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CORTICOSTEROID


Corticosteroids are the workhorses of the management of ocular inflammatory disorder. They are the most rapid & most effective ocular immunosuppressant available. Lessem et al. describe the use of split dose corticosteroid therapy for the treatment of immunoinflammatory disorders such as allergic intraocular inflammatory diseases .

Mechanism of action

The inflammatory action involves phospholipase A2 inhibitor protein which controls the release of inflammatory mediators (prostaglandins and leukotrienes) by inhibiting the release of arachidonic acid.

Corticosteroids can be used as topical, as periocular injection or systemically to treat the intraocular inflammations.

 

CORTICOSTEROID THERAPY: AT A GLANCE

Periocular steroid injections

Periocular subtenon injection of steroids provides a high concentration of the drug to the desired site of action. It is mainly useful in cases where the inflammation is not responding to topical therapy alone especially in intermediate and posterior uveitis.

Mechanism of Action:

Click here to read Mechanism of action of corticosteroid

Dosage

Periocular steroid is injected most commonly 0.5 ml of Triamcinolone (40 mg), a long acting depot preparation, in the supero-temporal quadrant by the technique described by Dr.Smith and Nozik.

Intravitreal steroid


In recent years there are several advances in the management of intraocular inflammation. One of them is intravitreal sustained drug delivery devices. Various corticosteroid agents can be effectively delivered by this approach and they have some advantages over intravitreal injections- predictable delivery to the target tissue, constant controlled release of drug for a prolonged period.

Mechanism of Action:

Click here to read Mechanism of action of corticosteroid

 

Sustained drug delivery devices

Fluocinolone acetonide sustained drug delivery devices (Retisert) releases the drug at the rate of 2 mcg/ day. Release of drug occurs through diffusion and in this way it provides necessary therapeutic drug levels. It is surgically implanted through pars plana in to the vitreous cavity. This device has a high potency similar to dexamethasone. However, recently published reports of the trials on this device have shown that they are associated with rise of intraocular pressure and cataract formation 7. Another such device is posurdex (Ozurdex). This device gradually releases 350-700 mcg of dexamethasone over a prolonged period when inserted in vitreous cavity. Unlike retisert, posurdex is biodegradable -it undergoes hydrolysis and ultimately reduces to lactic acid & glycolic acid.

 

Topical corticosteroids


Topical corticosteroids are very useful in the management of most of the anterior segment inflammations.

Mechanism of Action:

Click here to read Mechanism of action of corticosteroid

TOPICAL STEROID: Solution vs. Suspensions

Both solutions and suspensions are available for topical use.

Each steroid base (for example- prednisolone or dexamethasone) has more than one derivative or formulations (for example-acetate or alcohol preparations). The acetate and alcohol preparations form suspensions while the phosphate preparations form the solutions. It has been seen that acetate preparations are more potent than alcohols in terms of anti-inflammatory property. For example, the acetate form of prednisolone enters the aqueous fastest and has the best anti-inflammatory activity than its other formulations.
The solutions have poor penetration but cause less discomfort and there is no need to shake the vial before use. On the other hand, suspensions have better penetration but there is need to shake the vials 20-30 times to achieve adequate results of the therapy.

Important complications following topical corticosteroid therapy are increase in intraocular pressure (steroid responders), cataract formations, increased spread of infections etc. To reduce the chance of complications some advocate the use of weaker corticosteroid preparations such as rimexolone, fluorometholone and loteprednol etabonate


Systemic therapy: Oral CorticoSteroid

Oral steroids are given for systemic immunosupression and in severe ocular inflammation. Prednisolone is the most commonly used oral corticosteroid.

Mechanism of Action:

Click here to read Mechanism of action of corticosteroid

Doasge and preparations

Prednisolone acts in an hour or two and hence is the drug of choice in acute inflammation as the other immunosuppressive agents take a longer time to start their action. Oral prednisolone is used in a dose of 1-1.5 mg /kg body weight as an induction dose and based on the clinical response and the requirement of the patient it can be tapered to lesser dosage.

Pharmacokinetics:

Ideally corticosteroid should be taken as a single dose in the morning because the normal peak of corticosteroid production by the adrenal gland occurs in the morning. Also this kind of dosage schedule helps the patients to sleep better at night.

Side effects:

Systemic corticosteroids can cause a number of side effects. The most common side effects are cushingoid face, hypertension, peptic ulceration, hyperglycemia, psychosis, insomnia, osteoporosis, electrolyte imbalance. Alternate day dosage regimen is an effective strategy to reduce the side effects of the drug to some extent.

 

Systemic Therapy: Intravenous Corticosteroid

Intravenous corticosteroids are sometimes needed in patients who need aggressive management of the inflammation, as in a patient with optic nerve involvement, severe VKH, sympathetic ophthalmia, serpiginous choroiditis or in case of panuveitis. The most commonly used drug is methylprednisolone. The usual dosage is 500 mg to 1 gm intravenous infusion with 0.9% normal saline or sodium lactate solution over 30 to 60 minutes daily for 3 consecutive days, followed by high dose of oral corticosteroids. Caution should be taken as intravenous methylprednisolone can cause cardiac arrhythmias and cardiovascular collapse. Intravenous methylprednisolone should be followed by high dose oral steroid or immunosuppressive agent

Statutory Warning

Materials / Informations provided here are for educational purpose only ; and not to be used for medical advice, diagnosis or treatment