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Incidence of steroid-related glaucoma increases over the past 5 years
Growing use of intravitreal and subtenon’s triamcinolone a primary cause, surgeon says.
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Corticosteroid-related glaucoma has become much more common in the last 5 years, leading to a recent “epidemic,” according to Alan L. Robin, MD, OSN Glaucoma Section Member.
| Alan L. Robin |
The escalating problem is mainly due to the increased intravitreal and subtenon’s injections of triamcinolone by retinal surgeons for multiple indications, explained Dr. Robin, who has studied the effects of intravitreal triamcinolone on IOP with colleagues.
Increases in IOP can also be caused by topical corticosteroids, oral steroids and occasionally, possibly even nasal inhalers, he added.
Steroids are effective inhibitors of neovascularization and are among the most potent anti-angiogenic drugs known, he said. Retinal surgeons have been increasingly relying on them to improve intraocular neovascular, inflammatory and edematous conditions.
Frequency, potency affect IOP
Following steroid treatment, morphologic and biochemical changes such as enlarged cell size, actin cytoskeletal reorganization and the distribution of the protein myocilin mRNA occur in the trabecular meshwork, Dr. Robin said. However, the pathophysiology of steroid-induced IOP elevation is not entirely understood.
Following the administration of steroids in the eye, certain patients will experience increased IOP within 1 week to a few months. Dr. Robin cited one case report from Duke University in which a patient’s pressure increased to 60 mm Hg within 1 week.
“However, it is not uncommon for a patient’s IOP to go up late, 2 to 3 months after the injection, and many patients — about 5% to 10% — appear to have large IOP rises and are minimally unresponsive to topical medications used for lowering pressure,” he said.
Patients are at a heightened risk for developing elevated pressure when steroids are administered more frequently or in higher concentrations, and when long-lasting corticosteroids are delivered to the eye, according to Dr. Robin.
“It’s well-recognized that about 50% to 60% of individuals who are exposed to steroids frequently enough and in high enough concentrations can develop glaucoma,” he said.
“The reasons why we have seen so many cases [of elevated IOP] are because the injection is inside the vitreous, there is a high concentration within the eye, and it can stay there for 6 to 8 months,” he explained.
Prevention and treatment
To date, there are no preventive methods for steroid-induced glaucoma because it is not yet clear why some patients experience an increase in pressure and others do not, Dr. Robin said.
The epidemic has prompted Dr. Robin and colleagues Ray Sjaarda, MD, and Eric P. Suan, MD, to further investigate possible treatments for steroid-induced glaucoma. They have studied the effects of anecortave acetate, an angiostatic cortisene, on elevated IOP and have found promising results.
“Anecortave acetate works by a totally novel mechanism of action,” he said.
The drug lowered pressure in animals that developed elevated IOP after receiving an initial injection of dexamethasone followed by topical dexamethasone, he said.
Dr. Robin and colleagues have also tested the effects of anecortave acetate in steroid-responding patients, who have shown a marked reduction in IOP as a result of the treatment.
Dr. Robin said that they are hopeful the drug will potentially help those suffering from steroid-related glaucoma. Their investigation is ongoing.
For Your Information:
- Alan L. Robin, MD, can be reached at 6115 Falls Rd., Suite 333, Baltimore, MD 21209; 410-377-2422; fax: 410-377-7960; e-mail: glaucomaexpert@cs.com.
- Aleta Mayne is an OSN Correspondent based in Philadelphia, Pa.