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Bruce E. Onofrey, OD, RPh, FAAO Professor, U. Houston University...
Transcript of Bruce E. Onofrey, OD, RPh, FAAO Professor, U. Houston University...
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USE AND ABUSE OF
STEROIDS
Bruce E. Onofrey, OD, RPh, FAAO
Professor, U. Houston
University Eye Institute
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RULE #1
• UNDERSTAND THAT ALL
TREATMENTS HAVE SOME RISK
• KNOW RISK VS BENEFIT OF
THERAPY
• ALWAYS EVALUATE PATIENTS FOR
SIDE-EFFECTS AND ADVERSE
EFFECTS OF THERAPY
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RULE # 2
• YOU MUST HAVE A
DIAGNOSIS BEFORE YOU
TREAT
• TREATMENT IS EASY
DIAGNOSIS IS TOUGH
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RULE #3
• TREAT MECHANISMS, NOT
NAMES.
• RECOGNIZE PRESENCE OF
INFLAMMATION,
INFECTION, TRAUMA. THEY
CAN EXIST INDIVIDUALLY
OR TOGETHER.
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INFLAMMATION -THE
GOOD
• The Good
Destroy invading pathogens
Remove dead tissue
Replace damaged tissue with
scar tissue-fibrosis
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INFLAMMATION-THE
BAD • The Bad
Primary inflammation or
inflammation secondary to trauma,
infection or autoimmune disorders
must be controlled to minimize
damage and loss of function ie corneal
scarring
• Always TX underlying cause of
inflammation.
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STEROID
PHARMACOLOGY
• Mechanism of action@@@@@
Inhibit formation of leukotrienes
and prostaglandins-inflammatory
mediators
• Inhibit WBC migration
• Inhibit fibroblasts
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THE INFLAMMATORY CASCADE
Cellular phospholipid membrane
ARACHIDONIC ACID
CYCLOOXYGENASE
PROSTAGLANDINS
LIPOXYGENASE
LEUKOTRIENES
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STEROID INDICATIONS
ANTERIOR SEGMENT
Ocular Allergy • Acute Type I Anaphylaxis
• VKC
• AKC
• GPC
• Good for stabilization, then
consider maintenance
therapy
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Ocular Allergy-Seasonal
Lots of Itch, No tissue damage-
Initially@@@@, A Pure Histamine Act
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If There are Eosinophils, It Ain’t
Simple Allergic Conjunctivitis
• Eosinophils-Nasty little WBC’s full of
“ACID” (Major basic protein)
• Attracted by release of PAF (platelet
activating factor) and ECF (Eosinophilic
chemotactic factor)
• Produce permanent tissue changes seen in
VKC and GPC
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POST-OP USE
• Refractive surgery
• Cataract surgery, extended use can dramatically
reduce the incidence of post-op CME
• Reduce inflammation and pain
• Reduce regression and hazing-primarily for PRK
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OCULAR INFECTION
• VIRAL
EKC-Subepithelial infiltrates and
pseudomembranes@@@@-
minimize loss of accessory
lacrimal apparatus
Herpes simplex-Minimize corneal
scarring in disciform/stromal
disease
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BACTERIAL
• Staph can produce secondary
corneal inflammatory disease
• Marginal ulcers/phlectenular
disease
• Useful in bacterial corneal
ulcer management?
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For Chronic Lid Disease it
Beats Steroids Every Time
It blocks a complex organic
inflammatory molecule:
OH-POO=POO
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A NEW USE FOR DOXYCYCLINE?
Doxycycline inhibition of interleukin-1 in the corneal
epithelium.
Solomon A, Rosenblatt M, Li DQ, Liu Z, Monroy D, Ji
Z, Lokeshwar BL, Pflugfelder SC
Ocular Surface and Tear Center, Bascom Palmer Eye
Institute, Department of Ophthalmology, University of
Miami School of Medicine, Florida 33136, USA.
PURPOSE: To evaluate the effect of doxycycline on the
regulation of interleukin (IL)-1 expression and activity
in human cultured corneal epithelium. MP.
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RESULTS: Doxycycline significantly decreased IL-1beta
bioactivity in the supernatants from LPS-treated corneal
epithelial cultures. These effects were comparable to those
induced by the corticosteroid,
CONCLUSIONS: Doxycycline can suppress the steady
state amounts of mRNA and protein of IL-beta and
decrease the bioactivity of this major inflammatory
cytokine. These data may partially explain the clinically
observed anti-inflammatory properties of doxycycline.
