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AIM: To evaluate the incidence of increased intraocular pressure (IOP) and glaucomatous changes in systemic lupus erythematosus (SLE) patients in comparison with systemic steroids and immunosuppressive treatment. METHODS: Sixty-two women with SLE were divided into two groups: treated (n=47, 94 eyes) and not treated (n=15, 30 eyes) with systemic glucocorticosteroids (GC; GC-free). Twenty-one individuals in GC group were treated with immunosuppressive agents (immunomodulating and biologic). The visual acuity and IOP with ocular pulsatile amplitude (OPA) measurements, as well as scanning laser polarimetry (GDx) with nerve fiber index (NFI) measurement, spectral domain optical coherence tomography (SD-OCT) of the optic disk with retinal nerve fiber layer (RNFL) analysis and the macular region with ganglion cell analysis (GCA) were performed. RESULTS: Mean IOP values in group with combined GC and immunosuppressive therapy was 15.8±2.56 mm Hg and was significantly lower than in individuals with exclusive GC treatment (17.63±4.38 mm Hg, P=0.043). Contrary, no differences in mean IOP values between GC-free group and individuals treated with combined GC and immunosuppressive therapy were detected (P=0.563). Similarly, mean IOP in GC was 17.14±3.94 mm Hg and in GC-free patients was equal to 16.67±3.45 mm Hg (P=0.671). According to treatment regimen no statistical differences in optic disk SD-OCT for RNFL thickness, RNFL symmetry, cupping volume and the C/D ratio were observed. Similarly, no statistical differences for the mean and minimal ganglion cell layer (GCL) thickness measured in macular SD-OCT or NFI in GDx were detected. CONCLUSION: Combined immunosuppressive and systemic GC therapy in SLE patients may lower the risk of iatrogenic ocular hypertension. No relationship between treatment regimen and glaucomatous damage of optic nerve fibers in analyzed groups with SLE is detected.

Glaucoma has engulfed a huge population of the world into its claws of blindness as it remains asymptomatic until nearly 40% of the neurons are lost and the only option left is for patients to be subjected to symptomatic treatments or surgical methods, neither of which is completely effective in curing the disease as they do not restore the physiological dimensions at the neuronal level. Among the several factors that drive the pathophysiology of glaucoma, one is the involvement of fibrogenic factors, such as transforming growth factor β (TGFβ) which remodels the extracellular matrix (ECM) and, thus, the deposition of fibrotic material in the retina, resulting in the progression of primary open-angle glaucoma (POAG). The primary objectives of this study were to evaluate the protective effects of oxymatrine (OMT) in the steroid-induced glaucoma model in experimental rats and to determine the role of transforming growth factor β1 (TGFβ1) in the pathogenesis of glaucoma and its consequent inhibition due to the antioxidant and the antiinflammatory, and also the TGFβ1 antagonistic, behavior of OMT. To that end, we experimentally elucidated the role of OMT, a TGFβ1 antagonist, that is known to play antiinflammatory and antioxidant roles in the steroid-induced glaucoma model in experimental rats, and using the enzyme-linked immunosorbent assay (ELISA), we observed a direct inhibitory effect of OMT on the pathogenesis of glaucoma. The antioxidant and the antiinflammatory potentials of OMT were determined using several biochemical methods to determine the major antioxidants in the retinal layers, such as superoxide dismutase (SOD), glutathione peroxidase (GPX), catalase (CAT), and glutathione (GSH), along with the nitrite and the malondialdehyde (MDA) concentration levels. As a result, OMT was found to reduce the total protein content in the retinal layers, a correlation that has not been previously reported. Moreover, the impacts of OMT on the major governing ATPases, namely Na+/K+ ATPase and Ca2+ATPase, along with its impacts on the intracellular ionic concentrations of Na+, K+, and Ca2+, were determined and were found to point toward OMT, restoring homeostasis in glaucomatous animals. A clearer picture of the changes during the treatment was obtained using retinal images of the live animals and of the lenticular changes in the sacrificed animal; these images provided data on the pathological pathways leading to glaucoma inception and its consequent inhibition by OMT. The data reported in this study clearly indicate that OMT has a possible role in inhibiting the pathogenesis of glaucoma, and the data also permit the quantification of several biochemical parameters of concern.

