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   Table of Contents      
ARTICLE
Year : 1969  |  Volume : 17  |  Issue : 1  |  Page : 17-23

Effect of topical and systemic steroids on intraocular tension and aqueous outflow facility


Department of Ophthalmology, Institute of Postgraduae Medical Education and Research, Chandigarh, India

Date of Web Publication4-Jan-2008

Correspondence Address:
S D Gupta
Department of Ophthalmology, Institute of Postgraduae Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Gupta S D, Gupta J S, Gupta S B, Gopal H. Effect of topical and systemic steroids on intraocular tension and aqueous outflow facility. Indian J Ophthalmol 1969;17:17-23

How to cite this URL:
Gupta S D, Gupta J S, Gupta S B, Gopal H. Effect of topical and systemic steroids on intraocular tension and aqueous outflow facility. Indian J Ophthalmol [serial online] 1969 [cited 2020 Aug 9];17:17-23. Available from: http://www.ijo.in/text.asp?1969/17/1/17/37575

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Table 1

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Table 1

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This study is in continuation to our previous experimental study upon rabbits to produce glaucoma by administering corticosteroids, both locally as well as systemically. There was neither any significant rise of intra ocular pressure nor a fall in aqueous out flow facility in rabbits.

Now we studied the effect of corticosteroids on intra-ocular pressure and facility of aqueous out flow in human beings.


  Material And Methods Top


Eighty five cases of all age groups, who could co-operate, were included. A complete Ophthalmological check up was done to exclude ocular disease likely to affect intra-ocular pressure e.g.' uveitis, hyper mature cataract, detachment of retina etc.

The study was divided into the following groups:

Group I

Systemic steroids used in 50 patients.

Group II

Topical steroids used in 35 cases.

Subgroup (a) Control series of 15 normal volunteers.

Subgroup (b) Glaucoma series of 13 glaucoma suspects and 7 proved cases of chronic simple glaucoma.

Group I. Systemic steroid group:

This consisted of 50 patients (37 males, 13 females) of ages varying between 10 and 50 years who were either attending the medical out patients department or Rheumatoid arthritis clinic or were admitted in the medical wards. All of them got corticosteroids for more than two weeks for various diseases like rheumatoid arthritis, rheumatic fever, respiratory, neurological or cardiac conditions or skin diseases. Patients were questioned for any pain in the eyes, defective vision or haloes around light during the period of steroid therapy. Gonioscopy, tonometry and Blaxter bulbar pressure test were done in each case before starting steroids as well as at the termination of therapy.

Group II. Topical steroid group:

This was further divided into two sub-groups as follows:

Sub group (a) control series. This comprised of 15 patients attending the eye out door for conditions like refractive error, allergic conjunctivitis and blepharitis. Gonioscopy, tonometry and Blaxter bulbar pressure test were done in each case before the start of treatment with hydrocortisone acetate eye drops 1 per cent (Efcorlin Glaxo preparation) four times a day in one eye only, the other eye being kept as control. During this therapy weekly examination, including tonometry and Blaxter bulbar pressure test, was carried out for at least three weeks.

Sub-group (b) Glaucoma series. This comprised of twenty patients out of which 13 were glaucoma suspects having either Prodromal symptoms like discomfort or heaviness in eyes, colored haloes around light, difficulty in work during night or occasional mild headaches or by routine tonometry, tension being between 20 and 25 mm Hg. Three of them gave a family history of glaucoma. The other seven cases were proved cases of chronic simple glaucoma with elevated tension, field defects and open angle on gonioscopy. All these cases were put on Efcorlin eye drops 1 per cent four times a day in one eye only. Tonometry and Blaxter bulbar pressure test were performed in each case every week for at least 4 weeks.

The same Schiotz tonometer was used throughout this study. Width of the angle of the anterior chamber was graded according o SCHEIE'S classification. Facility of aqueous out flow was measured by Blaxter bulbar pressure test.


  Observations Top


Group I. Systemic steroids [Table - 1].

Patients ranged in the age group between 13 and 70 years, with a male and female ratio approximately 3:1. The dosage schedule is given below.