The observation that doxycycline was equally potent as
a corticosteroid, combined with the relative absence of
adverse effects, makes it a potent drug for a wide
spectrum of ocular surface inflammatory diseases.
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The observation that doxycycline
was equally potent as a
corticosteroid, combined with the
relative absence of adverse effects,
makes it a potent drug for a wide
spectrum of ocular surface
inflammatory diseases.
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DOXYCYCLINE
• Long acting/potent tetracycline
• Resistant to absorption problems
• Medium GI upset
• Good compliance (1-2 X/D dosing)
• No activity in acute bacterial eye disease
• Inexpensive
• Contraindicated in kids and pregnant patients
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Doxycycline
Indications/Dosage forms
• Indications:
• Back-up drug for Chlamydia
• Acne rosaceae/chronic Staph blepharitis
• Corneal erosion
• Dosage forms:
• 50 and 100mg tablets/capsules
• 25mg/5ml suspension
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Steroids and Dry Eye
• Recognized
Inflammatory component
to dry eye
• Risk VS Benefit
• “Jump start” Restasis
TX
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Topical nonpreserved methylprednisolone
therapy for keratoconjunctivitis sicca in
Sjogren syndrome.
Marsh P, Pflugfelder SC.
Ocular Surface and Tear Center, Bascom Palmer Eye Institute,
Department of Ophthalmology, University of Miami School of
Medicine, Florida 33136, USA.
CONCLUSIONS: These findings indicate that topical
nonpreserved methylprednisolone is an effective treatment
option for patients suffering from severe keratoconjunctivitis
sicca who continue to experience bothersome eye irritation
despite maximum aqueous enhancement therapies. They also
suggest that inflammation is a key pathogenic factor in this
condition.
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[Nonpreserved topical steroids and lacrimal punctal
occlusion for severe keratoconjunctivitis sicca]
Sainz De La Maza Serra M, Simon Castellvi C, Kabbani O.
Servicio de Oftalmologia, Unidad de Inmunologia Ocular y Uveitis, Hospital Clinico y
Provincial de Barcelona, Espana.
CONCLUSIONS: Topical nonpreserved
steroid therapy for two weeks before punctal
occlusion is effective in controlling symptoms
and corneal fluorescein staining in patients
with severe keratoconjunctivitis sicca
associated with Sjogren's syndrome.
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A Clinical Moment
• 28 YO WT male with C/O red, painful
OD X 1 month-first occurrence
• TX by primary care doctor with
gentamycin drops QID
• Told to use till gone
• Told he has “pink eye”
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HISTORY (Cont’d)
• BVA CF’s at 3 feet OD/20/20 OS
• A/C Deep with +3 cell and flare OD
• Post-synechiae 270 degrees OD
• IOP OD 2mm hg/ 17mm Hg OS
• (+) Hx lower back pain
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UVEITIS-
Know your Adjectives
• NON-GRANULOMATOUS VS
GRANULOMATOUS
• IDIOPATHIC VS SECONDARY VS
TRAUMATIC
• ANTERIOR VS INTERMED VS
POSTERIOR
• ACUTE VS CHRONIC VS RECURRENT
• UNILATERAL VS BILATERAL
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ANATOMICAL
CLASSIFICATION
• ANTERIOR
• INTERMEDIATE
• POSTERIOR
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ANATOMY
• IRIS-ANTERIOR
IRITIS/TRABECULITIS
• CILIARY BODY-
INTERMEDIATE
CYCLITIS/PARS PLANITIS
• CHOROID-POSTERIOR
CHORIORETINITIS/VITRIT
IS
FOCAL/DIFFUSE/VASCULIT
IS
• PANUVEITIS-
ENDOPHTHAMITIS
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UVEITIS WORK-UP
• PROPER PATIENT
EVALUATION-THOROUGH HX
AND APPROPRIATE LAB TESTS
• 80% OF FIRST TIME NON-
GRANULOMATOUS ANTERIOR
UVEITIS IS IDIOPATHIC
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GRANULOMATOUS
VS
NONGRANULOMATOUS
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NONGRANULOMATOUS
UVEITIS IT:
• Comes on FAST
• HURTS
