Is cataract development associated with steroid (corticosteroid) use?

Steroid Use and Cataract Development

Yes, steroid use increases the risk of posterior subcapsular cataract development, with the risk varying by route of administration, dose, and duration of treatment. 1, 2

Risk by Route of Administration

Systemic Steroids

• Highest risk of cataract development
• Established as a definitive risk factor for posterior subcapsular cataracts (PSC) 1, 3
• FDA drug label for prednisone explicitly states that "use of corticosteroids may produce posterior subcapsular cataracts" 1

Inhaled Corticosteroids

• Moderate risk, especially with high cumulative doses
• Higher cumulative lifetime doses of beclomethasone are associated with increased risk of PSC (p for trend <0.001) 2
• Highest prevalence (27%) found in subjects with lifetime dose over 2000mg (relative prevalence 5.5) 2
• Long-term prospective studies show increased risk of PSC cataract development (OR 2.50,95% CI 1.33-4.69) and nuclear cataract (OR 2.04,95% CI 1.21-3.43) in current users 4

Topical/Intranasal Corticosteroids

• Lower but still present risk with long-term use
• Evidence is mixed but suggests risk with prolonged use 5
• Case reports document rapid-onset bilateral PSC in patients with long-term nasal steroid use 5

Dose-Response Relationship

The risk of cataract development demonstrates a clear dose-response relationship:

• Higher cumulative doses correlate with greater risk 2
• Longer duration of treatment increases risk 3
• Combined use of multiple steroid routes (e.g., inhaled plus oral) significantly increases risk (OR 4.76,95% CI 2.59-8.74) 4

Age Considerations

Children

• In children on inhaled corticosteroids alone, risk appears lower 6
• One study found no evidence of cataract development in children using only inhaled corticosteroids 6
• However, children with JIA receiving topical corticosteroid eye drops have increased risk of cataract formation 7
• Risk increases as the number of drops of topical corticosteroids increases 7

Adults and Elderly

• Higher susceptibility to steroid-induced cataracts
• Older patients using inhaled or intranasal corticosteroids show higher risk 7, 2
• Adults over 49 years show increased risk with both current and past steroid use 2, 4

Clinical Implications

1. Monitoring recommendations:

   • Regular eye examinations for patients on long-term steroid therapy
   • More frequent monitoring for those on high doses or multiple routes
   • Particular attention to posterior subcapsular region during examinations

2. Risk mitigation strategies:

   • Use lowest effective dose of steroids
   • Consider alternative therapies when appropriate
   • For topical ocular steroids, limit to ≤3 drops daily when possible to reduce risk 7
   • Direct nasal sprays away from the septum to reduce local complications 7

3. Patient education:

   • Inform about potential ocular side effects
   • Advise reporting visual changes promptly
   • Discuss risk-benefit considerations for long-term therapy

Special Considerations

• Patients using both inhaled and oral steroids have significantly higher risk than those using either alone 4
• Patients with HIV may absorb intranasal steroids at a higher rate and should use caution 7
• The clinical significance of small differences in bone mineral density from steroid use remains uncertain 7

While steroid-induced cataracts are a recognized risk, the benefits of appropriate steroid therapy often outweigh this risk, particularly when used at the lowest effective dose and with proper monitoring.