Are steroids recommended before cataract surgery?

Steroid Use Before Cataract Surgery

Topical steroids are not routinely recommended before uncomplicated cataract surgery, but they are indicated for patients with pre-existing uveitis or inflammation, where preoperative control of inflammation for at least 3 months is essential for optimal surgical outcomes.

Preoperative Steroid Use in Standard Cataract Surgery

• According to the American Academy of Ophthalmology's Preferred Practice Pattern for cataract in the adult eye, there is no recommendation for routine preoperative steroid use in uncomplicated cataract surgery 1
• Currently, no pharmacological treatments are known to eliminate existing cataract or retard its progression 1
• The primary management of visually significant cataract is surgical rather than medical 1

Preoperative Steroid Use in Special Populations

Patients with Uveitis

• For patients with uveitis undergoing cataract surgery, preoperative control of inflammation for at least 3 months is recommended 2
• Topical steroids are the first-line treatment for both acute and chronic anterior uveitis 1
• In patients with posterior uveitis, systemic corticosteroid prophylaxis has been shown to improve visual outcomes and hasten visual recovery after cataract surgery 3
  • One study showed that patients receiving preoperative systemic steroid prophylaxis achieved their best visual acuity in 1.8 months (median) compared to 5.9 months for those without prophylaxis 3

Steroid Selection for Patients with Uveitis

• For anterior uveitis, topical prednisolone or dexamethasone are preferred 1
• For patients with posterior uveitis, systemic corticosteroids may be beneficial for rapid control of severe uveitis or in the presence of macular edema 1
• Loteprednol etabonate 0.5% is recommended for patients with pre-existing glaucoma or steroid responders due to its lower risk of IOP elevation 4

Important Considerations and Precautions

Risks of Steroid Use

• Prolonged use of corticosteroids may result in:

  • Posterior subcapsular cataract formation
  • Increased intraocular pressure in susceptible individuals
  • Glaucoma with damage to the optic nerve
  • Defects in visual acuity and fields of vision 5

• Steroids should be used with caution in patients with:

  • Glaucoma
  • Thin corneal or scleral tissue (risk of perforation)
  • History of herpes simplex (requires great caution) 5

Monitoring Requirements

• If steroids are used for 10 days or longer, intraocular pressure should be routinely monitored 5
• Frequent slit lamp microscopy is recommended for patients with a history of herpes simplex 5

Algorithm for Preoperative Steroid Use in Cataract Surgery

1. For uncomplicated cataract surgery in patients without inflammation:

   • No preoperative steroids are routinely indicated 1

2. For patients with pre-existing uveitis:

   • Ensure inflammation is controlled for at least 3 months preoperatively 2
   • For anterior uveitis: Use topical prednisolone or dexamethasone 1
   • For posterior uveitis: Consider systemic corticosteroids in addition to topical therapy 1, 3

3. For patients with glaucoma or steroid responders:

   • If steroids are necessary, use loteprednol etabonate 0.5% instead of prednisolone acetate 1% 4

4. For patients with dry eye disease:

   • Consider preservative-free formulations to minimize ocular surface irritation 4

By following these evidence-based recommendations, ophthalmologists can optimize surgical outcomes while minimizing the risks associated with steroid therapy in patients undergoing cataract surgery.