• Produces a RED EYE
• Fine KP / Sterile hypopion
• Recurrent
• HX of ACHING type systemic diseases
• 80% are idiopathic@@@@@@
• Commonly associated with
SPONDYLARTHROPATHIES@@@@@
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GRANULOMATOUS
UVEITIS
• Insidious / Chronic- “smoldering”
• Predominance of cells- “Mutton-fat” KP
• Most commonly associated with
underlying systemic disorders: TB,
Syphilus, Sarcoid, Toxoplasmosis,
etc@@@@@
• A medical consult is
MANDATORY@@@@@
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TEMPORAL
Acute Disease
• SUDDEN ONSET
• LASTS LESS THAN 6 WEEKS
• SEVERE SIGNS AND SYMPTOMS
• INTENSE PHOTOPHOBIA
• PRONOUNCED LIMBAL FLUSH
• PRONOUNCED CELL AND FLARE
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CHRONIC UVEITIS
• INSIDIOUS
• > 6 WEEKS
• SUBTLE SIGNS AND SYMPTOMS
• NO PHOTOPHOBIA
• WHITE EYE
• LOTS OF CELLS
• LITTLE OR NO FLARE
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ETIOLOGICAL
CLASSIFICATION
• INFECTIOUS
BACTERIA/VIRUS
• NON-INFECTIOUS
EXOGENOUS
ENDOGENOUS
• IDIOPATHIC
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INFECTIOUS
• BACTERIAL-HYPOPION
COMMON
• VIRAL- H. SIMPLEX AND
ZOSTER
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NON-INFECTIOUS
• EXOGENOUS-INJURY
• ENDOGENOUS
COLLAGEN VASCULAR
DISEASE
SPONDYLARTHROPATHIES
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IDIOPATHIC
• CAUSE IS UNKOWN
• MOST COMMON FORM OF
ACUTE ANTERIOR UVEITIS
• COMMON DURING HIGH
ALLERGY AND TIMES OF
STRESS
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DOES IOP GO UP OR
DOWN??
THE ANSWER
IS........
YES
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ANTERIOR UVEITIS
AND IOP
IT ALL DEPENDS ON WHATS
INFLAMED...........
• Cyclitis: DOWN
• Trabeculitis: UP
• Iritis: Either or neither or
BOTH????
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IOP CHANGE MECHANISMS
IN IRITIS
• Blockage of TM by
inflammatory GOOP
• Blockage of TM by glycoprotein
GOOP
• Posterior synichiae
• Anterior synichiae
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COMPLICATIONS OF
UVEITIS
• CORNEAL ENDOTHELIAL DAMAGE
• SYNECHIAE
• IRIS NODULES/ATROPHY
• CATARACT
• GLAUCOMA
• MACULAR EDEMA
• RETINAL DETACHMENT
• REDUCED ACUITY
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GOALS OF THERAPY
• REDUCE PAIN
• REDUCE PHOTOPHOBIA
• REDUCE INFLAMMATION
• PREVENT COMPLICATIONS
• BREAK AND/OR PREVENT
SYNECHIAE
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DRUG THERAPY
• CORTICOSTEROIDS-Oral vs Topical
• NSAIDS
• CYCLOPLEGICS/MYDRIATICS
• In secondary must TX underlying cause
• Multiple drop dosing increases tissue
levels, efficacy and reduces TX
failure@@@@@
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SYMPTOMS OF SYSTEMIC
DISEASE DO YOU HAVE??
• BACK PAIN-ANK. SPOND
• WRIST AND ANKLE PAIN-
REITERS SYNDROME
• PAIN WHEN URINATING-
SYPHILIS/OCCASSIONALLY
REITERS
• KNEE PAIN-JRA
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SYMPTOMS OF SYSTEMIC
DISEASE
• DIARRHEA/CRAMPING-CROHN’S
DISEASE
• COUGHING-TB AND SARCOID
• RASHES
BULLS EYE-LYME DISEASE
PALMS OR SOLES-SYPHILIS
VESICULAR-HERPES
• FEVER
• WEIGHT LOSS
• MALAISE
• LYMPHADENOPATHY
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NEED to KNOW@@@@@
The most significant short term
adverse effect of TOPICAL steroids
is steroid glaucoma
Avoid topical steroids in H. simplex
EPITHELIAL disease
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STEROID PRODUCTS
TOPICAL
• Hms medrysone-low efficacy
• Fluoromethalone-acetate vs alcohol-FML,
Eflone , Flairex
• Prednisolone-acetate vs phosphate-Pred
forte, Econopred
• Dexamethasone
• Steroid/antibiotic combinations
Vasocidin, FML-S, Tobradex
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TOPICAL STEROIDS-THE NEXT
GENERATION
Rimexolone/Vexol/Alcon
• Hybrid molecule-SAR-Structural Activity
Relationships
• Best of Fluoromethalone-Reduced Steroid IOP
response
• Best of Dexamethasone-Efficacy
• Problem-Efficacy??
