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Increase in IOP primary concern with use of steroid-based inhalers in children
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While a nip is in the air and snow may still be on the ground, optometrists, as well as other practitioners, are beginning to think about the coming of spring and therefore the onset of seasonal allergies that often plague their patients. Many patients are rejecting oral antihistamines in favor of nasal inhalers, which often are steroid based. Children, as well, may be placed on a steroid-based inhaler for asthma management. That use of steroid-based inhalers in children has potential ocular ramifications of which optometrists should be aware.
Increase in IOP
The primary concern when prescribing a steroid-based inhaler is the increased incidence of a rise in intraocular pressure (IOP), said J. James Thimons, OD, in group practice in Connecticut. “This is a potential problem in any individuals who are susceptible to the drug’s effects on the trabecular meshwork,” he said. “Certainly, any child who’s on any kind of steroid-based asthma therapy should be evaluated on a routine basis for IOP complications, and the corneal integrity should also be assessed to make sure that there’s no tissue breakdown or presence of viral-mediated disease. The sprays have a very high concentration and rapid access to the vascular system. The nasal system has a tremendous vascular plexus that allows the sprays to get into the ophthalmic plexus very easily.
“The take-home message for the primary care clinician is that when a child is using steroids via any modality, but particularly via the nasal delivery systems, he or she needs to be monitored on a chronic basis for IOP concerns,” Dr. Thimons continued. “That would be initially every 3 months. After a 6-month period, I would probably be a little more comfortable if he or she doesn’t show a response. However, they do need to be monitored while they’re on the drug.”
The first consideration is to establish the reason why the child has been placed on an inhaler, said Michael Bartiss, OD, MD, in private practice in Pinehurst, N.C. “A dramatic rise in IOP is relatively rare in children,” he told Primary Care Optometry News. “Usually when children are utilizing inhalers, it’s because they can’t breathe, and nothing else much matters if you can’t breathe. So from my perspective, the pediatrician or family doctor needs to take care of the child’s breathing problems first. If the optometrist determines that the child has indeed demonstrated a significant rise in IOP, this should be discussed with the child’s primary care provider or allergist and alternative method approaches sought.”
Rise in IOP: can kids handle it?
Children who undergo an increase in IOP may also be better equipped to handle the rise in pressure than adults might be. Due to the flexibility of the “young” sclera, a child may be able to better cope with a higher than normal IOP, said Dr. Bartiss. “When an infant gets glaucoma, he or she gets big eyes. The eye stretches because the sclera is so elastic. In an adult, the sclera loses elasticity, and therefore pressure increases sooner. True glaucomatous changes are more reversible in children for the same reason. Hand-held tonometers have made the evaluation of IOP in children much easier.”
While Dr. Thimons agrees that the healthy optic nerves in children “can tolerate a slightly higher pressure level without damage because of their blood flow perfusion rate to the optic nerve,” this rate of perfusion of the vascular system may be the very thing that makes steroid inhalers more dangerous in children. “The steroid inhalers are probably even a little more dangerous because children have a higher rate of perfusion of the drug into the ocular area, secondary to the idea that they don’t have well-described tissue barriers.”
Diminishing/discontinuing medication
The majority of patients will not experience a rise in IOP. However, if it does occur, Dr. Thimons suggested gradually tapering the use of the inhaler and eventually stopping it completely. This should be done in conjunction with their pediatrician. “You can’t stop it immediately because there’s a rebound effect that’s pretty profound in children,” he said. “But you do need to slow the steroid down, and you do need to treat the increased pressure. We would typically do that with a topical medical intervention in the form of alpha agonists or topical CAIs [carbonic anhydrase inhibitors]. If the situation demands — and in conjunction with the pediatrician — you may consider the use of other therapeutics. I usually don’t use prostaglandins as front-line drugs in children just because there is no established track record. Given the fact that the pressure will drop in the absence of steroids, and you’ve been monitoring the child and the pressure has crept up gradually, the reversal is pretty quick.”
The next step is comanagement, said Dr. Thimons, where the optometrist works with the clinician who is treating the asthma or allergies to come up with a regimen that meets the patient’s needs but presents no further ocular complications. “In that case, the child would need to be taken off of steroids and moved to a nonsteroid, probably an antihistamine-based inhalant,” he said.
The “rebound effect” usually occurs in the form of severe congestion as the child’s immune system “rebounds” from immediate cessation from long-term treatment of a nasal-based allergy, said Dr. Thimons. “The steroid should be gradually diminished if the patient has been on it for a long time,” he said. “If he or she has an acute response to steroids in just 2 to 3 weeks, you can stop the steroids very quickly. Typically, you’ll find that once the effect of the steroid component has been removed, and the trabecular meshwork has returned to its normal status, the IOP returns to normal and you don’t need to continue using the glaucoma drops.”
However, long-term steroid use can result in steroid-induced glaucoma that does not resolve after stopping medication, he said.
Simply reducing the amount of medication the child receives would probably not be enough, “because once he or she has demonstrated this response to steroids, even once-a-day therapy has a very high probability of producing a response,” Dr. Thimons noted.
However, before inhaler use is stopped, the optometrist should consult with the primary care physician, advised Dr. Bartiss. “If there are alternatives, then certainly they should be explored,” he said. “But the child needs to breathe first and foremost. You can always treat the rise in IOP with the topical drops until the child can get off the inhaler. But you have to communicate with the primary care physician or the allergist; that’s key.”
Dr. Bartiss added that steroids in the form of a long-term systemic medication, such as prednisone for an autoimmune disease, may pose a more potent threat to a child than an inhaler would. Practitioners should be wary also of advising a patient or his or her parents to reduce the medication, he warned. “I would talk to the primary care physician and express your concerns,” he said. “True comanagement is the ideal.”
Other complications
While not likely, the doctors agreed that cataract formation may result from long-term use of steroids. “Over the long term, there is the potential for cataract formation and the diminishment of the immune system so that the patient has a minimal but potential risk for developing conditions such as herpetic infectious keratitis and other immunosuppressed-based clinical presentations,” said Dr. Thimons. “Steroids are a local immunosuppressant; they produce a decreased level of immunity wherever they’re applied.”
A wide variety of side effects may stem from the use of steroids, in particular cortisone, said Dr. Bartiss, but the side effects are relatively rare and usually are the result of oral systemic medications.
For Your Information:
- J. James Thimons, OD, is a member of the Primary Care Optometry News Editorial Board. He can be reached at Ophthalmic Consultants of Connecticut, 75 Kings Highway Cutoff, Fairfield, CT 06430; (203) 334-2020; fax: (203) 334-2401; e-mail: jim.thimons@tlcvision.com.
- Michael Bartiss, OD, MD, a member of the Primary Care Optometry News Editorial Board, is in private practice. He may be reached at Family Eye Care of the Carolinas, 5 Regional Circle, Ste. A, Pinehurst, NC 28374; (910) 235-3700; fax: (910) 235-4447; e-mail: kidseyes@earthlink.net.