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Glaucoma following the prolonged use of topical steroid medication to the eyelids
Joun~al of the American Academy of Demaatology
C~tO et al
cutan6es des leuc6mies lymphoides chroniques. Ann Dermatol Syph 100:5-24, 1973. 7. Epstein E, MacEachen K: Dermatologic manifestations of the lyphoblastoma-leukemia group. Arch Intern Med 60:867-875, 1937. 8. Bureau Y, Barri~re H, Litoux P, Bureau B: Manifestations cutan~es v~siculo-bulleuses sp~cifiques au cours des leucoses lymphoides. Ann Dermatol Syph 98:261274, 1971.
I
9. Leong A S-Y, et al: Preferential epidermotropism in adult T-cell leukemia-lymphoma. Am J Surg Patho[ 4: 421-430, 1980. 10. Edelson RL: Cutaneous T-cell lymphoma: Other experimenlal observations. J Dermatol Surg Oncol 6:388-389, 1980. 1l. Edelson RL: Cutaneous T-cell lymphoma. Mycosis fungoides, S~zary syndrome and other variants. J AM Ac~,~ OeRr~A'rOl_2:89-106, 1980.
II
Glaucoma following the prolonged use of topical steroid medication to the eyelids J o h n E. E i s e n l o h r , M . D . Dallas, T X Glaucoma caused by ophthalmic medications containing steroids is an entity which is well recognized by ophthalmologists. ~ Glaucoma from skin preparations applied to the eyelids has been far less frequently observed. Presented here is a case of major eye damage which almost certainly was the result of the improper use of a steroid preparation designed for dermatologic use. (J AM ACAD DERMATOL 8:878-881, 1983.)
CASE REPORT This 33-year-old white woman was first seen Nov. 21, 1979, having been referred by family members. She reported that during the previous summer she began to experience episodes of blurred vision and had "trouble focusing." In addition, she was disturbed by periodically seeing "sheets of white light." Her family physician suspected migraine and prescribed an ergot preparation, which proved to be of no benefit. Subsequently, another physician supplemented the ergot with meprobamate, believing that she did indeed have migraine aggravated by stress. This combination proved to be equally ineffective in relieving her symptoms. She was in vigorous good health otherwise and took no medication on a routine basis. Her eyes had been examined in March o f the previous year by an ophthalmologist, who had found her vision to be 20/20 in each eye, with no abnormalities
Reprint requests to: Dr. John E. Eisenlohr, 2811 Lemmon Ave., East, Suite 301, Dallas, TX 75204.
878
noted in the flmdi. The discs were non-hal. She was asymptomatic at that time, and the intraocular pressures were not recorded. When her symptoms persisted, she consulted an ophthalmologist, who discovered her applanation pressures to be 55 mm Hg in the right eye and 57 mm Hg in the left eye. (The pressure readings in normal should be 20 mm Hg or less.) He also found severe cupping of the optic discs. She gave a history of having applied her mother's skin cream to her eyelids each night for the preceding 3 to 5 years to relieve the irritation from her cosmetics. The cream she used, which was available only by prescription, contained betamethasone 0.1%. She was instructed to discontinue the use of this medication at once and to begin a pilocarpine-epinephrine drop four times daily to each eye, plus acetazolamide, 500 mg twice daily by mouth. Within 2 days her pressures were within normal limits. When I first saw her a week later her best corrected vision was 20/20 in the right eye and 20/25 in the left eye. Her applanation pressures were 18 m m Hg in the right eye and 36 nun Hg in the left eye. Her discs
Volume 8 Number 6 June, 1983
Glaucoma )bllowing use o f topical steroid
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Fig. 1. A, The right disc is glaucomatous with an abnormally large cup/disc ratio. There is vertical encroachment of the cup toward the upper temporal disc margin. B, The left disc shows severe cavernous optic atrophy characteristic of far-advanced glaucoma. showed extreme glaucomatous cupping, especially on the left (Fig. 1), and her visual fields were devastated (Fig. 2). The angles were open and the lenses were clear. Neither eye was inftmaled. She was placed on phospholine iodide drops, 0.06%, timolol drops, 0.5%, plus the acetazolamide capsules, 500 nag twice daily. A week later she returned, complaining about both the visual and systemic side effects of the medications. She had stopped taking the acetazolamide and timolol altogether, believing the latter to be responsible for her blurred vision. Her pressures then measured 28 mm Hg and 40 mm Hg in the right and left eye, respectively. In an effort to secure better short-term compliance, the
