Pattern of steroid misuse in vernal keratoconjunctivitis resulting in steroid induced glaucoma and visual disability in Indian rural population: An important public health problem in pediatric age group

Abstract

Purpose:To know the pattern of presentations and management outcome of steroid induced glaucoma in vernal keratoconjunctivitis (VKC).Methods:Children of VKC using steroid with two of the following criteria were enrolled: Intraocular pressure (IOP) >21 mm Hg, glaucomatous optic disc and visual field defects. Misused topical steroids were classified in 4 groups; A- Highly potent drugs (dexamethasone, betamethasone), B- Moderate (prednisolone), C- Weak (loteprednol, fluorometholone), D- Unknown drugs. Active/conservative interventions were done to control IOP. Corrected distance visual acuity (CDVA), IOP, anterior segment and fundus examinations were noted. One-way ANOVA test and post hoc Tukey HSD test were used to compare the groups.Results:Out of 1423 VKC patients, 240 were using topical steroid without prescriptions. 92 eyes of 47 patients had steroid induced glaucoma. Hence prevalence of this complication was 3.30% in this study population. Mean age was 14.1 ± 3.8 years. Mean IOP was 38 ± 12 mm of Hg and mean vertical cup disc ratio was 0.67 ± 0.25. IOP was controlled by withdrawal of steroids (9 eyes), with antiglaucoma medications (27), trabeculectomy (57) and glaucoma drainage device (1). Mean CDVA at presentation was better in group C (0.23 log MAR). Mean IOP was highest in group A (43.1 mm Hg) followed by group D (40.5 mm Hg). At presentation 17 were blind (CDVA <3/60). Post treatment marginal improvement in CDVA was found (P = 0.46). However, statistically significantly improvement was noticed in IOP (P < 0.00001).Conclusion:Injudicious use of steroids leads to vision threatening complications like ocular hypertension and glaucoma in children of VKC. Weak steroids like loteprednol or fluorometholone should be used instead of higher potency drugs. Vision and IOP should be monitored fortnightly in children using topical steroids to detect steroid responders at the earliest.

Abuse of topical steroids in VKC resulting in steroid induced glaucoma in paediatric age group

“…In our study the prevalence is around 4.16%. 5 Marcuss ang et al, in their study showed 41(28.3%) out of 145 patients developed ocular hypertension in which 8(5.5%) patients progressed to glaucoma. 5 Corticosteroid induced IOP elevation is an iatrogenic condition caused by decreased trabecular outflow, usually reversible if the steroid therapy is discontinued earlier but when unrecognised causes primary open angle glaucoma, ultimately leading to glaucomatous optic atrophy which is irreversible.…”

“…Usually prescribed by pharmacy, general practitioners and quacks without the knowledge of its complications. 5 Vision loss resulting from cataract is reversible and relatively easy to manage but glaucoma is often recognised late leaving patients with permanent visual impairment. 6 Current therapy of ocular allergy involves elimination of the offending allergen, modulation of the immune system, and pharmacologic inhibition of the chemical mediators and rebamipide can be effective in VKC with giant papillae not responding to topical steroid.…”

Phase 3 Randomized Study of Efficacy and Safety of a Dexamethasone Intracanalicular Insert in Patients With Allergic Conjunctivitis

“…43,44 In addition, difficulties with drop administration technique (bottle tip contamination, failure to wash hands before eye drop instillation, and frequent hand-to-face contact during instillation) all lead to an increased risk of infections or injury. 42 Conversely, steroid eye drops can also be overused, either intentionally because they provide good symptomatic relief 45 or unintentionally because of the difficulty instilling a single drop. 44 In either case, overuse can lead to steroid-induced glaucoma and cataract.…”

Commentary: Blindness from glaucoma associated with steroid abuse in children

“…Low prevalence of steroid-induced glaucoma in the population would imply that it may not qualify to be a crucial public health issue to attract allocation of resources to plan preventive measures. However, a high incidence of glaucoma with insidious blindness and late presentation as in the study reported by Sen et al [10] in children using steroids would result in a significant proportion of blind years in those affected and care provider burden. There is no information of the direct economic impact of steroid-induced glaucoma and blindness in children, while childhood blindness accounted for close to USD 22.2 billion[11] cumulative loss over a lifetime in India in 1997.…”

“…Studies[39] in the recent past have highlighted the significant role played by injudicious use of corticosteroids in children, especially vernal keratoconjunctivitis, with a considerable proportion of those with acquired childhood glaucoma to be because of steroid induced. Sen et al [10] have studied the prevalence of steroid-induced glaucoma in a large cohort of children with vernal keratoconjuctivitis. In total, 15% of the children in their study have been using topical steroids for therapy without physician prescriptions and a little more than 3% of the children had steroid-induced glaucoma.…”