Glaucoma is the leading cause of permanent and irreversible blindness. It has been estimated that in 2040, 111.8 million of the world’s population will be affected by glaucoma.1 The term "steroid responder" refers to those who have increased intraocular pressure (IOP) after taking steroids. Although the prevalence of steroid-induced glaucoma (SIG) is unclear, it is believed that among the general population, roughly 33% have moderate, while 4-6% have a high response of IOP elevation in response to steroids.2 SIG in youngsters is becoming a major public health concern.3 According to a study of pediatric glaucoma patients, SIG is responsible for 24 percent of all pediatric glaucoma cases.4 It accounts for 5.86 percent of all glaucoma patients in our country, which is a significant percentage.5 SIG causes irreversible blindness, which has far-reaching consequences for an individual's quality of life, family, and the healthcare system. Since Pakistan's healthcare system is not as advanced as that of other developed nations, preventing this disease is an alternate and effective strategy to reduce SIG-related blindness. Pediatric SIG prevention would not only save our health and human resources, but it will also enable patients to participate in the country's growth in their own right. To prevent SIG-related blindness, there are a few actions that can be taken. • Role of Ophthalmologist: If an ophthalmologist prescribes a topical steroid for an ocular problem, it is his or her responsibility to assess intraocular pressure (IOP), and perform a dilated fundus examination at 4–6 weeks.3 If the patient sees another ophthalmologist for a follow-up visit, the attending ophthalmologist should examine the patient's IOP and optic discs. • Role of Allied Health Personnel (AHP): Allied healthcare professionals, such as physician assistants, and nurse practitioners, frequently prescribe steroids. Raised IOP is one of these medications' most harmful adverse effects. As a result, it's crucial that the healthcare team keep track of the patient's eye. When a patient visits an AHP, the AHP should measure IOP which can be done with a non-contact tonometer (NCT) or a Goldmann applanation tonometer. If the IOP rises, the AHP should refer the patient to a glaucoma specialist or ophthalmologist for further management.6 • Role of the Pharmacist: Self-medication is on rise in Pakistan with a frequency of 80.9-92.1% among the medical students.7 Steroids should not be provided without a proper prescription, and they should only be given for the duration of the treatment. Steroid supply without a prescription is a major issue in our system, and the government should take proper measures to combat it. • Role of Physician: The unjustified and irrational use of steroids, particularly by general physicians in underdeveloped nations needs attention.3 If someone needs steroids for a non-ocular problem then the treating physician must involve an ophthalmologist in the patient care. Alternatively, the physician should use steroid-sparing agents in patients who are at high risk of developing glaucoma e.g. family history of glaucoma, high myopia, younger age, diabetes mellitus, or connective tissue disorders. • Patient Education: The patient should be informed about the risks of glaucoma caused by steroids. Patients who self-medicate with steroids are showing a lack of understanding of the illness.3 This behavior ought to be avoided. They should be discouraged from using steroids for longer than the doctor recommends. They should be warned that self-medication can lead to SIG-related blindness that is irreversible. In conclusion, if these preventive measures are not implemented promptly, we will see an increase in SIG-related blindness soon. Not only will our healthcare system be overburdened, but our country's economic growth would be slowed as well. The government bears primary responsibility for public health and for enacting measures that will boost the nation's productivity. To raise public awareness, the government and health authorities should bring this public health concern up at every opportunity, including through seminars, walks, talk shows, and newspaper advertisements. If they don’t act to prevent SIG-related blindness then who will?

