1. Ocular NSAIDs &
Steroids : Uses &
Indications
MODERATOR PRESENTERS
DR. SANJEEV BHATTARAI AAYUSH CHANDAN
SRIJANA LAMICHHANE
2. Presentation layout
Introduction to inflammation
Introduction to NSAIDs
Mechanism of action
Classification of NSAIDs
Ophthalmic NSAIDs
Indications & contraindications
3. Inflammation
Part of the complex biological response of body tissues to
harmful stimuli such as pathogens , damaged cells , irritants
& is a protective response involving immune cells , blood
vessels & molecular mediators
Vital part of the immune system’s response to injury &
infection
4. Cardinal signs of inflammation
1. Redness (Rubor) : Vasodilation of capillaries to increased blood
flow .
2. Heat (Calor) : D/t transfer of internal heat to the tissue by
increased blood flow .
3. Pain (Dolor) : D/t Sensitization of sensory nerve endings .
4. Swelling (Tumor) : D/t increased vascular permeability &
escape of plasma protein from bloodstream .
5.Functio laesa : Loss of Function
5.
6. Features of inflammatory
response
1. Increased production of prostaglandins & leukotrienes :
Arachidonic Acid is produced by the action of
phospholipase
AA by the enzyme cyclooxygenase converts it into one of
the variety of prostaglandins that have effects on smooth
muscle & mediate some of inflammatory reactions
Lipooxygenase converts AA to leukotrienes which bring
about increase in permeability & oedema
8. 2. Liberation of histamine from mast cell
Caused by Allergan-Antigen Reaction causing an increase in
influx of Ca++ ions from mast cells
3. Vascular effects
In addition to the action of histamine , other locally active
agents can induce vasodilation & increased capillary
permeability
In the eye , permeability of the blood/aqueous barrier is
increased , leading to a turbid aqueous that contains more
protein than normal
9. 4. Fibroblastic activity
Part of the inflammatory response is to stimulate the
mechanism of wound repair .
e.g. Fibroblast & collagen forming activity
5. Increased Leucocyte Activity
These normally migrate into the site of inflammation to
attack & kill invading cells.
10. Because the effects of inflammation can be sometimes
excessive & in the eye lead to discomfort & loss of vision , it
is often desirable to limit the extent by the use of
appropriate drugs
Cyclooxygenase inhibiting agents : Steroids & NSAIDs
Interference with release or action of histamine : Mast cell
stabilizers & Antihistamines
11. NSAIDs
Developed as an alternative to steroids in the treatment of
inflammatory disease
Non-Steroidal Anti-Inflammatory Drugs
All NSAIDs have 3 major therapeutic effects
Anti-inflammatory
Analgesic
Anti-Pyretic
Most are the organic acid derivatives
12. contd..
Aka non-narcotic , non-opoid , aspirin like drugs or
antipyretic analgesics
There are more than 50 different NSAIDs on the global
market now
Do not depress CNS
Act primarily on peripheral pain mechanism
13. History
Sodium salicylate was used for pain & fever in 1875 AD.
It’s great success led to the introduction of aspirin in 1899 AD.
Indomethacin was introduced in 1963 AD.
After the discovery of ibuprofen the mechanism involving
cycloxygenase inhibition was revealed.
14. Cyclooxygenase
Enzymes responsible for the formation of prostanoids i.e.
prostaglandins , prostacyclins & thromboxane
Two main forms : COX1 & COX2
Recently COX3 also have been isolated (but is not
functional in human)
15. COX1 COX2
Continuously stimulated by
the body
Induced(normally not
present in cells)
Produces prostaglandin
involved in tissue
homeostatis , gastric
cytoprotection , platelet
aggregation , Renal blood
flow Autoregulation
Produces prostaglandins
that mediate inflammation,
pain and fever
Constitutively expressed in
most tissues like GI, platelets
Induced mainly in sites of
inflammation by cytokines
16. Prostaglandins
Potent bioactive lipid messengers synthesized from
arachidonic acid mediated by enzyme COX
4 principal bioactive prostaglandins generated in vivo are
Prostaglandin E2 (PGE2)
Prostaglandin F2α(PGF2α)
Prostaglandin I2 (PGI2)
Prostaglandin D2 (PGD2)
17. 1. Prostaglandin E2 (PGE2)
One of the most abundant PGs produced in the body.
Regulation of immune response , BP , gastrointestinal integrity &
fertility.