miotic was discontinued, and she was severely admonished to continue the timolol drops and acetazolamide twice daily. A week later, her pressures were bilaterally nomaal. Although she continued to complain bitterly about the side effects of acetazolamide, she was sufficiently frightened by this time to take it anyway. At this point, the hope was that the discontinuance of the steroid cream would allow her pressure to return to normal spontaneously. She was followed at 2- to 4week intervals, with instructions to discontinue acetazolamide 72 hours prior to an office visit so that any improvement, or lack of it, could be better evaluated. At each of four such visits her pressures on timolol
880
Journal of the American Academyof Dermatology
Eisenlohr
345
Fig. 2. The right eye maintains a good central island, with 20/15 vision, as well as some temporal field. The nasal peripheral field has been destroyed. The left field has been reduced to a small central ellipse, with which she can still see 20/20 after she is able to locate the vision chart. drops alone ranged'from 18 mm to 30 mm Hg in the right eye and from 34 mm Hg to 46 mm Hg in the left eye. No trend was established for the pressure readings to be lower with each succeeding visit, and she remained continuously depressed over the quality of life she was forced to endure on the carbonic anhydrase inhibitor. Approximately 3 months after the diagnosis of glaucoma was made she underwent successful glaucoma surgery (trabeculectomy) on the left eye. During the immediate postoperative period, which was uneventful, acetazolamide was not used. Her fight eye pressure on timolol drops alone during that time ranged from 26 mm Hg to 30 mm Hg, with the highest reading being recorded last. So, approximately 4 months after the original diagnosis and the cessation of topical steroids, she had a trabeculectomy done on the right eye also. This procedure was complicated by an anterior chamber hemorrhage 3 days postoperatively, which cleared without incident. Two years after surgery her best corrected vision is 20/15 in the right eye and 20/20 in the left eye. On no medication her applanation pressures are 14 nun Hg, right eye, and i5 mm Hg, left eye. Her fields are unchanged, and she has adapted fairly well to her limited peripheral vision. She no longer drives a car and reports " a l w a y s " bumping her head on kitchen cabinets and tripping over small objects on the floor. Because of this latter problem, and being fearful that she would stumble and fall with. a baby, she recently underwent a tubal ligation. The patient's parents, her brother age 32, her daughter age 12, her uncle age 74, several first cousins and first cousins-once-removed have been examined and
found to be free of glaucoma. No other family member is known to have glaucoma. This patient's problem is almost certainly the result of having used a steroid preparation intended for the skin and applied near the eyes for a prolonged period of time. COMMENT Cubey, 2 Zugerman et al, :~ and Vie, '~ who have reported similar cases, feel that small amounts of ointment reach the eye through the palpebral fissure after having been applied to the eyelids. Certainly the routine observation o f flecks of cosmetics in w o m e n ' s tear film would tend to confirm this hypothesis. In susceptible individuals, these small smounts o f medication will ultimately raise the intraocular pressure. This explanation f o r the entry o f steroid into the eye seems reasonable as far as the present case is concerned. Although most cases o f steroid-induced glaucoma are self-linaited if the inciting medication is discontinued, some are not. Whether or not the ultimate control o f the pressure in the present case is a result of surgery or merely a consequence of the passage of time cannot be answered with certainty. Yet, during 4 m o n t h s ' observation, no trend toward spontaneous remission o f her glauc o m a was observed. It should be e m p h a s i z e d that the patient presented in this paper treated herself with a medication which could not be obtained without a prescription. The report was prompted both by the relative infrequency o f such cases and also by the
Volume 8 Number 6 June, 1983