We report a case of successful argon laser synechiolysis as a non-invasive alternative for peripheral anterior synechiae release after trabeculectomy in a young patient with steroid-induced ocular hypertension. Steroid-induced ocular hypertension is a known complication of vernal keratoconjunctivitis due to prolonged treatment with steroids. In refractive conditions, augmented trabeculectomy becomes the surgery of choice in these patients.   In this article, we report successful treatment of iris tissue plugging the internal ostium with an argon laser and reinstatement of aqueous flow., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Kaur et al.)

Purpose: To know the pattern of presentations and management outcome of steroid induced glaucoma in vernal keratoconjunctivitis (VKC). Methods: Children of VKC using steroid with two of the following criteria were enrolled: Intraocular pressure (IOP) >21 mm Hg, glaucomatous optic disc and visual field defects. Misused topical steroids were classified in 4 groups; A- Highly potent drugs (dexamethasone, betamethasone), B- Moderate (prednisolone), C- Weak (loteprednol, fluorometholone), D- Unknown drugs. Active/conservative interventions were done to control IOP. Corrected distance visual acuity (CDVA), IOP, anterior segment and fundus examinations were noted. One-way ANOVA test and post hoc Tukey HSD test were used to compare the groups. Results: Out of 1423 VKC patients, 240 were using topical steroid without prescriptions. 92 eyes of 47 patients had steroid induced glaucoma. Hence prevalence of this complication was 3.30% in this study population. Mean age was 14.1 ± 3.8 years. Mean IOP was 38 ± 12 mm of Hg and mean vertical cup disc ratio was 0.67 ± 0.25. IOP was controlled by withdrawal of steroids (9 eyes), with antiglaucoma medications (27), trabeculectomy (57) and glaucoma drainage device (1). Mean CDVA at presentation was better in group C (0.23 log MAR). Mean IOP was highest in group A (43.1 mm Hg) followed by group D (40.5 mm Hg). At presentation 17 were blind (CDVA

Purpose: To know the pattern of presentations and management outcome of steroid induced glaucoma in vernal keratoconjunctivitis (VKC).Methods: Children of VKC using steroid with two of the following criteria were enrolled: Intraocular pressure (IOP) >21 mm Hg, glaucomatous optic disc and visual field defects. Misused topical steroids were classified in 4 groups; A- Highly potent drugs (dexamethasone, betamethasone), B- Moderate (prednisolone), C- Weak (loteprednol, fluorometholone), D- Unknown drugs. Active/conservative interventions were done to control IOP. Corrected distance visual acuity (CDVA), IOP, anterior segment and fundus examinations were noted. One-way ANOVA test and post hoc Tukey HSD test were used to compare the groups.Results: Out of 1423 VKC patients, 240 were using topical steroid without prescriptions. 92 eyes of 47 patients had steroid induced glaucoma. Hence prevalence of this complication was 3.30% in this study population. Mean age was 14.1 ± 3.8 years. Mean IOP was 38 ± 12 mm of Hg and mean vertical cup disc ratio was 0.67 ± 0.25. IOP was controlled by withdrawal of steroids (9 eyes), with antiglaucoma medications (27), trabeculectomy (57) and glaucoma drainage device (1). Mean CDVA at presentation was better in group C (0.23 log MAR). Mean IOP was highest in group A (43.1 mm Hg) followed by group D (40.5 mm Hg). At presentation 17 were blind (CDVA <3/60). Post treatment marginal improvement in CDVA was found (P = 0.46). However, statistically significantly improvement was noticed in IOP (P < 0.00001).Conclusion: Injudicious use of steroids leads to vision threatening complications like ocular hypertension and glaucoma in children of VKC. Weak steroids like loteprednol or fluorometholone should be used instead of higher potency drugs. Vision and IOP should be monitored fortnightly in children using topical steroids to detect steroid responders at the earliest. [ABSTRACT FROM AUTHOR]

Purpose: Vogt-Koyanagi-Harada (VKH) syndrome is a systemic inflammatory autoimmune disease with associated ophthalmic pathology. Glaucoma has been reported in patients with VKH. The purpose of this report is to examine the frequency and types of glaucoma associated with VKH.Methods: This was a retrospective case series. Electronic medical records of patients with VKH were reviewed from two medical centers: Duke University and the University of North Carolina.Results: Of 45 eyes with VKH, 28 (62%) developed ocular hypertension (OHT) or glaucoma. In the patients with VKH and OHT/glaucoma, 18/28 (64%) had posterior synechiae and/or peripheral anterior synechiae.Conclusions: We have shown a high prevalence of OHT and glaucoma in eyes with VKH. Furthermore, in addition to secondary open angle from corticosteroid treatment and uveitis, secondary angle closure resulting from posterior synechiae, frequently associated with iris bombé configuration, is an important cause of glaucoma in VKH eyes. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to evaluate the retinal nerve fiber layer (RNFL) thickness in vernal keratoconjunctivitis (VKC) patients who were under long-term topical corticosteroid therapy. Methods: Thirty-six eyes of 36 VKC patients with clear cornea and normal videokeratography and 40 eyes of 40 age- and gender-matched normal children were included in the study. Clinical and demographic characteristics of the patients were noted and detailed ophthalmological examination was performed. Visual acuity (VA), spherical equivalent (SE), axial length (AL) and RNFL thickness measurements were compared between the groups. To correct ocular magnification effect on RNFL, we used Littmann's formula. Results: All VKC patients had history of topical corticosteroid use and the mean duration of the topical corticosteroid use was 23.8 ± 9.09 months. There was no significant difference between the groups in terms of intraocular pressure (IOP). VKC group had significantly worse VA, greater SE and AL and thinner mean global, superior and inferior RNFL thickness. There were significant negative correlations between the duration of topical corticosteroid use and the mean global, superior and temporal RNFL thickness in VKC group. After correction of magnification effect, VKC group still had thinner mean global, superior and inferior RNFL thickness, and significant difference between the groups in inferior RNFL thickness did not disappear. Conclusion: Significant RNFL thickness difference between the groups suggests a possible effect of long-term corticosteroid use in VKC patients. Because visual field (VF) analysis in pediatric patients is difficult to perform and IOP may be illusive, RNFL thickness measurements in addition to routine examinations in VKC patients may help clinicians in their practice. [ABSTRACT FROM AUTHOR]

Glaucoma has engulfed a huge population of the world into its claws of blindness as it remains asymptomatic until nearly 40% of the neurons are lost and the only option left is for patients to be subjected to symptomatic treatments or surgical methods, neither of which is completely effective in curing the disease as they do not restore the physiological dimensions at the neuronal level. Among the several factors that drive the pathophysiology of glaucoma, one is the involvement of fibrogenic factors, such as transforming growth factor β (TGFβ) which remodels the extracellular matrix (ECM) and, thus, the deposition of fibrotic material in the retina, resulting in the progression of primary open-angle glaucoma (POAG). The primary objectives of this study were to evaluate the protective effects of oxymatrine (OMT) in the steroid-induced glaucoma model in experimental rats and to determine the role of transforming growth factor β1 (TGFβ1) in the pathogenesis of glaucoma and its consequent inhibition due to the antioxidant and the antiinflammatory, and also the TGFβ1 antagonistic, behavior of OMT. To that end, we experimentally elucidated the role of OMT, a TGFβ1 antagonist, that is known to play antiinflammatory and antioxidant roles in the steroid-induced glaucoma model in experimental rats, and using the enzyme-linked immunosorbent assay (ELISA), we observed a direct inhibitory effect of OMT on the pathogenesis of glaucoma. The antioxidant and the antiinflammatory potentials of OMT were determined using several biochemical methods to determine the major antioxidants in the retinal layers, such as superoxide dismutase (SOD), glutathione peroxidase (GP X ), catalase (CAT), and glutathione (GSH), along with the nitrite and the malondialdehyde (MDA) concentration levels. As a result, OMT was found to reduce the total protein content in the retinal layers, a correlation that has not been previously reported. Moreover, the impacts of OMT on the major governing ATPases, namely Na + /K + ATPase and Ca 2+ ATPase, along with its impacts on the intracellular ionic concentrations of Na + , K + , and Ca 2+ , were determined and were found to point toward OMT, restoring homeostasis in glaucomatous animals. A clearer picture of the changes during the treatment was obtained using retinal images of the live animals and of the lenticular changes in the sacrificed animal; these images provided data on the pathological pathways leading to glaucoma inception and its consequent inhibition by OMT. The data reported in this study clearly indicate that OMT has a possible role in inhibiting the pathogenesis of glaucoma, and the data also permit the quantification of several biochemical parameters of concern., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Das, Kashyap, Singh, Shree, Namdeo and Bodakhe.)