Involved in processes leading to classical sign of inflammation ,
redness , swelling & pain
Powerful bronchodilator
2. Prostaglandin F2α (PGF2α)
Derived mainly from COX1 in female reproductive system
Plays an important role in ovulation , luteolysis , contraction of
uterine smooth muscle & initiation of parturition
Recent studies also shows that it plays significant role in renal
function , contraction of arteries , myocardial dysfunction , brain
injury & pain
18. 3.Prostaglandin I2 (PGI2)
Regulate cardiovascular homeostasis
Potent vasodilator & inhibitor of platelet aggregation , leukocyte
adhesion
Important mediator of the edema & pain that accompany acute
inflammation
4. Prostaglandin D2(PGD2)
Synthesized in both CNS & peripheral tissue & appear to function in
both an inflammatory & homeostasic capacity
Involved in regulation of sleep
Pain perception
Most predominant in acute allergic response
21. Mechanism of action of
NSAIDs
1. Anti – Inflammatory effects
Anti-inflammatory actions of NSAIDs are most likely
explained by their inhibition of prostaglandin synthesis by
COX2
Aspirin irreversibly inactivates COX-1 and COX-2 by
acetylation of a specific serine residue.
This distinguishes it from other NSAIDs, which reversibly
inhibit COX-1 and COX-2
22. 2. Analgesic effect
A. The analgesic effect of NSAIDs is thought to be
related to:
the peripheral inhibition of prostaglandin production
may also be due to the inhibition of pain stimuli at a
subcortical site
B. NSAIDs prevent the potentiating action of
prostaglandins on endogenous mediators of peripheral
nerve stimulation (e.g., bradykinin).
23. 3.Antipyretic effect
The antipyretic effect of NSAIDs is believed to be
related to:
Inhibition of production of prostaglandins induced
by interleukin-1 (IL-1) and interleukin-6 (IL-6) in the
hypothalamus
“resetting” of the thermoregulatory system, leading
to vasodilatation and increased heat loss.
24. Beneficial action due to PG synthesis
inhibition
Anti-inflammatory effect
Analgesic effect
Anti-pyretic effect
Anti-thrombotic effect
Closure of ductus
arteriosus in new born
25. Adverse effects
1. Gastrointestinal disturbances
Commonest adverse effects of NSAIDs
Result mainly from inhibition of gastric COX-1
Commonly include gastric discomfort , Dyspepsia ,
Diarrhoea , Nausea & vomiting & in some cases gastric
bleeding & ulceration
So, it had been predicted that COX-2 selective agents
would provide good anti-inflammatory & analgesic actions
with less gastric damage
26. 2.Skin Reactions
Rashes are most common
Vary from mild erythematous , urticarial & photosensitivity
reactions to more serious & potentially fatal disease
including Steven Johnson syndrome
27. 3.Adverse renal effect
Decreased Na+ & H20 excretion
Renal failure
Decreased effectiveness of diuretics & antihypertensives
4. Cardiovascular side effects
Potential of NSAIDs when given alone to raise BP &
therefore predispose to adverse cardiovascular events such
as stroke & myocardial infarction
29. Contraindications to NSAIDs use
H/O ulcer disease
Advanced age
Long duration of NSAIDs therapy
Smoking & heavy alcohol
Patient with renal impairment , heart failure , hypertension
Patient with hypersensitivity reactions to salicylates or any
other NSAIDs
Asthmatics patients
30. Drug interactions
Drug Result
Diuretics Decrease diuresis
Beta-blockers Decrease antihypertensive
effect
ACE inhibitors Decrease antihypertensive
effect
Anticoagulants Increase of GI bleeding
Cyclosporine Increase nephrotoxicity
Alcohol Increase of GI bleeding
38. Topical NSAIDs in preoperative
period
Intraoperative miosis
Topical NSAIDs reduce pupillary constriction that occur
during cataract extraction and other intraocular surgeries
Post operative inflammation
Use of NSAIDs before surgery prevent the synthesis of
prostaglandin and provide prophylaxis for expected
inflammation
NSAIDs also prevent blood aqueous barrier breakdown and
reduce cells and flare in AC
39. Cystoid macular edema
Prevention of acute aphakic and pseudophakic CME
and treatment of chronic CME
Peak incidence of CME occurs between 4 & 8 weeks
after surgery
40. Topical NSAIDs for anterior
segment inflammation
Allergic and non-bacterial conjunctivitis
