Do oral steroids (corticosteroids) increase the risk of developing cataracts?

Oral Steroids and Cataract Risk

Yes, oral corticosteroids significantly increase the risk of developing cataracts, particularly posterior subcapsular cataracts, and this risk is dose-dependent and cumulative. 1

Evidence from Guidelines

The most recent and authoritative evidence comes from the American Academy of Ophthalmology's 2022 Cataract Preferred Practice Pattern, which definitively states that long-term users of oral corticosteroids are at higher risk of cataract formation. 1 This represents the current standard of care and should guide clinical decision-making.

The FDA drug label for prednisone explicitly warns that corticosteroid use may produce posterior subcapsular cataracts, confirming this as a recognized and serious adverse effect. 2

Mechanism and Type of Cataract

• Posterior subcapsular cataracts (PSC) are the characteristic type associated with oral corticosteroid use, which are particularly visually significant as they affect central vision. 3, 4
• The mechanism involves direct toxic effects on lens epithelial cells and metabolic changes in the lens. 5

Dose-Response Relationship

The risk increases with both higher doses and longer duration of treatment:

• Current users of oral corticosteroids show a 4-fold increased risk of PSC cataract development (OR 4.11) compared to non-users. 4
• The association is strongest with cumulative lifetime doses greater than 2000 mg. 1
• Even moderate doses can cause cataracts when used long-term. 6
• Doses exceeding 10 mg daily for more than 18 months significantly increase the risk of cataract formation. 6

Clinical Implications for Practice

Patients on long-term oral corticosteroids require:

• Regular ophthalmologic monitoring for early detection of cataract formation. 6, 7
• Counseling about cataract risk before initiating therapy, particularly for prolonged courses. 1, 7
• Use of the lowest effective dose for the shortest duration to minimize risk. 6, 5
• Consideration of steroid-sparing agents when long-term therapy is anticipated. 6

Important Distinctions

Intranasal corticosteroids do NOT carry the same risk:

• Two recent systematic reviews confirm that intranasal corticosteroids are not associated with significant cataract risk. 1, 7
• The incidence rate among intranasal steroid users (1.0/1000 person-years) is similar to non-users, while oral steroid users show doubled rates (2.2/1000 person-years). 8

Inhaled corticosteroids present a more nuanced picture:

• Low-to-medium doses of inhaled corticosteroids have no significant effect on cataract incidence in children. 1
• High cumulative lifetime doses (>2000 mg) may slightly increase cataract prevalence in adults. 1
• The risk with inhaled steroids alone appears negligible in most patients, even at high doses. 3, 9
• Combined use of both inhaled and oral corticosteroids dramatically increases risk (OR 4.76 for PSC cataract), representing a synergistic effect. 4

Common Pitfalls to Avoid

• Underestimating the cumulative dose effect: Even intermittent courses of oral steroids accumulate over time and increase risk. 4
• Failing to distinguish between routes of administration: The cataract risk profile differs substantially between oral, inhaled, and intranasal routes. 1, 8
• Not monitoring high-risk patients: Those on combined inhaled and oral therapy require particularly vigilant ophthalmologic surveillance. 4
• Confusing disease effects with medication effects: The underlying inflammatory condition being treated may independently affect cataract risk, though the steroid effect is clearly established. 1

Risk Stratification

Highest risk patients requiring closest monitoring:

• Those using both oral and inhaled corticosteroids concurrently. 4
• Patients on doses >10 mg prednisone daily for >18 months. 6
• Elderly patients with additional risk factors (diabetes, hypertension, smoking). 6, 7