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Mar 2012

Intravitreal Corticosteroid Therapy: Putting the Problem of Glaucoma in Perspective

Author Affiliations

Author Affiliations: Department of Ophthalmology, Medical College of Wisconsin, Milwaukee, Wisconsin.

Arch Ophthalmol. 2012;130(3):380-382. doi:10.1001/archopthalmol.2011.1097

Intravitreal corticosteroid therapy may be useful for a variety of retinal and ocular inflammatory conditions. Randomized clinical trials have shown its benefits in macular edema due to retinal vein occlusion.1,2 Sustained-release devices of fluocinolone acetonide and dexamethasone have made possible continuous and long-duration delivery of intravitreal corticosteroids for conditions such as diabetic macular edema3 and chronic idiopathic uveitis.4 However, as the duration of exposure to corticosteroids increases, so do the cumulative risks of cataract and glaucoma, as well as rarer effects of local immunosuppression, such viral retinitis.5 Although cataracts can be removed with a high success rate, corticosteroid-associated intraocular pressure (IOP) elevation carries risks of glaucomatous optic atrophy, and its management raises concerns of catastrophic visual loss from surgical complications, such as late-onset, bleb-related endophthalmitis. Nevertheless, it is the editorialists' impression that intravitreal corticosteroid therapy may be underutilized because of a fear of IOP elevation or of its potentially attendant surgical interventions, a fear that is disproportionate to actual risk. Consequently, our aim is to provide perspective on the risk-to-benefit ratio of intravitreal corticosteroid therapy with respect to corticosteroid-associated glaucoma. Physicians' cognitive biases, which can also thwart good decision making, will be discussed.

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