Most ocular allergies are type I hypersensitivity reaction
mediated by mast cells
Degranulation releases preformed mediators such as
histamine and initiates synthesis of newly formed mediators
including prostaglandins
Corneal Pain
Injury to corneal tissues stimulates prostaglandin synthesis
Corneal pain following abrasions , trauma or epithelial
erosions , PRK , treated with topical NSAIDs
41. Episcleritis
Topical NSAIDs may be useful
Oral NSAIDs may be required in recurrent cases
Tab Flurbiprofen 100mg TDS
Tab Indometacin 25mg TDS
42. Other indications
Non necrotizing scleritis
until inflammation resolves
(given in conjunction with topical steroids )
Tab indomethacin 75mg BD
43. Anterior uveitis
Systemic Aspirin can be used where steroids are
contraindicated
Phenylbutazone and oxyphenbutazone potent in uveitis
associated with rheumatoid disease
Naproxen is useful in ankylosing spondylitis
44. Diclofenac sodium
Trade name Igesic
Available as 0.1% ophthalmic solution
Indications Postoperative
inflammation
Temporary relief of pain
and photophobia in
patients undergoing
corneal refractive surgery
45. Flurbiprofen sodium
Trade name Eyefen , flur
Available as 0.03% ophthalmic solution
Indications Inhibition of
intraoperative miosis
Post operative
inflammation
46. Ketorolac tromethamine
Trade name Acular , Acular PF , Acular LS
Available as 0.5% and 0.4% ophthalmic
solution
Indications Allergic conjunctivitis
Post cataract surgery
inflammation
Post operative pain and
photophobia in PRK
Ketorolac 0.5% in
treatment of chronic CME
50. Dosing regimens of topical
NSAIDs
Indications Drug Regimen
Intraoperative miosis
prevention
Flurbiprofen 1 drop every 30 min , 4 times
before surgery
Ketorolac 1 drop every 30 min , 4 times
before surgery
Suprofen 1 drop every 30 min , 4 times
before surgery
Postoperative inflammation Diclofenac 1 drop QID for at least 1-2
weeks after surgery
Ketorolac 1 drop QID for at least 1-2
weeks after surgery
Cystoid macular edema Ketorolac I drop QID for at least 3
months
Indometacin 1 drop QID
Allergic conjunctivitis Ketorolac 1 drop QID for relief of ocular
itching during allergy season
Corneal pain Diclofenac 1 drop preoperatively and 1
drop QID postoperatively for 3
days
Ketorolac (non preserved ) 1 drop QID for 3 days
51. Oral NSAIDs in ophthalmic use
Ibuprofen
Trade name Flexon , Brufen `
Flexon(Ibuprofen
400mg +
paracetamol 500mg)
Brufen (Ibuprofen
400mg)
Indications As analgesic in stye &
chemical injury
1 Tab PO TDS
52. As oral NSAIDs has more systemic side effects (esp.Gastric
mucosal damage ) drugs for peptic ulcer is used
H2 antihistamines : Cimetidine , Ranitidine
Proton pump inhibitors : Omeprazole , Pantoprazole ,
Rabeprazole
Tab Ranitidine 300mg OD or 150mg BD
Tab Pantoprazole 40mg OD
53. Precautions for ocular NSAIDs
Increased bleeding of ocular tissues, including hyphemas
in conjunction with ocular surgery
Slow or delayed wound healing
Cross sensitivity with acetylsalicylic acid
54. Topical NSAIDs may cause keratitis: Continued treatment
with ophthalmic NSAIDs may result in epithelial breakdown,
corneal thinning, corneal infiltrates, corneal erosion in
certain susceptible patients
Pregnancy: Due to known effect of NSAIDs on fetal
cardiovascular system including closure of ductus
arteriosus, use of ophthalmic NSAIDs during late pregnancy
should be avoided
55. Contraindications
Hypersensitivity to any component of formulations
Nepafenac and Ketorolac: contact lens wearers
Flurbiprofen and Suprofen: patients with dendritic keratitis
56. Adverse Effects
Systemic absorption minimal in topical NSAIDs
Local effects:
burning sensation
stinging sensation upon instillation
conjunctival hyperemia
58. PRESENTATION LAYOUT
Introduction to steroids
Introduction to adrenal gland
Inflammatory response
Pharmacologic principle of steroids
Common ophthalmic steroids
Indications, contraindications and side effects of steroids
59. 59
Is a biologically active organic compound
Consist of four rings arranged in a specific molecular configuration
“Steroid" is a chemical name for any substance that has a characteristic
chemical structure consisting of multiple chemical rings of connected
atoms.
