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Harper’s Point Eye Associates
Steroids
Feast or Famine ?
Elliot M. Kirstein, OD, FAAO
Harper’s Point Eye AssociatesCincinnati, Ohio
Agenda
• History of steroids
• Benefits
• Risks
• Systemic application
• Ocular application
• Cases
Harper’s Point Eye Associates
Financial Interests
• Alcon – speakers alliance
• Optovue – speakers alliance
• Reichert – speakers alliance
• Aerie – speakers alliance
• Haag Streit - speakers alliance
History
• The discovery of the class of corticosteroid
called glucocorticoids began in the 1920’s.
• In the 1920’s, rheumatoid arthritis and
other arthritidies were thought to have an
infectious cause.
Harper’s Point Eye Associates
• By 1938, Dr. Philip Hench from the Mayo
rheumatic disease service, noticed a 65yo doctor with arthritis that improved the day
after becoming jaundiced.
• He later noted 31 other cases of joint pain
resolving, to some extent, with pregnancy,
infections, and post-surgically
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• The scientific community then abandoned
the infectious theory and started to look at the adrenal glands — substance X
• Multiple compounds were isolated from animal adrenals.
• Compound ‘E’ seemed to work particularly well in animals.
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• World War II was progress, and so money
was lacking, which left them frustrated.
• Merck gave multiple researchers around
the world the remaining 9 grams of compound ‘E’ – [make it work or drop this
idea]
Harper’s Point Eye Associates
• In September 1948, they injected their first
human patient.
• A 29-yo female with severe, erosive
arthritis that was chair-bound (unable to ambulate)
• After 4 days post-injection of compound E, she was able to walk out of the hospital.
Harper’s Point Eye Associates
In 1950, Dr. Philip Showalter Hench won the
Nobel Prize in Medicine.
Harper’s Point Eye Associates
Steroids in Medical Therapy
• A foundational element in most medical therapies is the control of inflammation.
• Inflammation causes harm to tissues and
keeping it at bay reduces scarring and loss of function.
• Reducing inflammation reduces patient
symptoms.
Harper’s Point Eye Associates
Applications• Medical conditions treated with systemic corticosteroids
• Allergy and respirology medicine
• Asthma (severe exacerbations)
• Chronic obstructive pulmonary disease (COPD)
• Allergic rhinitis
• Atopic dermatitis
• Hives
• Angioedema
• Anaphylaxis
• Food allergies
• Drug allergies
• Nasal polyps
• Hypersensitivity pneumonitis
• Sarcoidosis
• Eosinophilic pneumonia
• Some other types of pneumonia treatment protocols
• Interstitial lung disease
• Dermatology
• Pemphigus vulgaris
• Contact dermatitis
• Endocrinology (usually at physiologic doses)
• Addison's disease
• Adrenal insufficiency
• Nephrotic syndrome
• Chronic hepatitis (flare ups)
• Cerebral edema
• IgG4-related disease
• Prostate cancer
• Tendinosis
• Lichen planus
• Interstitial lung disease
• Dermatology
• Pemphigus vulgaris
• Contact dermatitis
• Endocrinology (usually at physiologic doses)
• Addison's disease
• Adrenal insufficiency
• Congenital adrenal hyperplasia
• Gastroenterology
• Ulcerative colitis
• Crohn's disease
• Autoimmune hepatitis
• Hematology
• Lymphoma
• Leukemia
• Hemolytic anemia
• Idiopathic thrombocytopenic purpura
• Multiple Myeloma
• Rheumatology/Immunology
• Rheumatoid arthritiseas
• Systemic lupus erythematosus
• Polymyalgia rheumatica
• Polymyositis
• Dermatomyositis
• Polyarteritis
• Vasculitis
• Ophthalmology
• Uveitis
• Keratoconjunctivitis
• Other conditions
• Multiple sclerosis
• Organ transplantation
Harper’s Point Eye Associates
Congenital adrenal hyperplasiaGastroenterology Ulcerative colitisCrohn's diseaseAutoimmune hepatitisHematology LymphomaLeukemiaHemolytic anemiaIdiopathic thrombocytopenic purpuraMultiple MyelomaRheumatology/Immunology Rheumatoid arthritiseasSystemic lupus erythematosusPolymyalgia rheumaticaPolymyositisDermatomyositisPolyarteritisVasculitisOphthalmology UveitisKeratoconjunctivitisOther conditions Multiple sclerosisOrgan transplantationNephrotic syndromeChronic hepatitis (flare ups)Cerebral edemaIgG4-related diseaseProstate cancerTendinosisLichen planus
Ophthalmic Applications
• Allergy
• Infection
• Dry Eye
• Keratitis
• Injury
• Uveitis
• Peri operative
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Ophthalmic Steroids
• Under prescribed
• Under dosed
Harper’s Point Eye Associates
Artificial tears and the “Ivory Tower”
Steroids and the Robo Doc
The Play
by
Elliot M. Kirstein, OD, FAAO
ACT I
“My eyes are so dry that
I want to tear them out!”