Prednisolone Dosage:

Less than 500 mg

(min. 140 mg.)- 4 cases

Between 501 and 1000 mg - 27 cases

Between 1001 and 2000 mg- 11 cases

Between 1001 and 2000 mg- 11 cases

Over 2000 mg (max. 3175 mg)- 3 cases

Incalculable dose- 5 cases

Duration of Prednisolone intake

Between 17 days and 3 weeks - 3 cases

Between 3 weeks and 4weeks- 10 cases

Between 4 weeks and 5 weeks - 6 cases

Between 4 weeks and 6 weeks- 4 cases

Between 6 weeks and 12 weeks- 11 cases

Between 12 weeks and 24 weeks- 5 cases

Over six months (max.1642 days)- 6 cases

The maximum intraocular pressure recorded in this series was 18 mm Hg and the average was 13.9 mm Hg In no case the difference between the initial and final readings, where more than one readings were taken, was more than 2 mm Hg.

Apart from the first case where the outflow facility fell from 35.5 per cent R. E. and 29. 3 per cent L. E. to 31.9 per cent and 21.2 per cent respectively 12 days after the initial examination (total dose of prednisolone 670 mg) no other case showed any significant fall in outflow facility. Inspite of this fall in out-flow in the first case, the intraocular pressure was only 11 mm Hg in each eye. There was no evidence of glaucoma in any eye in this series of 50 cases.

Group II. Topical steroids.

Sub group (a) Normal volunteers. This included 15 cases - 12 males and 3 females, in the age group ranging between 14 to 40 years. Eleven patients had wide open angles and 4 had grade I type open angle on gonioscopy. No case showed any significant difference between presteroid and post steroid measurements of intraocular pressure or outflow fraction [Table - 1].

Sub-group (b) Glaucoma suspect and chronic simple glaucoma cases [[Table - 2] see next page).

All the 20 cases, ranging between 30 and 67 years of age, used hydrocortisone acetate 1 per cent (Efcorlin) eye drops for 17 days to 2 months. On gonioscopy the angle was found open (wide open to grade II) in all the cases. Out of the 13 cases suspected of glaucoma 5 revealed an increase of intraocular tension from presteroid mean value of 19.6 mm to 23 mm Hg mean value after steroid therapy. There was a corresponding decrease in the outflow fraction from a mean presteroid value of 29.72 per cent to a mean value of 27.40 per cent. Two of these cases (case Nos. 4 and 5) had family history of glaucoma. Case No. 6 also had a family history of glaucoma but he did not show any rise in intraocular pressure following cortisone therapy though there was a fall in outflow fraction in the E. (Steroid treated) from 30.3 per cent to 28.5 per cent [Table - 3].

All cases of chronic simple glaucoma except one (case No. 2) showed a rise in intraocular pressure from a mean presteroid value of 22 mm Hg to a mean value of 27.5 mm Hg and a corresponding fall in out-flow fraction from a mean presteroid value of 25.87 per cent to 21.41 per cent [Table - 3]. Four of the 7 cases were using pilocarpine drops for medical control of glaucoma during this study. Case No. 17 [Table - 2] showed a marked rise in intraocular pressure in the right eye from 22 to 32 mm Hg with a fall in out flow fraction from 27.2 per cent to 20.5 per cent while hydrocortisone drops were used in the left eye and stopped in the other eye. Now, there was a rise of intraocular pressure on the left side from 21 to 30.5 mm Hg with a fall in outflow facility from 26.8 to 22.6 per cent in a period of 28 days and the tension in the right eye had come to normal and was thus maintained.


