Irreversible visual loss secondary to excessive topical steroid use in eczema.

CASEREPORT A 43-year-old male attended the ophthalmology department with a 2-week history of painless reduction in vision in his left eye. Past ophthalmic history included bilateral allergic conjunctivitis, primary open angle glaucoma (POAG) right eye, and ocular hypertension left eye, diagnosed on his first visit 18 months ago. Systemic enquiry revealed a history of asthma, hypertension, obesity, epilepsy, and atopic eczema. Current ophthalmic treatments included nedocromil sodium and latanoprost to both eyes. His only previous exposure to ophthalmic steroids was a 4week course of dexamethasone 0.1% q.i.d. (standard practice) following uncomplicated left cataract surgery 8 months ago. Intraocular pressures (IOP) 6 weeks postsurgerywere 23 and18mmHgright and left eye respectively. Ocular findings were as follows: Snellen acuity 6/9; hand movement with IOP of 46 and 56mmHg in the right eye and left eye respectively (upper limit of normal IOP is 21mmHg). Both eyes were quiet with some evidence of corneal scarring and grade 4 open anterior chamber drainage angles. Fundus examination revealed bilateral optic disc cupping. Treatment with systemic acetazolamide and topical ocular antihypertensives initially successfully normalised IOP in both eyes with slight improvement in visual acuity. On further questioning the patient revealed that as his eczema had flared up, and he had been applying 100 grams of Diprosone® (Schering-Plough) ointment each week continuously for the past 8months to his sideburns, neck, and body, although he denied applying any near his eyes. A diagnosis of steroid-induced glaucoma was made. Subsequent follow-up examinations showed labile IOP levels (despite maximal topical antihypertensive treatment and withdrawal of cutaneous steroids) and marked deterioration in optic disc cupping and visual fields (Figure 1). He subsequently underwent trabeculectomy.