Khatri & Ton Health Renaissance, January-April 2012; Vol 10 (No 1!

;"#-"$ %teroi& in&uce& ocular hypertension

Short Communication

Steroid induced ocular hypertension following pterygium surgery

BK Khatri1, H Ton2 1Consultant Ophthalmologist, Seva Sight Program, Cambodia 2Ophthalmologist, Battambang Ophthalmic Care Center, Cambodia Abstract Background: Steroid induced glaucoma is an important cause of ocular morbidit and blindness! Objective: To determine the incidence of steroid induced ocular h pertension follo"ing pter gium surger ! Methods: # total of 2$2 e es of 2$2 patients "ith primar pter gium "hich received steroid e e drops after undergoing surgical e%cision "ere selected! Pre&operative and post&operative intra&ocular pressure '(OP) "ere measured and follo"ed up after 2nd and *th "ee+s follo"ing surger ! esults: Ocular h pertension developed in ,'2.!2- /) e es! The (OP returned to normal after t"o "ee+s follo"ing discontinuation of topical steroid drops 'de%amethasone) and initiation of anti&glaucoma medication 'Timolol drops $!0/ B1)! !onclusion: 2earl one fourth of the patients receiving topical steroid follo"ing pter gium surger presented "ith ocular h pertension! 3easurement of (OP as earl as 2 "ee+s of initiation of steroid drops helps identif steroid induced ocular h pertension! "eywords4 glaucoma, pter gium, ocular h pertension #ntroduction Pter gium is a common e e disease in Cambodia! Pter gium e%cision "ith con5unctival free auto&graft is the treatment of choice! Topical steroid drops are used postoperativel to reduce inflammation and recurrence rate! 6levated intraocular pressure persists as long as steroids are continued! Once the steroids are "ithdra"n, (OP returns to baseline levels "ithin 1$ da s in appro%imatel 78 / of the e es! (n the remaining population, it ma even ta+e up to . "ee+s! Ho"ever, there have been fe" cases of irreversible (OP, ultimatel re9uiring glaucoma surger !2 The +no"n ris+ factors for the steroid induced glaucoma are pree%isting primar open angle glaucoma, famil histor of glaucoma, high m opia, diabetes mellitus, and oung age!. This stud "as carried out to determine the occurence of steroid induced ocular h pertension follo"ing steroid e e drops use after pter gium surger !

Methods Primar pter gium cases "ith no other ocular and s stemic patholog "ere included! The "ere prescribed descmethesone e e drops four times a da Primar pter gium cases "ith no other ocular and s stemic patholog "ere included! The "ere prescribed descmethesone e e drops four times a da after pte gium surger and follo"ed up at si%th "ee+s! The sub5ects "ith +no"n glaucoma "ere e%cluded! #n informed consent "as ta+en from all the patients before their enrollment in the stud ! Per gium e%cision "ith con5unctival auto&graft "as performed on 2$2 e es of 2$2 patients from <ul to September 2$1$ at Battambang Ophthalmic Care Center 'BOCC), Cambodia! 1e%acol '1e%amethasone = Chloramphenicol) containing 0mg of de%amethasone sodium phosphate and chloramphenicol 2$ mg '1 drop) "as used , times a da ! Similarl , 1/ tetrac cline e e ointment "as also used three times a da ! Patients "ere discharged at the ne%t da and follo" up "as done at "ee+ 2 and *! (OP Chec+ up before and after surger "as measured b The (care> tonometer! (OP?21 mm of Hg "as considered as ocular h pertension! esults @hen intraocular pressure '(OP) "as measured at "ee+ 2 during the follo"&up, nearl 20/ of the operated cases receiving topical steroid presented "ith ocular h pertension! Steroid induced ocular h pertension is due to reduced a9ueous humor outflo" facilit !1 Steroid responders '0/ general population) ma develop elevated (OP "ithin a short time follo"ing steroid administration Age and Se% characteristics
#ge :roup 2$&.7 ,$&*$ Total Se% Total 3ale ;emale 22 22 ,, '21!-8/) ,. 110 108 '-8!22) *0 '.2!18/) 1.- '*-!82/) 2$2 '1$$/)