Contains four cycloalkane rings ( core structure) 17 carbon atom
3 rings : cyclohexane
1 ring : cyclopentane
INTRODUCTION TO
STEROID
60. Hundered of steroids are found in plants, animals and
fungi
Animal steroid
All the human steroids are synthesized from the
cholesterol
Two principle biological function ;
Is an important component of the cell membrane which
alter membrane fluidity
Acts as signaling molecules
61. CORTISOL DEXAMETHASONE
Some examples of natural steroids
Vitamin D
Cholesterol
Estrogen
Progesterone
Cortisol
Some examples of synthetic steroids
Prednisolone
Dexamethasone
Betamethasone
trimcinolone
62. ADRENAL GLAND
Two in number, superior and slight
medial to kidneys
Two parts: adrenal cortex (80%)
adrenal medulla (20%)
Each weight about 4 grams
64. ZONA GLOMERULOSA : Produce mineralocorticoids i.e
Aldosterone
ZONA FASCICULATA : Produce glucocorticoids
e.g Cortisol , corticosterone , small amount of
adrenal androgens and estrogens
ZONA RETICULARIS : Produce androgens
e.g Dehydroepiandrosterone ,small amount
of estrogen and some glucocorticoids
65.
66. Secretion of mineralocorticoids depend upon extracellular fluid
concentrations of angiotensin II and potassium
Secretion of glucocorticoids is controlled by hypothalmic –
pituitary axis via ACTH(adrenocorticotropic hormone)
Thus secretion pathway of mineralocorticoids and
glucocorticoids does not depend upon each other
68. The hypothalamic pituitary adrenal (HPA) axis is our central
stress response system.
This system works in a straight forward manner
Any response i.e. stress is characterized by hypothalamic
release of CRH
This CRH binds to receptors of ant.pituitary gland,results in
the release of ACTH
ACTH binds to receptor of adrenal cortex and stimulate
release of cortisol
HPA axis
69. In response to stressors, cortisol will be released for
several hours after encountering the stressor.
At a certain blood concentration of cortisol this protection
is ostensibly achieved and the cortisol exerts negative
feedback to the hypothalamic release of CRF and the
pituitary release of ACTH (negative feedback). At this point,
systemic homeostasis returns.
70. FUNCTION OF MINERALOCORTICOIDS
Aldosterone increases renal tubular reabsorption of
sodium and secretion of potassium
Excess Aldosterone increases extracellular fluid volume
and arterial pressure but has only small effect on plasma
sodium concentration
Excess aldosterone causes hypokalemia and muscles
weakness
Deficient aldosterone causes cardiac toxicity
71. FUNCTION OF GLUCOCORTICOIDS
1.Effect on carbohydrate metabolism i.e stimulation of
gluconeogenesis
Decrease glucose utilization by the cells
Elevate the blood glucose concentration and cause Adrenal diabetes
Cortisol increases the enzyme required to convert the
amino acid into the glucose in liver cells
Cortisol causes mobilization of amino acids from the
extrahepatic tissue mainly from muscles
72. 2.Effect on protein metabolism
•Reduction of cellular protein
•Cortisol increases the liver and plasma protein
Reduction of protein stored in essentially all body cells
except those of liver cells
Decreases protein synthesis and increases catabolism of
protein already present
73. 3.Effect on fat metabolism
Mobilization of fatty acids
Excess cortisol causes obesity
It promotes mobilization of free fatty acids from adipose
tissue
Increases the concentration of free fatty acids in plasma ,
which increases there utilization for energy
Excess deposition of fat in chest and head regions of body
giving a buffalo like torso and rounded moon face
74. 4.Effect in resisting stress
Almost all type of stress ( trauma , infections , intense heat and
cold , surgery ) cause immediate and marked increase
adrenocotical secretion of cortisol
Glucocorticoids cause rapid mobilization of amino acids and
fat from there cellular store , making them immediately
available both for energy and synthesis of other compounds
so the damaged tissues can use the newly formed amino
acids for the maintenance of cellular life
75. 5. Effect on immunity and blood
Decreases activation and migration of leukocytes
Lyse and destroy lymphocytes
Administration of large doses of the cortisol causes significant
atrophy of all lymphoid tissue through out the body
Cortisol increase the count of red blood cells , the cause of which is
unknown , excess causes polycythemia
Deficient leads to anaemia
Inhibit migration of neutrophils to extracellular space and
adherence to vascular endothelium
76. 6.Effect as strong anti-inflammatory agent
Reduce histamine release from basophils induced by IgE
dependent stimulus
Inhibit phospholipase A2 which prevents biosynthesis of
arachidonic acid and subsequent formation of prostacyclin,
prostaglandins and leukotrienes
Decrease capillary permeability and fibroblast proliferation and
the quantity of collagen deposition thus influencing tissue
regeneration and repair
The anti-inflammatory effects are nonspecific, occurring
whether the etiology is allergic, traumatic or infectious
77. Mode of action
Every tissue has receptor for steroids
Binds to glucocoticoid receptor in nucleus and influence
the gene expression
Because cortisol
is lipid soluble it
can easily diffuse
through the cell
membrane
78. Transactivation : upregulates the expression of anti-
inflammatory proteins in nucleus
Transrepression : downregulates the expression of
proinflammatory proteins in cytosol
79.