fact that since early 1980, skin care products containing 0.5% hydrocortisone have been available on an over-the-counter basis. Currently in the Dallas area, at least eight such products are sold, and they are advertised aggressively. Each o f the preparations is accompanied by a warning to " a v o i d contact with the e y e s , " but they are at the same time r e c o m m e n d e d for " t e m porary relief of minor skin irritations, itching and r a s h e s - - d u e to soaps, cosmetics and j e w e l r y . " While hydrocortisone is not among the more potent steroids in its ability to raise the intraocular pressure, '~ there is no doubt that it possesses the capacity to do so.t In 1976, dermatologists 6 were alerted to the potential for damage to the eyes if over-the-counter steroid products were to become available. Since these products are now widely sold, it seems almost inevitable that physicians will encounter problems with glaucoma, herpes simplex, or, c o n c e i v a b l y , cataracts as a result of their use. W e should be aware of the ocular consequences which may o c c u r from the unrestricted sale and use o f these skin medications. SUMlVlARY A case of severe glaucoma which may well have been caused by the irresponsible application
Glaucoma following use of topical steroid
881
of a steroid preparation to the eyelids is presented. The patient sustained major damage to her optic discs and has profound loss o f her visual fields. While the case in question concerns the improper use of a prescription medication, p h y s i c i a n s are urged to b e alert for similar cases resulting from the use o f the many readily available over-thecounter skin care products containing 0.5% hydrocortisone. The fundus photographs were provided by Drs. Bruce Taylor and Richard Winslow. REFERENCES
1. Goldman H: Cortisone glaucoma. Arch Ophthalmol 68:621-626, 1962. 2. Cubey RB: GIaucoma following the application of corticosteroid to the skin of the eyelid. Br J Dermatol 95:207208, 1976. 3. Zugerman C, Saunders D, Levit F: Glaucoma from topically applied steroids. Arch Dermatol 112: 1326, 1976. 4. Vie R: Glaucoma and amaurosis associated with long term application of corticosteroids to the eyelids. Acta Derm Venereol (Stockh) 60:541-542, 1980. 5. Contrill HL, Palmberg PF, Zink HA, et at: Comparison of in vitro potency of corticosteroids with ability to raise intraocular pressure. Am J Ophthalmol 79:1012-1016, 1975. 6. Howell JB: Eye diseases induced by topically applied steroids. Arch Dermatol 112: 1529-1530, 1976.
C~tO et al
cutan6es des leuc6mies lymphoides chroniques. Ann Dermatol Syph 100:5-24, 1973. 7. Epstein E, MacEachen K: Dermatologic manifestations of the lyphoblastoma-leukemia group. Arch Intern Med 60:867-875, 1937. 8. Bureau Y, Barri~re H, Litoux P, Bureau B: Manifestations cutan~es v~siculo-bulleuses sp~cifiques au cours des leucoses lymphoides. Ann Dermatol Syph 98:261274, 1971.
I
9. Leong A S-Y, et al: Preferential epidermotropism in adult T-cell leukemia-lymphoma. Am J Surg Patho[ 4: 421-430, 1980. 10. Edelson RL: Cutaneous T-cell lymphoma: Other experimenlal observations. J Dermatol Surg Oncol 6:388-389, 1980. 1l. Edelson RL: Cutaneous T-cell lymphoma. Mycosis fungoides, S~zary syndrome and other variants. J AM Ac~,~ OeRr~A'rOl_2:89-106, 1980.
II
Glaucoma following the prolonged use of topical steroid medication to the eyelids J o h n E. E i s e n l o h r , M . D . Dallas, T X Glaucoma caused by ophthalmic medications containing steroids is an entity which is well recognized by ophthalmologists. ~ Glaucoma from skin preparations applied to the eyelids has been far less frequently observed. Presented here is a case of major eye damage which almost certainly was the result of the improper use of a steroid preparation designed for dermatologic use. (J AM ACAD DERMATOL 8:878-881, 1983.)
CASE REPORT This 33-year-old white woman was first seen Nov. 21, 1979, having been referred by family members. She reported that during the previous summer she began to experience episodes of blurred vision and had "trouble focusing." In addition, she was disturbed by periodically seeing "sheets of white light." Her family physician suspected migraine and prescribed an ergot preparation, which proved to be of no benefit. Subsequently, another physician supplemented the ergot with meprobamate, believing that she did indeed have migraine aggravated by stress. This combination proved to be equally ineffective in relieving her symptoms. She was in vigorous good health otherwise and took no medication on a routine basis. Her eyes had been examined in March o f the previous year by an ophthalmologist, who had found her vision to be 20/20 in each eye, with no abnormalities
Reprint requests to: Dr. John E. Eisenlohr, 2811 Lemmon Ave., East, Suite 301, Dallas, TX 75204.
