12.6  Systemic Steroids

Y (Why Have the Procedure)

“You have: Giant cell arteritis, optic neuritis, severe non-infectious uveitis, inflammatory orbit disease etc. You need to be on steroids to suppress your immune system which is contributing to this disease. If left untreated this condition can lead to vision loss or blindness.”

Aim:

  • Prevent vision loss


It is important to exclude infectious causes that may worsen if left untreated in an immunosuppressed or diabetic patient e.g. tuberculosis, syphilis, fungal infections. However, in the setting of potentially blinding conditions (e.g. GCA), do not delay initiating steroid use while awaiting tissue confirmation of diagnosis.

M (Mechanism, What is the Procedure)

“Systemic steroids can be given”:

  • “In a vein” (intravenous e.g. methylprednisolone)
  • “As tablets” (oral e.g. prednisone)


Consider additional treatment of oral proton pump inhibitor and calcium / vitamin D supplementation. Long term steroid treatment should involve collaborative care with a patient’s GP / Rheumatologist / Immunologist / Endocrinologist as appropriate.

C (Complications)

Significant systemic side effects are associated with systemic steroids and are largely dose related. Side effects / complications can be severe, especially in patients that need long term treatment:

Eye

  1. Cataract
  2. Glaucoma
  3. Central serous chorioretinopathy

Systemic

  1. Acute
    1. Immunocompromise (dependant on dose, duration and other medications)
    2. Altered mood (mania / psychosis / anxiety)
    3. Increased appetite
    4. HT
    5. Diabetes
    6. Gastritis or gastric ulcer
  2. Chronic
    1. Weight gain, cushingoid appearance (Truncal obesity, buffalo hump, “moon facies”)
    2. Osteoporosis, osteonecrosis (especially femoral head and knees)
    3. Diffuse myopathy (mainly upper and lower limbs)
    4. Growth deceleration (in children)
    5. Bruising (ecchymosis), skin thinning, hirsutism, acne
    6. Adrenal insufficiency (if rapid wean of long-term steroid)

A (Alternatives)

  1. Observation
  2. Steroid sparing agent e.g. methotrexate, azathioprine, mycophenolate, cyclosporin, cyclophosphamide, tacrolimus, biological agents. The choice of which agent to use is dependant on the patient, disease and clinician preference.
  3. Local Steroid treatment- subconjunctival, orbital floor, intravitreal

Confirm that the patient understands. Any questions?

Establish a plan for follow up and review of therapy and screening for complications.

          

All rights reserved. No part of this publication which includes all images and diagrams may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the authors, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law.

Vitreoretinal Surgery Online
This open-source textbook provides step-by-step instructions for the full spectrum of vitreoretinal surgical procedures. An international collaboration from over 90 authors worldwide, this text is rich in high quality videos and illustrations.

© 2021 WESTMEAD EYE MANUAL

Website by WebInjection