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What are the benefits and liabilities of using topical vs. intravitreal steroids in treating inflammation associated with eye disease?
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Steroids may be limited as monotherapy
 Michael S. Ip |
The use of intravitreal steroids in the treatment of macular edema for retinal vascular disease is beneficial because steroids are effective at reducing macular edema and improving visual acuity in many patients. This is true in diabetic macular edema and macular edema secondary to both central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO).
However, the beneficial effect of steroids is mitigated when compared with other effective treatments such as laser photocoagulation, which has a different mechanism of action and a slower time course to produce a clinically apparent effect. Laser photocoagulation has been demonstrated in clinical trials to be effective for diabetic macular edema and macular edema from BRVO. The use of anti-VEGF therapy with ranibizumab for macular edema secondary to CRVO and BRVO has been proven effective, and anti-VEGF therapy may also be effective for diabetic macular edema.
The pitfalls of steroids are mainly that elevated glaucoma and cataract are associated side effects. This is particularly true with the 4-mg dose, but much less so with the 1-mg dose. Thus, as a result of steroid side effects and the availability of other therapies such as laser and anti-VEGF drugs, steroids as a monotherapy should likely be considered only for macular edema secondary to CRVO.
Michael S. Ip, MD, is an associate professor at the University of Wisconsin, Madison.
Differences in side effects, dosing regimens, potency
 Judy E. Kim |
Compared with other routes of delivery, steroid delivered topically for treatment of ocular inflammation has the benefit of having lower or nonexistent risk of endophthalmitis, retinal tears or detachment, subconjunctival hemorrhage, pain, cataract and ptosis. In addition, it is less likely than intravitreal steroid to cause very high IOP. Topical steroids can be used as a method of challenge to see if sub-Tenon’s or intravitreal steroid injection is likely to cause IOP elevation.
Furthermore, steroid dosing and duration of treatment can be tailored to the severity of inflammation and can be tapered or discontinued as needed. In cases of mild but recurrent inflammation, low-dose or even once a day or less dosing may be effective in keeping the inflammation from recurring. Finally, studies have shown that topical steroid can be combined with topical nonsteroidal medications to give synergistic effect in treatment of pseudophakic cystoid macular edema.
However, topical steroid may not be as potent as sub-Tenon’s or intravitreal route of steroid delivery. Therefore, for more severe, chronic or vision-threatening inflammation, I often proceed directly to sub-Tenon’s or intravitreal steroid injection. Because my patients are often referred to me after failure of trial of topical steroid, I tend to proceed to other routes of steroid delivery sooner. Furthermore, patient compliance with topical steroid cannot be controlled, and poor compliance may reduce the efficacy of the drug.
Judy E. Kim, MD, is an OSN Retina/Vitreous Board Member and a professor at Medical College of Wisconsin.