But the li+elihood of ocular h pertension increases "ith increase in duration of the steroid use! &imitation Having no control group and no visual field evaluation are the limitations of this stud ! !onclusion Ocular h pertension developed in ,- '2.!2-/) e es overall! #t 2 nd "ee+4 1$ e es '22&28 mm of Hg) mean 2.!8A2!2
$

#t *th "ee+4 .- e es '22&0.mm of Hg) mean 28!-A-!(OP "as lo"ered do"n to normal in all e es after 2 "ee+s follo"ing discontinuation of topical steroids and initiation of anti&glaucoma medications! (iscussion Topical steroid drop use for more than 2 "ee+s increases (OP in 18&.* / of the population and ,*&72/ of patients "ith PO#:!, #rmla '17*.) in the 17*$s reported that after receiving de%amethasone or betamethasone .&, times dail for , "ee+s, .,&,2/ of normal individuals demonstrated an (OP rise from a baseline value of * to 10 mm hg to a final level of 2$& .1 mm Hg!0 The e%act pathoph siolog of steroid induced glaucoma is un+no"n! Based on histological studies* accumulation or deposition of e%tracellular matri% material, decrease protease and stromel sin activit , recognition of the T3 c tos+eleton and 12# content, increased nuclear siBe and 12# content, decreased phagoc tic activities and changes in the s nthesis of specific proteins, and changes in the s nthesis of specific proteins are considered as the pathogenetic mechanism of steroid induced glaucoma! (ncreased laminin deposition is also reported to be responsible for decreased outflo" facilit both in steroid induced glaucoma and in primar open angle glaucoma!1e%amethasone treatment causes specific up regulation of gl cosaaminogl can or the T(:C 'Trabecular mesh"or+ Dinducible glucocorticoid response)E3FOC '3 ocilin) gene in the human trabecular mesh"or+ cells but not in other cells! T(:CE3FOC is a 0$,&amino& acid secretor protein found normall in the cilliar bod , human retina and optic nerve head astroc tes and s+eletal muscles!8 The findings of our stud sho"ed that the (OP ma rise as earl as t"o "ee+s after steroid e e drop use Topical steroid ma cause ocular h pertension follo"ing pter gium surger ! 6arl detection, prompt treatment and close follo" up are recommended! @e suggest measuring (OP in all steroid using patients no later than 2 "ee+s after initiation of steroid treatment! Acknowledgement #ll patients and their relatives and the Battambang Ophthalmic Care Center are ac+no"ledged! eferences 1! Gertungo 3, 3aino #, Huaranta 3, Cardia I '2$$$)! # randomiBed, comparative open label stud on the efficac of latanoprost and timolol in steroid induced ocular h pertension after photorefractive +eratectom !6ur < Ophthalmolog , 1$42$0&211! 2! 3un5al GP, 1hir SP, <ain (S '1782)! Steroid induced glaucoma! (ndian <ournal Ophthalmol, .$4.-7&.82! .! Shu+la 1,Gidh a 2,Prasad 2 3 et al '2$$-)! 6valuation of patient age as ris+ factor of intraocular pressure elevation after intravitreal triaminolone!#3 < OphthalmolJ 1,,4,0.&,0,! ,! Tripathi CC, Tripathi B<, Haggerl C et al '2$$.)! 1rug induced glaucomas4 3echanism and management! 1rug safet , 2*4-,7&-*-!
'

0! #rmla 3; '17*.)! 6ffects of corticosteroids on intraocular pressure and fluid d namics, the effect of de%amethasone in the normal e e! #rch OphthalmolJ -$4,82&,71! *! (shibashi T, Ta+agi F, 3ori K, 2ishino H et al '2$$2)! 12# microarra anal sis on gene e%pression changes induced b de%amethasone in cultured human trabecular mesh"or+cells! (nvest Ophthalmol, ,.4.*71! -! 1ic+erson <6, Steel HT, Clar+ #; '1778)! The effect of de%amethasone in integrin and laminin e%pression in cultured human trabecular mesh"or+ cells! 6KP 6 e CesJ **4-.1& -.8! 8! Io @C, Iaura IC et al '2$$.)! Tissue differential microarra anal sis of de%amethasone induction reveals potential mechanisms of steroid induced :laucoma! (OGSJ ,,'2)4,-.& ,80!