  Discussion Top


This study comprised of 85 patients who were examined for any change in intra-ocular pressure and aqueous outflow facility during corticosteroid therapy. The systemic steroid group, including 50 patients of all age groups (average about 35 years) getting prednisolone for various disease entities, unlikely to affect the intraocular pressure as such, revealed neither rise in pressure nor fall in out-flow facility. The drug was administered for a period of 17 days to six months in total dosage varying from 140 mgm to 3175 mgm. Thus our findings are in agreement with other workers like TILLET,[9] LEE[6] and BLACK, OGLESBY, SALMANN AND BUNIM.[5]

BECKER AND MILLS[4] reported that at least 30 per cent of normal volunteers showed rise in intraocular pressure after two months of topical steroids, while similar doses of steroids were given to siblings of patients having glaucoma, approximately 75 per cent had marked or moderate elevations of intraocular pressure. According to ARMALY[1] there are three distinct and statistically different levels of response to identical concentration, frequency and duration of topical application of dexamethasone in clinically normal eyes, with no family history of glaucoma: low (5 mm Hg. or less), intermediate (6 to 15 mm Hg) and high (16 mm Hg or more). In the present study, however, none of the fifteen volunteers (average age 27.9 years) getting topical steroids in one eye showed any rise in intraocular pressure or fall in outflow facility. Five out of 13 cases (38.5 per cent) suspected of glaucoma showed an increase in intraocular pressure (low response) two of these cases had positive family history of glaucoma, while 6 out of 7 cases of established glaucoma (85.7 per cent) showed a definite rise in intraocular pressure, five had low response and one had intermediate response. The rise in intraocular pressure was reversible after withdrawal of steroids. In all our positive cases there was a corresponding fall in aqueous outflow fraction but one case suspected of glaucoma having positive family history showed a slight fall in outflow fraction without any accompanying rise in intraocular pressure.

In this study, thus, there was a definite rise in intraocular pressure with topical steroids in cases of chronic simple glaucoma which lends support to the hypothesis of BALLINTINE' that the main effect of steroid was to increase the rate of production of aqueous humor and the compensatory response to the increased rate of production of aqueous humour and the compensatory response to the increased rate of production was either adequate, or moderately or greatly impaired so that the administration of a steroid is in effect a sort of chronic water drinking test.


  Summary Top


A clinical study of 85 patients showing the effect of corticosteroids on intraocular pressure and facility of aqueous outflow is presented. There was no rise of pressure or a fall in aqueous outflow in patients getting systemic steroids, dosage varying from 140 mgm to 3175 mg for a period of 17 days to six months. Among the topical steroid group fifteen normal volunteers revealed no significant change but 38.5 per cent cases of suspected glaucoma and 85.7 per cent cases of established glaucoma showed a mean rise of 4.62 mm Hg. in intraocular pressure and a mean fall of 3.36 per cent in outflow facility. One case of proved glaucoma had a marked rise in intraocular pressure (10 nmm Hg) and a corresponding fall in outflow fraction after topical steroid therapy in each eye. In one case of suspected glaucoma there was a slight fall in outflow fraction but no rise in intraocular pressure.

 
  References Top

1.
ARMALY, M. F., (1965): Invest. Ophth., 4: 187.  Back to cited text no. 1
    
2.
BALLINTINE, E. J. (1966): A,M.A. Arch. Ophth., 75: 134.  Back to cited text no. 2
    
3.
BECKER, B. (1965): Invest. Ophth., 4: 198.  Back to cited text no. 3
    
4.
4 BECKER, B. AND MILLS, D. W.(1963): A.M.A. Arch. Ophth., 70: 500.  Back to cited text no. 4
    
5.
BLACK, R. L., OGLESBY, R. B..SALLMANN, L., VON and BUNIM, ff. (1960): J. Amer. .vied. Assoc., 174: 166.  Back to cited text no. 5
    
6.
LEE, P. F., (1958): Amer, J. Ophth., 46: 328.  Back to cited text no. 6
    
7.
MILLER, D., PECZON, J. D., and WHITEWORTH, C. G. (1965): Amer. J. Ophth., 59: 31.  Back to cited text no. 7
    
8.
8. NICHOLAS, J. P. (1964): A.M.A. Arch. Ophth., 72: 189.  Back to cited text no. 8
    
9.
9. TILLET, C. M. (1952): Amer. (. Ophth., 35: 659,  Back to cited text no. 9
    



 
 
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  [Table - 1], [Table - 2], [Table - 3], [Table - 4]



 

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