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Loteprednol/ B & L
Alrex .2%
Lotemax .5% • New “Soft” molecule
technology@@@@
• High receptor affinity and
rapid metabolism@@@@
• High efficacy
• “Reduced” steroid response
• No steroid cataract
• @@@@@@@@@@@
ONLY ALREX is FDA
approved for seasonal allergy
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Topical steroids and Glaucoma
@@@@@@@@@@@
• Dexamethasone-HIGHEST GLC
potential@@@@
• Low potential@@@@
Rimexolone
Lotoprednol
Fluoromethalone
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AUTOIMMUNE DISEASE
• Episcleritis
• Scleritis-Underlying systemic disease is
common-generally avoid topical steroids
• 4 types of scleritis
Anterior diffuse
Anterior nodular
Necrotizing anterior-97% syst. Dis (Avoid
topical steroids-scleral melting)@@@@@
Posterior
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NSAIDS OF COURSE
THEY’RE SAFER?
• Only anti-inflammatory in high doses
• Think RK good for -11.00 myope or
LASIK
• GI ulceration
• Renal failure
• Congestive heart failure
• All diabetics/No No No
• POOR anti-inflammatory effect
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Steroids Are Safer?
You must be kidding
• Extremely effective anti-inflammatory
effect
• Safe for short term use if………….
• No GI ulcer
• No psychotic
• No high BP
• No diabetes
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The 3 TOP REASONS FOR
STEROIDS IN EYE DISEASE
ARE: 1. TEMPORAL ARTERITIS
2. CRANIAL ARTERITIS
3. ARTERITIC ISCHEMIC OPTIC
NEUROPATHY
No, you probably won’t Tx it here, but
you’d better not miss it
80-100mg prednisone daily
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Temporal Pain?
• Elderly individuals can present with a wide range
of acute sx:
• Visual disturbance/VF loss
• Diplopia
• Ptosis
• Non-specific eye/head pain
• MY MOST COMMON NEGATIVE TESTS
• ESR / CRP / CBC
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The Stats
• Symptomatic patient
• ESR > 47
• NON-Ultra CRP > 2.45
• 98% chance of TA
• TX
• Follow up with TA biopsy within 2 weeks
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STEROID PRODUCTS
SYSTEMIC
• Steroid nasal inhalers before oral
antihistamines
• Know steroid equivalents
• Medrol dospak
• Prednisone-very flexible dosage
• Methyl prednisolone for IV injection-solu-
medrol
• Kenalog for local repository effect
good for chalazia
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Medrol Dospak
Methyl prednisolone
• High potency oral corticosteroid
• Good anti-inflammatory activity
(glucocorticoid)
• Low mineralocorticoid activity
• Convenient
• inexpensive
• Safe***
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Medrol Dose-pak
Indications/dosage forms
• Indications:
• Anterior uveitis/scleritis/Type I allergy
• Dosage form:
• Pre-labeled with descending dosage (automatic
daily taper over 6 days of TX
• Always take with food/avoid in diabetics/GI
bleeders/blood
thinners/NSAIDS/hypertension/psychosis
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STEROID SIDE-EFFECTS
• Inhibit good immune response
• Exacerbate infection
• Sodium and water retention
• GI Ulcers
• Increase BP
• Exacerbate diabetes mellitus
• Steroid cataract and glaucoma
• Psychosis
• Addison’s and Cushing’s disease
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OPTIC NEURITIS AND
STEROIDS
Optic Neuritis TX Trial
• After one year no advantage to
tx
• If initial treatment with oral
steroids, increased risk of
development of multiple sclerosis