Topical steroid eye drops have been used for years to calm ocular infections and inflammation, and they are the holy grail when it comes to quelling inflammation. No antibiotic, artificial tear, or prescription medication comes close to having the anti-inflammatory effects of steroids, which is why they are so useful for eyecare.
However, steroid eye drops do come with side effects, meaning that we must ensure that they’re used carefully and with caution. Of course, there are many cases where the benefits in the use of steroids far outweigh the risks of using them, and this risk-benefit ratio is something optometrists and ophthalmologists must always keep in mind.
Steroids work so well for fighting inflammation because they disrupt the inflammatory cascade by disarming arachidonic acid, downregulating many of the inflammatory pathways, stabilizing mast cells and cell membranes in general, inhibiting white blood cells, and slowing the rate that blood cells move through capillaries during an inflammatory episode. Basically, this calms the swelling, redness, pain, and heat that comes with the inflammatory cascade.
The effects of steroids are widespread, even in the eye care industry, and include regulation of apoptosis (cell death), oxidative stress, and the formation of new blood vessels, all of which can be extremely useful for the eyes.
But as discussed already, steroids do not come without side effects, and these side effects can be systemic as well as ocular, depending on the dosage.For use on many ocular conditions, short-term use of steroids has minimal risks and loads of benefits. Side effects from long-term use, however, must be weighed, and the type of steroid to use must be considered.The great thing about ocular topical steroids is that they are potent and effective... yet the side effects cannot be ignored.
A clouding of the natural lens within the eye, behind the iris and pupil, is known as a cataract. Often found in those over the age of 40, Prevent Blindness America reports that cataracts are diagnosed more often worldwide than diabetic retinopathy, glaucoma, and macular degeneration combined. They are so common that over 22 million Americans suffer from cataracts, from mild to severe.
There are three main types of cataracts. Nuclear sclerotic cataracts are the most common, and the usual cause for these is aging. This form is found in the central area of the lens, known as the nucleus, and they often give you a yellow or overall blurry view of the world.
Cortical cataracts usually begin in the outer periphery (or outer edge) of the lens and look like white wedge-like bicycle spokes. As they progress, the spokes widen until they completely overtake the central vision as well. These are found on the cortex of the lens, or the area surrounding the nucleus.
Subcapsular cataracts commonly occur at the back of the lens (a posterior subcapsular cataract), and these are often the result of steroid use - ocular, nasal, or systemic. These are the form of cataracts that we will focus on for this article.
The eye’s lens is primarily protein and water with the protein precisely arranged to keep vision clear, allowing light to pass through the lens. But as you age, the protein begins to clump and bind together, forming a cataract over time. As they grow, vision becomes cloudy and it becomes more difficult to focus. Vision with cataracts is similar to looking through a dirty windshield!
It is not entirely known why certain ocular steroids contribute to cataract formation, and systemic steroids are much more likely to be an issue. Causes could include the steroid binding to lens proteins, elevation of sugar in the fluid in front of the lens, and inhibition of lens fluid pumps. However, it is known that the topical steroids more likely to cause these changes include those which penetrate further through the eye. These include dexamethasone and prednisolone acetate. “Soft” steroids, which do not penetrate as deeply, are often safer to use long term, and the most common is loteprednol.
An increase in intraocular pressure (IOP) is a very well known side effect of topical steroids. This side effect is more common with topical preparations than with oral or steroids administered through other routes. The good news is that this side effect definitely doesn’t occur for everyone and most eye doctors all well versed in watching for IOP elevation in their steroid patients.
Steroid induced IOP elevation almost never occurs within the first two weeks of steroid use, and if it happens it will occur any time between 3 weeks and years. It is estimated that between 18-36% of the population are steroid responders. However, once the steroid is removed and you’re no longer taking it, IOP will return to baseline rather quickly.
This is a side effect that can be easily managed by your doctor, but they can’t ignore it. If left untreated, high IOP can lead to glaucoma over time. Glaucoma results in a gradual loss of peripheral vision, where you may or may not notice vision loss out to the side until the glaucoma has progressed quite far. With glaucoma, high IOP effectively squeezes the optic nerve in the back of the eye, killing off nerve fibers and causing vision loss.
Glaucoma can be a devastating disease, but with the correct use of steroids and the correct steroids used, we’re less likely to see this issue. The largest offender for inducing a steroid response is dexamethasone, and it’s much less likely to occur with fluorometholones and loteprednol.
Ocular steroids have a wide variety of uses, but there are certain conditions that must be avoided. The most prominent of these is herpetic lesions of the eye. If your doctor has diagnosed you with a herpes dendritic lesion on your cornea, steroids can actually cause this infection to worsen quickly.
In addition to this, if you have ever had a herpes lesion on your eye, there is a small chance that your infection could return after having used topical steroids. This is definitely something to mention to your doctor, especially if you’re seeing someone new.
In most cases, doctors are very aware of the corneal condition and what it should be treated with. By avoiding steroids in these patients, or using a prophylactic medication to cover against secondary infection, this side effect can be avoided.