878
noted in the flmdi. The discs were non-hal. She was asymptomatic at that time, and the intraocular pressures were not recorded. When her symptoms persisted, she consulted an ophthalmologist, who discovered her applanation pressures to be 55 mm Hg in the right eye and 57 mm Hg in the left eye. (The pressure readings in normal should be 20 mm Hg or less.) He also found severe cupping of the optic discs. She gave a history of having applied her mother's skin cream to her eyelids each night for the preceding 3 to 5 years to relieve the irritation from her cosmetics. The cream she used, which was available only by prescription, contained betamethasone 0.1%. She was instructed to discontinue the use of this medication at once and to begin a pilocarpine-epinephrine drop four times daily to each eye, plus acetazolamide, 500 mg twice daily by mouth. Within 2 days her pressures were within normal limits. When I first saw her a week later her best corrected vision was 20/20 in the right eye and 20/25 in the left eye. Her applanation pressures were 18 m m Hg in the right eye and 36 nun Hg in the left eye. Her discs
Volume 8 Number 6 June, 1983
Glaucoma )bllowing use o f topical steroid
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~i!!iii~!ii!!i, ~ ~~9149 ! ii~
Fig. 1. A, The right disc is glaucomatous with an abnormally large cup/disc ratio. There is vertical encroachment of the cup toward the upper temporal disc margin. B, The left disc shows severe cavernous optic atrophy characteristic of far-advanced glaucoma. showed extreme glaucomatous cupping, especially on the left (Fig. 1), and her visual fields were devastated (Fig. 2). The angles were open and the lenses were clear. Neither eye was inftmaled. She was placed on phospholine iodide drops, 0.06%, timolol drops, 0.5%, plus the acetazolamide capsules, 500 nag twice daily. A week later she returned, complaining about both the visual and systemic side effects of the medications. She had stopped taking the acetazolamide and timolol altogether, believing the latter to be responsible for her blurred vision. Her pressures then measured 28 mm Hg and 40 mm Hg in the right and left eye, respectively. In an effort to secure better short-term compliance, the
miotic was discontinued, and she was severely admonished to continue the timolol drops and acetazolamide twice daily. A week later, her pressures were bilaterally nomaal. Although she continued to complain bitterly about the side effects of acetazolamide, she was sufficiently frightened by this time to take it anyway. At this point, the hope was that the discontinuance of the steroid cream would allow her pressure to return to normal spontaneously. She was followed at 2- to 4week intervals, with instructions to discontinue acetazolamide 72 hours prior to an office visit so that any improvement, or lack of it, could be better evaluated. At each of four such visits her pressures on timolol
880
Journal of the American Academyof Dermatology
Eisenlohr
345
Fig. 2. The right eye maintains a good central island, with 20/15 vision, as well as some temporal field. The nasal peripheral field has been destroyed. The left field has been reduced to a small central ellipse, with which she can still see 20/20 after she is able to locate the vision chart. drops alone ranged'from 18 mm to 30 mm Hg in the right eye and from 34 mm Hg to 46 mm Hg in the left eye. No trend was established for the pressure readings to be lower with each succeeding visit, and she remained continuously depressed over the quality of life she was forced to endure on the carbonic anhydrase inhibitor. Approximately 3 months after the diagnosis of glaucoma was made she underwent successful glaucoma surgery (trabeculectomy) on the left eye. During the immediate postoperative period, which was uneventful, acetazolamide was not used. Her fight eye pressure on timolol drops alone during that time ranged from 26 mm Hg to 30 mm Hg, with the highest reading being recorded last. So, approximately 4 months after the original diagnosis and the cessation of topical steroids, she had a trabeculectomy done on the right eye also. This procedure was complicated by an anterior chamber hemorrhage 3 days postoperatively, which cleared without incident. Two years after surgery her best corrected vision is 20/15 in the right eye and 20/20 in the left eye. On no medication her applanation pressures are 14 nun Hg, right eye, and i5 mm Hg, left eye. Her fields are unchanged, and she has adapted fairly well to her limited peripheral vision. She no longer drives a car and reports " a l w a y s " bumping her head on kitchen cabinets and tripping over small objects on the floor. Because of this latter problem, and being fearful that she would stumble and fall with. a baby, she recently underwent a tubal ligation. The patient's parents, her brother age 32, her daughter age 12, her uncle age 74, several first cousins and first cousins-once-removed have been examined and
