Clinicians comanaging patients after penetrating keratoplasty should consider prescribing less potent steroids to avoid any delayed onset of steroid-induced ocular hypertension (OHT), a new retrospective review suggests. A UK-based team believes that less potent corticosteroids, such as rimexolone, fluorometholone or loteprednol etabonate, could be used as first-line agents because they possess a similar anti-inflammatory effect to prednisolone acetate or dexamethasone, with reduced ocular hypertensive response.

The risk of developing increased IOP after corneal transplantation can depend on many factors. The researchers excluded cases with a history of glaucoma and ensured that the surgical procedure and postoperative medical treatment were identical in each case. In 80 eyes, the most common indication was keratoconus (28.8%), followed by phakic eyes (33.8%), posterior chamber IOLs  (57.4%) and anterior chamber IOLs (8.8%).

The mean postoperative IOP increase was only significant in the anterior chamber IOL group (18.7mm Hg). The average time for developing hypertension was 9.8 months post-op, with an average IOP increase of 13.3mm Hg.

Prednisolone acetate 1% was switched to rimexolone 1% in 64 eyes and to fluorometholone 0.1% in 16 eyes. Using these steroids alone achieved IOP normalization in 26 eyes, with an average IOP reduction of 12.3mm Hg approximately 2.3 months after the switch. The remaining 54 required additional antiglaucoma medication.

After switching treatments, 17 eyes developed glaucoma and 13 eyes developed graft rejection, with no statistically significant differences between rimexolone and fluorometholone.

The researchers believe their findings should encourage practitioners to properly manage steroid-induced OHT and carefully monitor IOP after corneal transplantation. They note that clinicians should compare the safety and efficacy of alternative topical corticosteroids as prophylactic management after corneal transplantation.

Raj A, Salvador-Culla B, Anwar H, et al. Long-term outcomes on de novo ocular hypertensive response to topical corticosteroids after corneal transplantation. Cornea. September 10, 2019. [Epub ahead of print].