What is the role of oral steroids in the treatment of hyphema?

Updated: Jan 18, 2019
  • Author: David L Nash, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Answer

Other investigators have suggested that systemic steroids decrease the incidence of secondary hemorrhage. Initial studies supporting this claim were neither randomized nor double-masked. [37, 53] In 1980, a randomized, double-masked, prospective study by Spoor and associates observed a secondary hemorrhage rate of 20% in controls and 13% in treated patients, which was not statistically significant. [22] In 1991, Farber and colleagues compared treatment with oral ACA with oral prednisone in a well-controlled trial. [54] Their study suggested that both drugs decrease the incidence of secondary hemorrhage by a similar amount, albeit by different mechanisms. Because of the small number of rebleeds, the confidence limits were large and may have masked a real difference.

The previously mentioned 2013 Cochrane review noted that the evidence for the use of corticosteroids in traumatic hyphema is limited owing to studies with small sample sizes and low rates of complications. However, conflicting data continue to emerge. [35] A 2014 retrospective analysis that examined visual outcomes, incidence of rebleeding, and intraocular pressures in 98 eyes treated with corticosteroid therapy (as well as bed rest, elevation of head of bed, and hydration) and in 108 eyes treated with supportive therapy alone identified no difference between the visual outcomes or incidence of rebleeding. The intraocular pressure was significantly lower in the supportive therapy group. [55]

Other studies have recommended oral steroids combined with traditional treatments to reduce rebleeding rates. [51, 36] A randomized, comparative study of ACA versus oral steroids found no significant difference in the outcomes between the 2 treatments. [54] Despite conflicting data, many practitioners still tend to prescribe topical corticosteroids at least anecdotally for the potential benefits of avoiding complications due to intraocular inflammation.

The major difficulty with this study was that controls were not used. The lack of a true control population is unfortunate in comparing the 2 groups. In addition, the study excluded all patients with sickle cell trait. These patients are one group that should be considered for systemic ACA or systemic corticosteroid treatment. In addition, patients with gastric ulcer or diabetes mellitus and those who were intoxicated or had bleeding were excluded. The mode of action of prednisone is unclear and may be related to an anti-inflammatory influence on traumatized blood vessels with reduced engorgement and a propensity for rebleeding. Additional randomized studies with controls would be extremely helpful in determining whether a significant reduction of secondary hemorrhage occurs with systemic prednisone in comparison with systemic ACA.


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