Judicious and Effective use of Topical Corticosteroids
By: Paul M. Karpecki, OD, FAAO
Clinical Director – PECAA
Although the subject of malpractice conjures negative emotions and I don’t often like to write about it, having been an expert witness in a huge number of malpractice cases you garner provide insights that can help colleagues. And one of my roles with PECAA is to serve as a clinical director which includes protecting my PECAA “family” of doctors. So for time to time when I see similar cases coming up frequently I’ll use it as an opportunity to educate and help prevent a PECAA colleague from having to deal with this situation. Although the fact that we live in the US means that many of us may receive a subpoena just because we saw a patient and met the standard of care. I see these more often than not and I feel for the doctors that did nothing wrong. I thank my colleagues involved in these cases for allowing me to share them. A number of cases involved the use of topical corticosteroids which makes me believe that a pearl on this topic might be valuable.
Keep in mind that the use of topical steroids is necessary in proper clinical management of patients so avoiding their use is not the intent of this clinical pearl. In fact avoiding topical steroids in cases where they are indicated could lead to permanent scaring, irregular healing, distortion or irregularity of the cornea and even the risk of preventing a full recovery in cases of significant inflammatory eye disease.
Based on dozens of cases I’ve had to review or stand in depositions and trials as an expert, the following pearls could be extrapolated:
1. If a potential infectious keratitis is present, avoid the use of any topical corticosteroids including combination agents. In some cases it is very difficult to discern if a case is a sterile marginal keratitis (which is typically treated by a steroid/antibiotic combination agent) versus an infectious keratitis. In general an infectious keratitis tends to have significantly more pain, photophobia, discharge and redness. The infiltrate tends to be more central than peripheral and an anterior chamber reaction is often present. The abrasion over the infiltrate associated with an infectious keratitis tends to be larger or at least close to the size of the infiltrate. Infectious corneal ulcers appear to develop acutely. If there is any doubt, it’s best to begin with a pure antibiotic only and have the patient return the next day. If it turns out to be sterile then adding a steroid combination agent the next day won’t hurt to much, but it’s impossible to remove a steroid that’s already been used if it indeed turned out to be infectious. The pearl here is: if signs of a potential infectious keratitis are present, avoid corticosteroids and bring the patient back the next day.
2. The first time you write a prescription for a topical corticosteroid, write zero refills. Steroids work exceptionally well and suppress inflammation better than any agent we have. For that reason most patients condition, if inflammatory, will improve dramatically and patients may use this drop and all of the refills indefinitely, and may even cancel a follow-up appointment because their condition feels resolved. Multiplerefills could mean long-term use of a topical corticosteroid without the opportunity to measure intraocular pressure (IOP), even if properly educated about risks.
3. Don’t use topical corticosteroids on a corneal abrasion. Although there are times that it makes sense to control inflammation the majority of abrasions do not require the use of topical corticosteroids with our without a bandage contact lens. There are instances when an epithelial defect persists and inflammation may be keeping it from healing where steroids make sense. But what I’m referring to here is a traumatic corneal abrasion and it’s best to just prescribe a topical antibiotic and a bandage lens. If pain is significant consider a topical or oral NSAID rather than a corticosteroid.
4. Don’t use topical corticosteroids on patients with poorly controlled autoimmune diseases such as rheumatoid arthritis. Now this is not an absolute contraindication and there are numerous cases when we have no choice but to use a corticosteroid, however if the patient states their systemic disease is not controlled and not being managed by a specialist, avoiding a steroid until systemic disease control is achieved is prudent.
5. Don’t apply topical corticosteroids on top of a contact lens. Again this is not an absolute contraindication and there are cases when we would do this. But for more routine conditions like GPC, contact lenses can serve as a depot for medications and could increase contact time, This could potentially lead to a higher percentage of elevated IOP cases and therefor proper monitoring is essential or the development of an infectious keratitis.
6. Steroids in glaucoma patients or children have a known higher incidence of IOP rise. Again, this is not an absolute contraindication to use a corticosteroid on a glaucoma patient as we do this all the time, however proper and timely IOP monitoring is required.
Knowing these insights might help you effectively and conservative manage patients regarding topical corticosteroid use. Keep in mind that this should enhance your knowledge and confidence in prescribing topical corticosteroids as opposed to avoiding their use in appropriate inflammatory eye disease cases.