Steroids - Feast or Famine
4/18/2019
Steroids Feast or Famine ?
Elliot M. Kirstein, OD, FAAO
Harper's Point Eye Associates
Cincinnati, Ohio
Harper's Point Eye Associates
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Financial Interests
? Alcon ? speakers alliance ? Optovue ? speakers alliance ? Reichert ? speakers alliance ? Aerie ? speakers alliance ? Haag Streit - speakers alliance
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? History of steroids ? Benefits ? Risks ? Systemic application ? Ocular application ? Cases
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Agenda
History
? The discovery of the class of corticosteroid called glucocorticoids began in the 1920's.
? In the 1920's, rheumatoid arthritis and other arthritidies were thought to have an infectious cause.
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? By 1938, Dr. Philip Hench from the Mayo rheumatic disease service, noticed a 65yo doctor with arthritis that improved the day after becoming jaundiced.
? He later noted 31 other cases of joint pain resolving, to some extent, with pregnancy, infections, and post-surgically
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? The scientific community then abandoned the infectious theory and started to look at the adrenal glands -- substance X
? Multiple compounds were isolated from animal adrenals.
? Compound `E' seemed to work particularly well in animals.
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? World War II was progress, and so money was lacking, which left them frustrated.
? Merck gave multiple researchers around the world the remaining 9 grams of compound `E' ? [make it work or drop this idea]
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? In September 1948, they injected their first human patient.
? A 29-yo female with severe, erosive arthritis that was chair-bound (unable to ambulate)
? After 4 days post-injection of compound E, she was able to walk out of the hospital.
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In 1950, Dr. Philip Showalter Hench won the Nobel Prize in Medicine.
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Medical conditions treated with systemic corticosteroids
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Allergy and respirology medicine
Applications
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Asthma (severe exacerbations)
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Chronic obstructive pulmonary disease (COPD)
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Allergic rhinitis
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Interstitial lung disease
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Atopic dermatitis
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Dermatology
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Hives
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Pemphigus vulgaris
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Angioedema
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Contact dermatitis
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Anaphylaxis
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Endocrinology (usually at physiologic doses)
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Food allergies
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Addison's disease
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Drug allergies
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Adrenal insufficiency
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Nasal polyps
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Congenital adrenal hyperplasia
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Hypersensitivity pneumonitis
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Gastroenterology
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Sarcoidosis
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Ulcerative colitis
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Eosinophilic pneumonia
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Crohn's disease
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Some other types of pneumonia treatment protocols
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Autoimmune hepatitis
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Interstitial lung disease
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Hematology
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Dermatology
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Lymphoma
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Pemphigus vulgaris
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Leukemia
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Contact dermatitis
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Hemolytic anemia
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Endocrinology (usually at physiologic doses)
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Idiopathic thrombocytopenic purpura
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Addison's disease
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Multiple Myeloma
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Adrenal insufficiency
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Rheumatology/Immunology
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Nephrotic syndrome
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Rheumatoid arthritiseas
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Chronic hepatitis (flare ups)
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Systemic lupus erythematosus
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Cerebral edema
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IgG4-related disease
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Polymyalgia rheumatica
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Polymyositis
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Prostate cancer
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Tendinosis
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Dermatomyositis
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Polyarteritis
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Lichen planus
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Vasculitis
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Ophthalmology
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Uveitis
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Keratoconjunctivitis
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Other conditions
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Multiple sclerosis
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Organ transplantation
Congenital adrenal hyperplasia Gastroenterology Ulcerative colitis Crohn's disease Autoimmune hepatitis Hematology Lymphoma Leukemia Hemolytic anemia Idiopathic thrombocytopenic purpura Multiple Myeloma Rheumatology/Immunology Rheumatoid arthritiseas Systemic lupus erythematosus Polymyalgia rheumatica Polymyositis Dermatomyositis Polyarteritis Vasculitis Ophthalmology Uveitis Keratoconjunctivitis Other conditions Multiple sclerosis Organ transplantation Nephrotic syndrome Chronic hepatitis (flare ups) Cerebral edema IgG4-related disease Prostate cancer Tendinosis Lichen planus
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Steroids in Medical Therapy
? A foundational element in most medical therapies is the control of inflammation.
? Inflammation causes harm to tissues and keeping it at bay reduces scarring and loss of function.
? Reducing inflammation reduces patient symptoms.