80. It is better to understand “Increased concentration of drug
better than increased dozes”
81. Common Ophthalmic steroids
Corticosteroid Derivative Formulation Concentration
Prednisolone Acetate suspension 0.125% or 1%
Prednisolone Sodium
phosphate
solution 0.125% or 1%
Dexamethasone Alcohol Suspension 0.1
Dexamethasone Sodium
phosphate
Solution
Ointment
0.1
0.05
Flourometholo
ne
Alcohol Ointment
Suspension
0.1
0.1
Flourometholo
ne
Acetate Suspension
Suspension
0.25
0.1
82. Prednisolone
A synthetic analogue of the major glucocorticoid i.e
cortisol or hydrocortisone
Effective for external as well as intraocular inflammation
Commercially formulated as acetate and phosphate ;
acetate derivative being more effective anti-inflammatory
agent
Not available as an ophthalmic ointment.
83. Available in concentration of 0.5% and 1% W/V
Prednisolone acetate 1% is considered the standard, by which
all other topical ocular corticosteroids are compared
As compared with other topical ocular steroids , 1% prednisolone
acetate is generally considered the most effective anti-inflammatory
agent for anterior segment ocular inflammation
84. Has the greatest efficacy when compared to all other available
ophthalmic agents
So,is more likely to elevate IOP and have greater side effects
than its weaker counterparts
Systemic prednisolone recommendation
•Tab. Prednisolone acetate 1 mg/kg of body weight *OD
•Tab. Ranitidine 150 mg *OD * AC
•Tab. Calcium * 500 mg * OD
85. Dexamethasone
Structurally resemble cortisol
Available as an alcohol or phosphate derivative
0.1% ophthalmic suspension or solution
Alcohol derivative more active than phosphate
Resistant to metabolism after penetration into the
aqueous humor.
86. Very effective in reducing ocular inflammation
But has the propensity to increase IOP more than any other
topical ophthalmic corticosteroid
Usually limited to shortcourse therapy
Dexamethasone ointment is very useful for nighttime coverage
in cases of uveitis
87. Fluorometholone (FML)
Structurally resemble progesterone
Formulated both as an alcohol and acetate derivative
Relatively weaker corticosteroid
Decreased risk of unwanted complications, such as IOP rise
88. Treatment of choice in those patients with a history of pressure
rise due to corticosteroid therapy or previously diagnosed
glaucoma
An effective agent in external ocular inflammations , like
conjunctivitis, piguiculitis , scleritis and episleritis
Available as 0.1% drop
89. Medrysone
Like fluorometholone , a synthetic derivative of
progesterone
Weakest of the available ophthalmic steroids
Useful for superficial ocular inflammations , including
allergic and atopic conjunctivitis
Generally do not respond to intraocular inflammatory
conditions
Elevates IOP minimally or not at all
90. Betamethasone
Available as 0.1% eyedrop or ointment
Marked anti-inflammatory action
Low dose is enough
So, reduces the risk of side effects
92. Rimexolone
Available as a 1% ophthalmic suspension (Vexol)
Effective in suppressing cells, flare, keratin precipitates and
photophobia
Main advantage - more of site-specific action than other
corticosteroids
Less tendency to increase the IOP.
