctivitis. Depending on the etiology, clinically differentiating the necessity for a combination agent that includes an antibiotic component is pertinent to appropriately prescribing.
Intraocular control of the inflammatory cells in anterior uveitis may be caused by a variety of etiologies, including HLA-B27 conditions, herpes simplex or varicella viral infections, or juvenile idiopathic arthritis. Prednisolone acetate or dexamethasone are excellent topical ophthalmic agents.
If long-term corticosteroid therapeutics treatments are needed, be cognizant of intervals of use and total dosage. Beyond topicals, posterior uveitis or severe chronic anterior uveitis may indicate systemic steroid treatment.
Episodic inflammatory flare-ups of uveitis, episcleritis, scleritis, dry eyes, or allergies may suggest a low-dose steroid treatment. Short-term use of steroids such as Eysuvis are FDA-approved for acute dry eye treatment.
Ocular diseases that affect the anterior or surface would be managed with topicals with low penetration. For example, soft and moderate steroids should be considered first, if possible, for dry eye management.
Contraindication and complications
Corticosteroid use is contraindicated in patients with herpes simplex keratitis, severe bacterial or viral infections, and central corneal ulcers. Overall, soft steroids can minimize complications, such as raised intraocular pressure (IOP)—particularly a point of caution in patients with glaucoma.
Choosing the dose and duration with the least propensity to cause detrimental steroid complications is key. IOP elevations from topical steroids can take 2 weeks, normalizing in 2 to 4 weeks.10
When children require long-term steroid treatment, ocular hypertension and posterior subcapsular cataracts are common side effects.11
Glaucoma
Steroid-induced glaucoma triggers misfolding of proteins on a molecular level, affecting the trabecular meshwork and optic nerve.5,12 Steroid strength and duration of treatment should be determined carefully. Discontinuing steroid use can lower IOP, but damage to the optic nerve can be long-lasting.
Steroid-induced posterior subcapsular cataracts
Cataract formation and progression can become more advanced by steroid use, regardless of the route of administration, especially based on dose, duration, and timeline of use. Posterior subcapsular cataracts (PSCs) are largely associated with glucocorticoids, where epithelial cells precipitate and aggregate centrally.
The disparity is likely due to gene transcription errors on lenticular epithelial cells, as well as indirect growth factor alterations;13 the trend leads to vision disturbances, which can accelerate the need for cataract surgery.
In one study, 4 months of steroid use (oral, inhaled, injectable, or topical) led to higher risks of posterior capsular opacification formation in patients with intraocular lenses (IOLs) at the 1-year mark.14 Those with increased amounts of accrued inhaled corticosteroids were detected to have a higher prevalence of PSC and nuclear cataracts, particularly with greater than 2,000mg of beclomethasone.15
Role of eye exams and ophthalmic imaging
New or expedited onset of vision loss is stressful for patients and important for us to evaluate emergently. PSC-related changes may appear drastic to patients in some cases of unilateral presentations.
Be mindful of the context of changes in the chief complaint, ensure you know the specific signs and symptoms noted, and be thorough in understanding the patient’s medication and medical history.
Moreover, if the patient checks off the boxes of being young with steroid use, be attentive to the ocular exam for possible steroid-induced ocular complications such as early cataract formation.
Clinical pearls for identifying patients with PSC
- Pinhole patients to distinguish how pathologic elements can be in play to vision changes, and dilate patients for the best comprehensive assessment of the patient’s ocular health.
- Retinal imaging can provide complimentary corroborating evidence, especially if PSC limits certain views.
- Running a macula optical coherence tomography (OCT) can be beneficial to rule out central vision changes that may also be obscured by any central PSC.
Checking IOP is the mainstay for comprehensives and most office visits. Follow ups are perfect to ensure avoiding rebound inflammation and to taper as indicated. Be vigilant to catch any early indications of ocular hypertension for short- or long-term steroid users. Checking before the addition of a topical steroid is helpful so that it can be monitored at follow-ups.
Management and treatment of steroid-induced cataracts
When quality of life and best-corrected vision are taken into consideration, a referral for cataract surgery may be indicated. Educate the patient on their options, and share details of the possible steroid-inducted etiology with the referring ophthalmologist.
In addition, coordinating any findings related to steroid-induced complications with the prescriber and patient’s primary care provider is important to engage in patient-centered healthcare. Having multiple comorbid conditions needing corticosteroid treatment can have higher risks if doses and duration are higher.
Table 2: Comorbidities that increase risk for steroid-related ocular complications.3,6,16,17
| Type | Conditions |
|---|---|
| Chronic conditions | COPD, asthma, arthritis (rheumatoid, juvenile), rheumatic diseases (sarcoidosis, Sjögren's, lupus), inflammatory bowel disease, Graves' ophthalmopathy, connective tissues disorders |
| Acute conditions | Bell's palsy, acute gout, acute bronchitis, acute sinusitis, allergic reactions, anaphylactic shock, allergic rhinitis, multiple sclerosis (MS) exacerbation, autoimmune skin conditions, uveitis exacerbation, toxic pulmonary or cerebral edema |
| Replacement Therapy | Addison's disease, congenital adrenal hyperplasia |
| Prophylactic Treatment | Organ rejection prevention, preterm delivery |
Key takeaways
Perform your due diligence in patients taking long-term steroids:
- Steroid prescribers should start with the lowest dose and treatment period that is appropriate and indicated for a therapeutic result based on the condition’s severity, signs, and symptoms to limit complications surrounding corticosteroid use.
- Be cognizant of pre-existing diseases that put patients at higher risk for steroid-induced ocular complications.
- Document both short- and long-term high-dose steroid treatments used, whether oral, injected, inhaled, or topical.