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Ophthalmic Applications
? Allergy ? Infection ? Dry Eye ? Keratitis ? Injury ? Uveitis ? Peri operative
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Ophthalmic Steroids
? Under prescribed ? Under dosed
Artificial tears and the "Ivory Tower"
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Steroids and the Robo Doc The Play
by Elliot M. Kirstein, OD, FAAO
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ACT I
"My eyes are so dry that I want to tear them out!"
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ACT II
This scratch on my eye is killing me!
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ACT III
Dr., my eyes are on fire!
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Steroid Risks
? Increased IOP ? Immunosuppression ? Cataractogenesis
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Think about it........
If a person is uncomfortable enough to schedule a doctors appointment, they must be very uncomfortable. They are seeking immediate relief.
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What kind of dummy
would bring a knife to a gunfight?
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What `s the difference?
? Flourometholone .1% (FML) ? surface applications, less IOP effect, poor penetration
? Loteprednol (Lotemax) ? surface and internal applications, less IOP effect
? Prednisolone Acetate 1% (Pred Forte) ? surface and internal applications , more IOP effect
? Difluprednate (Durezol) - surface and internal applications , most powerful (2x pred), most IOP effect
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Ocular Allergy
? They've tried "Visene" ? They've tried "tears" ? They've tried Zyrtec, Benadryl.....
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Consider:
Ocular Allergy Therapy
? mast cell / antihistamine drop *** ? systemic OTC ? fluoromethalone or loteprednol q4h *** ? topical cortisone 1% with lid involvement ? Med?Pak for severe / seborrhea
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Infection
? Bacterial conjunctivitis / keratitis is rare ? Most are viral / inflammatory
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Harper's Point Eye Associates
It all started here ? "Blephamide" circa 1974
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Keratitis
? Cover with antibiotic ? Sooth with tears ? Treat with steroids
Keratitis
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Harper's Point Eye Associates
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Sterile infiltrate or infectious ulcer?
staph exotoxin
? An exotoxin is a toxin secreted by bacteria.
? An exotoxin can cause damage to the host by destroying cells or disrupting normal cellular metabolism. They are highly potent and can cause major damage to the host.
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? antibiotic ? steroid ? q3h first day ? follow with q4h x 6 days ? Consider lid therapy ? Counsel ? extended wear ? Discard ? case and lens ? Suggest ? daily lens
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Marginal "ulcer"
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Epithelial Herpes Simplex primary
? Zirgan ? Valtrex ? Tears ? NO STEROIDS
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Stromal Herpes Simplex Uveitis
? History of previous primary epithelial
? Possible chamber reaction
? Risk neurotropic ulcer
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Stromal Herpes Simplex Uveitis
? Zirgan ? Valtrex ? Tears ? STEROIDS (topical)
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Herpes Zoster
? Zirgan ? Valtrex ? Tears ? STEROIDS (topical and
systemic)
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central location
Send this one away!
chamber reaction hypopyon
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Dry Eye basics
? Compromised tear causes chronic surface trauma ? Trauma causes inflammation ? Inflammation is treated with anti inflammatory
medications
tears & supportive therapy cyclosporin ? lifitegast tetracyclines antibiotic ointments steroids
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Dry Eye Jump Start
? Restasis or Xiidra bid ? Lotemax qid x 14 days then bid x 14
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Injury - treatment goals
? Promote healing ? Prevent infection ? Minimize pain
Injury - treatment
? healing / pain - STEROIDS ? infection ? antibiotic prophylaxis ? pain ? topical and oral NSAID's / tears
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Conjunctival Injury
? healing / pain STEROIDS
? infection ? antibiotic prophylaxis
? pain ? topical and oral NSAID's / tears
? healing / pain STEROIDS
? infection ? antibiotic prophylaxis
? pain ? topical and oral NSAID's / tears
? Bandage contact lens
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Corneal Injury
Lid and Adnexa Injury
? healing / pain - STEROIDS ? infection ? antibiotic prophylaxis ? pain ? topical and oral NSAID's
? Severe allergy ? Herpes Zoster
Oral Steroids
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? Zirgan q3h ? Valtrex 2000 mg /day ? No Steroids
Primary Simplex Keratitis
? Zirgan q3h ? Valtrex 2000 mg /day ? Pred Forte 1% q4h
Stromal Herpes Keratitis
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