93. LOTEPREDNOL
Available as 0.2% and 0.5% concentration
Less potent steroid
Indicated for temporary relief of the signs and symptoms
of seasonal allergic conjunctivitis
95. BIOAVAILABILITY OF TOPICAL STEROIDS
Fraction of unchanged drug reaching the systemic circulation
Depends upon the ability to penetrate cornea
The ideal steroid should be biphasic i.e solubility in both the
lipid (hydrophobic) layers of the epithelium and endothelium and
the aqueous (hydrophilic) media of the stroma
96. Acetate and alcohol derivatives more lipophilic i.e fat soluble
Sodium phosphate and hydrochloride more hydrophilic i.e
water soluble
So, in intact epithelium , penetration of acetate greater while in
absence of epithelium penetration of phosphate greater
Acetate and alcohol derivatives are more effective then the
phosphate derivatives in suppressing corneal inflammation both
in the presence and absence of corneal epithelium
97. Preparations
LOCAL :
Eyedrops-suspension or solution
Ointments
Injection - subconjuctival , sub-tenon’s
capsule or retrobulbar
SYSTEMIC : Tablets
Injections(intra venous)
-
98. Routes of administration
TOPICAL SYSTEMIC
Effective in anterior
segment diseases
Effective in posterior
segment diseases
Ease of application, relative
low cost
Difficult application,
relatively high cost
Dosage vary with severity of
disease
Generally single dose daily
Absence of systemic
complications
Systemic complications
present
100. Alternate day therapy
Single dose on alternate day, systemic administration of
corticosteroids is as effective as divided daily dose
Permits metabolic recovery and prevents toxic side effects
from accumulating
Patients receives the entire total dose that would be given
over a 2-day period as a sing dose , every other morning
Alternate-day systemic therapy applies only to shorter acting
systemic steroids like prednisone, in case like chronic uveitis
101. Why steroids dozes tapered ??
Synthetic cortisone medication mimic cortisol,i.e naturally
occuring hormone produced by adrenal gland
Excess production of cortisol – negative feedback
mechanism (HPA axis)
Using large dose for few days or smaller dose for more
than two weeks—prolonged decrease in HPA axis function
102.
103. So tapering is required i.e continuing the therapy for
several days in reduced dose
Gives time for adrenal glands to return their normal
patterns of secretion
Eliminating doses too quickly can result in adrenal
crisis (a life-threatening state caused by insufficient
levels of cortisol).
Also reduces the chance of recurrence of the disease
104. Locally (in case of topical) ??
Corticosteroids reduce the leukocyte cells locally
White cells proliferate when therapy stops
Immature cells can produce large quantities of antibodies to
residual antigen in the ocular tissue
Massive polymorphonuclear leukocytic reaction follows
the resultant antigen- antibody reaction
105. This sequence of events , unless interrupted immediately , can
lead to a recurring , serious necrotizing inflammation
Thus depending upon response and dozes used , topical
therapy should generally be tapered over several days to
weeks
Removal of corneal epithelium caused appearance of
leukocytes in tear fluid within 2-5 hrs which was greatly
reduced by 1% prednisolone and 0.01% flurbiprofen
106. When to taper the dose??
Shouldn’t be tapered too quickly
Should wait until the inflammation is completely
controlled before tapering
Tapering when the eye is just starting to improve or
stabilize may prolong the inflammation and the therapy
116. Generally contraindicated in:
Peptic ulcer
Osteoporosis
(an increased risk of fracture )
Psychoses
Topical steroids are contraindicated in mechanical
lacerations and abrasions of the eye because they delay
healing and promote the development and spread of
infection
117. Should be used with caution in
Diabetes mellitus
Chronic renal failure
Congestive heart failure
worsen the condition
Systemic hypertension
Infectious diseases
glaucoma
118. Patients with prolonged systemic therapy, lack sufficient
adrenal reserve to respond to stress like trauma and surgery , so
require additional corticosteroids to cover the stress.
119.
120. Adrenal insufficiency
Cushing’s syndrome
Peptic ulceration
Osteoporosis
Hypertension
Muscle weakness or atrophy
Inhibition of growth
Diabetes
Activation of infection
Mood changes
Delay in wound healing
SYSTEMIC SIDE EFFECTS
121. OCULAR SIDE EFFECTS
Adverse event can occur with all routes of
administration & all preparations currently
available.
Side effects more with long term high doses
therapy.