Aim: To evaluate the incidence of increased intraocular pressure (IOP) and glaucomatous changes in systemic lupus erythematosus (SLE) patients in comparison with systemic steroids and immunosuppressive treatment., Methods: Sixty-two women with SLE were divided into two groups: treated ( n =47, 94 eyes) and not treated ( n =15, 30 eyes) with systemic glucocorticosteroids (GC; GC-free). Twenty-one individuals in GC group were treated with immunosuppressive agents (immunomodulating and biologic). The visual acuity and IOP with ocular pulsatile amplitude (OPA) measurements, as well as scanning laser polarimetry (GDx) with nerve fiber index (NFI) measurement, spectral domain optical coherence tomography (SD-OCT) of the optic disk with retinal nerve fiber layer (RNFL) analysis and the macular region with ganglion cell analysis (GCA) were performed., Results: Mean IOP values in group with combined GC and immunosuppressive therapy was 15.8±2.56 mm Hg and was significantly lower than in individuals with exclusive GC treatment (17.63±4.38 mm Hg, P =0.043). Contrary, no differences in mean IOP values between GC-free group and individuals treated with combined GC and immunosuppressive therapy were detected ( P =0.563). Similarly, mean IOP in GC was 17.14±3.94 mm Hg and in GC-free patients was equal to 16.67±3.45 mm Hg ( P =0.671). According to treatment regimen no statistical differences in optic disk SD-OCT for RNFL thickness, RNFL symmetry, cupping volume and the C/D ratio were observed. Similarly, no statistical differences for the mean and minimal ganglion cell layer (GCL) thickness measured in macular SD-OCT or NFI in GDx were detected., Conclusion: Combined immunosuppressive and systemic GC therapy in SLE patients may lower the risk of iatrogenic ocular hypertension. No relationship between treatment regimen and glaucomatous damage of optic nerve fibers in analyzed groups with SLE is detected., (International Journal of Ophthalmology Press.)

The hazy corneal donor-recipient interface after corneal transplant may cause difficulties when implanting the XEN gel stent via ab-interno approach. We aim to describe XEN gel stent implantation via ab-externo approach in refractory steroid-induced glaucoma after corneal lamellar keratoplasty. Under local anaesthesia, the XEN injector needle was inserted 7 mm behind the limbus with the bevel facing up, directly beneath the conjunctiva and advanced to the marked 2.5 mm scleral entry wound. The needle then pierced the sclera until the needle tip was just visible in the anterior chamber (AC). The slider was pushed until the tip of the XEN stent was seen in the AC. The needle was slowly withdrawn while still pushing the slider to complete stent deployment. Subconjunctival Mitomycin C 0.01% (30 µg/0.3 mL) was then injected posterior to the bleb. Three eyes of three patients with steroid-induced glaucoma after lamellar keratoplasty underwent XEN gel stent implantation via ab-externo approach placed at the superotemporal quadrant. Pre-operatively, all patients had uncontrolled IOP between 30-45 mmHg despite maximum medications and selective laser trabeculoplasty. After XEN gel stent implantation, IOP ranged between 10-17 mmHg with one or two topical antiglaucoma at 12 months. Complications include hypotony maculopathy, stent migration and hyphaema, all of which were successfully managed. Corneal graft remained clear at 12 months. XEN gel stent implantation via ab-externo approach is able to achieve good intraocular pressure (IOP) control without compromising cornea graft in patients with steroid-induced glaucoma after lamellar keratoplasty at 12 months., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Tan et al.)

