What is the role of corticosteroids in the treatment of ophthalmologic manifestations of ankylosing spondylitis?

Updated: May 15, 2020
  • Author: Jean Deschênes, MD, FRCSC; Chief Editor: Hampton Roy, Sr, MD  more...
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Answer

Answer

Corticosteroids decrease the recruitment of inflammatory cells and alter cell function. They may be administered topically, via periocular injection, or systemically, and then tapered slowly.

Topical steroids are used to treat disease limited to the anterior segment. Prednisolone acetate 1% is most effective in reducing anterior chamber inflammation. Adverse effects include cataract formation and increased intraocular pressure. Therapeutic levels of corticosteroids cannot be achieved in the vitreous via the topical route; therefore, this method of administration is ineffective for posterior segment disease. An alternative route of delivery may be considered when the anterior uveitis is severe or unresponsive to topical treatment. However, before injecting depot steroids, a 4- to 6-week course of topical steroids may be useful to ensure that the patient is not a steroid responder. Typically, prednisolone acetate 1% is prescribed every hour while awake, with dexamethasone ointment at bed time.

Periocular corticosteroids may be used to treat severe anterior uveitis, intermediate uveitis, or CME. Complications include cataract formation and increased intraocular pressure, which may be refractory to all forms of therapy, short of surgical removal of the injected material.

Systemically administered corticosteroids may be considered for vision-threatening uveitis unresponsive to maximal topical and periocular therapy. An internal medicine or rheumatology consultation is advisable in the management of these patients in the absence of an ophthalmologist specialized in uveitis.

If systemic treatment is required, it is necessary to determine whether medical contraindications to systemic corticosteroids exist, particularly in children and in elderly patients. Systemic corticosteroids suppress growth in children. They may exacerbate diabetes mellitus in susceptible individuals. Weight gain and fluid retention are expected effects. Electrolyte imbalance is a common complication. Long-term hazards include osteoporosis, compression of the spine, gastrointestinal hemorrhage, and reduction in immune response to infection, especially tuberculosis.


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