By Lisa B. Arbisser, MD
This retrospective chart review evaluated the effects of age and axial length on IOP response in patients prescribed topical corticosteroids after cataract surgery. The results indicate that younger patients with high myopia have a higher risk for postoperative steroid response after uneventful cataract surgery and may require more frequent IOP monitoring, alternative topical anti-inflammatory medications or a shorter than usual course of topical corticosteroid treatment.
Specifically, they found that those younger than 65 years with an axial length of at least 29.0 mm had a 39-fold increased risk for an IOP higher than 28 mmHg and a 35-fold increased risk for an IOP higher than 35 mmHg than did patients older than 65 years with a normal axial length.
The findings of this truly significant paper by David F. Chang, MD, will change how difficult cases are managed.
This was a retrospective review 1,642 consecutive patients from Dr. Chang's practice who had cataract surgery during a two-year period. All patients routinely received topical prednisolone acetate 1.0% postoperatively three times daily for two weeks, after which the frequency was reduced to twice daily for an additional two to three weeks. However, if a patient was a known steroid responder or was diagnosed with a steroid response in the first operative eye, topical prednisolone 1.0% was used for less than one week in the second eye or not at all. IOP was recorded preoperatively, one day postoperatively and at least one additional time in the first postoperative month while the patient was taking a topical corticosteroid agent.
The authors diagnosed 39 patients as steroid responders, which they defined as an IOP increase greater than 25 percent while on topical prednisolone (minimum 28 mmHg) followed by a decrease of more than 25 percent after use of the drug was discontinued. They did not count any IOP elevation during the first 72 hours because of the multifactorial etiology of immediate postsurgical IOP spikes. They also did not separately evaluate glaucoma history as a risk factor. However, 33 of the 39 steroid responders had no preoperative history of glaucoma or ocular hypertension.
The authors say that although the literature describes the typical steroid response as occurring after several weeks of topical therapy, six of their seven most severe responders were diagnosed between five and 14 days postoperatively, which suggests that younger myopic patients may need to be checked sooner.
The study's results also provide important information for ophthalmologists who give intravitreal and sub-Tenon's steroid injections to myopes. While previous studies have indicated that younger adult age increases the risk for steroid responsiveness after intravitreal injection, the authors believe this to be the first study to show the same association with topical therapy in a large adult population.