What is the relationship between steroid (corticosteroid) toxicity and cataract formation?

From the Guidelines

Long-term use of corticosteroids is associated with an increased risk of cataract development, and patients should be informed of this potential side effect when starting therapy. To manage this risk, several strategies can be employed:

• Minimize steroid exposure: Use the lowest effective dose for the shortest duration possible, as recommended by 1.
• Regular eye exams: Schedule annual comprehensive eye exams for early detection, which can help identify cataracts before they significantly impair vision 1.
• Consider alternatives: If possible, use non-steroidal medications or local steroid applications instead of systemic steroids, as suggested by 1.
• Protect eyes from UV light: Wear sunglasses with UV protection when outdoors, which can help reduce the risk of cataract progression.
• Surgical intervention: If cataracts significantly impair vision, cataract surgery may be necessary, as noted by 1. The risk of cataract development increases with higher doses and longer duration of corticosteroid use, and posterior subcapsular cataracts are the most common type associated with steroid use 1. While the association between topical corticosteroid use and cataracts is unclear, minimizing periocular steroid use is advised, as noted by 1.

From the FDA Drug Label

WARNINGS Prolonged use of corticosteroids may result in glaucoma with damage to the optic nerve, defects in visual acuity and fields of vision, and in posterior subcapsular cataract formation. Reactions associated with ophthalmic steroids include elevated intraocular pressure, which may be associated with optic nerve damage, visual acuity and field defects, posterior subcapsular cataract formation, secondary ocular infection from pathogens including herpes simplex, and perforation of the globe where there is thinning of the cornea or sclera

The relationship between steroid (corticosteroid) toxicity and cataract formation is that prolonged use of corticosteroids may result in posterior subcapsular cataract formation 2, 2.

• Key points:
  • Prolonged use of corticosteroids is associated with an increased risk of cataract formation
  • The specific type of cataract formation associated with corticosteroid use is posterior subcapsular cataract
• Clinical decision: Use corticosteroids with caution and monitor for signs of cataract formation, especially with prolonged use.

From the Research

Relationship Between Steroid Toxicity and Cataract Formation

The relationship between steroid (corticosteroid) toxicity and cataract formation is well-documented in various studies 3, 4, 5, 6, 7.

• Steroid-induced posterior subcapsular cataracts (PSCs) are a common complication of long-term corticosteroid use, particularly in patients with systemic autoimmune diseases 5.
• The incidence of PSCs is correlated with the dose and duration of corticosteroid use, with higher doses and longer treatment durations increasing the risk of cataract formation 3, 4.
• The mechanism of steroid-induced cataract formation is not fully understood, but it is thought to involve the activation of glucocorticoid receptors in lens epithelial cells, leading to changes in gene transcription and cellular processes such as proliferation, differentiation, and apoptosis 7.
• Other potential mechanisms include the formation of glucocorticoid-protein adducts in the lens, although the evidence for this is inconclusive 6, 7.

Risk Factors for Steroid-Induced Cataract

Several risk factors have been identified for steroid-induced cataract, including:

• Long-term use of corticosteroids, particularly at high doses 3, 4, 5.
• Systemic autoimmune diseases, such as rheumatoid arthritis and lupus 5.
• Younger age, with pre-adolescent patients being at higher risk 3.
• Family history of cataracts or other eye diseases.

Clinical Presentation and Diagnosis

Steroid-induced cataracts typically present as posterior subcapsular cataracts, which can cause visual symptoms such as blurred vision, glare, and sensitivity to light 3, 4.

• Diagnosis is typically made through a comprehensive eye examination, including visual acuity testing, slit-lamp examination, and retinoscopy 3.
• A thorough medical history, including a history of corticosteroid use, is essential for diagnosis 3, 4, 5.

Treatment and Management

Treatment for steroid-induced cataract typically involves cataract surgery, which can be performed to improve visual acuity and reduce symptoms 3.

• The decision to undergo cataract surgery should be made in consultation with an experienced eye surgeon, taking into account the individual patient's risk factors and medical history 3.
• In some cases, alternative treatments such as intraocular lens implantation may be considered 3.