ACT II
This scratch on my eye is killing me!
ACT III
Dr., my eyes are on fire!
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Steroid Risks
• Increased IOP
• Immunosuppression
• Cataractogenesis
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Think about it……..
If a person is uncomfortable enough to schedule a doctors appointment, they must be very uncomfortable.
They are seeking immediate relief.
What kind of dummy
would bring a
knife to a gunfight?
Harper’s Point Eye Associates
What ‘s the difference?
• Flourometholone .1% (FML) – surface applications, less IOP effect, poor penetration
• Loteprednol (Lotemax) – surface and internal applications, less IOP effect
• Prednisolone Acetate 1% (Pred Forte) – surface and internal applications , more IOP effect
• Difluprednate (Durezol) - surface and internal applications , most powerful (2x pred), most IOP effect
Harper’s Point Eye Associates
Ocular Allergy
• They’ve tried “Visene”
• They’ve tried “tears”
• They’ve tried Zyrtec, Benadryl…..
Harper’s Point Eye Associates
Ocular Allergy Therapy
Consider:
• mast cell / antihistamine drop ***
• systemic OTC
• fluoromethalone or loteprednol q4h ***
• topical cortisone 1% with lid involvement
• Med–Pak for severe / seborrhea
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Infection
• Bacterial conjunctivitis / keratitis
is rare
• Most are viral / inflammatory
Harper’s Point Eye Associates
It all started here – “Blephamide”
circa 1974
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Keratitis
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Keratitis
• Cover with antibiotic
• Sooth with tears
• Treat with steroids
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Sterile infiltrate
or infectious ulcer?
Harper’s Point Eye Associates
staph exotoxin
• An exotoxin is a toxin secreted by
bacteria.
• An exotoxin can cause damage to the host
by destroying cells or disrupting normal cellular metabolism. They are highly
potent and can cause major damage to
the host.
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Harper’s Point Eye Associates Harper’s Point Eye Associates
Marginal “ulcer”
Harper’s Point Eye Associates
• antibiotic – steroid
• q3h first day
• follow with q4h x 6 days
• Consider lid therapy
• Counsel – extended wear
• Discard – case and lens
• Suggest – daily lens
Epithelial Herpes Simplex
primary
• Zirgan
• Valtrex
• Tears
• NO STEROIDS
Harper’s Point Eye Associates
Stromal Herpes Simplex
Uveitis
• History of previous primary epithelial
• Possible chamber reaction
• Risk neurotropic ulcer
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Stromal Herpes Simplex
Uveitis
• Zirgan
• Valtrex
• Tears
• STEROIDS (topical)
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Herpes Zoster
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• Zirgan
• Valtrex
• Tears
• STEROIDS (topical and systemic)
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central location
chamber reaction
hypopyon
Send this one away!
Dry Eye
basics
• Compromised tear causes chronic surface trauma
• Trauma causes inflammation
• Inflammation is treated with anti inflammatory medications
tears & supportive therapy
cyclosporin – lifitegast
tetracyclines
antibiotic ointments
steroids
Harper’s Point Eye Associates
Dry EyeJump Start
• Restasis or Xiidra bid
• Lotemax qid x 14 days then bid x 14
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Injury - treatment goals
• Promote healing
• Prevent infection
• Minimize pain
Harper’s Point Eye Associates
Injury - treatment
• healing / pain - STEROIDS
• infection – antibiotic prophylaxis
• pain – topical and oral NSAID’s / tears
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Conjunctival Injury
• healing / pain -STEROIDS
• infection – antibiotic prophylaxis
• pain – topical and oral NSAID’s / tears
Harper’s Point Eye Associates
Corneal Injury
• healing / pain -STEROIDS
• infection – antibiotic prophylaxis
• pain – topical and oral NSAID’s / tears
• Bandage contact lens
Harper’s Point Eye Associates
Lid and Adnexa Injury
• healing / pain - STEROIDS
• infection – antibiotic prophylaxis
• pain – topical and oral NSAID’s
Harper’s Point Eye Associates
Oral Steroids
• Severe allergy
• Herpes Zoster
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PrimarySimplex Keratitis
Harper’s Point Eye Associates
• Zirgan q3h
• Valtrex 2000 mg /day
• No Steroids
StromalHerpes Keratitis
Harper’s Point Eye Associates
• Zirgan q3h
• Valtrex 2000 mg /day
• Pred Forte 1% q4h
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Seborrheic Contact Dermatitis
Harper’s Point Eye Associates
treatment
• Hydrocortisone cream 1% BID
• A safer, effective treatment are topical immunomodulators, such as tacrolimus (Protopic)
• Zaditor – BID
• Zyrtec – or equivalent
• Medrol Pak – for severe presentations
………..Allergy workup
Harper’s Point Eye Associates
Uveitis
• Under diagnosis and under treatment is number one failure
• Use strongest topical STEROIDS available
• QID initial therapy NEVER indicated
• Cyclo when greater than 1+
• Consider Valtrex for possible herpetic etiology (especially with elevated IOP)
Harper’s Point Eye Associates
Peri operative
(same as injury)
• Promote healing - STEROIDS
• Prevent infection - antibiotics
• Minimize pain - STEROIDS / tears / NSAIDS
Harper’s Point Eye Associates
STEROIDS and IOP
What ‘s the difference?