Purpose: To report the clinical features, treatment outcomes and blindness associated with steroid-induced glaucoma in vernal keratoconjunctivitis (VKC)., Materials and Methods: Records of patients with VKC, who visited our tertiary centre from 1992 and 2009, were reviewed and those with steroid-induced glaucoma were included in the study. Glaucoma was diagnosed based on intraocular pressure (IOP) ≥22 mm Hg on two consecutive visits (ocular hypertension) and/or glaucomatous optic disc damage. Blindness was defined as best corrected visual acuity of ≤20/400 or visual field <10°., Results: Of the 4062 VKC subjects, 91 (157 eyes) had steroid-induced glaucoma (SIG), showing a prevalence of 2.24%. Of these 87% were men. The median (IQR) age at onset of VKC was 12 years (7-17). At presentation, the median duration of VKC was 48 months (24-72) and the median duration of steroid usage was 24 months (12-36). The median cup-to-disc ratio (CDR) was 0.9 (0.7-0.9) and median mean deviation was -21.9 dB (-30.0 to -10.2). IOP was medically controlled in 66% eyes (104/157) and 34% eyes (53/157) needed glaucoma surgery. High presenting IOP (OR: 1.04; p=0.05) and increased duration of steroid usage (OR: 1.07; p=0.02) were significantly associated with need for glaucoma surgery. At presentation, 29/91 subjects (31.8%) were bilaterally blind due to SIG. Higher CDR at presentation was significantly associated with blindness in this cohort (p=0.02)., Conclusion: In this cohort of VKC with SIG, the disease predominantly affected adolescent males. Glaucoma was severe with one-third needing surgery and one-third blind due to SIG., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The aim of this study was to compare the ocular hypertensive effect of the commercially available Betamethasone, Fluorometholone in Iran and Loteprednol Etabonate in patients undergoing keratorefractive surgery., Methods: In this prospective randomized clinical trial, 300 eyes of 150 patients were included, and patients were randomly assigned to 3 groups and used one of the 3 steroid drops (Betamethasone 0.1%, Fluorometholone 0.1%, and Loteprednol Etabonate 0.5%) after myopic photorefractive keratectomy (PRK). Intraocular pressure (IOP) was measured 2, 4, and 6 weeks post-surgery. Twenty-two mmHg was set as the threshold IOP for starting anti-glaucoma medication and tapering steroid drops., Results: Of 300 eyes from 150 patients over the first 6 postoperative weeks, 2 eyes in Fluorometholone group (2%), 12 eyes in Betamethasone group (12%), and 16 eyes in Loteprednol group (16%) had IOP equal or more than 22 mmHg. Analysis of variance (ANOVA) test showed that the rise in IOP was significantly different between groups in the 2nd and 4th ( P  ≤ 0.001) postoperative weeks but not at 6th week ( P  = 0.230). An IOP rise equal or more than 10 mmHg was detected in 13 and 15 eyes in Betamethasone and Loteprednol groups, respectively. None of the eyes in Fluorometholone group had such an IOP rise., Conclusions: Loteprednol and Fluorometholone were associated with the most and least increase in IOP, respectively. The highest pressures were detected 4 weeks after surgery in the Betamethasone and Loteprednol groups and 6 weeks after surgery in the Fluorometholone group. Fluorometholone was the safest among the three examined steroid drops in terms of IOP rise.