Year : 1985 | Volume
: 33 | Issue : 1 | Page : 33--35
Dry eyes : A late effect of topical steroids
IS Jain, SL Bansal, Amod Gupta, K Vishwanath
Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
I S Jain
Dept. of Ophthalmology, P.G.L. Chandigarh-160012
|How to cite this article:|
Jain I S, Bansal S L, Gupta A, Vishwanath K. Dry eyes : A late effect of topical steroids.Indian J Ophthalmol 1985;33:33-35
|How to cite this URL:|
Jain I S, Bansal S L, Gupta A, Vishwanath K. Dry eyes : A late effect of topical steroids. Indian J Ophthalmol [serial online] 1985 [cited 2021 Jan 18 ];33:33-35
Available from: https://www.ijo.in/text.asp?1985/33/1/33/27328
Dry eye syndromes are being increasingly recognised as iatrogenic in origin. Apart from radiotherapy, severe allergic reactions to drugs like sulphonamides, barbiturates and phenylbutazone consumed systemically can lead to `dry eye' of varying severity. Topical drugs for the eye e.g. β-blockers and some preservatives used in ocular collyria are also reported to lead to dry eyes. Contact lenses are another cause for the same .
Over the past few months, one of us (ISJ) bad observed a condition of dry eye occurring in patients of vernal conjunctivitis and over a period of observation. It was seen that only the cases treated with topical steroids had this complication. This made us suspect that steroids could possibly be the offenders. Then onwards we started assessing the tear secretion in cases who had been on topical steroids for any ocular disease. To our surprise, we found some seriously low readings after prolonged topical steroid therapy.
MATERIALS AND METHODS
Patients on topical steroid therapy presenting to us after June, 1981 form the material of this report. In all cases the steroid brand used was recorded alongwith the frequency and duration of usage. In patients, who used the drops intermittently, the total steroid was summed up if the interval was not more than a month at any stage. Following patients were excluded from the study :
(i) In whom a dry eye could have been maltreated /worsened by steroids.
(ii) With a diagnosis of Sjogren's syndrome, Steven-Johnson syndrome, severe trachoma and hypovitaminosis A.
(iii) Who used steroids for less than a month.
Other drugs used topically alongwith the steroids were also recorded. The included patients were subjected to Schirmer's test, basic tear secretion test, tear film break up time and an assessment of the tear strip at lower lid margin. The doubtful cases were subjected to Rose Bengal staining and the patients with severe symptoms were undertaken for fluorescein staining to exclude/con firm the punctuate epitheliopathy. The patients were classified into three groups :
(i) with Schirmer test reading of less than 6 mm. This cut-off value is according to the previously published reports,..
(ii) with readings of 6-10 mm.
(iii) (iii) with readings of 11-15 mm.
The first two groups of patients were put on normal saline or methylcellulose 0.5% drops and if possible, steroids were reduced, diluted or stopped. The tear strip was graded arbitrarily as poor, fair or good.
Most of the clinically suspected cases had reduced tear secretions. We did not think ii important to take the total number of case! which we tried to assess because to give conclusions regarding incidence etc., a prospective study with a baseline assessment i., essential. Such a study is underway with us.
During the present study. we found that there was no significant differences between Schirmer test I and basic tear secretion and also that break-up time estimation of the tear film was not dependable. This is so firstly because BUT readings are not reproducible and secondly even in cases with severely dry eyes (Schirmer test readings of less than 5 mm), it was well within the normal range. Both these findings have been already confirmed,.
However, we found a good relation between the dryness of eyes and the tear strip at lower lid margins. For these reasons, we have not considered Schirmer's test II readings and BUT estimation in tabulating the findings.
A total of 40 eyes (20 patients) fall into either of the three categories. The age and sex, steroid brand used, duration and frequency of use, Schirmer test readings (mean of at least 3 readings), tear strip grade, other drugs used topically, other steroid stigmata and response to artificial tears of the patients are given in the table. It was found that 12 eyes (30%) had their Schirmer readings below the cut-off value following the use of topical steroids. Another 20 eyes (50%) were suspiciously dry whereas the rest eight were relatively unaffected.
Interestingly enough out of the 12 severely affected eyes, five had other stigmata of prolonged topical steroid therapy eg. ocular hypertension, cataract, keratopathy etc. Conversely, out of eight eyes with steroid stigmata, 5 had severely affected tear secretion. Most of the patients with Schirmer readings of less than 10 mm. showed a moderate to marked subjective relief with artificial tear drops.
No patient in this series used such other drugs as could effect the tear secretion. A check on the preservatives of the steroid or other drops used by these patients showed that they had thiomersal, phenylmercuric nitrate, phenylethyl alcohol, phenyl hydroxybenzoate and Sodium pentachloraphenate but none had benzalkonium chloride.
One of the patients was advised by the treating surgeon to use drops only for the left eye but she continued using for both the eyes and hence the affected tear secretion in both the eyes. The beneficial response to tear drops was marked in 50%, moderate in 30% and mild in 20% of the cases.
Topical steroid therapy is well known to cause ocular hypertension or glaucoma, cataracts, perpetuation/worsening of herpetic corneal disease and precipitation of secondary fungal infection on viral or bacterial corneal ulcers. We happen to have seen three cases of fungal corneal ulcers occurring in recent aphakes who used topical steroids indiscriminately. The uncommon and innocuous side effects of topical steroids mentioned include a mild ptosis or mydriasis.
Our suspicion of a dry eye syndrome occurring with topical steroid therapy arises from clinical observation alone. In the past we have been seeing 15 patients of dry eyes in the age range of 19-74 years (average 40.4 years) in one year. But now the number of such patients has increased considerably so that we saw more than 20 cases in a period of 6 months. The age range in this series is 8-65 years. (average 31.9 years). If at all, age has an effect on tear secretion; it should have led to a lesser number of dry eyes in the present group. Iatrogenesis appears to be playing a significant role in the causation of dry eyes. Out of the 40 eyes examined, 12 (30%) were definitely dry eyes, whereas another 20 eyes (50%) had significantly low Schirmer test readings. Leaving aside the eyes with readings of more than 5 mm, 30% is a significant number to make us look into the problem seriously.
Benzalkonium, the preservative used in ocular collyria has been blamed to affect precorneal tear film adversely, but such an effect is insignificant considering the low concentrations of the preservative used7. However, none of our patients had Benzalkonium, as the preservative even in other drugs used by them topically.
An occurrence of dry eye syndrome after the use of topical steroids when other offending drugs and diseases have been excluded is a significant finding. The greater severity of dryness co-existent with other steroid stigmata only makes it more authentic. As yet, we don't know how steroids lead to dry eyes. But it is worth to have a baseline assessment of tear secretion before any patient is put on topical steroids and to use dilute steroids as and when possible.
Tear secretion was assessed on patients on prolonged topical steroid therapy. 30% of patients had significant tear deficiency. A further investigation seems to be desirable in this direction.
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