• Flourometholone .1% (FML) – less IOP effect
• Loteprednol (Lotemax) - less IOP effect
• Prednisolone Acetate 1% (Pred Forte) – more IOP effect
• Difluprednate (Durezol) - most IOP effect
Harper’s Point Eye Associates
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Be on the alert!
• “SOFT” steroids
• Nasal and Inhaled steroids
• Injected steroids
• Chronic systemic steroids
Harper’s Point Eye Associates
Approved2/2019
Harper’s Point Eye Associates
For the treatment of postoperative inflammation and pain following ocular
surgery.
2 times greater penetration to the aqueous humor due to the submicron particle size
SubMicron technology allows for less frequent application when compared with
Lotemax Gel.
Harper’s Point Eye Associates
Case #1
Glaucomatocyclitic Crisis
Posner-Schlossman Syndrome
Harper’s Point Eye Associates
Visit #110/18/2007
48 y/o Caucasian male routine examination
• OcHx – High pressures in past exams no treatment, father (deceased) had glaucoma.
• MedHx – NIDDM – poor control of sugar, no family Hx of DM, A1C = 8.5?• V/A OD = 20/20-, OS = 20/20- with best correction
• IOP - OD = 37 mm, OS = 39 mm
• Fundi - 2+ ma’s, cotton wool, & blot hemorrhage, no IRMA or DME OU• Nerves - small, c/d OD = .4, OS = .5
• Threshold Fields – inferior nasal depression OS
• HRT – Moorfield’s analyses – outside normal limits in 4 sectors OD, normal OS
• Gonio – angles 4+ open 360 degrees OU trace tarbecular pigmentation no angle neo vascular changes
• CCT - 614 microns OD, 664 OS
• 30-2 – Inferior nasal depression - OD
Harper’s Point Eye Associates
HRTMacula
10/18/2007
Harper’s Point Eye Associates
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Harper’s Point Eye AssociatesOS
OD
Harper’s Point Eye Associates
Assessment:
• NPDMR OU
• POAG OU
• High PAK values
Plan:
• Detailed discussion of compliance
• Rx OU qpm latanoprost .005% + q12h brimonidine .1%
• RTO in 2 weeks to repeat IOP
• Schedule retinal evaluation
• Telephone internist to discuss assessment and plan
Harper’s Point Eye Associates
Visit #2 No change in ocular or medical Hx
11/2/2007
IOP – OD 25, OS 24
Assessment: reasonable progress in IOP reduction with meds
Plan: RTO 6 weeks to follow up
Harper’s Point Eye Associates
Visit #312/29/2007 11:00AM
Painful OS past 7 days with blurry vision
• V/A – OD = 20/20-, OS = 20/70 with PH
• IOP – OD = 22, OS = 45
• Conjunctiva - OS 3+ limbal injection
• OS pupil - peaked @12:00 fixed, posterior synechiae, OD = reactive
• A/C OS – 4+ cells and fibrin without PAS
Angles open 360 degrees OD & OS
• Cornea – 2+ edema with folds OS only
Harper’s Point Eye Associates
Assessment: glaucomatocyclitic crisis – OS
………………..Rule out herpetic
Plan: (in office)
Discontinue latanoprost – OSCombigan q 30 minutes OScyclogel 2% q6h OS
acetazolamide 1 X 500 mg POpred forte 1% OS q1h
Consider valtrex
Monitor IOP
Harper’s Point Eye Associates www.medscape.com
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Harper’s Point Eye Associates
2:00 PM
• V/A = unchanged
• IOP = OD – 21 mm, OS = 29 mm, posterior
synechiae broken, pupil dilated
• Patient reported pain somewhat reduced
Harper’s Point Eye Associates
New Plan
• Combigan OS 1gtt q12h
• Acetylzolamide PO 250 mg q12h
• Pred Forte 1% 1 gtt q1h OS
• Cyclogel 2% q6h OS
• RTO 24 hours
Harper’s Point Eye Associates
Visit #4 12/30/2007
“eyes feel better”
• V/A = unchanged
• IOP - OD = 22 mm, OS = 28 mm
• A/C = 3+ cells (synechia broken) pupil round & dilated
Harper’s Point Eye Associates
1/2/2008Visit #5
• V/A - unchanged
• IOP – OD = 20mm, OS = 22mm
• A/C – 2+ cells
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Discussion
• ongoing follow up & care
• acetazolamide and serum glucose ?