Although less common, this is another side effect of steroids. Topical steroids can inhibit the healing of some epithelial and stromal corneal conditions. However, where steroids are necessary and unavoidable, it is acceptable for you to be given artificial tears for use along with the steroids as a way to prevent any issues.
Although it was thought in the past that topical steroids might delay the healing of corneal bacterial ulcers, this has since been found false and steroids sometimes have major benefits for this. The Steroids for Corneal Ulcers Trial (SCUT) showed that steroids weren’t associated with more complications when used on corneal ulcers. However, they didn’t find a huge benefit, either, aside from use on some central and severe ulcers.The main point here is that this is not something to worry too much about with mild steroid use, as your doctor will continually monitor you for this side effect.
This is a super common side effect of steroid eye drops, along with many other eye drops. The more concentrated the drop, the more it will sting as well (meaning, if you’re on a stronger steroid for something like uveitis, it’s going to burn!!)
Steroid eye drops will burn no matter what because they’re penetrating inside of the eye, in many cases. For those of you with loads of inflammation (red, irritated, sore eyes), this side effect is going to be worse and may even keep you from using certain eye drops. However, do note that as the inflammation heals (which the steroids help with) you will notice less burning and stinging after putting them in.
Common with many eye drops, steroid eye drops will give you temporary blurred vision after instilling them into your eyes. This is common with many eye drops, especially thicker ones, because they spread over the front of the eye, creating a new layer of liquid you have to look through. If this an ointment or gel, or a liquid steroid that is white in color, you can expect blurred vision for up to 30 minutes (in some cases). For thinner drops, a few minutes is common.
This common side effect is nothing to worry about and is not permanent. To quell this effect, we recommend instilling the drops and then closing your eyes for a few minutes to let the medication do its job.
This one makes the list, but this side effect can happen due to any medication, food, or other substance at any time. Put simply, your body can react to anything at any time. Reactions to the actual corticosteroid substance in the medication is rare, however it is possible. More common are reactions to the preservatives and other chemicals that are sometimes found in steroids and other eye drops.
Preventing an allergic reaction is as simple as knowing what you’re sensitive to (preservatives included) and avoiding them. Although you can’t always avoid every reaction, this is the simplest way. In addition to this, fighting a reaction to the medication is as simple as discontinuation of the steroid eye drop right when you notice a reaction. As with any medication, make sure to discuss any side effects you notice with your doctor. Some may be avoidable and others will merely need to be monitored closely.
Typical conditions where steroids are used for the front of the eye include dry eye disease, some forms of conjunctivitis, chalazia, and some corneal ulcers. Although steroid use in dry eye disease is controversial, steroids can be a powerful and effective way to decrease inflammatory episodes and flare ups. When used correctly, and for short periods of time, steroids can be an effective way to calm periodic dry eye episodes that occur due to allergies, traveling, infections, or other irritants in the environment.
Steroids are also used often by optometrists and ophthalmologists before beginning therapy with Restasis (cyclosporine) eye drops. The thought is that, if the steroid can help calm the eyes, Restasis also has a good chance of doing so.
Many doctors will begin steroid eye drops a few days or weeks prior to cataract surgery (and other forms) because it prepares the eye for surgery by downregulating the inflammatory cycle. If you’ve got dry eyes or blepharitis, the last thing a surgeon wants to deal with is extra bacteria and inflammation hanging around on your eyes. It just puts you at more risk of complications later.
In addition to this, one of the most common uses of steroids is post-surgery. Whether you had cataract surgery, glaucoma surgery, surgery on your retina, or LASIK, you’ll be heading home with topical steroids. It is known that some people end up with more inflammation post-surgery than others, but there’s no way to know who will respond this way. Because of this, everyone goes home with them!
Uveitis is technically an inflammation of the uvea of the eye, which makes up the iris, choroid, and ciliary body. Basically, you can have inflammation inside the eye that either affects the front chamber of the eye (like the iris) or the posterior chamber (the choroid). In both conditions, topical steroids are warranted, and you’ll be using them often (think at least every hour to begin with!) In some cases of posterior uveitis, systemic steroids or implantable steroids may be used.
Uveitis can be incredibly damaging to the vision if not treated completely, and steroids normally get the job done. However, with the increased frequency and dosing that is used, side effects are more common for those using topical steroids (and any other form of steroids) for uveitis treatment. Your healthcare professional will be following you every few days, however, so if you notice any side effects, checking with your doctor is best.
When using steroid eye drops, you should always make sure to closely follow the instructions of your doctor. Their dosing is specific to your condition and is tailored for you to prevent side effects while healing inflammation quickly. Make sure to wash your hands before handling the eye drop bottle. It may be kept at room temperature unless otherwise noted.
Once you’ve instilled the eye drop, keep the eyes tightly closed in order to prevent spill-over onto your cheeks, and to ensure the medication stays in the eyes. The drops will burn and blur your vision slightly anyway, so it’s best to just keep those eyes closed! After using the medication, make sure to report side effects to your eye doctor or pharmacist. They may have tips for you or suggestions for how to decrease the particular effect.
Have you ever used steroid eye drops? What side effects did you notice? Let us know in the comments below!