122. Posterior subcapsular cataracts
Ocular hypertension or glaucoma
Secondary ocular infection
Retardation of corneal epithelial healing
Keratitis
Corneal thinning or melting
Scleral thinning
Uveitis
Mydriasis
Ptosis
Transient ocular discomfort
OCULAR SIDE EFFECT
123. Cataract
Occurrence of PSCC
with all routes
High incidence found in
long term systemic therapy
then the topical therapy
Opacity associated with steroid administration resemble with those
produce by ionizing radiation and ocular disease such as uveitis ,
retinitis pigmentosa and retinal detachment
124. Glucocorticoids enter lens fibres
reacts with lens crystallins
conformational change within cells
release of sulfhydryl groups
Form disulfide bonds protein aggregation
CATARACT
Mechanism
125. Mechanism
High blood glucose level
High level of sorbitol
Indrawing of water
Swelling of fibers and disruption of
cytoskeletal structures
cataract
126. mechanism
Corticosteroid induces the production of the new lens fibers
through equatorial region
Which goes and accumulate in posterior sub capsular region
Finally causes cataract
127. Ocular hypertension or glaucoma
Reversible elevation of pressure with repeated
use of topical steroids.
Steroid induced glaucoma ; a form of secondary
open-angel glaucoma
Recently developments in corticosteroids are aimed at
developing agents with less IOP effect and agents that can
be used intraocularly and periocularly
128. How steroids increase IOP…..?
GAGs present in the
trabecular meshwork
can not depolimerized
(stabilizing lysosomal
membrane)and they
retain water in
extracellular space lead
to narrowing of
trabecular meshwork
Suppress the
phagocytic activity of
endothelial cells of
trabecular meshwork
leading to collection of
deberies in trabecular
meshwork
Inhibit the
formation of PGE
and PGF leading to
decrease in
aqueous outflow
facility
Obstruction of aqueous outflow
130. Individuals differ in their responsiveness: approximately 4%
develop pressures higher than 31 mm Hg after 6 weeks of
therapy with topical dexamethasone
Steroid- induce IOP elevation almost never occurs in less than 5
days and rarely in less than 2 weeks
Steroid-induce IOP rises are usually reversible by discontinuance
of therapy if the drug has not been used for more than 1 year ,
but permanent elevations of pressure are common if the therapy
has continued for 18 months or more 1
1 (armaly MF and becker b . Mills DW ARCH OPHTHALMOL 2003)
131. If IOP rises when we use the steroid ?
1) First stop steroid therapy and may use other anti-
infalmmatory agents like NSAIDs and cyclosporine
2) If IOP persist at higher level then IOP lowering agent can be
used like beta-blocker , carbonic acid inhibitor but
prostaglandin analogue are contraindicated
3) If IOP remains at higher level then we can move to other
surgical procedure
132. Retardation of corneal epithelial healing
Effect on collagen
synthesis and fibroblastic
activity
Persistent epithelial
staining can be noted
134. Mydriasis
Increase in pupillary diameter
approximately 1 mm
Belharoptosis
Due to inhibition of sympathetic
innervation on muller muscle
135. Other ocular side effects
Transient ocular discomfort
Calcium deposits on cornea ; (Dry eye develop a
calcific band keratopathy)
136. SOME IMPORTANT FACTS
s Is not s
i.e cotricosteroids are not stored in adrenal gland, they
synthesized from cholesterol in the presence of stimulus
They promote growth of skeletal muscle (anabolic effect) and the
development of male sexual characteristics (androgenic effects)
Drugs used by athletes to boost strength and enhance physical
performance
Anabolic steroid ??
Ocular inflammation can result in permanent LOSS OF vision & immediate steps to limit the extent of inflammatory process might be needed to preserve sight
Arachidonic Acid is produced by the action of phospholipase
AA by the enzyme cyclooxygenase converts it into one of the variety of prostaglandins that have effects on smooth muscle & mediate some of inflammatory reactions
Lipooxygenase converts AA to leukotrienes which bring about increase in permeability & oedema
Closure of the ductus before birth may lead to right heart failure. Prostaglandin antagonism, such as maternal use of nonsteroidal anti-inflammatory medications (NSAIDs), can cause fetal closure of the ductus arteriosus
When surgical ligation is not indicated, prostaglandin inhibitors (eg, nonsteroid antiinflammatory drugs [NSAIDs]) are used to close the ductus arteriosus. Intravenous (IV) indomethacin or IV ibuprofen is used to treat patent ductus arteriosus (PDA) in the neonate and in premature infants
Core structure of steroid composed of 17 carbon atom bounded in four fused rings i.e. 3 cyclohexane and 1 cyclopentane
Steroids vary by the functional grups attached to this four ring core and by the oxidation state of the rings
Although the cells of adrenal cortex can synthesize samall amounts of cholesterols from acetate
Membrane fluidity means the viscosity of lipid bilayer which can affect the rotation and diffusion of proteins and other biomolecules within the membrane
Signaling molecules means that helps in the signal transduction
adrenal medulla functionally related to the sympathetic nervous system secrets the hormones epinephrine and norepinephrine
Where as the adrena; cortex secrets entirely different groups of hormones
The secretion of the anterior putitary is controlled by the hypothalamic releasing and hypothalamic inhibitory hormones secreted within the hypothamus and then conducted to the ant pituitary through minute blood vessles called hypothalamic hypophysial portal vessels
The hypothalamus receives signals from many sources in the nervous system
The HPA axis is an eloquent and every-dynamic intertwining of the central nervous system and endocrine system.