found to be free of glaucoma. No other family member is known to have glaucoma. This patient's problem is almost certainly the result of having used a steroid preparation intended for the skin and applied near the eyes for a prolonged period of time. COMMENT Cubey, 2 Zugerman et al, :~ and Vie, '~ who have reported similar cases, feel that small amounts of ointment reach the eye through the palpebral fissure after having been applied to the eyelids. Certainly the routine observation o f flecks of cosmetics in w o m e n ' s tear film would tend to confirm this hypothesis. In susceptible individuals, these small smounts o f medication will ultimately raise the intraocular pressure. This explanation f o r the entry o f steroid into the eye seems reasonable as far as the present case is concerned. Although most cases o f steroid-induced glaucoma are self-linaited if the inciting medication is discontinued, some are not. Whether or not the ultimate control o f the pressure in the present case is a result of surgery or merely a consequence of the passage of time cannot be answered with certainty. Yet, during 4 m o n t h s ' observation, no trend toward spontaneous remission o f her glauc o m a was observed. It should be e m p h a s i z e d that the patient presented in this paper treated herself with a medication which could not be obtained without a prescription. The report was prompted both by the relative infrequency o f such cases and also by the
Volume 8 Number 6 June, 1983
fact that since early 1980, skin care products containing 0.5% hydrocortisone have been available on an over-the-counter basis. Currently in the Dallas area, at least eight such products are sold, and they are advertised aggressively. Each o f the preparations is accompanied by a warning to " a v o i d contact with the e y e s , " but they are at the same time r e c o m m e n d e d for " t e m porary relief of minor skin irritations, itching and r a s h e s - - d u e to soaps, cosmetics and j e w e l r y . " While hydrocortisone is not among the more potent steroids in its ability to raise the intraocular pressure, '~ there is no doubt that it possesses the capacity to do so.t In 1976, dermatologists 6 were alerted to the potential for damage to the eyes if over-the-counter steroid products were to become available. Since these products are now widely sold, it seems almost inevitable that physicians will encounter problems with glaucoma, herpes simplex, or, c o n c e i v a b l y , cataracts as a result of their use. W e should be aware of the ocular consequences which may o c c u r from the unrestricted sale and use o f these skin medications. SUMlVlARY A case of severe glaucoma which may well have been caused by the irresponsible application
Glaucoma following use of topical steroid
881
of a steroid preparation to the eyelids is presented. The patient sustained major damage to her optic discs and has profound loss o f her visual fields. While the case in question concerns the improper use of a prescription medication, p h y s i c i a n s are urged to b e alert for similar cases resulting from the use o f the many readily available over-thecounter skin care products containing 0.5% hydrocortisone. The fundus photographs were provided by Drs. Bruce Taylor and Richard Winslow. REFERENCES
1. Goldman H: Cortisone glaucoma. Arch Ophthalmol 68:621-626, 1962. 2. Cubey RB: GIaucoma following the application of corticosteroid to the skin of the eyelid. Br J Dermatol 95:207208, 1976. 3. Zugerman C, Saunders D, Levit F: Glaucoma from topically applied steroids. Arch Dermatol 112: 1326, 1976. 4. Vie R: Glaucoma and amaurosis associated with long term application of corticosteroids to the eyelids. Acta Derm Venereol (Stockh) 60:541-542, 1980. 5. Contrill HL, Palmberg PF, Zink HA, et at: Comparison of in vitro potency of corticosteroids with ability to raise intraocular pressure. Am J Ophthalmol 79:1012-1016, 1975. 6. Howell JB: Eye diseases induced by topically applied steroids. Arch Dermatol 112: 1529-1530, 1976.