Systematic Literature Review and Meta-analysis of IOP Elevation post Intravitreal Steroids

Abstract

Purpose: : Currently there is no consensus regarding IOP monitoring post intravitreal (IV) steroids. We conducted a systematic literature review following the PRISMA statement to develop best practice recommendations on IOP monitoring.

Methods: : MEDLINE, EMBASE and the Cochrane Registry were searched through August 2011. Inclusion criteria were prospective RCT, cohort or retrospective study,≥15 years of age and English publication. Case reports, review articles, editorials and studies without a definition for ocular hypertension (OHT) were excluded. Meta-analysis or descriptive statistics were performed where appropriate. The main outcome was proportion of subjects with OHT (IOP >21mmHg or >10mmHg rise from baseline). Secondary outcomes included timing of IOP rise, treatment and risk factors.

Results: : After screening 1338 abstracts 174 full text articles were reviewed resulting in 129 eligible studies. 4 mg triamcinolone acetonide (TA) was the commonest dosage and drug used. The pooled proportion of subjects with OHT was 32.1% (95% CI; 28.2-36.3) of which 50-70% had history of POAG. Medications were used in 40-50% with 2-9% requiring surgery. For fluocinolone acetonide (FA) implant, 55-67% and 79% had a ≥10 mmHg rise after 0.59 or 2.1mg respectively. Medications were used in 20-78% and 40% required surgery. For dexamethasone implant, a ≥10 mmHg rise occurred in 12-15% following 0.35mg and 7-18% following 0.7mg. Antiglaucoma medications were used in 6-16% of subjects and 0.6% required surgery. IOP elevation occurred 1 week after TA and after 2-4 weeks with implants. Mean time to IOPmax was 2-3 months in all groups. Eyes with FA implants took longer to return to baseline IOP compared to the others (9 vs 6 months). Risk factors for developing secondary OHT included preexisting glaucoma, uveitis, higher baseline IOP, younger age, higher dose of TA and history of OHT with previous steroid injection.

Conclusions: : IV steroids commonly cause secondary OHT. The majority can be controlled medically however some cases, especially FA implants, require surgery. All patients receiving IV steroid should be warned about this potential side effect. Based on this analysis we recommend checking IOP at 1 week after IV TA injection and 2 weeks after IV implantation. IOP should then be checked 2 weekly for the first month followed by monthly for 6 months after IV TA injection and dexamethasone implant and for 9 months after FA implant.

Keywords: corticosteroids • drug toxicity/drug effects • intraocular pressure