. The HPA axis is responsible for the neuroendocrine adaptation component of the stress response. This response is characterized by hypothalamic release of corticotropin-releasing factor (CRF). CRF is also known as CRH or corticotropin-releasing hormone. When CRF binds to CRF receptors on the anterior pituitary gland, adrenocorticotropic hormone (ACTH) is released. ACTH binds to receptors on the adrenal cortex and stimulates adrenal release of cortisol. In response to stressors, cortisol will be released for several hours after encountering the stressor. At a certain blood concentration of cortisol this protection is ostensibly achieved and the cortisol exerts negative feedback to the hypothalamic release of CRF and the pituitary release of ACTH (negative feedback). At this point, systemic homeostasis returns.
Hypokalemia means the serious decrease inplasma potassium concentration
Normal value : 4.5meq/l
Lower : 2meq/l
This hypokalemia results in muscle weakness
Which in turn decreases the output of T cells and antibodies from lymphoid tissue as a result the level of immunity for almost all foreign invaders of the body is decreased
This ability of cortisol and other gulococorticoid to suppress immunity makes them useful drug in preventing immunological rejection of transplantation
And these binding causes:
Steroids are widely used in ophthalmology to suppress inflammation ,reduce symptoms and minimize scaring and corneal vascularization
Are more effective in acute condition than in chronic condition
Shouldn’t be used in infective cases ,which often worsen the condition
The water soluble salts generally formulated as solutions
And more lipid soluble derivatives are available in suspension and ointments
Hydrocortisone cream 1% is used in periocular eczema and in ant uveitis at night time
steroid cream like hydrocortisone ,0.5% ,1% for periocular eczema
For severe ant.uveitis overnight
As the dosage or duration of the therapy increases so does the risk of undiseriable effects so in long term therapy alternate day therapy should be consider
It is important to avoid self regulation of the dosage, either by adding more or stopping the drug without a schedule.
Consequently white cells proliferate…..
This immature white cells…..
used more than two weeks, and stop abrubtluy may cause a syndrome called steroid withdrawl syndrome that could include fatigue, joint pain, muscle stiffness, muscle tenderness, or fever.
Used in allergic and severe blepharoconjuntivitis only when the alternative and adjunctive medicines like mast cell stabilizer, anti histamine,NSAIDs hav failed to control sympotms
Before starting steroid therapy in uveitis once should know whether
; there is systemic association
Or any infectious component and the patient is at risk for recurrence
Answer of these may help u to choose appropriate treatment { toxoplasmosis ,systemic syphilis lyme disease
Still the treat the inflammatory process should be treated but 1st start with
Sustained release corticosteroid implants are exciting development
Recently,
ophthalmologists reported the use of orbital steroid
injections for the treatment of Graves disease.
Periocular injections of steroids can reduce diplopia
rates, decrease extraocular muscle size, and reverse
Graves compressive optic neuropathy.
Steroid should be used great caution in patient
Systemic administration is generally contraindicated in such patient
Although steroid-related PSCs do
not usually occur in adults within the first year of therapy,
regardless of dose, children can manifest lens changes at
lower doses and within shorter periods.
The exact mechanisms for development
of the lens opacities have still not been fully
Elucidated, possibly glucocorticoids causes cataract formation by entering
Ptosis is noted in the subtenon injection of the steroid to treat posterior uveitis and cystoid macular oedema
Ptosis developed within few months average time is 13.9 month
Sometime steroid is misunderstood with the anabolic steroid