• methazolamide?
• inflammation and prostaglandins
• herpetic risk?
Harper’s Point Eye Associates
Case #2
Systemic Steroid Induced Glaucoma
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Harper’s Point Eye Associates
Visit #1• 2/5/2007 Routine exam 60 y/o Caucasian female• Family Hx positive POAG (sister), Meds- QD 81 mg PO
aspirin• OD = 20/25, OS = 20/25• OD = 19mm, OS = 20mm• Open angles• .35 c/d OD & OSPlan: Rx spectacles & RTO 1 year, discuss family Hx
glaucoma and early cataracts
Harper’s Point Eye Associates
Visit #21/3/2008 11:30 AM
left eye has been sore for 2 weeks and OS vision seems a little blurry
• V/A with Rx – OD = 20/25-, OS 20/30-
• IOP – OD = 40mm., OS = 66mm
• conjunctiva white OU, corneas clear
• A/C angles grade 2+ open 360 degrees OD & OS, no A/C reaction
• C/D - OD .45 OS .65
Harper’s Point Eye Associates
1/3/2008Fields
Harper’s Point Eye Associates
• Medical Hx – Fibromyalgia Dx with Tx 10 Mg PO qd prednisone ongoing, which was supposed to
be tapered & discontinued by 11/15/2007, but patient continued with pred to “feel better over the holidays.”
• Impression: IOP response (steroid induced
glaucoma) resulting from oral steroid abuse.
1/3/2008
Harper’s Point Eye Associates
• Plan: (in office)
• Combigan (timolol .5% + brimonidine 2.0%) q 30 minutes OU
• Latanoprost X 1 OU
• Acetazolamide 500 mg PO X1
• Monitor IOP
1/3/2008
Harper’s Point Eye Associates
• 12:30 PM
• IOP – OD = 20mm, OS = 23mm
• Plan: Rx qpm latanoprost OU, Combigan q12h OU, acetazolamide 250 mg PO q12h, RTO 1/4/08, 10:00 AM, call in evening to check status
1/3/2008
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Harper’s Point Eye Associates
Visit #31/4/2008 10:00 AM
patient reports “significant headache”
• IOP – OD = 18mm, OS = 20mm
• HRT3 images show possible NFL changes from baseline exam
• Threshold field depression OS>OD
Harper’s Point Eye Associates
1/3/2008
Harper’s Point Eye Associates
Assessment:
• Excellent resolution of increased IOP
• Headache from oral CAI
• Filed loss & subtle NFL changes secondary to IOP spike
Plan:
• Discontinue oral CAI
• SQ Combigan and latanoprost
• Call internist to discuss (encourage) aggressive oral steroid taper
• RTO 5 days to monitor IOP & meds
The Secret Steroid
64 year old Caucasian male
routine examination
• No family Hx of glaucoma
• Reports statins and beta blockers Tx HBP
and elevated blood lipids
• No other reported systemic problems
pertinent findings
• -5.00 OU = 20/20 OD and OS
• 4+ angles
• Full screening fields
• Small nerves with .35 c/d OU
• IOP 36 / 34
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impression and plan
• Significant IOP risk with no significant field
or nerve loss
• Rx qd prostaglandin (sample) and follow
up in 2 weeks
2 week follow up / plan
• IOP 18, 19
• Call in Rx
• Schedule 3 month follow up
3 month follow up / plan
• Drops well tolerated
• No change in health vision or medications
• IOP 41 / 46
• Add BID dorzolamide timolol (sample) and
f/u 2 weeks
2 week follow up
• IOP 18 / 21
• Call in Rx dorzolamide timolol and schedule follow up in 3 months
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3 month follow up
• No reported change in health or
medications
• IOP 35 / 38
Discussion with patient
• Review of surgical options
• Discussion of possible causes:
ie. family history, medications………
quarterly steroid injections
to treat seborrhea
• “I thought you asked “am I taking any
medicines?”
Hidden steroids
• Injections
• Nasal strays
• “soft” steroids
dermatologist
• Discontinued steroid injections……
• Added Plaquenil 200 BID………………….
Harper’s Point Eye Associates
Discussion
• Steroid response from various types of steroid administration
• “Soft” steroids
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Harper’s Point Eye Associates
Thank you!
Elliot M. Kirstein. OD. FAAO
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